LINC 2019 live case guide

Find all live cases and live case centers listed below.




6 livecase(s)
  • Tuesday, January 22nd: - , Room 2 - Main Arena 2

    Case 10 – Left ilio-femoral acute deep vein thrombosis

    Case 10 – GAL 02: female, 45 years (K-B)
    • Gerard O'Sullivan
    2 week history of low back pain, radiation to left groin,
    1 week history of a painful swollen leg
    No specific risk factors

    1. Pre op: CTPA to assess for pulmonary embolus CTV for intra-abdominal veins US to confirm popliteal vein is patent
    2. Initially supine; ultrasound guided puncture right internal jugular vein; Capturex device (STRAUB MEDICAL) in position – get the goalkeeper in place!
    3. Now turn prone; ultrasound guided puncture of left popliteal vein; 10F sheath; 5000u IV Heparin
    4. 65 cm torqueable catheter and 180 cm glidewire; once past lesion exchange for 0.025“ wire
    5. Aspirex Thrombectomy catheter (STRAUB MEDICAL)
    6. 8F Hockey Stick (CORDIS) for aspiration post thrombectomy – pay attention to profunda and internal iliac veins
    7. IVUS-Volcano (PHILIPS) to assess diameter and confirm need for a stent
    8. 14 mm ATLAS balloon (BARD) to 20 atm
    9. SINUS Venous 14/150 stent (OPTIMED) – slow deployment; repeat balloon to same diameter and pressure
    10. IVUS (PHILIPS) to confirm full stent expansion; followed by venography to confirm rapid flow
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  • Tuesday, January 22nd: - , Room 2 - Main Arena 2

    Case 13 – May-Thurner-Syndrome left

    Case 13 – GAL 03: male, 55 years
    • Gerard O'Sullivan,
    • M. Mullin
    55 year old male presents with left lower limb swelling, pain and impending ulceration of the left lateral gaiter region December 2017.
    Background History:
    Antiphospholipid syndrome complicated by reccurent left sided DVT and PE
    Aortic valve replacement complicated by subdural haematoma, requiring evacuation 2013
    Recurrent subdural and subarachnoid haemorrhages due to lifelong anticoagulation

    Antiphospholipid syndrome
    DVT and PE. IVC filter in situ
    Recurrent subdural and subarachnoid haemorrhages
    CT venogram: IVC filter
    Left sided May-Thurner syndrome
    Bilateral lower limb varicose veins, including enlarged left greater saphenous vein.
    Severe ulceration along LATERAL border left foot – normal ABPIs

    1. CT venogram. Supine. General anaesthetic. Urethral catheter
    2. Right internal jugular vein puncture
    - 5F microaccess kit (COOK); 10F 23 cm sheath
    3. Guidewire placement
    - 260 cm Glidewire and 100 cm kumpe catheter to left common femoral vein.
    - 5000uIV Heparin.
    4. Biplanar venography
    - (AP and LAO for left) and IVUS Volcano (PHILIPS) evaluation;
    - left iliac system under pressure; but right may be abnormal also IVUS very helpful in this regard
    5. Balloon angioplasty from the common femoral veins to the renal IVC
    - 14 - 16 mm angioplasty @ 18–20 atm (ATLAS, BARD) of the common femoral and external iliac veins
    - 16 - 18 mm ATLAS (BARD) @ 18–20 atm of the common iliac vein
    6. Stenting
    - Abre (MEDTRONIC), Zilver Vena (COOK) or Venovo (BARD) 16/14mm diameter – uncertain of length as yet – stent from normal to normal
    7. Post stent balloon dilatation to nominal diameter stents
    8. Repeat venography and IVUS
    9. Post-op care
    - Pneumatic boots until discharge and class II thigh high stockings 3/12
    - Anticoagulation for life as per haematology department
    - Follow-up colour doppler US day one post-op
    - Follow-up CT venogram 6/52
    - CTV at 6/52
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  • Tuesday, January 22nd: - , Room 2 - Main Arena 2

    Case 13 – May-Thurner-Syndrome left

    Case 13 – GAL 03: male, 55 years
    Limited physical performance
    History of acute venous thrombosis right common iliac vein (2013)
    Several catheterizations as newborn

    MR-venography: atresia of entire inferior vena cava starting from the liver veins, bilateral common iliac vein occlusion, prominent collateral veins (vena azygos and lumbar veins)
    Spiroergometry: limited oxygen uptake during exercise due to impaired venous return (60% of norm)
    Villalta score: 9 points

    patent common femoral veins

    1. General anaesthesia, Ultrasound-guided access:
    right and left common femoral veins and possibly right jugular veins (10F)
    2. Passage of occlusion of vena cava and iliac veins using stiff angled glidewire 0.035“, Astato 0.018“
    CTO wire with 30 g tip load, angled CXI 0.035“ support catheter
    3. Lesion examination by selective venograpy two planes, intra-occlusion venography and provisional IVUS
    4. High pressure Balloon angioplasty up to 20 mm in vena cava, up to 14 mm iliac veins
    5. Stenting of IVC with two overlapping 20 mm Venovo (BARD) stents and high pressure postdilation up to 20 mm (ATLAS GOLD, BARD)
    6. Y-reconstruction of iliac confluens using Venovo 14 mm kissing stents (BARD)
    7. Kissing Balloon postdilation of iliac confluens with 14 mm ATLAS GOLD balloons (BARD)
    8. Possibly stent extensions to both external iliac veins using Venovo 14 mm stents (BARD) with postdilation up to 14 mm high pressure
    9. Final venograms and assessment of peak flow velocity in both common femoral veins by Duplex sonography
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  • Tuesday, January 22nd: - , Room 2 - Main Arena 2

