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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3722_Библиотеки_им_академика_М_И_Перельмана
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Occlusion rate
at 1-year (or
greater)
93–97% [28,
• Cutaneous (soreness,
29]
bruising, tenderness, and
induration)
• Supercial phlebitis
• Thermal: nerve injury and
94% [30]
skin burns (rare)
• DVT (rare)
• Cutaneous (soreness,
bruising, tenderness, and
induration)
• Supercial phlebitis
• Thermal: nerve injury and
skin burns (rare)
• DVT (rare)
S. S. Ahmed et al.
Cost
data
• Robust long-term
SFJ beyond the supercial epigastric
vein
80–100J/cm of energy deposition
• Pull back at a rate for a goal of
• Thigh-high compression stockings
data
• Robust long-term
SFJ
(30–40mmHg) are typically used
• Position catheter tip 2cm from the
• Pullback 7cm for the rst cycle
remainder of the vein
pullback for a “double cycle”
• Advance catheter and repeat 7cm
• Pullback 6.5cm/cycle for the
(30–40mmHg) are typically used
• Thigh-high compression stockings
thrombosis
[25,
26] Mechanism Technique (for GSV) [27] Advantages Complications [20, 22–24]
$$ Heat-induced
Technique
Thermal
Table 7.4 Comparison of thermal axial ablation therapy, non-thermal axial ablation therapy, and ultrasound-guided foam sclerotherapy in treatment of the GSV
Laser $$ Heat transfer • Position catheter tip 2cm from the
Radiofrequency
(ClosureFAST)
7 Venous Interventions
Occlusion rate
at 1-year (or
greater)
97% [31]
259
94% [32]
73% [33]
72% [34]
ecchymosis)
• Cutaneous (pain and
• Supercial phlebitis
• Allergic reaction
compression not
required
• Post-procedure
from the SFJ
• Position catheter tip 5cm peripheral
anesthesia
• No tumescent
US probe
dose
dose
rst dose
• Manually compress centrally with
• Push trigger for 3s to deliver rst
• Pull back 1cm and apply a second
• Compress treated vein for 3min after
dose and compress for 30s
• Subsequently pull back every 3cm/
ecchymosis)
• Cutaneous (induration and
• Supercial phlebitis
anesthesia
• No tumescent
• Dual modality
to the SFJ
• Position catheter tip 1cm peripheral
simultaneously injecting sclerosant
and pulling back at a rate of
for 2–10s to induce venospasm
• Activate wire rotation at ~3500rpm
• Engage motor trigger while
1.5mm/s every 3s
• Pain
• Supercial phlebitis
anesthesia
• No tumescent
for 2weeks
• Thigh-high compression stockings
• Detach canisters and attach syringe
• DVT
determined
concentration
• Fixed pre-
to transfer unit at the top of the
perforators
• Fills incompetent
polidocanol canister and waste 3mL
maximum of 15mL
• Elevate leg 45°
• Inject in aliquots of 5mL for
microfoam reaches SFJ
• Apply pressure at GSV once
• Hyperpigmentation
• No tumescent
for 2weeks
• Thigh-high compression stockings
• Ulceration
• Matting
anesthesia
• Inexpensive
in a preferred ratio
2
room air or CO
dependent on vessel size
to under 10mL per session
• Inject in aliquots of 3–5mL limiting
Cost
[25,
26] Mechanism Technique (for GSV) [27] Advantages Complications [20, 22–24]
Technique
blood
$$$ Polymerization with
Non-thermal
Cyanoacrylate glue
(VenaSeal)
wire and chemical
detergent
$$$ Mechanical rotating
Mechanochemical
(ClariVein)
$$$ Detergent • Attach canisters to generate foam
Polidocanol
(Varithena)
$ Detergent • Mix 1–1.5% STS or 2–3% POL with
Ultrasound-guided
foam sclerotherapy
Cost: $=<$500, $$=500–1000, $$$>1000in U.S. dollars.
