LINC 2019 live case guide

Zürich

• Tuesday, January 22nd: 8:50 - 9:10, Room 2 - Main Arena 2

  Case 09 – Woven nitinol stent for chronic total occlusion of common femoral vein

  Center:

  Zürich

  Case 09 – ZUE 01: male, 39 years (FJ-C)

  Operators:

  • Nils Kucher,
  • Dai-Do Do

  CLINICAL DATA
  Severe post-thrombotic syndrome right leg
  History of provoked deep venous thrombosis left leg 2009
  
  PRESENT STATE
  Villalta score: 12 points
  Hetercygote Faktor-V Leiden mutation
  
  DUPLEX
  Right leg: chronic thrombosis of common femoral and femoral vein
  Patent iliac veins
  
  PROCEDURAL STEPS
  1. Analgosedation propofol, fentanyl; ultrasound-guided access: of the size and location of metastases.
  2. Lesion examination with selective venography in two orthogonal views, deep femoral vein imaging using balloon occlusion venography of common femoral vein, provisional IVUS
  3. Passage of femoral vein occlusion using stiff angled glidewire 0.035“, Astato 0.018“ 30 g tip load, angled 0.035“ CXI support catheter
  4. Balloon angioplasty up to 12 mm high pressure of common femoral vein, provisional cutting ballon up to 8 mm
  5. Placement of Blueflow stent (14 x 100 mm or 14 x 150 mm) likely from the jugular approach
  6. Postdilatation high pressure of Blueflow up to 14 mm (ATLAS GOLD, BARD)
  7. Final venograms and assessment of peak flow velocity in common femoral vein by Duplex sonography

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• Tuesday, January 22nd: 11:10 - 11:25, Room 2 - Main Arena 2

  Case 12 – Endovascular Y-reconstruction of chronic total occlusion of infrarenal inferior vena cava and iliofemoral veins

  Center:

  Zürich

  Case 12 – ZUE 02: male, 24 years, (F-A)

  Operators:

  • Nils Kucher,
  • Dai-Do Do

  CLINICAL DATA
  Massive descending bilateral iliofemoral DVT in September 2018 including the infrarenal IVC diagnosed late
  and treated conservatively, ongoing shortness of breath, ongoing severe spinal and biliateral leg claudication,
  limited physical performance since childhood
  
  PRESENT STATE
  Villata score: 6 points;
  Spiroergometry: limited oxygen uptake during exercise due to impaired venous return
  
  CT VENOGRAPHY
  Obtained 4 weeks after onset of symptoms:
  - chronic total occlusion of perirenal inferior vena cava with descending DVT into both iliac and common femoral veins
  - acygos collaterals
  
  DUPLEX
  Preserved leg inflow veins
  
  PROCEDURAL STEPS
  1. General anaesthesia, ultrasound-guided access bilateral femoral veins (below occlusion) and possibly right jugular vein (10F)
  2. Passage of occlusion of vena cava and iliac veins stiff angled glidewire 0.035“, Astato 0.018“ CTO wire with 30 g tip load
  3. Lesion examination by selective venograpy two planes, intra-occlusion venography and provisional IVUS
  4. High pressure balloon angioplasty up to 20 mm in vena cava, up to 14 mm iliac veins
  5. Stenting of IVC with 20 mm Venovo stent (BARD) with high pressure postdilation up to 20 mm (ATLAS GOLD, BARD)
  6. Y-reconstruction of iliac confluens using Venovo (BARD) 14 mm kissing stents
  7. Kissing balloon postdilation of iliac confluens with 14 mm ATLAS GOLD balloons (BARD)
  8. Stent extension to both common femoral veins using Venovo 14 mm stents (BARD) with postdilation up to 14 mm high pressure
  9. Final venograms and assessment of peak flow velocity in both common femoral veins by Duplex sonography

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• Tuesday, January 22nd: 12:10 - 12:20, Room 2 - Main Arena 2

  Case 14 – Endovascular Y-reconstruction of chronic total occlusion of entire suprarenal and infrarenal inferior vena cava and iliac veins

