Dr. Antonios Gasparis begins the session by discussing patient selection with venous outflow obstruction. Next, Dr. Nicos Labropolous presents the clinical impact of edema. The importance of IVUS findings in venous disease is led by Dr. Paul Gagne. The last part of the session concludes with case reviews by Drs. Gagne, Gasparis, Fastabend and Gibson on a variety of topics. During this session, you will find an interactive dialogue by all the faculty members.
These sessions are designed to:
Identify why patient selection is important in the treatment of deep venous disease
Help in the management and treatment of patients with both superficial and deep venous disease
Explain why IVUS plays a role in the diagnosis and treatment of deep venous disease
Review best practices in the diagnosis and treatment of patients with deep venous disease
mm hmm. Yeah. Mm hmm, mm hmm. Yeah. Mm hmm, mm hmm, mm hmm, mm hmm, mm hmm. Mhm. Mhm. Okay, mm hmm, mm hmm. Yeah. Mhm, mm hmm. Yeah, mm hmm. Yeah. Yeah. Mm hmm. Mhm, mm hmm. Mhm, mm hmm, mm hmm, mm hmm, mm hmm mm mm hmm. Hello and thank you all for joining us this evening. I'm heather Hudnut page. I am the general manager of the peripheral vascular business at Philips. And on behalf of phillips and the venus symposium, I'd like to welcome everyone to the virtual deep venus summit on deep venous pathology. These programs are especially important to us that phillips is our mission is to elevate patient care by bringing imaging and therapy together and through doing so simplify care and improve the lives of patients around the world. Education plays a critical role in that mission. Especially as we think about the venus disease. And we are committed to hosting these types of programs along with the venus symposium. Big thanks to doctors guessed paris um uh laboral Liberopoulos gagne faster. Bennett Gibson for leading this educational program and for sharing their vast knowledge of deep venous disease. I know you will leave inspired with a greater knowledge of deep venous pathology and practical tips and tricks to improve care for your DVD patients with that. I will pass to dr Tony gasp arose to kick off our evening. Thank you heather. Um so I want to welcome everybody to deep venous summit. Uh we've been doing these programs with phillips. Oh I don't know how long paul, 17 years. Yeah. Yeah. So we started this off way back when um really the beginning of the venus interventions. And since I've this was the key in evaluating and identifying the venous pathology um phillips has been putting these programs together with this group um as I said for the last eight years or so, so they just decided to move this onto the virtual world since we've had this challenge over the last year with Covid. And this is actually the first of for programs that will be doing and uh we'll be talking about the venus pathology. Um There's gonna be a couple of talks and mostly clinical cases. Nikos is gonna kick it off with the clinical impact of edema. And then Paula is going to talk about IV's findings for venus pathology and intervention. Um then carl myself, paul and Kathy Gibson. I will be presenting some clinical cases on how to evaluate these patients and management of these patients. So I think Nicholas, why don't you share your screen and we'll start off with your presentation on the evaluation of the patient with leg swelling. Thank you Tony. Good evening everybody. Let's start with the first lecture. And here are my disclosures. This is a very interesting paper was published about four years ago indicating the significant impact of the demon in our patients. Lower limb chronic edema had significant psychological social and physical implications for the patient's quality of life. And here you can see some of the common lower extremity causes for swelling and put top of the list, you know the venous reflux and depends on bosses. Currently it's obstruction among many others. And here in a recent paper publishes Tony and some other friends that many drugs that can cause leg edema, primarily the anti hypertensive hormones, Penta, noyce's and other categories common rights like the insides etcetera. If there is some conditions with the peasants have been lymphedema is a characteristic, you know, popular mitosis or the positive component composite Stember sign, then ability to pinch a fault at the based on the second floor and then you have people who sleep Idema which basically female patients symmetric oedema from the hip down to the ankle which usually painful and then have conditions like the armchair legs. People have you know bound on the chair and they can use the muscle pump and having significant edema, which is really electronics. So let's start with our first question, what is the most common cause of food trailing? I think you're talking about foot alone or, yep, so a little trick question there. Mhm. Most people got it correct. I had just you know, I would say lymphedema but now is gonna hear later vein this is implicated but in most patients is spared as a food. So the correct answer here would have been actually lymphedema. So let's go to the next slide here is one of the common conditions described that I cubed debate from bosses is a female 69 years old with recent onset of pain and edema and as you see here are the pictures. The portal vein is from both is very dilated and it's not compressible. And you see also the colonial veins along the artery that are both from both. And one of DVD is a common cause of swelling and it can cause swelling at the acute states, but also at the chronic level because of post robotic disease. If the thrombosis damaged the bulge or the trump doesn't lies, then we have you know, reflex an obstruction and it can give you chronic edema. We know also iliac vein from bosses and Slattery current DVT increases the odds for developing science symptoms. Here is a person with post traumatic syndrome and uses class 1 to 5 symptomatic and pleasant hill ulcer as you see here and the key signs of swelling, discoloration and see all these veins spreading in the patient's leg and the divinity over 30 years ago. And this person is very difficult to treat because it's actual reflex from the commerce emerald vein all the way down to answer. And we don't have really good solutions for patients like that. And here is a person with less complicated problem which is obviously reflecting the great atmosphere in from the groin to the mid calf, the interior accessories and tributaries and the person is also an aneurysm of this afternoon's in in the area and as you hear, This person is typical. His mother had varicose veins. The veins appeared over 20 years ago and slowly became worse. And we know now that Venus Reflux is the most common cause of swelling. However, when treated the swelling symptoms improved, the swelling may not always go away but definitely gets better. And here we see a patient with political system or Baker's cyst discovered out of Baker in 1887. In the female was 62 years old and said, you know, paying is wailing that got worse in the last four days. Nobody convenes nativity typically located in posterior medial upper calf are really complex in your neurovascular bundle. And here in the next case such a compression hemorrhagic baker system right here compressing the tibial nerve and the political vein now rarely. But sometimes you published this paper, this person's can present with pain Australian due to compression of the nerve and the political layer. And here we see in the near future and you see the knees filled with fluid and conditions like that are common in people with arthritis, trauma infection, gout and other qualities you see in here, this person had also reflected in the great atmosphere, saying the diameter was more than a reflex duration of sorts. But you know, mrs wailing cannot be explained by the great atmosphere reflex. So you have to think of other pathologists like in this space here you have a personal fresh hematoma on one side and see how the hematoma goes from the knee joint all the way down. This is a person who's after tribulation that's higher in our 4.2 no DVT. Usually the pain is much stronger than that of DVT. That is a very bad pain in a dissection hematoma that is growing. And this person presented with the hard you know calf and the person had you know, compartment syndrome such as the hematoma needs to be evacuated because you can lose muscle because of the compartment syndrome. And however another case with Elliot Krane compression, especially early formal sit here on the top compressing the external iliac vein and higher up the common iliac vein diameter is only 2.7 millimeters. And such persons develop often debate from bosses as they have you know, a malignant lesion and a compression of debate. And here is a patient that my colleague Tony. So at the clinic is has a chronic obstructive, broader disease and restricted mobility. And it's been made 90 years old and he has some you know, significant swelling science of venous hypertension and also alteration in our typical allegations. As you see here the contributions of venous reflux is very small. The major problem here is the C. O. P. D. And the restricted mobility. So if you have to treat veins emancipation you're not gonna see much benefit. Here's another person that we call Idema is owned by the paper of Dr Dean Edell in General school surgery. This place has long started units hypertension. That has led to swelling because of inadequate or insufficient drainage from the lymphatic vessels, expenses, swelling, pain, eating heaviness is kingdom patients like that. When they treated for the reflux, they get better but the swelling doesn't go away because the flip qualified demise and no reversible. There's another patient who has, you know, skin damage and varicose veins and it's a high velocity terrific max and a lot reflects along direction. But the the small and defense were normal. Such patients can benefit from surgery and this person got significant improvement after the separation. Lebec chemists and ultrasound guided forms your therapy. Another condition is starting food disorders and described by doctor You'll from paris. People are having, you know, a small arts basically the food is flood or that a big arts have a concave food that difficulty using their muscle pump and therefore they develop more often viewed as a potential. And here's another patient. Right, right and failure. Male, 65 