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Fig. 7.4 Ultrasound images demonstrate a dilated perforator vein in the thigh (Arrow) and reux for greater than 0.5s
S. S. Ahmed et al.
UGFS.It is important that patients be aware
prior to treatment.
• Extravasation of sclerosant is the most feared
complication of UGFS and can result in
ulceration secondary to tissue necrosis.
Treatment consists of local wound care.
Peri-Ulcer Varices Management
It is not uncommon to nd that there are patients
with VLU and venous insufciency by
examination, however, noninvasive studies are
inconclusive or disgruent. In these patients, it is
prudent to perform a more detailed direct
ultrasound evaluation of the wound area, which
may demonstrate varices around and coursing
from the ulcer. In these situations, percutaneous
foam sclerotherapy of these varices under
ultrasound (can be combined with uoroscopy to
ensure no deep vein reux) guidance. In doing
this, it is possible to accelerate VLU healing.
Case Example
Courtesy of Sreekumar Madassery, MD
A 72-year-old female with long-term wound
care management of bilateral painful VLUs, despite
compressive therapy, arterial evaluation, wound
care including skin substitutes and other conservative approaches. After percutaneous sclerotherapy
of peri-ulcer varices, there was rapid VLU healing
with eventual wound closure (Fig.7.5).
Conclusion
A thorough understanding of the pathophysiology of supercial venous disease that results in
venous hypertension and VLU is essential.
Prompt evaluation, diagnosis, and endovenous
intervention can improve the time to ulcer
healing and prevent signicant morbidity. The
optimal treatment should be directed at the
intended source of venous hypertension, which
can be mixed between supercial venous reux
and deep vein obstruction. While early endovenous intervention is benecial in shortening
healing time, it is important to remember that
recurrent ulceration is common and continued
follow-up of patients with prior VLU is
important.
Finally, it should be noted that superficial
venous closure has grown in abundance over
the years, often for cosmetic reasons, as well
as for symptomatic grounds. This is a vital
conduit for other vascular beds in patients
such as those with CAD and PAD, thus it
should be considered with some caution in all
comers. For patients with VLU, many operators will choose to intervene on patients that
have significant varicosities in the venous distribution of the wound and those that demonstrate peri-wound varices, as these anecdotally
can have a greater healing result, compared to
patients with less obvious reflux- related
sequelae.
and insignificant areas of GSV and SSV reflux.
below the knee.
7 Venous Interventions
261
Long standing (>1 year) LLE distal leg and ankle venous
non healing ulcers despite wound care, compression
therapy, skin substitutes, and attempts at increased ambulation.
Noninvasive venous studies showed relatively small caliber
Fig. 7.5 Case example of nonhealing VLU that improved after endovenous intervention
7.3 Deep Venous Disease
Direct percutaneous
sclerotherapy of abnormal
peri-ulcer varices, with
tourniquet applied just
sections, it is estimated that billions of dollars are
2 months after embolization and continued wound care, rapid VLU healing was
noted, with eventual wound closure as well as pain relief.
spent each year on venous leg ulcers worldwide
BrianP.Holly and MarkLessne
with direct medical costs per patient averaging
over $5000 (USD) per year [20]. Therefore,
preventing ulcer formation is the main goal of
treatment. This section will review indications
7.3.1 Introduction
for deep venous disease treatment, including
stent placement and techniques to maximize
Deep venous disease can be categorized as acute,
patient safety and efcacy.
subacute, or chronic with symptoms resulting
from deep venous reux or obstruction. The
exact categorization of the chronicity may be
difcult, however, many consider >4weeks into
the chronic phase. Acute venous disease rarely
leads to limb loss outside of phlegmasia cerulea
dolens, which is an extensive, occlusive venous
thrombosis leading to venous gangrene in
40–60% of patients [18, 19]. Even chronic deep
venous disease resulting from venous stenosis/
occlusion or from compression syndromes rarely
results in limb loss. Causes of obstruction or
compression may include occlusion from
thrombosis, compression from a mass, postthrombotic syndrome, or non-thrombotic causes.