  Center:

  Zürich

  Case 14 – ZUE 03: male, 46 years (W-C)

  Operators:

  • Nils Kucher,
  • Dai-Do Do

  CLINICAL DATA
  Limited physical performance
  History of acute venous thrombosis right common iliac vein (2013)
  Several catheterizations as newborn
  
  IMPORTANT ITEMS
  MR-venography: atresia of entire inferior vena cava starting from the liver veins, bilateral common iliac vein occlusion, prominent collateral veins (vena azygos and lumbar veins)
  Spiroergometry: limited oxygen uptake during exercise due to impaired venous return (60% of norm)
  Villalta score: 9 points
  
  DUPLEX
  patent common femoral veins
  
  PROCEDURAL STEPS
  1. General anaesthesia, Ultrasound-guided access:
  right and left common femoral veins and possibly right jugular veins (10F)
  2. Passage of occlusion of vena cava and iliac veins using stiff angled glidewire 0.035“, Astato 0.018“ CTO wire with 30 g tip load, angled CXI 0.035“ support catheter
  3. Lesion examination by selective venograpy two planes, intra-occlusion venography and provisional IVUS
  4. High pressure Balloon angioplasty up to 20 mm in vena cava, up to 14 mm iliac veins
  5. Stenting of IVC with two overlapping 20 mm Venovo (BARD) stents and high pressure postdilation up to 20 mm (ATLAS GOLD, BARD)
  6. Y-reconstruction of iliac confluens using Venovo 14 mm kissing stents (BARD)
  7. Kissing Balloon postdilation of iliac confluens with 14 mm ATLAS GOLD balloons (BARD)
  8. Possibly stent extensions to both external iliac veins using Venovo 14 mm stents (BARD) with postdilation up to 14 mm high pressure
  9. Final venograms and assessment of peak flow velocity in both common femoral veins by Duplex sonography

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• Tuesday, January 22nd: 16:30 - 18:00, Room 2 - Main Arena 2

  Case 18 – Oblique hybrid stent placement for postthrombotic May Thurner Syndrome

  Center:

  Zürich

  Case 18 – ZUE 04: female, 29 years, (H-D)

  Operators:

  • Nils Kucher,
  • Dai-Do Do

  CLINICAL DATA
  History of acute iliac vein thrombosis (left) during complicated gemini-pregnancy in 23rd week of gestation
  treated with enoxaparin 1 mg/kg twice daily (in August 2018), caeserian section for twins in October 2018;
  currently breastfeeding and still treated with enoxaparin but severe venous claudication with leg swelling and venous claudication.
  
  DUPLEX
  Postthrombotic changes of common femoral veins, May Thurner anatomy with compressed left common
  ilica vein, preserved leg inflow veins
  
  ULTRASOUND
  Post-thrombotic changes left iliac and common femoral veins
  Linear flow pattern left external iliac vein
  Left common iliac vein compressed down to 2 mm (May-Thurner anatomy)
  
  PROCEDURAL STEPS
  1. Ultrasound-assisted access left femoral vein (10F), analogosedation propofol, fentanyl
  2. Passage of iliac veins with stiff angeld glidewire 0.035“, Astato 0.018“ CTO wire with 30 g tip load,
  4F Berenstein catheter or angled CXI 0.035“ support catheter
  3. Selective venograpy two planes, intra-occlusion venography, deep femoral vein imaging using
  balloon occlusion venography of common femoral vein and provisional IVUS
  4. Balloon angioplasty up to 14 mm (ATLAS GOLD, BARD)
  5. Left iliac vein stenting (SINUS obliquus 14 x 150 mm, OPTIMED)
  6. Provisional stent extension to common femoral vein (SINUS XL Flex 14 mm, OPTIMED)
  7. Postdilation high pressure up to 14 mm (ATLAS GOLD, BARD)
  8. Postdilation high pressure up to 14 mm (ATLAS GOLD, BARD)
  9. Final venograms and assessment of peak flow velocity in common femoral vein by Duplex sonography

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