LINC 2018 live case guide

Galway

• Tuesday, January 30th: 9:10 - 9:30, Room 2 - Main Arena 2

  Case 11 – Left lower limb DVT

  Center:

  Galway

  Case 11 – GAL 01: female, 57 years (A-J)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  CLINICAL DATA
  - 8 day history of low back and pelvic pain; 4 days history of leg pain
  - Swollen, purple, tense; normal pulses
  
  PRESENT STATE
  - No prior history, no medications, no cancer
  - Recently laid up with severe flu
  - US diagnosed left Ilio-femoral deep vein thrombosis; confirmed on CT
  
  PROCEDURAL STEPS
  1. Prone position; US guidance
  - 11F sheath; 5000u IV Heparin
  2. Initial venograms; cross lesion with hydrophiic wire (MERIT MEDICAL); confirm position in IVC
  3. Penumbra Indigo 8F Cat system 80 cm long
  4. May or may not use Alteplase 5–20 mg
  5. Repeat venography
  6. Aspiration
  - 7F Detachable Hub sheath (TERUMO) or 8F 45 cm Hockey Stick (CORDIS)
  7. IVUS
  - VOLCANO/ PHILIPS
  8. Balloon
  - Atlas 14–16 mm at high pressure (>20 atm) (BARD)
  9. Venous Stent
  - Zilver Vena 14/140 mm inferiorly (COOK); 16mm x 100 or 140mm superiorly; repeat balloon dilatation to nominal diameter stent
  10. IVUS to confirm full stent expansion; minimal venography to finish; CDUS Day 1; pneumatic compression boots; Class 2 thigh high stockings x 6 weeks
  

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• Tuesday, January 30th: 12:15 - 12:30, Room 2 - Main Arena 2

  Case 15 – Dealing with a chronic post thrombotic iliac obstruction

  Center:

  Galway

  Case 15 – GAL 02: female, 57 years (S-C)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  CLINICAL DATA
  - Swollen left leg 10 months after an IF DVT
  - Initially presented April 2017 with acute L IFDVT
  - Delayed diagnosis
  - Attempted lysis treatment complicated by genuine anaphylactic reaction to iodinated contrast
  - Abandoned
  - CTV showed IVC to ankle DVT
  - Transferred to Galway; 3 days CDT improved situation, did not stent
  - Anticoagulated for 7 months; leg has improved; still some venous claudication
  - MRV to follow: MRV shows chronic iliac occlusion IVC to L CFV
  - We think CFV is good enough for inflow
  
  PROCEDURAL STEPS
  1. Access R IVJ; L FV or PFV General anaesthetic; supine, urethral catheter
  - 10F 35cm sheath
  - 8F Hockey stick
  - 5f CXI catheter (COOK)
  - Road runner wire (COOK) or Glide wire (MERIT MEDICAL)
  2. Ideally cross from above and below; confirm position – multiple obliques
  3. Predilatation @ 20atm
  - 16 mm Bard Atlas CIV EIV
  - 14 mm CFV 12 mm PFV
  - or FV cephalad end
  4. Stent choice
  there is no right or wrong; no stent has a proven advantage over another – so: deploying from inferior to superior
  - 14 mm Wallstent/ Veniti Vici/ Bard Venovo/Cook Zilver Vena/ OPTI MED Sinus Venous/ MEDTRONIC Abre; then 16 mm to CIV
  5. Identifying the dominant inflow by IVUS is probably the key step to this case
  6. Post stent dilatation; same size balloons to high pressure
  7. Confirm full stent expansion with IVUS
  8. Venography to finish
  9. Pneumatic compression boots
  (Tyco/COVIDIEN); Class 2 stockings; CDUS day 1; full anticoagulation before, during and after
  
  

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• Tuesday, January 30th: 13:30 - 15:00, Room 2 - Main Arena 2

  Case 17 – IVC sewn graft – occluded – what to do?

