IR perspective on Iliac venous stenting, by Peter Schnatterbeck

DVT causation: flow, endothelial injury and hypercoagulability

Stenting increases the endothelial injury in veins!

stent can still occlude with good flow

very important to have pneumatic boots and to get out of bed early.

thrombus in vein incites a lot of inflammatory process - leads to vein fibrosis and valve disruption

Rationale to treat acute DVT

- 50% of ileofemoral DVT cases get PTS

- 15% approx get ulceration

- 45% approx remain symptomatic with non op Rx

PS says surgery has a place in UL DVT because there is limited endo to offer in UL DVT

The ATTRACT trial showed no difference - states need to be cautious after this trial

what to see on imaging

Does the DVT enter the IVC

Is there a mass lesion like cancer

Is there a PE? Is there right heart strain?

Is there a May Thurner?

new devices: FlowTriever is similar to ClotTriever. FT can suck out PE clot.

for IVC or ileofemoral DVT wthout PE consider ClotTriever with FlowTriever protection discs.

You can’t put an IVC filter in through a popliteal puncture because the device shaft length wont be enough

Can’t use a mechanical thrombectomy device on an occluded stent; you can use an aspiration device though.

Picture of the ICVO classification system

when you use TPA use a checklist for the contraindications

FU measures (5)

Anticoagulation

pneumatic boots overnight

Then pneumatic compression stockings

DUS on day 1 post op and CT / MRV at 6 months

Early mobility v important

CHRONIC DVT

is a different beast

no clear consensus on what is a significant lesion

Imaging to use is much more complex. US is of limited use.

Intraoperatively need combination of multiplanar venography and IVUS

can reconstruct an occluded IVC even with only about 5 cm patent in the infrahepatic segment

you would almost always end up having to overstent across orifice of the right CIV when you stent the left CIV; of little consequence.