years old from our clinic who present with varicose veins and skin diamonds as possible. Style flow in deepest for official events. Even the standing position. See the president's studying now this is a government femoral and this is a great sergeant. The higher the possibility in both veins in the starting position. This is a long time ago and one of the early papers in 1925. Kiev describing this phenomenon. We know it's very common. Such patients ought to optimize the the the heart function first before there's any thought to treat veins in the lower extremities. So come to the second question here, what is the most going most frequent cause for unilateral swelling, venous reflux? Her failure? Electron compression was finally called injury. And here most people got the correct actually, give you the answer in a few slides earlier, is venus reflex and here is a remarkable paper to dr Charles Michel because one of my mentors and Imperial College is one of the biggest pioneers of micro situation And together DR leavitt for ST George's basically they saw that the filtration in the lower extremities or if you like the reabsorption of the fluid. It happens on the lymphatic and not on the business side. And basically, in patients chronic venous disease, it team offers remain after treatment. This could be explained by the imperative to act and function of a long period of time. Unfortunately, most healthcare practitioners, I'm not familiar with this and maybe annoyingly promised that their presence would go back to normal when actually they don't have the condition of liberal Kadima, here's a nice slide from dr mortimer who is the World authority of lymphedema. That shows how basically the fluid comes back to this lymphatic capillaries and lymphatic ducts from the micro circulation and dr mortimer part is a very nice day with dR auction in journalistic investigation and so that Idema develops when the microvascular filtration rate exceeds lift drainage for a sufficient period. Because the microvascular filtration rate is high. The link flow is low or combination of the two In an organism in 2018 19 Dr mortimer left us with some messages. For venous edema is relatively lymphatic failure, has increased venous fluids, depression over women lift trainings potentially reversible if highly lowered. For venous hypertension is reduced. Lymphedema is impaired lymph drainage with normal live load and generally reversible and flip. Lymphedema is lymphatic failure resulting from sustained, increased venous filtration, exhausting and eventually damaging lymph drainage capacity equivalent to lymphedema and generally irreversible. Like I saw you a couple of patients earlier, these places get better when you treat them but the fema doesn't disappear. And if you look now a little bit about the compression, the physiologic benefits are increasing the flow velocity, reducing the venous volume, reducing the ambulatory venous pressure, improve calf muscle function and increase the industrial warfare stress. Which basically creates an anti robotic environment and on the micro circulation. You see this is the control of edema which is based on the micro micro circulatory alterations. One suppressing cytokine and promoting an antiquity antiquity in the ceiling and I didn't show you all the basic science is a beautiful paper product of master on that. Many people cancelation when you use compression. How you can take a second. Skin biopsy can demonstrate how they cytokines can be reduced. And basically for the first time to see uh at the microscopic level, you know how compression can impact, you know the, you know, our microvascular environment. This like to finish my talk and Tony. Thanks Nico. Um, I mean it's a nice summary on adama. And as we can see there's a pretty long differential diagnosis in these patients and prior to proceeding with any invasive interventions, you know, ruling out the most common things and making sure you identify what the underlying cause of the edema is as important. Um, I think you showed very nicely that and a lot of patients that adama even if it's a venus cause may not improve. Um what percentage of patients would you say after intervention may not may still have persistent swelling. If you take all cameras that will include, you know, probably more than 50% only I would say if you because it's talking about chronic diva obviously. Right so and I like also paul and bob and carl the communities offer of the elections particularly car when he gets, you know, his nice talk, you know, in the dealership portion demonstrating very naturally how many people are remaining steam after treatment? Well, can you can you add to that? Yeah, I think, you know, and the patients who have had longstanding swelling best you can do is you can treat them and and tell them that there's a good chance that swelling is not going to get better and in those cases a lot of times I'm treating those patients because they have accompanying heaviness or maybe venus clarification or skin damage or some other uh finding or symptoms related to their swelling. The patients who really ah whereas swelling alone is their main problem. Um It's a long differential, you gotta work through all that and then and then tell them that, you know, it's not a guarantee they're going to get better. Yeah, I agree. I mean, and I think Nicholas mentioned the around 60%. There's a couple of papers show 11 was the original no glenn and Raju paper that after ili extending and superficial ablation, there was about 70% of patients still had some form of swelling, only about a third of them had complete resolution. About a third had some improvement and about a third had no improvement whatsoever. Um And I think a lot of it is is what peter mortar talks about with lymphedema where you have a chronic stress in the lymphatic system. So even if you get rid of the venus hypertension, um the lymphatic system is damaged from the chronic um lymphatic hypertension that is exposed to. Um Yeah, if you do the right thing to be optimistic, the patients do get better, but the degree of improvement, it varies right, right? And this is the thing with patient expectation, right? Like paul said, you're gonna they gonna get better from a clinical perspective as far as their pain. Their heaviness, but the swelling, you have to be careful what you tell them as far as expectation. Um And it's the same thing with superficial disease. I mean, there was a paper recently published last year showing that even after superficial venus intervention, About 40% of the patients still have um persistent swelling of some sort. Um So if it's a purely swelling only, I think you just need to you know, let the patient know that there isn't, you know, you're gonna have improvement, but it's not 100% carl. Any comments on that. I think this this good relates back very clearly to patient expectations and your communication with the patient pre operatively they've got to understand the Dema is our toughest symptom to get rid of. And clearly the two Nico's comments, the more the patient has advanced skin damage from deena's hypertension, they're less likely as their demon is gonna go away and that's got to be due to the lymphatic irreversible injury. Yeah. I mean I if they can't tell me, you know, they wake up and their leg is completely normal, then I'm more optimistic that they're going to improve after intervention. If they have persistent swelling even in the morning, then I'm less enthusiastic for just swelling. One of the attendees. How do you diagnose lymphedema. Nico Yeah. Is mostly clinical diagnosis is that is primarily affects only females and it's symmetrical because from the hip to the ankle and on pulp patient actually it's it's painful and that's typically kinkel diagnosis. There is no other, you know any lab tests. I mean you can exclude other causes but if you see a person really be demon it's very obvious basically the foot and ankle is spared. And what do you see? Can you see anything on ultrasound or the other? You see. Yeah. You see dense fat concentration like you know little pockets and pillows of fat, you know and you see poor differentiation of the epidemic's like you see of lymphedema but you don't see this extra amount of fluid. Yeah. Yeah. The other thing I think that is when you when you talk to them and say when you go on a diet, what happens? And they say I lose the fat in my face and my chest and my arms and my legs stay the same. That that's the last place they lose weight. And they're often have easy bruising on their legs or they may not see bruising but they say I bruise easily um is really common. And the other thing I say to them when you get a massage or go to for a pedicure, do you let them rub your calves? And if they say no then that's another hint that they don't like they don't find that pleasurable. The other classic thing is also easy bruising. You know, they get very easily bruises. Kathy I have a question for you from one of the audience in patients with lymphedema, stage three and superficial reflux. Would you consider vein ablation only if the veins are also causing symptoms. So if it's just for a demon, No, you know, but there can be flyable lymphedema where they have wounds, skin changes. Um some other symptoms that you may attribute to venus disease, then I will, but I'll tell them, I don't think that you're adam is going to improve, you know, so they can have the combined symptoms from the veins and a lymphedema and I think you can make them better. But again, as the other panelists have said, patient expectation is key. You, I mean, I don't know how many people I've seen come from different clinics that they've had an ablation, sorely disappointed and upset that their leg is not different than it was before they came in because somebody told them taking care of the sadness reflex was going to cure their problem. Yeah, I try to avoid them, especially if they have a history of lymphedema being their primary problem, you know, since teenager And then it progressed to stage three and by the way, you know, I had a couple of kids and now has also, you know, varicose veins. Yeah, so you have to be very clear for them. This is the bucket of symptoms that I can help you with or you hate looking at these veins. If you can see them. I may be able to prove that. But this other thing over here is not going to get better and could get worse. It could get worse. Yeah. Alright. Um Mhm. Live