SIR Today 2021| March 26, 2021
Three IRs duked it out during Thursday’s “Battle of the Veins” session, moderated by Sabina Amin, MD, and Sarah B. White, MD, MS, FSIR. Parag Patel, MD, MS, FSIR, filled in for Dr. White.
Lawrence "Rusty" Hofmann, MD, FSIR, Kush R. Desai, MD, FSIR, and Elizabeth B. Spencer, MD, FSIR, presented on two different topics: Stenting a nonthrombotic May-Thurner and recanalization of chronic fem-pop occlusions.
How I do it: Stenting a nonthrombotic May-Thurner
Up first was Dr. Hofmann, who said that he leverages 20 years of Stanford-created data to guide his approach. He brought a case example of a 48-year-old woman with a history of cervical cancer who had had a hysterectomy and radiation. Following these treatments, she developed a severe left lower extremity (LLE) edema.
Dr. Hofmann outlined his approach and offered attendees several tips to consider when stenting. “You never need to go bigger than 16 mm ever when sizing a stent,” he said, or else it could lead to severe back pain. Dr. Hofmann prescribes postprocedure anticoagulant for 2 weeks. “With this routine we’ve witnessed zero occlusions and zero in-stent restenosis,” he said.
Dr. Desai presented next with a case involving a 61-year-old with pelvic pain for 1 year that had worsened with prolonged standing; the patient had pain in her LLE but no history of DVT. “I like to stage treatment when there are two potential sources of pelvic pain,” Dr. Desai said—though since the patient had both pelvic pain and a mixed compensation iliac obstruction, he opted to treat both in the same procedure. According to Dr. Desai, his approach to nonthrombotic iliac vein lesion is based on the findings of the VIDIO Trial. He also echoed Dr. Hofmann’s warning about stent sizing. “Do not size to the pre-stenotic dilation of the common iliac vein—size it to the normal external iliac vein,” he said.
Following the procedure, he did not prescribe anticoagulants, and the patient reported that her venous claudication symptoms resolved, and her pelvic symptoms were 90% improved.
In the final presentation, Dr. Spencer began by discussing how she determines patient candidacy. She looks for patients with symptoms such as pelvic pain, recurrent lower extremity pain or wounds. Dr. Spencer presented the case of a 26-year-old with severe pelvic pain syndrome who had a hysterectomy suggested to her but had chosen not to pursue one. She later developed a right gonadal vein thrombus and May-Thurner, and since her physician was nervous about stenting the May-Thurner, they treated her gonadal thrombus and also completed the hysterectomy. When Dr. Spencer met the patient, she had more pain and her pain had not been relieved.
Dr. Spencer outlined her procedure steps—she chose the jugular approach, then decided to switch to a saphenous approach, and mapped out her plan. “It’s hard for your eyes to adjust to landmarks and bony things and not fake yourself out,” she said, which is why she draws outlines on her screen and places a mark to help measure their stent length. Following the procedure, she put the patient on blood thinners for 3–4 weeks and followed up within 6 months.
How I do it: Recanalization of Chronic Fem-pop Occlusions
Dr. Spencer kicked off the second round by reviewing her standard approach to recanalizing chronic femoral and popliteal occlusions. “It’s a subject near and dear to my heart, as many people suffering from this are truly suffering,” she said. According to Dr. Spencer, the key to these recanalization procedures is to restore inflow to the femoral and popliteal venous system. You cannot enter a scarred/occluded vein and recanalize with no inflow, she said.
“Medical management is equally as important as the technical success,” Dr. Spencer said, spending ample time detailing the drug regimen that she recommends before procedure.
She also warned attendees that the procedure is difficult, especially when crossing obstructions. “It should feel challenging. If it’s easy, you’re probably in a collateral.” It requires a high level of skill, Dr. Spencer said, and these recanalizations will often fail without vigilant medical management and surveillance.
In his case, Dr. Hofmann presented a 62-year-old male with left leg swelling who had occlusive DVT in his femoral and popliteal veins. While Dr. Hofmann chose posterior tibial access, he advised that it’s a difficult approach because the patient can spasm easily. When using this approach, he uses a tourniquet and a pediatric micropuncture kit. He also advised attendees to inform their nurses that an ACT machine would be needed. In terms of tool selection, he has his own favorites, but said, “whatever works well in your hands is the right tool to use.” Following the procedure, he recommended a high-dose anticoagulant.
Dr. Desai presented a 28-year-old female with a history of LLE DVT who had progressive pain and swelling. On investigation, his team found that she had periumbilical varicosities, corona phlebectatica present around the left foot, and mild hyperpigmentation around the malleolus. In addition, a previously placed stent in the femoral vein was compressed, occluded and calcified. Dr. Desai chose to do two procedures—one to address pain, and one to handle the calcium build up on the femoral stent.
According to Dr. Desai, treating the iliac often results in better patency. “Iliac occlusion accounts for the most severe PTS symptoms,” he said. “We don’t get very durable results with the femoral.”
In the final presentation, Mahmood K. Razavi, MD, FSIR, sidestepped the vein battle to present on primary reasons why venous interventions fail. “What does failure mean?” he asked. “Is it judged by patency or clinical improvement?” Dr. Razavi said that there are many reasons for failure of patency, like disease etiology or extent, and clinical improvement can fail due to poor patient selection or technical failure. What both categories have in common, Dr. Razavi said, is that there is a presence of vessel wall inflammation. However, one aspect that isn’t widely discussed is the issue of inflow/outflow. Dr. Razavi presented two case studies where the procedure was unsuccessful because of inflow and outflow issues and introduced the concept of through flow. “It’s not widely acknowledged,” Dr. Razavi said, but can play a key role in why a patient’s symptoms aren’t resolved.
Registrants can view the Battle of the Veins and pick their own winner on demand via the Digital Video Library.
Watch for this article to be published on the morning of Friday, March 26.