Venous stenting

Oliver Schlager

Division of Angiology

Medical University of Vienna

Disclosure

Speaker name:

Oliver Schlager

I have the following potential conflicts of interest to report:

Consulting

Employment in industry

Stockholder of a healthcare company

Owner of a healthcare company

Other(s)

I do not have any potential conflict of interestX

Indications for venous stenting

Venous obstructions

Residual stenosis after thrombolysis

Postthrombotic syndrome

Venous atresia

May-Thurner Syndrome (Cockett’s Syndrome)

Other compression (tumor, cysts, fibrosis,…)

Meissner MH et al. J Vasc Surg 2007;46:4S-24S

Kahn SR et al. Circulation 2014;130(18):1636-61

Edema

Pain

Pruritus

Hyperpigmentation

Lipodermatosclerosis

Venous ulcer

Heaviness and/or tension

Venous claudication

Quality of life ↓

Productivity ↓

Chronic venous obstructions

Classification of venous disease

ScaleClinical signs

included?Patient symptoms

included?

Specific forPostthrombotic

Syndrome

CEAP + - -

VCSS* + + -

Widmer + - -

Brandjes + + +

Ginsberg + + +

Villalta + + +

*Venous Clinical Severity Score

Strijkers RHW et al. Phlebology 2012;27Suppl1:130-5

Clinical Etiologic Anatomic Patho-

physiologicC0: no sign of venous

disease

C1: teleangiectasies,

reticular veins

C2: varicose veins

C3: edema

C4a: pigmentation,

eczema

C4b: lipodermatosclerosis,

atrophie blanche

C5: healed ulcer

C6: active ulcer

Ec: congenital

Ep: primary

Es: secondary

s: superficial veins

p: perforator veins

d: deep veins

Pr: reflux

Po: obstruction

Pr, o: reflux +

obstruction

pn: not identifiable

Porter JM et al. J Vasc Surg 1995;21(4):635-45

Guidelines

SVS/AVF guidelines:

In a patient with inferior vena cava or iliac vein chronic total occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we recommend venous angioplasty and stent recanalization in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. [Grade – 1; Level of evidence - C]

In a patient with inferior vena cava or iliac vein chronic total occlusion or severe stenosis, with or without lower extremity deep venous reflux disease, that is associated with skin changes at risk for venous leg ulcer (C4b), healed venous leg ulcer (C5), or active venous leg ulcer (C6), we recommend venous angioplasty and stent recanalization in addition to standard compression therapy to aid in venous ulcer healing and to prevent recurrence. [Grade – 1; Level of evidence - C]

O‘Donnel TF et al. J Vasc Surg 2014;60(2 Suppl):3S-59S

ESVS recommendations:

Wittens C et al. Eur J Vasc Endovasc Surg 2015;49(6):678-737

In patients with clinically relevant chronic ilio-caval or ilio-femoral obstruction or in patients with symptomatic non-thrombotic iliac vein lesions, percutaneous transluminal angioplasty and stent placement using large self expanding stents should be considered. [Grade – IIa; Level of evidence B]

In patients with clinically relevant chronic ilio-caval or ilio-femoral obstruction or in patients with symptomatic non-thrombotic iliac vein lesions, percutaneous transluminal angioplasty and stent placement using large self expanding stents should be considered. [Grade – IIa; Level of evidence B]

O‘D

on

nel

TF e

t al

. J V

asc

Surg

20

14

;60

(2 S

up

pl)

:3S-

59

S

Artery Vein

Endothelialized strands – synechiae – endoluminal fibrosis

Pathophysiology

Mackman N. Nature 2008;451(7181):914-8

Maleti O. Phlebolymphology 2014;21(3):131-7

Vessel

Stent

Chronic outward force

Radial resistive force

Crush resistance

Stent requirements

www.venous-stent.com®Optimed

Dedicated venous stents

Bard

Boston Scientific

Cook

Medtronic

Optimed

Veniti

InterventionOptimal puncture site (popliteal, jugular, femoral)

Sedoanalgesia vs. general anesthesia

High-end ultrasound system + IVUS

Urinary catheter

6F + 10F introducer sheath

Choice of wires (Terumo 0.035‘‘ stiff, angled, Astato Asahi 0.018‘‘,...)

Choice of nc high-pressure balloons (Atlas Gold,...)

InterventionFemale patient, 51 y, iliofemoral DVT 2001, postthrombotic syndrome

After the intervention

Continuous i.v. UFH until next day

Starting the next day: Vit K antagonist or NOAC (+/- clopidogrel)

Compression stockings

Clinical and sonographic follow up

Conclusion

Choose the right indication (PTS, DVT, MTS, other compression)

“Treat the patient”, not the morphology

Use dedicated venous stents

Periprocedural management

Thank you for your attention

oliver.schlager@meduniwien.ac.at

Venous stenting

Oliver Schlager

Division of Angiology

Medical University of Vienna