Mahmood Razavi, MD, FSIRMahmood Razavi, MD, FSIR

Director, Director,

Clinical Trials & ResearchClinical Trials & Research

St Joseph Heart & Vascular CenterSt Joseph Heart & Vascular Center

Chronic Venous Occlusion:Chronic Venous Occlusion:Tools & TechniquesTools & Techniques

Disclosures

Scientific Advisory Board• 480 Biomedical, Abbott Vascular, Bard, Boston

Scientific, Covidien, EmboMedix, Javlin, Mercator, Neuravi, Reflow Medical, Trivascular, Veneti, Walk Vascular

Consultant• Cordis

Grants• NIH, WL Gore

Central Venous Occlusions

Upper extremity > lower extremity Upper extremity

• Malignant obstruction (majority involve SVC)

• Benign etiologies: dialysis related, CVC, pacer wires, thoracic outlet synd

Lower extremity• Thrombotic/post thrombotic; venous

compression (May-Thurner)

Central Venous Occlusions

Anatomy: central to thoracic inlet (BCV & SVC) and SFJ (CFV, iliacs, IVC)

Not always symptomatic, sx drive tx Criteria for significant stenosis

• Presence of collateral circulation• Pressure gradient (2-3 mmHg)• Area stenoses > 50%

No support in the literature& not widelyaccepted

General Rules

More than one access may be required in many cases

Length of procedure unpredictable; may be frustrating or intimidating

Most common elements of success:• Planning, persistence, practice

Current devices not designed for venous occlusions

General Rules

Sharp recanalization may be needed in many cases

Must be familiar with expected course and curvatures of BCV and iliacs

Angioplasty alone rarely effective (non-dialysis patients)

BMS associated with poor patency in veins peripheral to BCV and SFjxn

76-Y-O female 76-Y-O female With RUE edemaWith RUE edema

Hx sig for multipleHx sig for multipleRSV & IJ RSV & IJ Catheteriztions & RUECatheteriztions & RUEAVGAVG

Pitfalls

Main channel not always clearly evident Collaterals: may be mistaken for main

channels!! Rupture also possible if main channel is

over-dilated

18-year-old female with chronic LLE PTS due to inadequately treated DVT 1 year earlier. DVT was due to a surgical misadventure during lap. appendectomy and injury to L CIV

Approach

Thrombolysis, anticoagulation, and angioplasty alone are largely ineffective with limited applicability in non-dialysis chronic occlusions

Stents needed in majority of CVO Stents used as last resort in outflow

circuit of dialysis pts (stent-grafts??)

Stents

Iliacs & CFV: 10-16 mm stents (NiTi stents with higher compression resistance & radial strengths preferred)

IVC: Wallstent (if > 16mm diameter needed) SVC: BE stents, nitinol stents (may need to

be anchored in BCV) BCV: nitinol stents, stent-grafts SCV: avoid stents, S/G preferred if needed

Stenting of Points of Venous Confluence

Double Barrel CavaDouble Barrel Cava MBZ-configurationMBZ-configuration T- configurationT- configuration

Fenestrated configurationFenestrated configuration

UE venogram showing bilateral BCV & SVC occlusions & extensive collateral veinsUE venogram showing bilateral BCV & SVC occlusions & extensive collateral veins

20-year-old female with history of treated lymphoma and multiple central venous catheters presents with chronic UE and cervico-facial edema

42-year-old female with high altitude exercise intolerance and prominent superficial veins on abdomen and pelvis

Hx sig for prolonged umbilical vein catheterization after birth

Author Year No. of Pts. Primary Patency

Secondary Patency

Nagata 2007 71 88% 95%Nicholson 1996 76 91% 91%Chatziioannou 2003 18 100% 100%

Courtheoux 2006 20 83% 94%Furui 1995 16 81% N/ALanciego 2009 149 86.6% 93.3%

Hennequin 1995 14 93% 93%Kee 1998 43 79% 93%Smayra 2001 16 74% 74%Tanigawa 1998 23 74% 88%

Thony 1999 24 88% 100%Miller 2000 23 83% 87%TOTALS 493 87% * 94% *

Sample literature on Stenting in Malignant SVCSSample literature on Stenting in Malignant SVCS

Author Year No. Patients

Primary Patency

Secondary Patency

Bornak 2003 9 67% 100%

Kee 1998 16 77% 85%

Qanadli 1999 12 93% 100%

Smayra 2001 14 29% 64%

Rizvi 2008 32 44% 96%

TOTAL 51 66% * 85% *

Stenting: Benign SVCSStenting: Benign SVCS

* Weighted Value* Weighted Value

Lower Extremity CVO

Acute technical success 80%-92% Primary patency of stents above SFJ

70%-80% at 1-yr (74% in NVR) Primary patency in non-thrombotic

conditions >80% in the literature

Outflow Stenting 6-yr primary/secondary patency

• Non-thrombotic dz 79% / 100%• Thrombotic dz 57% / 86%

Significant reduction in pain, swelling, ambulatory venous pressure

Sig improvement in healing of ulcer and QOL

Neglen P. JVS 2007;46:979

Iliac veins stented in 528 limbs with deep venous reflux

5-yr results: 2° patency 88% Healed active ulcer 54% Improved pain 78% Improved edema 55%

5-yr freedom from: Ulcer recurrence (C5) 88% Dermatitis 81%

Raju S JVS 2010;51:401-8

Conclusions

Symptomatic CVO require reestablishment of flow

Endovascular approach is the first line of therapy

Familiarity with the venous pathophysiology is a must before attempting to treat