Complex venous angioplasty and stent placement

AgnieszkaMarek

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EXAM:
1. Left lower extremity and pelvic venogram
2. Venous balloon angioplasty
3. Venous stenting

HISTORY: Left leg DVT with post thrombotic pain and swelling

Intravenous conscious sedation was administered by a dedicated
independent observer with continuous hemodynamic and respiratory
monitoring performed, including the use of pulse oximetry.

FINDINGS/TECHNIQUE:

The patient was placed in the supine position on the stretcher and
the left leg extremity prepped and draped in standard sterile fashion.
All elements of maximal sterile barrier technique were followed
including cap and mask, sterile gown, sterile gloves, large sterile
sheet, hand hygiene and 2% chlorhexidine for cutaneous antisepsis.
5 cc 1 % lidocaine was used for local analgesia. Using ultrasound
guidance, the posterior tibial vein was accessed with a 21-gauge
needle followed by wire and sheath.
Venography performed from this position demonstrated numerous small
collateral vessels without direct in-line flow to the popliteal vein.
Multiple unsuccessful attempts were made at passing a wire to the
popliteal vein. Attempts from this position were abandoned. Sheath was
removed and hemostasis achieved with manual compression.

5 cc 1 % lidocaine was used for local analgesia. Using ultrasound
guidance, the small saphenous vein was accessed with a 21-gauge needle
followed by wire and sheath. Venography performed from this position
demonstrated tortuous collaterals with faint visualization of a
previously thrombosed superficial femoral vein. These terminated in
the inguinal region with numerous collaterals and nonvisualization of
the common femoral vein.

Using combination of multiple wires and angled catheters, the
superficial femoral vein was traversed to the region of the origin of
the common femoral vein. Balloon angioplasty was performed using a 7
mm x 100 mm Mustang balloon throughout this course. The balloon and
wire were unable to be passed into the pelvis. Pelvic venogram
demonstrated complete occlusion of the common and external iliac veins
with numerous paraspinal and cross pelvic collaterals.

5 cc 1 % lidocaine was used for local analgesia. Using ultrasound
guidance, the the common femoral vein was accessed with a 21-gauge
needle followed by wire and sheath. A angled Glidewire and Kumpe
catheter were used to traverse one of the collateral vessels to the
inferior vena cava. Contrast injection through the Kumpe catheter
confirmed IVC position.

The occluded tract was balloon angioplastied with a 10 mm x 5 cm
Mustang balloon. Follow-up venography demonstrated flow which was
deemed adequate flow and inflow. The decision was made to place
stents from the IVC to the external iliac vein just proximal to the
common femoral vein.

A 17 x 80 mm Venovo stent followed by a 14 x 80 mm Venovo stent were
placed and dilated up to adequate size with an Atlas balloon.
Venography performed after stent placement demonstrated very sluggish
flow within the stents. Angioplasty was again performed from the
popliteal access point through the common femoral vein and into the
pelvis using 10 mm Mustang balloon. Despite multiple passes with
multiple different balloons and wires, sluggish flow was still
observed within the pelvic veins. No additional intervention could be
performed and the procedure was terminated.

Needles and wires were removed and hemostasis achieved with a woggle.
Sterile dressing applied. The leg was wrapped with an Ace bandage.

The patient tolerated the procedure well without immediate
complication and left the radiology department in stable condition


IMPRESSION:

Left leg venography from the posterior tibial vein, small
saphenous/popliteal vein and common femoral veins demonstrating post
thrombotic collateralization.
 
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