This document discusses chronic venous occlusions, including tools and techniques for treatment. It provides an overview of central venous occlusions in the upper and lower extremities. General rules for treatment include that more than one access may be required, procedures can be unpredictable and frustrating, and familiarity with venous anatomy is important. Stenting is often needed for chronic occlusions, though stent selection depends on the location of the occlusion. The document reviews literature on outcomes of stenting for venous occlusions. It concludes that reestablishing flow is needed for symptomatic chronic venous occlusions and an endovascular approach is generally first-line therapy.

1. 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

2. 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

3. 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)

4. 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 widely
accepted

5. 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

6. 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

7. 76-Y-O female76-Y-O female
With RUE edemaWith RUE edema
Hx sig for multipleHx sig for multiple
RSV & IJRSV & IJ
Catheteriztions & RUECatheteriztions & RUE
AVGAVG

11. Pitfalls
♦ Main channel not always clearly evident
♦ Collaterals: may be mistaken for main
channels!!
♦ Rupture also possible if main channel is
over-dilated

12. 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

18. 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??)

19. 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

21. Stenting of Points of Venous Confluence
Double Barrel CavaDouble Barrel Cava MBZ-configurationMBZ-configuration T- configurationT- configuration
Fenestrated configurationFenestrated configuration

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

24. 20-year-old female with history of treated
lymphoma and multiple central venous
catheters presents with chronic UE and
cervico-facial edema

29. ♦ 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

34. 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/A
Lanciego 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

35. Author Year No.
Patients
Primary
Patency
Secondar
y 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

36. 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

37. 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

38. ♦ 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

39. 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