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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3663_Библиотеки_им_академика_М_И_Перельмана
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104
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R. Posham et al.
Fig. 29.4 An 18Fr sheath (18Fr × 40 cm Check-Flo Performer
Introducer, Cook Medical Inc., Bloomington, IN) is advanced through
the “port-hole” fenestration using the swallow-the-balloon technique,
i.e., pushing the sheath over a gradually deating balloon to minimize
step-off
Fig. 29.5 Crocodile Jaw Grasping Forceps (model 4162; LYMOL
Medical Corp, Woburn, Massachusetts) are advanced through the
sheath to directly grasp the lter neck
29 Stent-Excluded IVC Filter Causing Severe Abdominal Pain: ThePorthole Retrieval Technique
105
Fig. 29.6 From a left CFV access, a 14mm × 6 cm Balloon (XXL
Balloon, Boston Scientic, Watertown, MA) was simultaneously
inated over a safety wire in the IVC stent lumen to assist in freeing the
lter legs from the surrounding soft tissue, prevent crumpling of the
stent as the lter was pulled into the sheath, and provide temporary
hemostasis in case of IVC rupture
Fig. 29.7 Computed Tomography Maximum Intensity Projection
(CT-MIP) images obtained at 3months post procedure shows the “porthole” at the level of the right renal rein, and the remainder of the stent
in good apposition to the IVC wall. There is no evidence of thrombosis,
hematoma, or other abnormality
AngioVac Thrombectomy
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
ofTwo- Month- Old Iliocaval Thrombosis
ina15-Year-Old Resulting fromGunshot
Wound andSurgical Caval Ligation
ZivJHaskal
A 15-year-old male received an accidental gunshot to the abdomen resulting in pulseless electrical activity arrest, open thoracotomy, hemorrhagic shock and injuries to gastrointestinal,
liver, and pancreatic injuries. A bleeding inferior vena cava
(IVC) injury was primarily repaired. With ongoing resuscitation and emergent transfer, he underwent reoperations, washout of abscesses, and bullet removal (Fig.30.1). CT imaging
demonstrated infrarenal thrombus in the IVC extending into
the common iliac veins (Fig.30.2). He was discharged after
1month and was readmitted 3weeks later for thrombectomy.
Whilst under general anesthesia, femoral and jugular
venography demonstrated the ilio-midcaval thrombosis(Fig.
30.3). Probing the surgical site of occlusion led to opacifying
abdominal lymphatic trunks that lled the thoracic duct without leak (Fig.30.4). The hard occlusion, at the surgical clips
was traversed with sharp recanalization from the jugular to
femoral axis. This was dilated with serial balloons to 14mm
without extravasation, after which the AngioVac circuit was
assembled and the jugular cannula activated in the upper IVC.
30
Fig. 30.2 Coronal CT at week 3 demonstrates the lower caval throm-
bosis (red arrow), and the surgical clips at its ligation (yellow arrow);
cephalad of this, the IVC is patent
Transfemoral occlusion and angioplasty balloons and
Arrow PTD were used to macerate and push thrombus
toward the suction cannula (Figs.30.5 and 30.6). Four collection baskets were lled with extracted hard rubbery
thrombus. Stents were deferred given his age and expected
growth. After nal 16 mm IVC dilation, prograde ow was
Fig. 30.1 CT image after third operation demonstrates open abdomen,
mid abdominal abscess (multiple others were present, not shown), lack
of caval opacication
Z. J Haskal (*)
Department of Radiology and Medical Imaging, Interventional
Division, University of Virginia, Charlottesville, VA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_30
present in the iliac and femoral veins, with residual adherent
clot in the left iliac vein at end (Fig.30.7). Enoxaparin anticoagulation was initiated and he was discharged after 1day.
His leg swelling resolved at follow-up. At 5years, he has no
leg swelling and no venous claudication.
