Technical talk on venous stents, by Peter Schnatterbeck

Peter Schnatterbeck

DVT triad: flow, endothelial injury and hypercoagulability

Stenting increases the endothelial injury in veins rather than improving it!

Also, a stent in veins can still occlude despite good flow

It is very important to have pneumatic boots and to get out of bed early.

Thrombus in vein incites a lot of inflammatory process - leads to vein fibrosis and valve destruction.

Rationale to treat acute DVT

- 50% of patients with ileofemoral DVT get PTS

- 15% approximately will get ulceration (this seems rather a high figure from acute DVT…)

- 45% approximately remain symptomatic with non op Rx

PS says surgery has a place in UL DVT because there is limited endovenous to offer in the ULs

The ATTRACT trial showed no difference - PS states need to be cautious after this trial

What are the things to look for on imaging

Does the thrombus enter the IVC?

Is there a mass lesion like cancer?

Is there a PE? Is there right heart strain?

Is there a May-Thurner or similar type of compression?

New devices: FlowTriever is similar to ClotTriever. FT can suck out PE clot.

For IVC or ileofemoral DVT without PE consider ClotTriever with FlowTriever protection discs. PS says these seem to be a bit like an Amplatzer plug.

You cant put an IVC filter in through a popliteal puncture because the device shaft length wont be enough.

Can’t use a mechanical thrombecdtomy device on an occluded stent; you can use an aspiration device though.

Picture of the ICVO classification system

When you use rTPA lysis use a checklist for the contraindications

FU measures of importance, 5:

Anticoagulation

pneumatic boots overnight

Then pneumatic compression stockings

DUS on day 1 post op and CT / MRV at 6 months

Early mobility is v important

CHRONIC DVT

is a different beast

no clear consensus on what is a signifiant lesion

Imaging to use is much more complex. US is of limited use.

Intraoperatively need combination of multiplanar venography and IVUS

can reconstruct an occluded IVC endovenous even with only about 5 cm patent in the infrahepatic segment

you would almost always end up having to overstent the right side when you stent a left CIV such as for a May-Thurner.