Tips for Successful Venous Occlusion Intervention

HARALDUR BJARNASON, MD The key to successful inferior vena cava (IVC) and iliac vein recanalization is to understand the anatomy. One must take into account the overall anatomic situation, inflow and outflow, or more precisely, the health of the common femoral veins and feeding veins (profunda and femoral), as well as the cephalic extension of the obstruction. It is therefore crucial to have good cross-sectional imaging for planning purposes. I have relied on CT venography with formatting in the coronal and sagittal view, but I also feel very comfortable using MRI. If the disease extends far proximal into the IVC to the level of the renal veins or even the hepatic veins, cross-sectional imaging will provide information regarding the renal vein patency and the hepatic veins. I also perform a duplex ultrasound examination of the lower extremity veins, which will give a better indication of the health of the common femoral vein and display prognostic indications on how widespread the postthrombotic changes are in the deep veins of the entire limb. Procedures that only involve the iliac veins can be performed using local anesthesia and intravenous sedation, but IVC recanalization typically requires the use of propofol. For IVC recanalization, a urinary catheter is also placed, as these procedures can be prolonged. Patients are fully anticoagulated during the procedure with unfractionated heparin, with a target activated clotting time of approximately 300 seconds. HOW TO CHOOSE THE ACCESS SITE I select my approach based on the preprocedural imaging evaluation. For isolated iliac vein recanalization, my primary access choice is the right internal jugular vein, although I also like to have the ipsilateral groin prepped in case I cannot recanalize from the IVC. The reason for the jugular vein (remote) approach is that if there is involvement of the common femoral vein, profunda femoral, and femoral vein, I can more easily dilate the inflow vessels from above, as coming from below is much more challenging. The remote approach also gives you distance from the diseased area and allows for more precise distal stent placement. The challenge with the jugular vein approach is precise proximal stent placement (at the bifurcation), especially with stents that foreshorten significantly during deployment. For the more complicated bilateral iliac vein and IVC occlusions, I typically have both groins prepared, along with the right neck. I then make my first puncture in the common femoral vein, where there is the least amount of disease present, and I will perform the recanalization all the way through the iliac veins and the IVC from there. I typically dilate the IVC and the ipsilateral iliac veins from that access and then puncture into the right internal jugular vein and place a 45-cm-long, 10-F introducer. I then recanalize the contralateral iliac venous system from the jugular vein access, which allows for inflow angioplasty on the more diseased side, and stents are placed accordingly.