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Stenting of Ilio-femoral outflow - 3 years experience

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Stenosis or occlusion of inferior vena cava, iliac and femoral veins may result from compression or thrombosis. It significantly reduces quality of life of patients. Stenting of proximal venous outflow can relieve symptoms of chronic venous disease.

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Stenting of Ilio-femoral outflow - 3 years experience

  1. 1. 3 years experience with venous stenting Michał Molski MD PhD Stanisław Molski MD PhD DSc Prof. Vascular Surgery Department, Szpital ESKULAP Osielsko, Poland
  2. 2. Herewith, the speaker has disclosed that there is no relevant relationship with any commercial interests related to the content of the following presentation. Michal Molski 17.08.2019
  3. 3. Symptoms • Pain, heaviness, cramps, venous claudication • Varicose veins • Oedema • Discoloration • Lipodermatosclerosis Complications • Deep Venous Thrombosis • Ulceration Michal Molski 17.08.2019 Chronic Proximal Venous Outflow Obstruction (cPVOO)
  4. 4. Chronic Proximal Venous Outflow Obstruction (cPVOO) Post-thrombotic • Segmental / Multisegmental • Wall fibrosis and trabeculations Non-thrombotic Iliac Vein Lesion ( NIVL) • Subsegmental • Vein compression • May-Thurner, etc. Mixed lesions Michal Molski 17.08.2019
  5. 5. Diagnosis • Clinical examination • 15% shows abdominal / groin varicosieties • USG doppler • Stenosis / occlusion of veins • Lack / diminishment of respiratory flow phasicity • Groin / pubic / abdominal varicosities • Inversed flow in internal illiac vein • MR / CT • Flebography • Pletysmography Michal Molski 17.08.2019 Chronic Proximal Venous Outflow Obstruction (cPVOO)
  6. 6. Guidelines for cPVOO stenting – AVF 2009 Michal Molski 17.08.2019
  7. 7. Guidelines for cPVOO stenting – ESVS 2015 Michal Molski 17.08.2019
  8. 8. Material Since 2013 we have screened potential patients for cPVOO • Pubic / abdominal / groin varicosities • Venous ulceration unsusceptible for treatment • Unilateral symptoms of CVI with „normal USG” • cPVOO on USG / CT/ MR Michal Molski 17.08.2019
  9. 9. Material Between 2013 and 2019.06 • 54 patients were qualified for cPVOO stenting Between 2016.03 and 2019.06 • 36 patients were admitted for the cPVOO stenting • 18 patients remain in a queue • Limitations from polish health provider • Patient rejections / reschedules • 1 patient was qualified for endophlebectomy + stenting Michal Molski 17.08.2019
  10. 10. Michal Molski 17.08.2019 Procedure is performed on hybrid OR • In local anesthesia and analgosedation • USG guided venous acsess belof CFV confluence
  11. 11. Venous Access Venous acces site puncture under USG guidance • Superficial Femoral Vein – 28 cases ( 77% ) • Greater Saphenous Vein – 4 cases ( 11% ) • Popliteal Vein – 1 case ( 2,8% ) • Small Saphenous Vein – 1 case ( 2,8% ) • Common Femoral Vein – 1 case ( 2,8% ) • External Iliac Vein – 1 case ( 2,8% ) • Additional Internal Iugular Vein – 3 cases ( 8,4% ) Michal Molski 17.08.2019
  12. 12. Post procedure protocol • LMWH & Pneumatic compression overnight • USG next morning • Ambulation and hospital discharge next day • Compresion hosiery • LMWH @ therapeutic doses for 14 days • NOAC for at least 6 months • Follow up visit @ 14 days / 3 months / 6 months / 12 months • Discontinuation of anticoagulation if • No residual stenosis • No significant lesions in inflow segment • D-dimers in normal range Michal Molski 17.08.2019
  13. 13. Result of ascending phlebography PTS Total occlusion, 10, 28% PTS Stenosis, 16, 45% May-Thurner, 3, 8% No problem, 7, 19% Michal Molski 17.08.2019 36 patients
  14. 14. Phlebographical cPVOO Michal Molski 17.08.2019 Left, 21, 73% Right, 5, 17% Bilateral, 3, 10% 29 patients
  15. 15. Anatomical involvement 6 ( 20,6% ) 12 ( 41,2% ) 7 ( 24% ) 3 ( 10,2% ) 1 ( 3,4% ) Michal Molski 17.08.2019 2 / 29 ( 6,9% ) cases were disqualified from stenting due to inadequate inflow
  16. 16. Technical sucess Primum non nocere Technical sucess in 20 /27 cases ( 77,7% ) • 5 failures to cross the lesion • 3 cases involved IVC + bilateral illiac veins • 2 cases unilateral lesions • 2 failures to dilate EIV stenosis Michal Molski 17.08.2019
  17. 17. Complications Inhospital • No clinically significant hematomas • No periprocedural DVT • No Pulmonary Embolism • No A-V fistulas After discharge • 1 readmission @ day 3 post-op due to back pain • Resoluted after bed rest and NSAIDs • 1 anemia due to menorhagia on NOAC ( hgb 7g/dl ) @ 3 months post-op • 1 adverse reaction to rywaroxaban  dabigatran Michal Molski 17.08.2019
  18. 18. Patency 20 patients follow-up 2-39 months ( average 20 months ) Reooclusions • 2 thrombosis @ 2 weeks • 1 thrombosis @ 3 years Patency • at 2 weeks 18 / 20 ( 90,0% ) • at 3 months 14 / 16 ( 87,5% ) • at 1 year 10 / 11 ( 90,9% ) • at 2 years 8 / 9 ( 88,8% ) • at 3 years 6 / 7 ( 87,5% ) Michal Molski 17.08.2019
  19. 19. Results Michal Molski 17.08.2019 Improvement in Villalta score ( average ) • Before 10,8  After 3,88 Improvement in clinical symptoms • Oedema • Pain • Cramps • Venous claudication • Varicosities reduction • Ulceration healing
  20. 20. Conclusions Michal Molski 17.08.2019 cPVOO stenting • Significantly improves symptoms • in postthrombotic lesions • in nonthrombotic iliac vein lesion ( NIVL ) • Gives good longterm patency up to 3 years • Gives longterm symptom improvement up to 3 years • Complications are unfrequent • Sucess rate is high
  21. 21. Future Continuation of cPVOO stenting program • IVUS • Endophlebectomy
  22. 22. Thank you Form Daugava river in Riga

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