Mark J. Garcia MD, MS, FSIR

Chief Interventional Radiology

Medical Director Center for Comprehensive Venous Health

Medical Director, Center for Heart & Vascular Peripheral Labs

Christiana Care Health Services

Newark, DE

Speaker Honoraria:Bayer Medrad, BTG/EKOS, Cook, BSX

Steering Cmt:Bayer/Medrad-PEARL, BTG/EKOS-ACCESS PTS

Consultant:Merit Medical, BSX, Gore, Fusion Medical

Stock Ownership:ELGX, Fusion Medical, Tack It

Research: NIH-ATTRACT, BTG/EKOS-ACCESS PTS, Cook-VIVO, Medtronic-In Pact II, BSX-HTN IV

Modalities:

Doppler US

CTV

MRV

IVUS

Venography

Cost Analysis

Indications

Pros/Cons

Appropriateness/Guidelines

Technique Pearls

Cost Analysis: (Global)

DUS

LE IVC

CTV

Abd/pelvis

MRV

Abd/pelvis

IVUS Venogram

LE IVC

CMS 118

201

Total = 319

807 878 132 95

117

Total = 212

BC/BS 124

135

Total = 259

803 1032 316 95

192

Total = 287

Doppler US:

Indications – Diagnostic tool:

Peripheral > central eval (dec sensitivity peripherally)

r/o DVT

Insuff exam

f/u post intervention

eval peripheral vasc mass

Pros: cheap, quick, easy, no rads, flow physiology

Limitations: tech dependent, false +, early false –,

body habitus, central imaging

CTV:Indications – Diagnostic tool:

Central anatomy:

IVC – thrombosis, atresia, absence

Iliacs – compression, thrombosis

Renals – Nutcracker, PCS

f/u post intervention

Extravascular anatomy (esp compression, masses)

Non-diagnostic US

Pros: Big picture view, quick, easy

Limitations: Rads, contrast, $$, streak artifacts, +/- flow physiology

MRV:Indications – Diagnostic tool:

Central anatomy:

IVC – thrombosis, atresia, absence

Iliacs – compression, thrombosis

Renals – Nutcracker, PCS

f/u post intervention

Extravascular anatomy (compression, masses)

Non-diagnostic US

Pros: Big picture view, no-rads,

Limitations: contrast, $$, motion, metallic voids, technique challenges, time, +/- flow physiology

IVUS:

Indications – Diagnostic tool:

Central anatomy:

IVC – compression

Iliacs – compression ** May-Thurner

Renals – Nutcracker

Intra-op: compression, sizing, localizing, stent apposition

f/u post intervention – lumen size

Pros: Intra-luminal view, non-rads, easy, quick

Limitations: Invasive, additional $, flow physiology

Venography:Indications – Diagnostic tool: Venous Intervention:

identify clot burden,

compression, reflux,

flow physiology

IVC – Atresia, absence, fliter eval

Iliacs – M-T

Renals – Nutcracker, PCS

Pros: Anatomic & Luminal eval, flow physiology (wash-out info, collateral filling)

Limitations: Invasive, rads, $, technique challenges, contrast ARF

Venography:

Renal Issues/Allergies:

Prep – hydration

Limit contrast w/ IVUS, CO2

CO2

Venography:

Indications – If there is any consideration for

intervention…..MUST do.

As a diagnostic tool,

it should be second in line, after non-invasive

diagnotic tool(s) have been utilized.

To maximize flow physiology:

Image thru “wash-out” phase

From leading edge to trailing end of contrast

For “compression” evaluation:

Obtain minimum 2 views

21 yo F with 6 mos onset of swollen Lt leg

No trauma, travel, hx of DVT

DUS – No DVT – abn CFV waveform

CTV – M-T compression

38 yo M with hx of Rt leg DVT since 1999 with

significant, asymmetric swelling (10 cm thigh

differential), mild venous ectasia

DUS – Chronic venous changes Rt fem-pop

Venography 9/13 – Fem strictures w/ very

sluggish flow into profunda collaterals

PTA, EKOS – patent but to & fro though improved

flow

“Rethrombosis of fem-pop veins”

• Patent Fem-pop

• No change in leg size

• Some mild venous ectasia

• No varicosities

65 yo F with longstanding, severe cellulitis &

ulcer Lt leg, persists despite Abx, ECS x > 1 yr

DUS – “No DVT”

VS – felt reflux not sole etiology of issues

CT – Prominent parametrial vessels ? PCS

Venography:

As a diagnostic tool, venography should be second

in line, after non-invasive diagnotic tool(s) have been

utilized.

If non-invasive studies are inconclusive or there is

any consideration for intervention …..MUST do.

Consider alternative agents (CO2), tools (IVUS) in

appropriate setting