angiogram. Anybody use that. All right. All right. Why don't uh why don't you start sharing your screen um or Jenna. If you're doing it and we'll move on to the next talk, we'll catch up on some of the questions as we go along. But I don't want to fall behind. So, paul is gonna talk about us about Ivan's findings for venus pathology. Go ahead paul. All right. These are my disclosures. Thank you Jenna. So, you know, patients are we're trying to evaluate for deep vein inclusive disease. Traditionally been treated or evaluated with pornography. And And clearly, you know, as you can see on the panel on the left with a big black arrow that we've got some post robotic changes there. This is somebody who's got a stenosis and the external iliac vein. You can see some collaterals. This is very obvious. What you don't know is in the veins that look a bit normal above and below that area. Is there a scar. There is their exclusive disease there as well. Uh pornography doesn't really show us that well. And you can see here the long segment narrowing on the common iliac vein on the panel on the right And again how much of that vein is scar? How much of that could be some acute thrombosis. And what's the size of that vein? So you know you can see what's going on there with with pornography but you really aren't getting the detail. That really helps to make informed decisions. If you're going to intervene. Next slide please. Here's an example of a cat scan. A lot of patients will have evidence of compression and you can see in panel A. That the you're right at the junction of the left common iliac vein and ibc under the bifurcated commune iliac arteries. In panel B. You can see under the left common iliac artery over the top of the of the anterior aspect of the of the vertebral body. There really isn't much of a vein there. It's really just a wisp of scar tissue. And you can see that continuing in panel C. Under the left common iliac artery. You can see just a wisp of scar tissue and really not much in the way of lumen. And then if you go down to panel D. You can see the two arteries and you can see that the left common iliac vein is smaller by almost half compared to the right common iliac vein. So this is a patient who on cat scan has a diagnosis of chronic post robotic disease and scoring of the left common iliac vein. Excellent please. This is a classic main thermal lesion. Now take deep vein outflow tract obstruction. Uh Really has two faces. You can have post robotic disease. Uh And this is in patients who have had a prior dvt. But you'll be surprised when you start evaluating patients with chronic venous hypertension and you use intravascular ultrasound. How many patients you'll find have post robotics scar sneaky I sclerotic changes to the to the vein wall with narrowing of the vein that picks up that's picked up on intravascular ultrasound. Some of these patients will have occlusion. Some of them will have strictures. Uh An intravascular ultrasound is particularly helpful for not only identifying the one area where it's most denotes like you saw in the Vienna grams but also gives you a sense of the full length of that legion. There may be areas that look reasonably good on two dimensional venogram. But actually when you look at it with intravascular ultrasound you find that there's diffuse scar and narrowing throughout a long segment of the veins that need to be treated. And then finally once you do treat with maybe a stent in angioplasty you can confirm that you've gained good lumen that the lumen has improved the way you expected. You have good wall opposition with diagnostic intravascular ultrasound. Again not so easily detected with pornography. Next slide please. Now this is the I. V. System from Philips. We typically use the P. V. 035 system because that gives you the depth of field that you want in order to evaluate the inferior vena cava and iliac veins. If you use the smaller profile five or six french catheters, you tend to get wire buyers bias within the iliac veins because of the tortuous course of the iliac veins. And you don't get to see the entire anatomy intra Luminal lee that you need to see. So you need the 035 system. Next please. Now this is what chronic post robotics scar looks like. You can see on the right this big chunk of scar that you can find in a vein here. The common femoral vein with some channels throughout. So there may be a little bit of flow in here. Oftentimes though the flow the path of these resistance is through collaterals and you don't really appreciate these. And then on the panel on the left you can see a common from Mulvane opened up, launched totally again you see the cynic ei these little wisps of scar and channels through this block of scar in the common thermal vein. And this is a cellular collagen. This is not cellular. This is not intimate hyperplasia. This is chunks of collagen that are non compressible. Next please. And this is what it looks like on intravascular ultrasound on the panels on the right you see a normal common iliac vein and external iliac vein. If you look at the panel looking at the common iliac vein you see that the vein is extended. The wall is thin, it's even hard to appreciate the vein is approximately twice the size of the adjacent artery that you see just above it. You see the same thing down uh at the external iliac vein the vein being notably larger than the external iliac vein with the wall being thin and there's no echoes within the lumen of the vein. If you look over on the panels on the left, starting at the top, you see that the communal yak vein is just a small whisp. It's a rather narrow slit. So if you're picking this up on one view of a venogram it might look about the size of the artery. But obviously you can see here with intravascular ultrasound this is a small room and you see around the loom in these hyper dense white hyper echoing areas. This is the scar from intramural uh an intra Luminal scar from prior dvt. If you look at the panel on the bottom, you see that the catheter, the Ivies catheter is within the external iliac vein and the external iliac vein is not much different in size than the adjacent artery. So we know that this is contracted and sclerotic and therefore not a normal vein but suffering from post robotic changes. And if you look right around the catheter, you see some chunks of white tissue on the right and left sides of the catheter. And this is against scar. Within the lumen of the scarred external iliac vein. Next slide, please, here's another example. Again, looking at the panels on the left compared to the normal on the right we see in the upper left a abnormal common iliac vein. Uh You see dark lumen around the catheter above it and then an area of white hyper coke scar going up right through the middle of that. That's a web and a very sclerotic and narrowed vein. Uh And again, if you look at the panel on the bottom, you see that white Area of tissue at about 12:00 within the extra exact vein just above the catheter. This is scar tissue in the lumen of this external iliac vein. And again note that the external iliac vein here is not much bigger in size than the adjacent artery. And therefore this is a small contracted and scarred external iliac vein from prior DVt. And these are the kind of findings sometimes that you'll find in patients who come in with significant symptomatic chronic venous hypertension and have no history of DVT, which you pick up on ultrasound, I will tell you that this patient had a DVt in the past and clearly intravascular ultrasound is the standard of of imaging for pelvic veins. Next place paul. Yeah. In a patient with without any collaterals? Yeah. Would you expect significant obstruction? What would you? So you have in your IV's findings, if you have no collaterals. So if you have chronic venous hypertension. And uh and you don't have collaterals on your venogram. Yeah I mean we we know that that 30-40% of the time at least uh you will have a high grade stenosis on intravascular ultrasound. To explain the clinical presentation of chronic venous hypertension and there'll be no collaterals on pornography. So so collaterals are are helpful when you see them. But when you don't see them it doesn't mean anything if the clinical presentation is that of chronic venous hypertension that I think answers the question. So so this is a patient who again presented with And all these patients are presenting and being evaluated essentially for seat 45 and six disease. For patients with C. three disease who have you know, clarification symptoms or severe heaviness that's recurring and developing during the course of the day. So that's the clinical context of these lesions that were identifying On intravascular ultrasound. So here's a lesion patient comes in with c. four disease unilateral. We go ahead and put a catheter up into the iliac veins to look at the iliac and common thermal thinking that the patient likely has outflow obstruction. We've already evaluated the infra inguinal veins and that doesn't really explain the clinical presentation and we don't see what appears to be a high grade compression lesion, we don't see a diffuse the small iliac vein. But what we see is this white scar or white tissue that seems to be protruding into the lumen. It doesn't seem to be compromising the flow all that much, or the luminous eyes all that much. And you look at you go, well, could this be a web? Could this be a cynic? I or occasionally people have described iliac vein valves, although very rare as Nikos will attest, I'm sure. But could this be one of those very rare valves? So next slide please? And this is what it looks like. I'm not moving the catheter. I'm just letting the patients breathing and heart rate affect the movement. And you see right where we saw that wisp of tissue coming in and out. So it's not very thick. You're kind of looking at going, is this anything? So I decided to put a balloon up because I did have a patient who clinically had severe chronic venous hypertension. Next slide please. And you can see here, I even surprised myself. I was a little slow in getting my foot off the pedal to capture this image. But you can see this very focal high grade stenosis and it was much more of a tight waist at the initial inflation of the balloon. Right where we saw on I vous that web. Next slide please. So we balloon that open and extended in. That patient got better. So you will find these very fine abnormalities within