de Graaf: A redo is most likely the result of suboptimal inflow. After the procedure, I impart to the patient that compliance with anticoagulation is critical to success.ĭr. If there is a clear contraindication to anticoagulation, I see little value in treating other than in the very rare potential limb loss situation (ie, phlegmasia). If I have concerns about whether the patient can take anticoagulation, this must be addressed before intervention. Some questions I ask: Can they afford the medicine, and if not, how can I arrange for them to be able to successfully obtain medication? Are there barriers to them taking the medication? These can vary, including medical (ie, fall risk, recent surgery, metastatic disease) and psychiatric comorbidities. Before I do the procedure, I assess the patient's ability to take anticoagulation, including comorbidities and financial concerns. Management after the procedure, including ensuring patient compliance, is often overlooked but is as important as the procedure itself. The only difference in acute cases is that if there is thrombus in the inflow, particularly profunda or CFV, it needs to be removed to ensure that the iliofemoral outflow tract remains patent. Bridging disease from the profunda (in the event of a diseased CFV) to healthy outflow is the key to success, and IVUS can be very helpful here. The second common technical issue where failure occurs is incomplete disease coverage, whether at the inflow or outflow end. Assuming that the profunda is sufficient, stent placement in the CFV is needed and usually leads to durable patency. To assess the profunda, selective venography and intravascular ultrasound (IVUS) are often both necessary, and unfortunately, as of now, judgment is largely subjective and experiential. Without a good-quality profunda, I have found that there is a high risk of rethrombosis. In chronic obstruction (and indeed some acute), there is significant postthrombotic involvement of the common femoral vein (CFV) therefore, I have found that close attention to the quality of profunda inflow is vital. If there is insufficient inflow, reocclusion is likely. Starting with technical issues, whether acute or chronic, inflow must be respected. I will focus on a few of the dominant concerns. Desai: Let me reframe the question: What are the possible failure mechanisms after treatment of a thrombotic (acute or chronic postthrombotic) venous obstruction? Broadly, they separate into technical (procedural) errors and management issues, with the latter including patient factors. Maastricht, the When you approach a deep venous occlusion case, how do you plan ahead to reduce the likelihood of a redo procedure? What has past experience taught you about how to predict these outcomes?ĭr. Northwestern University Feinberg School of Medicineĭirector of Radiology/Interventional Radiology and Nuclear Medicine Associate Professor of Radiology, Surgery, and Medicine
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