However, venous leg ulcers account for 70% of
all chronic leg ulcers and are associated with high
recurrence rates. As discussed in previous
7.3.1.1 When toTreat Deep Veins
The presence of deep venous disease is not, by
itself, an indication for treatment as many patients
with deep venous reux, venous stenosis, or
compression may be entirely asymptomatic
depending on the anatomic distribution,
compensatory collateralization, and patient
condition. For example, seemingly signicant
(>50%) left common iliac vein compression can
be found not uncommonly in healthy subjects or
those without lower extremity symptoms [21–
23]. Therefore, conrmation of clinically
signicant and correlative signs and symptoms of
deep venous disease is mandatory prior to
intervention. The previously mentioned
classication systems are available to assist with
this assessment.
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S. S. Ahmed et al.
In patients with deep vein obstruction, postthrombotic syndrome (PTS) develops in 20–50%
of patients and presents as lower extremity swelling, abdominal fullness or bloating (in the setting
of IVC occlusion), lower extremity heaviness,
fatigue, and/or paresthesias.
• Venous stasis changes are also seen including
lipodermatosclerosis, skin bronzing, dilated
varicose, spider, or reticular veins, and in
severe cases, ulcerations [24].
Many signs and symptoms of supercial
venous disease may overlap with those of deep
venous disease. It is an important principle that
when patients’ symptoms can be ameliorated by
treating the supercial venous reux alone, this
should be pursued rst and exclusively.
• Treatment of deep venous disease, almost
always requires implantation of a permanent
stent in the iliac veins and should be reserved
for those patients in whom symptoms are pre-
dominately related to deep venous obstruction.
• Additionally, while conservative management
is often the rst-line therapy for mild venous
disease—including weight loss, exercise,
lower extremity compression, and leg
elevation—for patients with venous ulcers
related to deep vein disease, a trial of
conservative management is not always
required and more aggressive interventional
therapies early on may be warranted.
• Early endovenous treatment has been shown
benecial for supercial venous disease and
likely holds true for symptomatic deep venous
disease in the setting of severe symptoms, as
well [5]. Medical management can and should,
however, still be offered concurrently with inter-
vention for venous stasis ulcers: aside from
wound care and compression, pentoxifylline has
been found to be a more effective therapy for
venous wounds than compression alone [25].
• Primary patency for iliac vein stenting in non-
thrombotic disease is reported to be 90%—
100% and 74%–89% in post-thrombotic
disease [26].
• Additional indications for recanalization or
reconstruction include deep vein occlusion
secondary to recurrent DVT, post-thrombotic
syndrome, and thrombosis of the IVC, all
leading to lifestyle limitations.
• Surgical treatments are rarely utilized and
reserved for cases refractory to stenting.
7.3.1.2 Work-Up
A thorough history and physical are essential to
the diagnosis, and should evaluate for:
• Signs and Symptoms of venous obstruction.
• Prior vascular interventions (including venous
catheterizations as a neonate and child),
history of surgery, infections, and/or
radiotherapy that may have compromised the
deep venous system.
• Personal and family history of VTE and relevant details (anatomic location, recurrence,
provoking factors, genetic disorders).
Typically, some imaging is performed for
patients with clinical suspicion of deep venous
disease.
• Duplex ultrasound to evaluate the supercial
and deep venous system is almost always the
rst imaging test.
• Depending on the patient’s body habitus and
skill set of the sonographer, ultrasound can be
very useful to depict iliac vein compressions
and even IVC patency.
– Even when the pelvic veins cannot be
imaged, deep venous reux or loss of phasicity and augmentation in the common
femoral vein may be indirect signs of iliac
vein or caval obstruction and may warrant
cross-sectional or catheter-based venography and intravascular ultrasound for further evaluation.
• Lab work for systemic causes of lower extremity swelling should also be considered in the
appropriate clinical context.