  Center:

  Galway

  Case 17 – GAL 03: male, 47 years (M-M)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  CLINICAL DATA
  - Leiomyosarcoma IVC resection 1996;
  - IVC sewn graft;
  - patient for years and discharged to GP;
  - recent severe RTA;
  - no head injury;
  - mildly swollen legs but now more severe
  
  CT
  CT abdomen with IV contrast as shown
  
  PROCEDURAL STEPS
  1. Access
  - 10F 35 cm sheaths above and below- RIJV + L CFV + R CFV
  2. Support catheters
  3. Hydrophilic catheters and wires
  4. If successful in crossing, then CBCT (SIEMENS) to confirm all intra-luminal
  5. Exchange to 260 Lunderquist wires (COOK)
  6. Capturex from above to trap any debris
  - Consider use of Aspirex (STRAUB) – I don't know how acute this is really
  7. Attempt balloon dilatation
  - Kissing 14 mm balloons (BARD ATLAS) entire length of occlusion
  8. Kissing stents with high resistance to compression
  - Veniti Vici 14/120 mm and or Sinus XL 24/80 to top end; distal extension to mid CIV or EIV bilaterally
  9. Post stent implantation to same high pressure (>20 atm)
  10. IVUS , venography and CBCT to finish
  - Normally I wouldn't use this much radiation but this is a bit unusual!!!
  
  

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• Tuesday, January 30th: 16:30 - 18:00, Room 2 - Main Arena 2

  Case 19 – SVC occlusion in a dialysis patient

  Center:

  Galway

  Case 19 – GAL 04: male, 39 years (J-G)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  CLINICAL DATA
  - 3 prior renal transplants, current one is failing
  - innumerable previous central lines for dialysis
  - now has symptoms of SVC obstruction
  
  PRESENT STATE
  - Clinically sleeps with 4 pillows
  - swollen face, lips, hoarse voice – CTV initially read as no obstruction – however at MDM complete obstruction noted
  - Previous attempt to cross failed
  
  PROCEDURAL STEPS
  1. General anaesthetic; cardiothoracic back up; 6 units grouped and cross matched. Arterial line
  2. Access above and below 14F sheaths
  3. Get good support catheters up close to occlusion and obtain best oblique. Try to cross with a variety of wires including hyrdophilic; stiff hydrophilic; Road Runner (COOK); Asahi Astata 30g curved tip
  4. If unsuccessful then, in best oblique; line up TIPS need or Trans-Septal needle with a snare- shoud we go from south to north or via versa??
  5. If we get across then balloon dilatation- unlike in iliacs where we go straight to 16 mm we will start here with 4/6/8/10; probably use a covered stent? Viabahn 13 mm x 50 mm; possibly reinforce with a Venous Stent like Bard Venovo
  6. Post dilate to 12/14 mm
  7. CBCT and IVUS to finish
  

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• Tuesday, January 30th: 16:30 - 18:00, Room 2 - Main Arena 2

  Case 20 – Covera (Bard) covered stent graft to resitance venous stenosis

  Center:

  Galway

  Case 20 – GAL 05: male, 49 years (A-O-M)

  Operators:

  • M. Al Hajiry,
  • Gerard O'Sullivan

  CLINICAL DATA
  - Right arm AVF created 2010
  - treatment resistant cephalic vein stenosis
  - brachial artery to cephalic vein
  - recurrent high venous pressures prolonged bleeding – has been dilated every 6 weeks to 3/12 – we are looking for a bit more durability
  
  PRESENT STATE
  End stage renal disease
  
  PROCEDURAL STEPS
  1. Right arm AVF access using micropuncure set and then a pursestring suture
  2. Cross lesion using hydrophilic wire and then stiff wire into IVC
  3. Predilate with high pressure balloon to 10mm (its usual size)
  4. Covera stent graft (BARD) to cover the lesion and avoid covering much of subclavian vein beyond
  5. 3000u IV Heparin
  6. Purse-string suture
  7. Dialysis following day
  
  

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