the lumen of these iliac veins that you're just not going to pick up on pornography. So if you don't do an I. V. A study, you really are gonna miss a significant number of the lesions and underdiagnosed the patient's problems and mistreat them because you won't address their underlying path of physiology. Now, other than post robotic disease, the other type of disease detected with ISIS and occasionally with photography. But but most consistently with IV's is non robotic compression lesions. And we know this on the left side historically as um a thermal lesion and compression of the left common iliac vein by the right common iliac artery. But but what we've learned in the last 10 to 15 years is that you can get compression of the right common iliac vein by the artery against the pelvic sidewall. And you can also get compression of the external iliac veins. Cranial e especially where the common iliac artery bifurcate its uh and then the common femoral vein occasionally at the level of the inguinal ligament. And and this can be due to tumor or the normal an atomic structures as listed here. Uh And and the benefit of diagnostic I've this is that you can see the normal vein adjacent to this area stenosis. And what you'll find is that that vein diameter can be quite variable. You can have areas of pre synaptic facilitation adjacent to the compression points where the vein is actually abnormally dilated. Uh And you can have adjacent areas that are quite normal in size. And so uh detecting what the size of the veins are in order to plan your stent is critical. So you don't end up with a stent embolization and you're going to need to anchor that stent with a 1 to 4 millimeter oversized depending on the I. F. U. Of the stent in healthy vein in order to make sure that not only does it open the lesion but it also doesn't travel next please. So here's a classic may thunder lesion seen on pornography on the panels on the left at the top. You see the indentation of the left common iliac vein. You see some pristine arctic dilatation as you go south from the stenosis in the pelvis and then the cross pelvic collateral. So when you see this lesion you know you have a pretty good idea of at least part of what you're dealing with. But this is extremely rare to have a beautiful venogram showing you this. But if you know if you're new to ivy's, you can see on the panels on the right, in the middle top you see a very dilated vein adjacent to the artery that's that pristine arctic area on either side of it. The panel A and panel see you see that the vein is malformed and compressed but not particularly narrowed. But then when you go to panels D. And E. So those are the bottom two on the left. And the center on on the panels you can see that the veins are not much bigger than the IV's catheters themselves. And so these are areas of high grade stenosis. And of course when you look at the venogram you can see that that's expected. And so it's not a real surprise. But let me show you a case where it wasn't so obvious. Next slide please. So this is a patient who I met many years ago. Next slide please. And she came in with a seat for disease she had in duration in the skin. She had stasis dermatitis. Uh This has come on over the last year, year and a half. He didn't have much history of swelling before that. No history of DVt. So we did a venogram. You can see here there's no cross pelvic collaterals. There's no real narrowing. Next slide please. But when you look at the composite maybe there's a little bit of narrowing at the external iliac vein and maybe some compression of the commonly acting but no cross pelvic collaterals. I've not yet got anybody to stent on the basis of the venogram. Can you play this video? Thank you. So we're in the I. V. C. That's a wire from the contra lateral leg. We have an I. V. Catheter in the middle. The wires going off into the contra lateral iliac vein. So we're now in the common iliac vein. You see the artery above deforming the common iliac vein but not particularly narrowing it. And now we're coming down along the common iliac vein with the ivies catheter in it the adjacent artery. You see that the vein is larger than the artery. So that's a normal vein. And we're gonna see here in just a second the artery dividing into the internal iliac and external iliac vein with some deformation of what's now the external iliac vein. So we have external and internal iliac artery, external iliac vein. As we pull the catheter a little bit lowering the pelvis, we see that the extra iliac vein is being compressed and narrowed. And if you'll bear with me just a moment longer you can see there's just a tiny slip of lumen of the external iliac vein detected on I've this and as we pull the catheter down a little bit more we see that the external iliac vein is quite normal. The wall is thin, there's no intra Luminal scar. This is a high grade external iliac vein stenosis at the bifurcation of the internal and external iliac vein. Next one please. And so this is our measurements For that. You see this high grade stenosis with a cross sectional area on the panel on the left of 36.8 on the right. You see our reference vessel which was the normal external iliac vein just below The area of stenosis. You can see that the cross sectional area was 135 millimeter squared. And you see that the minimal and maximal diameters is listed in the little green box here ah And the bottom of the right panel. So it was 10.6 plus 17.4. If we add those two diameters up since this is an ellipse not a circle we get 28. And if we divide that by two we get 14. And that's about the diameter of this external iliac vein. So if we're choosing a stent We're going to want to up size 1-4 mm in place. Maybe a 16 millimeter stent there and that's what we're used to treat. This External iliac vein stenosis on the left. Next slide please. So I've this has helped us size our stent and here's our stent from the external iliac vein up to the mid common iliac vein across the area of stenosis. Next please. And this is playing this video please. And this is the I. V. S. Run after stenting. You see the wire going off to the contra lateral common iliac compression of the common iliac. And here we are in the community iliac vein coming down towards the leg from the umbilicus. And you'll see the stent come just at the bifurcation of the artery. Here's the stent in the vein. Here's where we had that high grade stenosis of the external iliac vein now widely patent. And this patient's symptoms resolved and didn't come back over the last 10 years. Next slide please. So let's talk a little bit about measuring with intravascular ultrasound. Next slide, please play the video on the left please. So one of the things you really need to be attentive to is that sometimes when you run a catheter down through the iliac veins. And especially I've seen this with the external iliac vein but less so on the common. But I have seen it with the comedy like vain just with breathing. Look at that change on the left and the size of the external iliac vein. It looks small at rest. And then you have the patient take some deep breaths and the vein collapses. Play that video one more time please on the left. So you can see here when we first pulled the catheter down it looks like a small external iliac vein, like a slit much smaller than the artery on the left. And then without moving the catheter, I'm just leaving the catheter there and having a patient take a deep breath. You can see the phase it changes and it's important to appreciate this and have the patients take those deep breaths because you don't want to put a stent in that small vein and then find that you undersized the stent for the actual size of the vein and then it travels. And you can see the difference here there was a change in size of this vein as you see on the panel on the right From 26 mm up to 110 squared or 76% change in the absolute size of that vein that was not a fix stenosis. Next please next slide. Now I've this is helpful in evaluating patients who suffer from an acute deep vein thrombosis after thrombosis of thrombin ectomy. It helps you identify the residual thrombosis and then it also helps you if you have a stenosis, either chronic scar or compression lesion to identify the lumen and and size the stent that you may need to place appropriately. Next slide please. And you can see here again our normals on the right and on the left. You see that the top panel and the common iliac vein. You see that the vein is dilated compared to the artery. So you know this isn't chronic, this is more acute because you don't have the post traumatic scar. And then you see the filling defects within the lumen of the vein and this is thrombosis that has not disappeared after treatment and still needs to be addressed. And then if you look at the bottom again you can see the very dark lumen in the external iliac vein which again is twice the size of the adjacent artery. So this is more of an acute process. There is going to be flow through the lumen. But you can see how much residual disease there is in that vein that is yet to be properly addressed. So I've this can be very helpful to not only determine how acute this lesion is because if these veins are small compared to the artery or normal rather equal in size to the ordinary. You know this was acute on chronic but in this case you know that this is largely an acute process. Next please. So I this is essential for identifying deep vein pathology. It really is the gold standard today venogram without I've this leads to a lot of false negatives and inappropriate under treatment of patients I've this helps to diagnose the normal vein diameter and choose the correct stent. So the stem doesn't m belies it identifies the pathology. So you know if it's chronic scar and post robotic disease you may want to have a course of anti coagulation after stenting and then it helps for a patient selection for stenting. Is there a lesion or not to explain the patient's clinical presentation? And then finally not only does it help but stent diameter but also make sure that the stent length is appropriate to cover all the disease identified X. Slide, please. Thank you. Thanks paul. Um We got a ton of questions. I was going to interrupt you but uh I was on a roll. You were on a roll. I didn't want to stop you. Um How about the role of actual imaging in patients who you suspect 11 compression and don't want to don't want to