• Etiologies with the suspicion of inferior vena
cava or iliac vein involvement are typically
diagnosed via CT or MRI.
7 Venous Interventions
263
Iliac Vein Compression
Acute or chronic deep vein thrombosis (DVT) of
the inferior vena cava (IVC) and iliac veins, otherwise known as iliocaval thrombosis, can lead to
lower extremity edema, pain, and other limbthreatening occlusive symptoms. Iliocaval thrombectomy, recanalization, and/or reconstruction
(i.e., angioplasty/stenting) are accepted treatment
options in management of this disease.
Non-thrombotic iliac vein lesions (NIVL)
may lead to May-Thürner disease commonly
caused by an obstructive anatomical variant that
can lead to occlusion of the left iliac vein due to
compression from the right iliac artery as it
crosses over the vein. Some other causes include
compression by a pelvic mass (tumor, broids,
etc.), pregnancy, or retroperitoneal brosis. Initial
diagnosis requires evaluation for DVT. Once
DVT has been ruled out, then further work-up for
May-Thurner syndrome (MTS) includes imaging
evidence to suggest compression.
Imaging Findings Suggestive ofIliac Vein
Compression
• Duplex ultrasound—sluggish venous outow,
venous reux, poor
• augmentation.
• CT/MR Venography—Generally very sensi-
tive and specic (>95%) for diagnosing iliac
vein compression [27].
• Catheter venography—Filling defects, com-
pression was seen in multiple projections,
transvenous (hemodynamic) pressure
measurements.
• Intravascular Ultrasound (IVUS)—Now con-
sidered by many to be the gold standard to
diagnose iliac vein compression with
improved sensitivity and specicity relative to
catheter venography alone [28]. IVUS can
accurately measure normal vessel diameter,
percent stenosis, identify exact location of ste-
nosis, and aid in planning stent placement.
Treatment (When toStent)
• Stent placement is an established treatment
for symptomatic NIVL with excellent long-
term patency. Stent placement should be
considered for symptomatic patients with
venographic and IVUS ndings demonstrating
a signicant ow-limiting stenosis.
• Thrombolysis can be used if necessary.
• Stent diameter should be sized according to
the diameter of the normal vessel adjacent to
the stenotic segment. The stent must cover the
stenosis entirely.
Figure 7.6 demonstrates left common iliac vein
compression by the overlying right common iliac
artery, ndings are consistent with non- thrombotic
MTS.Figure7.7 demonstrates restored ow of the
left common iliac vein via stent placement.
Case courtesy of Osman Ahmed, MD
Iliac Vein Occlusion
Iliac vein occlusion (ILVO) most often is the
result of an iliac vein thrombus that failed to
adequately recanalize. Patients presenting with
ILVO often have similar symptoms to those with
iliac vein compression, however, symptoms are
often worse. Post-thrombotic syndrome (PTS) in
these patients can be severe and debilitating.
Treatment (When toStent)
• Any patient with an ILVO, in whom the occlusion can be crossed with a wire, will require
stent placement.
• Stent should be sized according to the closest
segment of patent/healthy vein. The stent must
have good venous inow and extend into an
open outow vein.
Stent Placement Below theInguinal Ligament
In the case of ILVO, often the diseased segment
of vein extends below the inguinal ligament.
• It is mandatory to stent from healthy vein to
healthy vein, as this gives the stented portion
of the vein the best chance of maintaining
long-term patency, by creating good inow
and outow. This may also require extending
the stent below the inguinal ligament into the
femoral vein.
– Stenting below the inguinal ligament has
been considered controversial as some
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S. S. Ahmed et al.
c
Fig. 7.6 Pre-intervention contrast CT pelvis (a), intra-
vascular ultrasound (b), and venogram (c), all demonstrate compression of the iliac vein by the overlying right
Fig. 7.7 Post-stent
placement intravascular
ultrasound (a) and
uoroscopy X-ray (b)
demonstrate restored
ow of the left common
iliac vein. Coils can also
be noted in Fig.7.2b as
gonadal vein
embolization was
concurrently for pelvic
congestion
a b
common iliac artery. These ndings are compatible with
non-thrombotic May-Thurner syndrome
report decreased patency rates when
extending the stent below the inguinal
ligament. However, more recent reports
demonstrate similar patency rates and
rates of clinical improvement when
extending the stent below the inguinal
ligament if required to cover all diseased
segments [29].
