Steven D. Abramowitz

Endovascular Iliocaval Reconstruction for Chronic Iliocaval Thrombosis: The Data, Where We Are, and How It is Done

Iliocaval thrombosis, or thrombosis of the inferior vena cava and iliac veins, is associated with significant morbidity in the form of limb-threatening compromise from phlegmasia cerulean dolens, development of post-thrombotic syndrome, and death secondary to pulmonary embolism. Endovascular iliocaval reconstruction is an effective treatment for iliocaval thrombosis with high levels of technical success, favorable clinical outcomes and stent patency rates, and few complications. It is often able to relieve the debilitating symptoms experienced by affected patients and is a viable option for patients who fail conservative management. This article presents an approach to endovascular iliocaval stent reconstruction in patients suffering from chronic iliocaval thrombosis that takes into consideration background, patient selection and indications, timing of intervention, procedural steps, technical considerations, postprocedural care, and outcomes, along with providing schematic illustrations that serve to outline iliocaval stent reconstruction and management of chronic venous occlusions.

Open Surgical Management of Deep Venous Occlusive Disease

Endovascular techniques have revolutionized the management of deep venous occlusive disease. Open surgery, however, is still required for cases that prove refractory to endovascular interventions. The surgical management of deep venous occlusive disease typically involves venous bypass. Preoperative planning before open venous surgery relies upon dynamic imaging to clarify the location and severity of venous obstruction, the assessment of infrainguinal reflux, and the delineation of bypass origination and target vessels. Adjunct arteriovenous fistulas and anticoagulation may improve patency rates of open surgical venous bypass. The timely recognition and management of complications improves secondary patency rates.

VESS06. An Intravascular Ultrasound-Based Scoring System May Predict Future Stent Failure in the Treatment of May-Thurner Syndrome

comparison to CEA. Patients enrolled in this project were compared with those undergoing CEA during the same period (2016-2017). The primary outcome was a composite of in-hospital stroke and death. Average treatment effects were estimated by augmented inverse-probability weighting. Additional analysis was performed using multivariable logistic regression as well as various matching techniques, such as propensity score matching and coarsened exact matching. Adjusted analysis accounted for age, sex, race, insurance status, coronary artery disease, congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, symptomatic status, restenosis, prior vascular procedures, degree of ipsilateral stenosis, and preoperative medication use. Results: A total of 637 patients underwent TCAR compared with 12,049 patients who underwent CEA. Patients undergoing TCAR were older, more likely to be symptomatic, and had more medical comorbidities, such as coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and prior vascular procedures, compared with CEA patients (Table). The majority of TCAR procedures were done under local/regional anesthesia (95.3% vs 9.7% in CEA; P < .001). On average, TCAR was 36.7 minutes shorter than CEA (78.0 6 33.9 vs 114.7 6 42.5 minutes; P < .001). On univariate analysis, there were no differences in the rates of in-hospital stroke/death (1.3% vs 1.7%; P 1⁄4 .42), overall neurologic events (2.0% vs 1.9%; P 1⁄4 .83), in-hospital myocardial infarction (0.7% vs 1.1%; P 1⁄4 .31), and 30-day mortality (0.5% vs 0.9%; P 1⁄4 .08) between CEA and TCAR, respectively. Patients undergoing CEA had higher rates of cranial nerve injury (2.8% vs 0.8%; P < .01) and postoperative hypertension (18.3% vs 11.6%; P < .001) compared with TCAR patients. On multivariable analysis and using different matching methods, there were no differences in overall stroke, stroke/death, or overall neurologic events (Fig). The absolute difference in adjusted stroke/death rates between the two groups was 0.3% (95% confidence interval, 1.7% to 1.0%; P 1⁄4 .64). Conclusions: Despite a substantially higher medical risk in patients undergoing TCAR, analysis of the preliminary results from the SVS Vascular Quality Initiative TCAR Surveillance Project showed similar in-hospital stroke/death rates between TCAR and CEA after multivariable adjustment and rigorous matching. Further studies with larger sample sizes and longer follow-up will be needed to establish the equivalence of TCAR compared with CEA.

SS25 Endovascular Renal Vein Confluence Stenting Does Not Compromise Renal Function or Patency

Age (years) 1.00 (0.95-1.05) .945 Gender (male) 0.86 (0.27-2.67) .790 Diabetes 5.50 (1.42-21.30) .014 14.83 (1.58-139.52) .018 Hypertension 1.00 (0.32-3.11) 1.000 BMI (kg/m) 1.00 (0.89-1.11) .940 Smoking Former smoker 0.55 (0.16-1.91) .348 0.45 (0.08-2.65) .380 Current smoker 5.50 (0.54-55.49) .148 13.70 (0.61-309.76) .100 Kidney injury 0.57 (0.05-6.76) .657 Pulmonary disease 1.56 (0.43-5.59) .499

Radiographic Findings of Distressed Venous Stents and Inferior Vena Cava Filters: Clinical Implications

OBJECTIVE The objective of our study was to describe an association between the radiographic appearance of distressed intravascular implants and venous stenosis or occlusion and to determine the success of reparative endovascular procedures. MATERIALS AND METHODS Seventy-eight patients with distressed stents or inferior vena cava (IVC) filters characterized by pursing (short-axis contracture), straightening, longitudinal contraction (long-axis contracture), or fracture were identified from retrospective review of a venous registry for the period from February 2004 to October 2016. Patients originally presented with superior vena cava (SVC) syndrome (n = 25), arm swelling (n = 16), iliocaval thrombosis (n = 21), and lower extremity deep venous thrombosis (n = 16), and stents were initially placed in 65 and filters in 13. Implants were located in the IVC (n = 24), subclavian vein (n = 16), brachiocephalic vein (n = 15), common iliac vein (n = 10), multiple veins (n = 4), axillary vein (n = 4), common femoral vein (n = 3), SVC (n = 1), and internal jugular vein (n = 1). Implants included Wallstents in 63 patients; Smart stents in two patients; and Celect Platinum, Denali, Greenfield, and Trapease IVC filters in two, three, two, and six patients, respectively. Venographic indication, distress type, time from initial normal placement to identification of distress, venographic finding (patent, mild stenosis, high-grade stenosis, or occlusion), treatment, revascularization outcome, and complications were recorded. RESULTS The mean time to distress was 23 months. Fifty-two (67%) patients underwent venography for symptoms and 26 (33%) for surveillance. Forty-five (58%) implants were pursed; 19 (24%), straightened; nine (12%), contracted; and five (6%), fractured. Venography depicted 48 (62%) high-grade stenoses, 19 (24%) complete occlusions, and six (8%) mild stenoses. Of the 73 patients who underwent an intervention, 29 (40%) underwent angioplasty, 15 (21%) underwent angioplasty and stenting, 15 (21%) underwent sharp recanalization, and five (7%) underwent thrombolysis. Revascularization was successful in 67 (92%). Three minor complications occurred. CONCLUSION Distressed intravascular implants are associated with high-grade venous stenosis or occlusion. Reparative interventions are usually technically successful.