undergo I. V. S. Or invasive procedure. I mean I do have some patients who are skeptical about undergoing an invasive procedure and I'm pretty confident that they probably have something. So I will do a ct venogram typically at our institution. Um The problem is though, and what I tell them up front is that you know, especially if it's a compression lesion. It's sometimes hard to appreciate on a ct venogram. If something's there and then you're not going to pick up the webbing, you're not going to pick up some of these other lesions that we pick up with IV's. So um I do it occasionally but not too often because I tell patients that you know they suffer more radiation. They if they have if they're older patients and it could be a challenge with the dialogue and I tell them it may not be as valuable. But occasionally there are patients who present with ulcers or bad painful legs with severe like automatic sclerosis for example. And they just reluctant to undergo I. V. S. And and an invasive procedure. And if I can detect that there's a lesion with axial imaging then I may be able to convince them that it's in their best interest and to move. How about a patient who comes in with like a three month history of swelling. Yeah I don't typically um if it's a little bit of swelling. I don't necessarily recommend actual imaging. Occasionally they will have patients who come in with a very quick course of swelling. They were perfectly fine 6 9 months ago. And now they've got a big swollen leg, not just a little swollen but a big swollen leg. And those patients I'm worried about a tumor and all oftentimes get a cat scan to rule out, you know, at an empathy or some mass compressing the veins Cathy um in which clinical scenario would you think or would you I have I've is to be more useful than pornography or? Oh you know, I used them and never force them from each other actually. You know, I used them together. Uh So where is it especially useful? Is somebody where you're worried about contrast load? Um You know, then I'll then I'll be very judicious about when I'm giving my doing my videography, you plan your pornography out. Like if somebody's got to uh you know, a G. F. R. That you are unhappy with, then you're making sure that you get the before image. You need the after image that you need. And most everything else do with Avis. But I think that they offer complimentary information. So if somebody with normal renal function um doing both. Uh you know, and I think that I this I just gives you more detail. Um you can see flow better with pornography, you can see the collaterals better with pornography. So I think there really are a marriage of two technologies that most people use. And for me the main thing is again, just deciding how much dying dying radiation. I'm going to give them depending on their age and some other things. Nick. Oh yes. How do you differentiate on ibis? Um scars or webs versus rhombus And also some nice images. The throne which is the typical fresh homogeneous spawn c appearance where the scarring is typically typically irregular with significant world thickness. In fact in our paper we saw that the wall thickness on the chronic scenario right? Is much more than the acute DVT. When I get beauty. Everything is smooth and homogeneous for the chronic is irregular, Right? And very bright typically. All right. Ah carl access for these cases. Where is your preference? Um And specifically one of the attendees is asking uh G. S. V. At the ankle. Well um I've never access to GSP at the ankle to do a pornography and nervous for deep venous disease. It's never occurred to me most of the time I use the mid femoral vein for access. Um If the patient has a DVT or we expect trying to conclusion a lot of times I will go papa teal, that's problematic. And our patient population which tends to be elderly and obese. Um And I do use anesthesia for these cases. I just think that it's better to have anesthesia monitoring these folks. But the access of the mid femoral works best for me. And I actually marked the lesser. Try o'Connor and make sure that access below the lesser troll cantor. I use ultrasound guidance for every single access. And it's particularly important with these cases because the at the level that I'm accessing the femoral vein rotates Posterior Lee to the femoral artery and it's very easy to um to produce an 80 fistula if you're not real careful. And that that can be tricky. Um All your cardiologist out there doing these cases and I'm one of them. Uh I know how easy it is to stick the thermal vein at the level of the greater trow cantor but get below that. It's a different story. And you've got to use ultrasound guidance um paul in patients who have combined compression and post traumatic changes in the femoral vein with multiple lesions, what's your strategy? Do you address the femoral vein or you just deal with the Elliott compression or both? Or? So the iliac vein compression and post the robotic scar on the thermal blanket? Yeah. Like how do you differentiate what's causing the patient's symptoms? Is it the compression or is it the the femoral vein? Yeah, that's a good question. Um There isn't an absolute, there isn't an absolute answer to that. It's it's challenging. Um I think that if patients come in you know with advanced skin changes, ulcer, no ulcer healed ulcer. Not so much venus clarification. But it could you know, that's just a less common presentation but certainly could be. And you have isolated federal vein scar. Um Then you know typically that's not all that's symptomatic. Um If you have scar though that's extending down into the papa till and tibial veins then you know that very well could be the cause of much of the patient's symptoms. Um And so you know treating the iliac vein compression may not give much improvement. The one setting where I would go ahead and treat the iliac vein is if I'm planning on engine blasting the scar within the femoral pop until tibial veins because I've got somebody who's got non healing ulcer or something that's particularly debilitating. Uh and I'd like to make sure my outflow is adequate and and not impeded in those cases but most of the time it's it's not going to help much if it's just a local compression lesion. Kathie, what do you think? Yeah this is actually my case that I'm going to show uh my case study is combined. What's up? I said this so we'll leave it for them. Yeah. Okay. Nico I got a good question for you. Um Have you found that common femoral vein or external iliac vein compression on ivy's with the patient and prone this appears in the supreme position. Yes. Or actually with a small flexion of the hip. Actually. Its cooperation with some people of the green a ligament over the external iliac vein. I have beautiful videos. Maybe we can solve some other time of of this happening because that's absolutely geologic nothing to worry about. So is there an optimal position prone or supine for imaging? Well, it's dynamic. If you put the present composition, you reduce the iliac vein stenosis. In many of the cases side by side. It's an M. R. I. Right? And it's applying is worth. But if you're supplying and flex your hip right, then you can cause stenosis from the green a ligament or your external iliac vein. So a lot of times positional. Typically we treat what is you know, a fix stenosis I would like and we should now make more studies for the alien queen itself because a lot of the non robotic really advanced diagnosis is actually positional. Who are the best candidates for such treatment? Alright, one more question and then we'll go on to the cases. Do I'll ask the whole panel do you think adama is always present in patients with venous hypertension? Whether it's superficial and deep done no Tony have classic skin downwards or even answer actually these people if you do proper studies macro diva is on microscopy but it's not perceived by the human eye. Right. But in reality like the question is asked often people don't have to have a demon. Yeah. All right. Uh Why don't we move along and who's up first for the cases corals, are you? I think it's me. All right, charlie. Yes. Shoot away. All right. Hold on as as carl is pulling up? Nico if the ultrasound is normal at the groin, your waveform, what are the chances that there's an iliac vein stenosis? Well, if it is all cameras, not much, but if there are people who have appropriate symptoms on that leg, it can be, you know up 10-15%. Because a normal ultrasound cannot exclude cyanosis. Where an abnormal ultrasound guarantees there is bilateral problem. Well, I've lost my slides, Jenna, you have. There you are. Alright, next slide. There we go. Are they showing, yep. Okay, so I'm gonna talk about the so called Rocca Talansky lesion. And um uh everyone talks about the row Kotowski lesion and I've I'm not sure that this case represents rock intensity, but we're gonna talk about it. Um It's very controversial as far as I'm concerned, it's my disclosures. So this patient is a 64 year old lady uh with the long history of left leg pain and swelling symptoms progressing should provoke DVT on three prior occasions. Uh and way back in 89 and 2012. And in February of 2020 is on any coagulation chronically at this time. Just a history of a previous art ablation of bilateral G. SVS. Years ago on the exam she had severe Dema of the left lower extremity was scarring left hand territorial surface due to old stasis ulcer severe hyperpigmentation and duration and large varicose network of the left anterior thigh extending into the calf, she was C. Five had a very high Vcs. S at 21. So carl um Jenna has your slides so just let her know when to move on. Okay, Jenna next slide. I'm not seeing what you're seeing. So I've got an issue. I'm advancing to myself. Oh so you have a leg up? Okay. We have the leg up. Um So this is what the leg looked like. And point out the the severe hyperpigmentation and in duration lipo dramatic sclerosis of the left leg. She also has some evidence of problems with the right but much less severe. And look at the knee. You can see varicose vein, the lateral knee area up moving up into the thigh which actually went up into the anterior thigh. So that left leg is quite bigger than the right. Yes. Much bigger. She's got you know, very very bad uh skin changes in the Dema and symptoms. Um And this is despite ablation years ago for G. S. V. So there's obviously something a lot more going on with this patient. Um So first