The document discusses the advantages of intravascular ultrasound (IVUS) imaging over traditional venography for diagnosing venous diseases, emphasizing its higher sensitivity in identifying iliac vein lesions and guiding stent procedures. It highlights the effectiveness of IVUS in uncovering anomalies often missed by venography, such as residual thrombus and anatomical variations, while also noting the absence of radiation exposure. The author concludes that IVUS is superior for improving outcomes in venous interventions due to its detailed imaging capabilities.

1. Pitfalls of IVUS Imaging
SESHADRI RAJU MD.FACS
RANE CENTER
JACKSON. MS.

2. Disclosure
Stock in Veniti, Inc.
US Patent: IVUS use in venous disease
Venous stenting is currently off label

3. GOT TO HAVE IVUS FOR STENT PRACTICE
Diagnostic sensitivity of ≈85%
• Sensitivity of transfemoral venography is ≈50% to
identify iliac vein lesions (Negus et al; Raju et al).
• Sensitivity of standard ascending venography worse.
• Primary &Postthrombotic lesions are missed.
• Venography not sensitive enough to pick up anomalies
in stent inflow/outflow and in the stent stack itself. Ie.
to guide stent procedure.
• No radiation exposure
• Can stent with fluroscopy and IVUS alone in renal
patients and those with contrast allergy

4. With IVUS, stentable obstructions are found in
>90% of primary cases with advanced CVI

6. Non-thrombotic iliac vein lesion (NIVL)

7. Normal venogram but IVUS stenosis (PTS). Note
trabaculae and perivenous fibrosis on IVUS but
not seen on venogram. IVUS area 72 sq mm.

8. Same case after stenting. Area now 164 sq mm.
In adults CIV should measure ≥ 175 sq mm

9. Normal Lumen Size
• CIV: 16 mm Diameter; 200 sq mm Area
• EIV: 14 mm Diameter; 150 sq mm Area
• CFV: 12 mm Diameter; 125 sq mm Area
The basis of symptoms in CVD is elevation of
peripheral venous pressure.
Peripheral venous pressure begins to rise with as
little as 20% stenosis and becomes significant at
50% stenosis.

10. “Normal Venogram” with Residual
Thrombus on IVUS after PMT

11. Venographic Sensitivity for complete clot lysis
(PMT and CDT) n = 110 venograms
93/110 (85%) “Venographic Success” had residual
thrombus on IVUS
Sensitivity of Venography for Complete Lysis = 20%

12. CLASSIC ROKITANSKI STENOSIS
Due to perivenous fibrosis

14. CIV 7mm
11mm
MRV: Unlike venography measurements are possible
provided the radiologist gives measurements

15. Stent Compression
Venogram normal; IVUS shows compression

16. Missing Border
At hypogastric orifice

18. CONCLUSIONS
IVUS is “King” in the Endosuite
• With IVUS, you simply see more ‘stuff’ than is
ever possible with venography. This will make
a difference in improving outcome in cases at
the margin.
• Lack of radiation and contrast hazards allow
repeated use.
• IVUS is semi-quantitative, venography is not.
Makes a difference in diffuse lesions and focal
lesions that are borderline.

19. END

21. Postthrombotic focal stenosis
Note perivenous fibrosis and normal venogram

22. Balloon ‘Sizing’
Proximal and distal NIVL

25. IVUS IN PRIMARY STENOSIS WITH WEB

26. IVUS
Tips and Tricks
Seshadri Raju MD.FACS.
The Rane Center
Flowood, MS

28. Trabeculum
Cannot see in venograms

29. NIVL (MTS)

30. Malpositioning the stent behind the
iliac artery.

32. • This was a 10 mm stent
which thrombosed.