Tips andTricks
Note: It is expected that the interventionalist
caring for the patient with deep vein disease
possesses basic and fundamental skills in endovascular techniques including catheter and wire
crossing, stent deployment, radiation safety, as
well as mitigation of and therapy for complications. A list of “tips and tricks” cannot replace
7 Venous Interventions
265
formal and proper training through an accredited interventional/endovascular program.
IVC andIliofemoral Occlusions
Since all deep venous disease must start and end
with a healthy vessel to establish normal inow
and normal outow, the segments of diseased
veins must be carefully delineated prior to intervention in order to guide appropriate access.
• Avoid accessing a vein that will limit the ability to treat the entire segment of diseased vein.
Common femoral vein access may be appropriate for isolated iliac vein or IVC obstruction but may hinder treatment of disease
extending to distal external iliac and common
femoral vein.
– In this case, a mid-femoral vein, popliteal
vein, or greater saphenous vein access may
be preferred.
• As discussed above, it is mandatory for stents
to bridge from normal vessel to normal vessel.
Iliofemoral stents may be placed down to but
ideally never beyond the lesser trochanter.
– It is critical to maximize inow into the
stent by ensuring adequate ow is present
from the deep femoral and/or femoral
veins.
Equipment
• Micropuncture or single wall needle for
access.
• Guidewires:
– Crossing Wires: 0.035 and 0.018 stiff
hydrophilic wires and weighted wires (30g
tip load).
– Working wires: Super stiff Amplatz wire.
• Sheath: ≥8 or 9 Fr sheath (to allow for IVUS
catheter and venous stents, respectively), 7 Fr
MPA guide catheter for extra support;
Alternatively, prefabricated support systems
such as Triforce (Cook, Bloomington IN).
• Catheters: Angled diagnostic or support
catheters.
• Balloons: Noncompliant, high-pressure
balloons.
• Stents: Dedicated venous stents; Wallstents or
Z-stents (less commonly); covered stents
available for bailout in case of complications.
• Intravascular Ultrasound: 0.035 compatible
IVUS catheters.
• Niche devices: Trans-septal needle, Chiba
needle, RF Power Wire, snares.
Venous Recanalization Procedure Steps
1. Access site selection: Internal/external jugu-
lar, brachial/basilic, common femoral, femoral, popliteal, and posterior tibial veins are all
viable access options.
2. Robust support, such as triaxial system with
sheath, guide catheter, and crossing catheter
is mandatory. The system should be placed
close to the occlusion (“take the ght to the
sight”). Attempt crossing using glidewire and
support catheter. Rotate the wire while applying minimal forward pressure in an
Archimedes screw type fashion clockwise
and then counterclockwise—do not let wire
prolapse into a J shape.
Tip: For chronic total occlusions, keep
catheter closely behind tip of wire and cross
incrementally, advancing catheter to wire tip,
millimeter by millimeter if necessary.
3. Once successfully crossed, repeat venogram
to conrm expected, intraluminal position.
Tip: Can further conrm with lateral view
and cone beam CT (ideal), as there can be
inadvertent spinal canal crossing if not
cautious.
4. Place stiff working wire, such as Amplatz
wire.
5. Intravascular ultrasound (IVUS) has been
shown to be more sensitive in detecting
stenotic lesions compared to venography and
is critical to aid with proper vessel sizing,
conrmation of stent expansion, and
evaluation of residual disease.
(a) IVUS is used complimentary with venog-
raphy, which demonstrates hemodynamic
obstruction, such as lling of venous collaterals or poor contrast washout.
266
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S. S. Ahmed et al.