question, what's the next appropriate step in this patient? She's in the office and we just took that picture uh initiate conservative treatment. Uh do a ct scan of the pelvic veins with venus timing and MRV or lower extremity ultrasound mm hmm. I think mostly are gonna get the correct answer. But yeah. So lower extremity ultrasound? Same as the winner, yep. That's good. Excellent. Mhm. So the second question what finding on an ultrasound suggests the possibility of deep venous obstruction is impulsive style venus flow. Nikos mentioned that earlier DVt of the thermal properties of veins. Does that suggest deep venous obstruction? Higher up loss of common femoral Doppler respiratory authenticity or fem pop deep venous reflux? Is that a sign of hypes of obstruction more approximately? Very good. We've got a smart group here the we always look at the femoral vein, paul, respiratory physicist. E on our routine diagnostic doctor of the lower extremities. It's very helpful if there is reduced physicist. E it means there is approximate instruction. However, if if the sign is not present, if there's preserved respiratory phases city, it does not necessarily mean that that there's a proximal obstruction because they know that that that there's not proper instruction because there there could be. And the collateral circulation providing for respiratory phases city? How about the presence of reflux in the femoral Patillo veins? Yeah. How about that? Does that does that represent the possibility of approximate instruction? To me? It doesn't to me it most commonly means that the patient has had prior DVT. Um I know that a lot of people look at this and wonder about proximal obstruction of the deep veins in the pelvis. If they have uh them pop deep venous reflux. But I don't think it does look at it statistically, I would look at the other way Tony. I mean, I think it's it's suggested there could be. but I think if there's no reflux in the deep system and no reflux in the superficial system there's a good chance there's no illegal cable disease. That's what Marston's paper showed. Um So I look at it you know, in the opposite, if I see reflux I just think could be go back to my clinical presentation Tony. This study has not been a problem to retrospective studies suggesting their findings, but reflex can be associated with obstruction without excluding previous debates from boston. The subject by statistics here statistics. I agree with carl over 90% of the people who have reflex. There's to be a previous dvt or superficial brain disease but not practical obstruction on its own. I agree. And I point that out because he had you know carl had it was one of the options. And I I often hear people and actually somebody just commented, I thought that deep reflex indicates proximal obstruction which I think is a misnomer or fallacy or myth Kathy, do you agree on that also? Yes I I'd agree. I mean I I see a number of for example people with varicose veins in their twenties um that also have deep venous reflux and no obstruction. You know when they present young and they seem to have genetic problems with valves or overflow from the superficial right, right. That's what I see most very very frequently. So what did the ultrasound show? She's got some reflux of the left hand to accessory. You remember her G. S. V. Has been a bladed says reflux of the calf gsp. There's sonic even the left hepatic vein and the left coming from a Doppler is a basic and so this is the reflux and her inter accessory and her calf Gs. V. It's actually pretty good reflux there. And this is the uh this is mislabeled. It's the left common femoral vein apologize but it's it's a basic. Go to the next slide. There you go. Okay. Oh just mention as you're moving along carl just say next. Okay next slide. So with these findings and with the horrible appearance of her leg we did take this lady to the cath lab and did pornography which is quite abnormal. Yeah pretty impressive. She has a long narrowing of the external common iliac vein. She's got some narrowing more importantly at the origin of the left common iliac bane. There's uh transport of the collateral development which is quite significant. So we proceeded then to ivy this next slide. Next slide. Next slide went to the office. You see the to the office and the other wire and then for being a cava confluence and there is a compressive lesion of the proximal left common iliac vein And there's the common iliac and extra iliac vein is very small and sort of diffusion. They're thick walled. And it correlates pretty well with where the vein was narrowed on the venogram? So right there. Yeah yep. Okay. Okay so next slide I got you carl. Next question. What is the diagnostic impression that left common iliac connection? Iliac vein select all of these. That might be correct. Cto with extensive collaterals, ili ephemeral compression. Arrgh Kotowski lesion. The thing that everybody loves to talk about all the time. Then the chronic from biotic inclusive disease. Check any of that are that are correct? So you gotta really ephemeral compression syndrome. Yes you definitely have uh you don't have a C. T. O. Yet really optimal compression. Uh For sure we saw that and uh you can argue whether it's a rock atanzi lesion or not if it's not real Kotowski it's a diffuse linear stenosis of the external iliac vein impartially of the common iliac vein. Um It's chronic from biotic. This is the result of old thrombosis but it's uh not necessarily from biotic inclusive. So let's go to the next slide. So the iris measurements resulted in measurement of 62% stenosis of the compressive lesion at the origin of the common iliac vein, 78% stenosis of the tight area. The external external iliac and 57% of the left common femoral vein. Next slide. So we proceeded to treat and this is I want to make some points on the procedure itself with this extensive disease. I would like to pre dilate. So we pre diluted with a 12 by six atlas. Gold balloon placed 14 by 1 60 vinovo stent and overlap the 14 by 60 vinovo And post deal with a 12 x six atlas. The original balloon looked very inadequate by Ibis. And so we did another with a 14 x six Atlas and gotta gotta gotta result will show in a minute. But at the point here is that I think we know now that with the newer night and all stents that we're using now. Um as opposed to the the wall stance you have to post dilate. You really need to post dilate and you need to post dilate with a 1 to 1 balloon ratio with your stent size in order to improve the crystalline structure of the night. North stem. It's been demonstrated to us by Stephen black uh and erin Murphy and I think that is appropriate. So afterwards this is what the office looks like. The next slide. You got the office up. Okay, you can see the stents fully. It's open and you get the slightly oval appearance to these vinovo stents and uh nice dark lumen. Obviously a clean lumen. So you brought this down to the level of the common femoral. Yes. And I'm gonna show you why in a moment. Mhm. Okay. Next slide the iris measurements post we had 100 and 50 square millimeters in the common, 135. Next culiacan and 42 in the common femoral. Next slide, let's look at the post venogram. I think it's interesting from the question that you asked. It was good flow, The collateral veins had basically disappeared um and it's a good result. But if you look right at the inguinal ligament area, that stent happened to end right at the inguinal ligament. So I overlapped with another stent to avoid the problem of a hinge point at the inguinal ligament. Yeah, I see that. Yeah. So I just thought that was one point that needed to be made. I try real hard not to end these stents at the inguinal ligament. You don't realize when you're looking at a a PV diagram, the posterior location of the deep veins and how they rotate from posterior to anterior in the lower pelvis. And when they cross the inguinal ligament, if you end the stent right there, you're going to produce a hinge point that will pinch that uh the the the vein that coming from a vein and caused an inclusion. I'm not so much worried about stent fractures anymore. Like we used to be. But um although I think they occurred they don't seem to be clinically relevant. But even on your original uh instagram, I probably would have brought it down to the common federal. Anyway, it seemed like there was some disease there, there was some disease there and I think it measured 57%. So yeah, you want to stem from good to good. So that's the point there, we don't want we don't spot stand like we do in the periphery. So if you were, you know, you landed right at the annual ligament. If you had pixie dust and you could remove that, you can adjust that stent. Where would you like the end to be? Uh Well if if say the patient has no disease beyond the common iliac or more cephalopod, external iliac, I would be happy to end it. Just uh cephalopod cephalon ring of the inguinal ligament. But if you do have disease in the calm, you know, right at that junction of the inguinal ligament, you come down to like the mid femoral head. Did you come all the way down to the lesser troll cantor of the lower common family? Depends on the, on the situation, the disease and the and the common femoral. Um if I'm doing a post dvt case, I'm very concerned about the pro Fundora being open. I want to make sure we actually never uh jail The profundity with the stent ephemeral generally comes in about the level of the lesser Tropicana. And we know that we can stand to the lesser trow kanner safely. But I don't necessarily feel like you have to do that or should do that necessarily. And paul, I mean with personal biotic disease, I mean how often is the, if you have changes in the level of the inguinal ligament. The throne has probably, you know, included the common ephemeral. So you probably have some disease in the common funeral, you're gonna have to come down now I come down to the end to cover the full extent of disease. You know, how about using uh I know that I don't know if the vici is out that reverse deployment for this situation. I don't I don't see a great need for that to avoid the issue I had with this case. Now what I do is before I place the stent when I I could have the office catheter up. I'll just use the markers on the eye vista to count how far down to our, I need to come and use what they used the longer stents. I'll just use a stent that matches the right size and