Recanalization of an ilio-femoral chronic venous obstruction

This didactic procedure concerns a left side ilio-femoral chronic venous obstruction.

Educationnel objectives

• Plan a step-by-step ilio-femoral chronic venous obstruction procedure.
• Materials choice: guidewires, support catheters, balloons and dedicated stents.
• Learn different techniques to advance and manipulate guidewire through the occlusion.
• How to proceed to an optimal lesion preparation?
• Tips and tricks for a good positioning and implantation of the stents.
• Advantage and usefulness of IVUS to optimize the procedure?
• Importance of adjunctive pharmacotherapies?

Step-by-step procedure: Left internal carotid artery stenting

1) Access sites:

• Femoral access: Echo guided puncture at mid femoral vein (Sheath position: upstream to the lesion and avoid conflict between the sheath and the occlusion).
• 7 French sheath.
• First contrast injection to establish vein cartography with different collaterals.
• Anticoagulation.

2) Recanalization

• Park an angled stiff Terumo® RADIOFOCUS® wire 0.035” at the entry of the occlusion.
• Advance the wire through the occlusion: with a combination of torque and push movements with the support of a vertebral Glidecath® TERUMO®catheter 4Fr.
• Improve wire support after advancing through the lesion with a support catheter TrailBlazer™ catheter (after 2-3cm through the occlusion, improving the support to ensure enough pushability is extremely important).
• Check the trajectory of the wire in different orthogonal projections to be sure that the wire is in the vessel structure.
• Advancement with the loop wire technique in the common iliac vein (in case of failure to advance with the straight tip of the wire).
• Angio control to check the progression of the wire.
• Tips and tricks: To be sure that you are in the IVC: In the lateral projection, the wire or the catheter should be ventral to the vertebral body.
• After crossing the lesion exchange with a 0.035” Amplatz super stiff™ wire.
• Balloon pre-dilatation: Balloon pre-dilatation should be done from healthy -to- healthy part of the vein. A 7*60 mm Mustang® balloon used to dilate at the distal part of the occlusion (usually start at the proximal part of the occlusion unless facing difficulties to progress the balloon through the occlusion).
• Pre-dilatation with a 12*80mm Mustang® balloon.
• Stent diameter choice: external iliac vein: 12-14cm and common iliac vein: 14 -16 cm.
• IVUS control VISION PV 8.5 Fr 0.035”*90cm : Useful information from IVUS: results of the pre-dilatation, maximum point of the compression, length and diameter of the stent and landing zone of the stent (in addition to reducing contrast injection and radiation).
• Positioning the stent from healthy to health part of the vein.
• Use a dedicated vein stent ATLAS GOLD® 14*60mm, ABRE™ STENT 14*150mm, ABRE™ stent 12-80mm (avoid overlapping at the level of the ligament area).
• Post dilation of the stent.
• IVUS control : stent opening geometry and control the landing zone.
• Final angio control: stent patency with no visualization of the deep femoral vein and the collaterals.
• Adjunctive therapies: Aggressive anticoagulation to maintain stent patency.
• Femoral access: Echo guided puncture at mid femoral vein (Sheath position: upstream to the lesion and avoid conflict between the sheath and the occlusion).
• 7 French sheath.
• First contrast injection to establish vein cartography with different collaterals.
• Anticoagulation.

Protocol

• Procedure time 125 min
• Exposure time 29.91 min
• Exposure 11463 mGy.cm²
• Contrast vomule :70ml Ioméron 350

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