    Case 15 – Failing dialysis graft

    Case 15 – GAL 04: male, 66 years (H-G)
    • Gerard O'Sullivan,
    • G. Rahmani
    End stage renal disease. On maintenance haemodialysis through a right arm arterio-venous fistula-brachiocephalic.
    High venous pressures with excessive bleeding post HD

    Diabetes mellitus, haemodialysis

    1. Supine, local anaesthetic, right arm AV access towards heart
    - 9F sheath
    - 3000u IV Heparin
    2. Initial venography to confirm lesion and measure appropriate diameter and length
    3. Cross lesion under roadmap control; predilatation with 8 mm balloon
    4. Lutonix (BARD) 8/40 drug eluting balloon
    5. Covera (BARD) 8/60, 9/60, 10/60 stent graft
    6. Completion venography
    7. Purse string suture
    8. Anti-platelet medications NSA 300mg stat and 75 mg/d x life
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  • Tuesday, January 22nd: - , Room 1 - Main Arena 1

    Case 06 - Post cancer IVC and iliac vein occlusion with impending ulceration

    Case 06 – GAL 01: male, 26 years
    • Gerard O'Sullivan,
    • M. Mullin
    26 year old male, initially presented with a scrotal mass (July 2017), and was found to have metastatic testicular cancer. Subsequent CT demonstrated large retroperitoneal lymph nodes and IVC; 3 months
    into treatment he developed right iliofemoral and left common iliac venous thrombosis. He was treated with therapeutic Innohep (Figure 1). Unfortunately, whilst on treatment, he suffered a further left lower limb DVT in October 2017. Gradually worsening swelling both legs, worse on the right. The patient was referred to the IR clinic in December 2018 with bilateral lower limb swelling and signs of chronic venous hypertension (Figure 2).

    In complete remission from original cancer. Worsening right leg swelling – impending ulceration;
    frequent sick leave; barely able to hold down a job. Works as a foreman in a yard.

    Bilateral lower limb post thrombotic syndrome and chronic venous hypertension December 2018.
    MRV demonstrates an occluded and fibrotic infrarenal IVC and common iliac veins with reconstitution at the level of the common femoral vein (Figures 3–5). The patient had also developed numerous abdominal
    wall collateral veins.

    1. Pre-op: Bloods: FBC, U&E, Coag; MR venogram, general anaesthetic, urethral catheter
    2. Right internal jugular access 10F sheath; bilateral common femoral vein puncture using 5F microaccess kit (COOK) – attempt to cross from neck initially; 7500uIV Heparin
    3. Crossing cather (CXI/CROSSER/RUBICON) to get from above to below or visa versa.
    4. Biplanar venography (AP and LAO for left, AP and RAO for right) and IVUS (VOLCANO, PHILIPS) evaluation
    5. High pressure balloon predilatation (ATLAS, BARD) 14 mm kissing throughout IVC and Iliac veins to groins
    6. Stents Veniti Vici (BOSTON SCIENTIFIC) 14_120 kissing IVC and CIVs_ Wallstents 14_90 (BOSTON SCIENTIFIC) into groins_NORMAL to NORMAL
    7. Post dilatation to same diameter and pressure
    8. IVUS and venography
    9. In case of rupture back up 12F sheaths and GORE Viabahn 13 mm_100
    10. Standard post op care_ boots_ stockings_ maintain full anticoagulation; Colour Doppler Day 1 and CTV at 6 weeks
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  • Tuesday, January 22nd: - , Room 2 - Main Arena 2

    Case 19 – Chronic LLE swelling and venous claudication

    Case 19 – GAL 05: female, 34 years (L-E)
    • Gerard O'Sullivan
    Moderately swollen left leg; marked varicose veins; significant venous claudication

    Developed LLE DVT 2012 while on OCP. Repeat DVT LLE 2016.
    No other risks. Non smoker. No longer on OCP. On life long anticoagulation.
    CTV shows left ilio-femoral venous occlusion

    1. Supine. GA. Urethral catheter.
    - RIJV 10F sheath 30cm long. Left femoral venous puncture mid thigh 4F catheter.
    - 5000u IV Heparin
    2. Crossing the lesion
    - 8F 55 cm Hockey stick to provide support. Crossing catheter (CXI); choice of wires - angled glide; stiff angled
    glide (both Merit Medical); Roadrunner (COOK)
    3. Confirm correct plane with oblique views, IVUS and venography.
    4. Predilatation
    - BARD ATLAS 16 mm @ >20 atm L CIV; 14 mm@ >20 atm LEIV L CFV
    5. Stenting
    - BARD Venovo or COOK Zilver Vena or MEDTRONIC ABRE of appropriate length
    6. Post dilatation to nominal dimater stents @ >20 atm
    7. Completion venography and IVUS
    8. Standard post op care
    - Pneumatic boots, stockings - Class 2 thigh high; maintain full AC; check CDUS day 1/30/180
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