you can, you can just determine your length by the ivies catheter very readily. I think the I think that reverse the deployment system for Vici is very good when you've got diffuse disease going down to your federal refund. If embarrassed, vain uh confluence and you really want to jail it. Excuse me. You really want to nail it right at the confluence and get all the scars and diffusing this. Keep disease common thermal. I mean obviously these stents don't force showing like the wall stones but even when you're putting a second stand and bring it down. You you know you may have the marker where you wanted to land but when you're deploying it. It doesn't always. Yeah I said I think that that reverse reverse system is rather clever for for the that situation. Alright go ahead. Alright so follow up one week later her leg pain and edema had improved significantly. Her stents were open. She had restored respiratory phases. City still had populated advance in Nicaea and was no dvt. She was improved one month later She would look the same symptoms remain moderately improved but she still had a Dema and and and and pain like heaviness and discomfort. Hervey CSS was still very elevated at 15. Some of that is related to the severity of her skin damage but still lots of you know really high B. S. B. C. S. S. So we decided to proceed with ablation of our left hand to accessory with Quebec to me of the varicose veins connected to the entire accessory simultaneously and informs claire therapy of varicose studies and also incidentally the kathie G. S. V. And that is to be done shortly. That's the end of the case. All right. Um Kathy I think you're up. Right. Yes I think I am. Let me get it shared right as you're putting it up. Ah anybody. What is the best way to do your venogram? Is it with the patient ethnic. Of course. Yeah. But is it with deep exhalation or inhalation or it doesn't matter. How do you guys do it? Well paul. I mean Tony you know that I get great vina Gramm's and you know I don't pay any attention to whether they're holding their breath or not. Yeah true. If you look for non robotic it's nice to do a very good val salva particular person to find to make sure it's not positional. That's the only thing. Yeah. I usually have them hold their bra so take a deep breath and push the and hold it. Yeah. Alright. Yeah that's what I do. Uh You ready for me to go see my screen? Okay so my case is a little bit like the last one but there's I think a few kind of hints and tips in this. These are the disclosure slides. So this is a 75 year old woman. Also like the last case has had three previous DVT. She's chronically anti coagulated. She has left like aching heaviness and like a dramatic sclerosis with some venus clarification type symptoms of difficulty climbing upstairs or exercising. And she dislikes taking warfarin and managing her in ours. So she's an overweight elderly female and her left leg is larger than the right and she has some visible varicose veins in her calf with like more dramatic sclerosis and hyperpigmentation. Not as bad as the last case but still bothersome to her and inhibits her exercise routine and you can see the left leg's larger than the right so her duplex shows that her G. S. V. Is re flexing and the measurements are there on the side. She also has reflux in her common femoral femoral political and tibial veins with noted webbing and some post inclusive changes throughout all of her veins. And then what looks like a nibble lesion, anomaly acting. Um Non robotic lesion it looks like on the Elvis velocity ratio which we always measures 3.8. And she's got reversal of flow in her internal iliac vein. So initially I thought that this would mostly be a kind of non from biotic type of case. Um So clinical decision making. Do I continue conservative management? Do I change your anti coagulation? Do I treat the GSB 1st? And if so how do I do it or do I treat the outflow first? So because she had really significant venus clarification type symptoms I attempted to access from the left femoral vein and I found that her left femoral vein was much more diseased than I thought that it was going to be and had difficulty gaining the mid thigh access that I like to do under ultrasound guidance so I could access and then nothing would thread. So I had to access a little higher than I like to do. So it was in the femoral vein but pretty close to the common femoral vein I was able to track a wire into the I. V. C. But my access is too low. And you'll see that in these pictures here that you can see these cross pelvic collaterals. Uh you see that this is really abnormal. You see these veins here. There's some extra visitation but I'm really too high to cover all the area of disease. And you'll see that on my um I visited I'm going to show you. And so this Ibis, because I'm starting from the femoral vein is going to be a movie going from the vena cava down towards my catheter. So we can see that here. It's the cava, there is a compression of the common iliac vein there and it's small. And then what you can see throughout is lots of webbing. So this isn't strictly a nivel there's robotic changes throughout this vein. Um Here's your external iliac. There's a collateral. You see webs and as they get lower it gets worse. Either it's very thickened and abnormal. And then I'm into my sheets. So I haven't reached a normal place where I could treat from the position that I'm in. So what do I do now do I continue conservative management try from the papa teal and see whether I can get up with maybe a little bit more elbow grease or other techniques. Do I go from the iJ. Whoops, Where's my polling question? Do you guys have that? Okay. I think I might have missed my first polling question. But this is the we're pressed for time. So what do I do? Let's go continue conservative management. Political access IJ access contra lateral or do something surgical paul. What do you think? Um Is the pre op duplex ultrasound show a healthy inflow or healthy deep thermal bank. So you know I've gone from the papa till if I think that the femoral vein is ratty but not included. I think getting through it a chronically included femoral vein is hard but if it's open I'll go from the pop and just land right at the the formal vein counted that as my inflow and go up through um jugular vein is an option and it's easy to land right at the deep thermal vein there. But I find that sometimes getting across diffuse the diseased or included. Really like veins you lose a little bit of flexibility in the cave A because it's big even with a stiff sheath. So I like coming from the leg. But that's my decision point. Is am I confident that the deep thermal vein is healthy and a good inflow vessel? Okay. Okay let's see what I did. So so most people said what did you do? Um I went from the neck. So here I went I j. And what you can see I decided to do because I wanted to ivy's the femoral vein and the deep femoral vein is I did buddy wires went ibis both and to make a decision um And you can see the two different wires there though. I've this catheter is going into the deep femoral vein on this picture. And so I kind of had my pick of where I wanted to land things. I'm going kind of fast because they know we're pressed for time. So then I pre dilated and also stinted and then post dilated. And this case I did when the nightingale stents were just kind of first out. And what I did is not what I would do now, right. What I would do now is I would do a night and I'll stand all the way down. But I put a wall stand low, kind of down under the inguinal ligament because there was a little nervous about how these stents would behave under the inguinal ligament. I'm not worried about that anymore with more experience. Um but I'm landing kind of, you can see where the deep femoral vein is coming because of the wire. I landed a little higher than what I'd like to like to it or what my goal was. But it wasn't bad. So I put a 12 millimeter walsten in below. And then I ballooned it to 12 millimeters. And then up above. Um you see there there's after one stents put in, looks better. But you can see all the collateral still up above. So I'm not finished. So then I'm treating the comment and I put a 14 Atlas balloon in and then a 14. Think that's a beachy Yeah, vici And that's not a venogram. You can see I've is a second. Not one of the beautiful movie vina, grams. I had trouble with that. But collaterals were gone. You can see they're also one thing to note the size of the bladder. This wasn't a fast case. Can see it took me a while. Her bladder is very full. Um This is the ivy's going from common femoral vein to next. So this is kind of I landed right in here. There's still a little webbing. But you see that the common femoral vein is an okay size here and then it gets more diseased further up. So very diseased here. External, quite diseased. And then it's, I'm coming up to the Vienna Kaveh and this lady has been open Now I put this in right after VHS were approved. So she's almost two years I think. Or about two years. The state open. So this is just kind of also um if you don't get it the first time there may be another strategy to try. I think we're almost sorry. It's so slow. Why would you do this case from a jugular again? Sure. Yeah, I would but I would probably not put a wall standing at the bottom. I do not know all the way. Um Okay. Duplex exam six weeks post stenting and then this is during what the stents look like. And this kind of brings the point of how curvy. Uh these are and how this other point that carl brought up is you don't want to end the stent in a straight section. and then this is flo post op through the stents. Yeah you're right Kathy I think it was your priest and Davis was my priest and Davis. Yes I don't have the post. I don't think I have the post office post office look good if I meant to put the post in. Ivascyn. But yeah that was protestant. But the ultrasound looks great. Ultrasound looks great. Yeah. So I didn't subject you to three services but you'll take my word for it. The third eye. This looks great. Um So one week of back and growing pain as usual and she noted improved improvement and heaviness and aching. So I gave her three weeks of anoxic parent then put her back on her warfarin which she hates. Um still has some varicose veins and what do I do now? Okay my choices are continued conservative management. Excuse me treat the superficial veins. How in the thermal