Tip: With IVUS in a suspected compressive lesion, leave the IVUS catheter at
the site over multiple respiratory cycles to
conrm the lesion is xed and not a
“pseudo stenosis,” that should not be
treated (Fig.7.8). Patient leg positioning
can also x pseudo stenotic lesions.
6. Angioplasty and/or stent according to clinical
scenario (see tips above).
Tip: While IVUS and venography are
essential tools for optimal stent positioning, bony landmarks can also be used,
including the right vertebral pedicle and
spinous process for left iliac vein stent
placement [30].
Stenting theILIAC Venous Conuence
There are four main techniques employed when
stent reconstruction of the bilateral iliac veins
and iliac venous conuence is required (Fig.7.9):
1. Double barrel: Self-expanding stents are
placed extending from the IVC into the iliac
veins in parallel fashion.
2. Fenestrated Inverted Y: A single stent is
placed extending from the IVC to one of the
iliac veins, jailing the contralateral iliac vein.
The interstices of that stent are then crossed
from the contralateral side and dilated,
allowing for placement of another stent
through the dilated interstice and into the
contralateral iliac vein.
3. T-stent: A single stent is placed extending
from the IVC to one of the iliac veins, jailing
the contralateral iliac vein. A second stent is
placed in the contralateral iliac vein up to
and abutting the rst stent, but not crossing
into it.
4. Coaxial IVC-double barrel: A single, large
stent is placed in the IVC, followed by parallel
stents placed into the IVC stent and extending
into the iliac veins.
In general, fenestrated inverted Y and T-stent
techniques are strongly discouraged and there is
data to support that these techniques lead to
worse patency [31]. The fenestrated inverted Y
technique, however, is the only option when
presented with a patient who requires iliac vein
stent placement on a side jailed by a previously
placed iliocaval venous stent (Fig.7.10).
Complications
1. Failure: The most common “complication” of
recanalization procedures is the inability to
cross the lesion. If this occurs, consider
alternative access, obliquities, techniques, or
imaging to delineate the geometry of the
Fig. 7.8 (a) Initial IVUS image demonstrates venous stenosis. (b) Later in the respiratory cycle the stenosis is shown
to be a normal, well-expanded vein, not a xed lesion (“pseudo stenosis”)
7 Venous Interventions
267
Fig. 7.9 Techniques of
Iliac Conuence Stent
Placement: (a) Double
Barrel—two stents have
been placed parallel
from the iliac veins to
the IVC (b) T stentRight iliac vein stent
abuts a left iliocaval
venous stent (this is
strongly discouraged)
(c) Coaxial—a large
IVC stent is placed, and
(d) two double barrel
stents have been placed
coaxial from the iliac
veins into the IVC stent
ab
cd
occlusion better. Alternatively, consider referral to a center with more expertise and
experience.
2. Vessel perforation: Contrast extravasation
outside the vein wall is usually asymptomatic
if resulting from a wire perforation. It is the
failure to recognize an extraluminal wire and
subsequent balloon dilation that can have
catastrophic consequences. Always conrm
the wire position before proceeding with
intervention. If extravasation persists, balloon
tamponade, and reversal of anticoagulation
usually seal the leak; however, covered stents
should be readily available during all vascular
procedures.
Tip: Bleeds from the IVC are usually well-
tamponaded in the retroperitoneum. Extra
care and caution should be taken in patients
who have had prior surgical violation of their
retroperitoneum in whom this protective
effect may be lost. Likewise, patients with a
history of radiation to the abdomen or pelvis
may be at higher risk for vessel perforation or
rupture.
3. Intraprocedural thrombosis: Adequate inow
and outow across a vein is essential to
maintain patency. Intraprocedural thrombosis may be a result of poor inow, outow, or
inadequate anticoagulation. This can initially
be treated with additional anticoagulation
and pharmacomechanical thrombectomy.
However, an exhaustive search for the etiology of the thrombosis is warranted with
venography and IVUS.
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