106
30 AngioVac Thrombectomy of Two-Month-Old Iliocaval Thrombosis in a 15-Year-Old Resulting from Gunshot Wound and…
107
Fig. 30.3 Initial transfemoral venogram demonstrates partial patency
of the right iliac vein (black arrow), complete caval thrombosis and
extensive paravertebral collaterals, and reconstitution of the patent
upper IVC (yellow arrow)
FIg. 30.4 Contrast injection during attempts to traverse the surgical
occlusion lls an abdominal lymphatic trunk in continuity with the thoracic duct
108
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Z. J Haskal
Fig. 30.6 Inferior vena cava gram after partial thrombectomy and
Fig. 30.5 Through and through jugular to right femoral wire access
has been established. A left transfemoral 16 mm balloon has been
14mm midcaval angioplasty. The AngioVac catheter is faintly seen at
the top
inated centered at the level of the surgical clips (prior occlusion). The
inated AngioVac cannula is seen at the top. A small caliber left femoral arterial sheath is also present
30 AngioVac Thrombectomy of Two-Month-Old Iliocaval Thrombosis in a 15-Year-Old Resulting from Gunshot Wound and…
109
Fig. 30.7 IVC venogram demonstrates restoration of caval patency.
Some caudal partial thrombus remains
Single-Session Total IVC andIliofemoral
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Endovascular Construction forCaval
Agenesis
MinaS.Makary
31
A 30-year-old male with congenital IVC atresia and chronic
bilateral iliofemoropopliteal thrombotic occlusions presented with progressive worsening of debilitating lower
extremity edema. Abdomen and pelvis CT redemonstrated
absence of the IVC and new subacute-on- chronic bilateral
iliofemoral thromboses and numerous retroperitoneal and
body wall venous collaterals. Duplex ultrasound evaluation
demonstrated similar ndings in both femoral and popliteal
veins.
Bilateral popliteal and right internal jugular vein
approaches conrmed prior ndings, including a small
suprahepatic IVC remnant (Fig.31.1). Blunt recanalization
of both popliteal, femoral, and iliac veins was performed
using directional catheters and guidewires. IVC construction
was performed using antero- and retro-grade blunt and sharp
techniques, including the Rösch-Uchida transjugular liver
access targeting an inated balloon with uoroscopic and
cone-beam CT triangulation (Fig.31.2). IVUS was used to
conrm passage of guidewire through bilateral lower extremities and the neo-IVC.The 24F Inari FlowTriever was used
to aspirate clot, followed by venoplasty. Twenty mm diameter Abre (Medtronic) venous stents were deployed within
neo-cava and kissing 16mm stents for the iliac and central
femoral veins followed by balloon dilation (Figs.31.3 and
31.4). Dual antiplatelet and anticoagulant was initiated. He
had near-complete resolution of lower extremity symptoms
at 2-week follow-up. At 6 months, he was functional and
able to return to work, having been previously disabled.
a
M. S. Makary (*)
Division of Vascular and Interventional Radiology, Department of
Radiology, The Ohio State University Wexner Medical Center,
Columbus, OH, USA
e-mail: mina.makary@osumc.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
Z. J. Haskal (ed.), Extreme IR, https://doi.org/10.1007/978-3-031-24251-9_31
Fig. 31.1 Conventional diagnostic venography demonstrated (a)
occlusion of the bilateral iliofemoral veins and development of venous
collaterals, (b) absence of IVC with drainage through the para-lumbar
venous plexus, and (c) presence of a small suprahepatic venous remnant
which was used in subsequent venous construction
110
31 Single-Session Total IVC andIliofemoral Endovascular Construction forCaval Agenesis
111
Fig. 31.1 (continued)
b
c
112
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M. S. Makary
a
b
Fig. 31.2 Caval construction with sharp techniques utilizing a RöschUchida transjugular liver access needle in a suprahepatic venous remnant targeting an inated balloon placed in the lower retroperitoneum
via the popliteal access, with (a) uoroscopic and (b) cone-beam CT
triangulation
Fig. 31.3 Caval construction with overlapping 20mm venous stents,
followed by kissing 16mm stents for the iliac and central femoral veins
with corresponding venoplasty
31 Single-Session Total IVC andIliofemoral Endovascular Construction forCaval Agenesis
113
a
b
Fig. 31.4 Completion venography demonstrating a patent (a) neo-IVC and (b) iliofemoral veins, with contrast ow to the right atrium
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