ablation, foam glue or surgery. So she's better but still has symptoms. So she was on Coumadin beforehand. Yes she came to me on Coumadin. So that's easy as far as postant. Yes. Yes I said you're going to be and I can tell you I was going to keep her on Coumadin for six more months. And what if she wasn't um I would do three weeks of Lovenox and then probably put her on a Doha Doha back. That's what I usually do for how long six months minimum. Actually she was on it indefinitely. Three she's had three D. C. T. In general. One of the questions management post standing for your reference there indefinitely. Anti coagulated. We switched them to do wax pretty readily after six months. All right. But if they if they come in on a doe act though I do three weeks of an ox appearance and then switch it back to the duo app. Mhm. Okay well you're choking. I'm choking so I need to keep going second. We're gonna we're gonna let you go. Okay. So what I did on her I treated her with glue. Didn't stop the antique regulation. Um I like using non thermals when they've got lipo dramatic sclerosis which she had and she doesn't look all that much different in this picture but she felt better and her varicose veins are diminished. So I finished up six months of warfare and then switch her to eloquence. That's it. Okay. Alright we're gonna skip paul's and I will show you my case quickly as we're over time. But we the beauty of the virtual world is we just go um And I'm just gonna go quickly through this a couple of teaching points that I wanted to show you. These are my disclosures. So there's a patient who had an ablation done for gSP reflux from eight millimeter. Safra's vein a year ago for a venus holzer. He also ended appealing and comes back with persistent leg swelling. Um And some pain using compression stockings? B. M. I. is 38. The swelling again is unilateral. You got some on the other side but much worse on the left side. And this is what the leg looks like. Um paul. Would you go looking for any any any disease in the deep system in this patient? You know I would look with the ultrasound as best I can because if you find post robotics car that's important. But I don't know that I would necessarily go looking for compression lesion right off the bat, right and Tony. Maybe here because of swelling all the way up to the calf and circumferential skin diamonds extensive. That's most likely of some debate disease, you know, not just superficial. Uh it was 38. Right. Yeah. Right. Yeah. He does not have you know, he's got some swelling on the other side but not this circumferential skin damage. Alright. I'll concede that Nikos. And given his previous, you know venus ulcer Um Safa Knees was eight, nothing huge. Um So and he did heal with the superficial ablation. So the question is does he have anything in the deep system that potentially can be a cause of recurrence? Um So infrequent veins were normal, no reflection, obstruction, pelvic veins short compression and there was retrograde filling of the internal iliac. And this is the venogram. So what do you see here? Kathy yeah I'm sorry muted. So you see I think pan your we've got some pancaking on the one side, You've got some venous collaterals. Mhm. Four. You've got some retrograde flow in the internal. And it looks like, I'm assuming this patient's spine and it looks like you're left common is still scarred with as Kathy points out the collaterals. Um I stole this from your slide as you were presenting earlier. So I added it into this. So you see there's two channels here. Um And most likely this is the scar tissue that you would see um In typical presentation iliac vein compression. So these are fixed lesions that um obviously as nicolas mentioned earlier sometimes compressive lesions when you stand them up um that compression is not as significant. Um But if you're going to treat this, what where where channel did you go through carol? Any thoughts? Would you try the top or the bottom or it doesn't matter. First of all who's who's seen this is like the second or third case. I've seen like this. I've seen these and I think you go through which one you get through your skin is going to open it up. You can get through either one of them. I mean they're not inclusive. So I will say I've had one of these where I went through what was probably the smaller channel as much stent expansion as I expected. Right. Um So I think you know the one thing I would say of all the compression lesions is those left common iliac may 3rd a type chronic lesions. Oftentimes have a lot more scarred fibrosis than the others. Always aggressively pre dilate them first. And I would probably use how the balloon reacts to the aluminum in to see if that's the right lumen to put a stent in. So this is the lower channel um that I'm I've been through, I looked through both and they look pretty similar as far as area reduction. You see, it's pretty tight there just the catheter making it through and the vein opens up. And we're coming down into the external iliac. Read about. Here's the internal iliac is gonna take off here, right there. Here's your internal iliac. And excellently I've been here. So about a 64% area reduction. Is that is that good enough for you, Paul to intervene? Yeah, it would. Um The tone is a different scenario here is the venice flattened and has, you know, the spurs. So this is basically, it wouldn't matter maths, really. The area reduction. I think it's the exception in the rule. But you want to throw in the comment though, paul on video and and I mean, I think you know what the video study showed is that the the cross sectional area In um greater than 50% when you treated it. And seat 45 and six patients. These are people that had skin damage or worse when you send to those open, they tended to get better clinically at six months with a drop of their VCS escorts in the compression legions, not to post robotic patients but in the compression lesions It seemed that a slightly higher degree of narrowing was better predictor of depression. Excuse me. I have a clinical improvement. Maybe more of a 60 ah stenosis. So how about stem sizing here? So this is the external iliac and um I decided to use that as a landing zone rather than common alien because the common like seemed to be dilated. Um Would you what would you use carl with the night, newer nightingale stance? I would probably use a 14. Okay. Okay. Yeah. Alright. And would you bring this uh down to the external, would you stop above the internal over there personally? I would take to bring it down into the external. Well into the external. For sure. Alright. So we pre dilated with the 12 And post dilated with a 14 and use the 14th stent. And now we stopped about here, do you Cathy do you bring it lower down or is this good for you? Um I often bring them the more I do this the more I tend to use a small, definitely smaller diameters than I used to and longer stance. My habit. All right. You can speak. I think that it's acceptable what you did. I also think it would be acceptable to extend it further paul. What are you saying? I was gonna say? I think of the you know the external iliac really dips in the pelvis and I think of the extra iliac in thirds there's the cranial third, the third right above the inguinal ligament and then the middle third. And I don't like to land a stent especially the stiffer stents in the middle third because as the stench straightens out it causes tenting and narrowing of the vein. And we don't really know the implications of that clinically. But I just try to avoid it. So if I'm gonna be stenting to the middle third of the, extra of the pain I do what Kathy does and I go down to just above the inguinal ligament. Yeah so obviously here's the proximal third and you hear you can see a like a 60% 60 degree oblique view. You can see it's coming sweeping down oops nicely. It's not really because here is where it's gonna come down and into the growing, yep. So you're in the top third is good. Yeah. Um And then as far as where is the, so what I did actually to decide which obviously we stand to the the the lower portion as you can see my irises there. Um And I actually put a Katherine up and over the bifurcation and when I did a simultaneous venogram for both sides. It seemed obvious that the stent would lay nicer into the I. V. C a little bit going from the lower part than the top part because my my other concern is you know, if this really is collagen scar tissue or whatever when the extent expands, can it potentially compromise the contra lateral side? I don't know. Yeah. Um This is the the venogram first that thing you see the stents are a little bit high here. Um And here's the ibis but you know, based on the ibis, that's where it needed to go. Um So that's pretty much it. I think that looks good Tony. You've got plenty of room for the contra lateral side right there at the confluence. You're not really gonna compromise the other side. Yeah. I mean unfortunately it was a little higher than I wanted it. But on Ivan's that's where you know the lesion was. And you're better off extending a little bit into the ibc than than missing the lesion and having to put a second state. One thing got to be careful as as you know, Tony is making sure that stents not the same size as the I. V. C. And I think With the flared night and all stents, if you're thinking you're putting a 14 in and it flares to 17. You've got to make sure Your Kaveh isn't 17 that could interfere with the other side. So it's just a it's it's not it's not a reason not to use it. It's just something to think about. Yeah. Alright. Um Well I think we're gonna stop it. Hear any last comments from me. I know we have a bunch of questions still, but we'll try to answer them um and get them out to you guys. Thank you. Thanks for setting this up and inviting me. Okay, so this is the next DVS is going to be June 4th. Put on your calendar. Um We're gonna be talking about non robotic allergic vein lesion, it's gonna be a live case. Um So we'll talk in the morning, so put it on your calendar. Well, we will have a live case for you guys from my belief of Elias and Englewood. Thank you everyone and invite you to our venus symposium next month. Whoever can make it. We'll see you there. See you Cathy. Good bye guys, Good night carl. Everybody take care and I'd like to thank last thing phillips for putting this together. Excellent. Absolutely. Thank you. Well done everyone. Thank you. Bye bye.