In this interactive case, Dr. William Harris demonstrates the treatment of right common iliac venous thrombosis using the Aspirex™ Mechanical Aspiration Thrombectomy System, followed by stent placement with the Venovo™ Venous Stent System to address underlying venous compression. This experience allows viewers to engage with the procedure while highlighting procedural approach, device utilization, and key clinical considerations in managing venous obstruction.
All right, cool. All right. Welcome back to Chattanooga, uh, Vascular Institute of Chattanooga. We're here with a gentleman with a large, with a large DVT. He's a, he's a fairly large individual too. Um, so you had pretty significant swelling. His right lower extremity and so Um, what we're going to do is do a venogram on him and see, we did an ultrasound on him, showed somewhat significant clot in his femoral and his iliac vein on the right side. So we're gonna go in and see if we can improve his flow. You can see here, this is his saphenous vein. He's actually got some clot into his saphenous vein too. He's had some improvement in swelling, but the symptoms have been going on about 1 week, 1 week and a half. Still gonna burn, sir. So we're gonna get access in the common femoral vein. Right here you can see the artery right there. some I'm sticking in the common just because he's pretty hard to visualize to a certain extent. So I'm using a micropuncture to start. To stay safe. And sometimes I will start in the common femoral and then move my way down if I have to, if I feel I need it's necessary spot. That's air. Yeah, I see that. Can you come lower? So I like starting off with the micropuncture, it kind of gives us a. Good idea of what we're getting into life. And then allows us to kind of gauge how much we need to upsize and whatnot. So we. DSA. And there's some significant clot right in the common femoral itself. So in this situation, I'm probably gonna wanna move down further south. Can you increase the depth of the ultrasound? Anyway we can clean that up some. there So, I mean, it looks like clot into the external and common, so having both located. What I may do is actually cut down lower and prep out his lesser saphenous vein and then go through his lesser saphenous vein also. Oh really. Pivot in the middle of the case. So in this kind of instance where he has a significant thrombus uh in there, my, my plan is to get access a little bit lower if I can and then I'm gonna try and go for the superficial femoral. Um, But if I have to, I can go lesser saphenous also and get into the popliteal vein. Which is pretty superficial. Original ultrasounds show a common femoral vein thrombosis. It suggested it was external iliac. Um, it's a really good question. So, go a little more superficial on the ultrasound. So I'm actually gonna access his, trying to access his GSP right here. And you use that as running room. To, um, Let's get a sheet there. Just looking for a little flash of blood. It may be somewhat chronically occluded, but my wire, you can see the tip of the needle in. So I'm gonna run the wire and and see if we, yep, we got lucky. So Wires going into the system there. And so we got a little bit of lower axis next. Can I get 6 French sheath to start, please? DSA. So we've gotten into the saphenous vein, which gives us a little bit more running room. That's good. And then we'll be able to treat that iliac system right there. So. Putting in the wire. Hey, can you give 6000 of heparin, please? doesn't really heavily. It's not. We're, we're gonna take a look at it with Ibis. Yes, sir. Yeah, so life. Situation like this, the wire, we've gotten wire axis all the way up the iliac, so that's a good place to start. We'll kind of pre-dilate with the 6 front sheath and then we'll go up to 11 front sheath, which will allow us to do whatever we want to do. So, Another question. The audience, uh, Doctor Harris, would you ever consider using an IJ approach? Yes, 100%. I absolutely would, um, especially in somebody of this body habitus, it's not a bad idea. Yeah, and I do that, especially for occlusive lesions where they're 100% occluded. I think an IJ approach is a reasonable way to go. OK, so we've upsized to an 11-front sheath. We're gonna run the ibis up. Can I get a Yeah, perfect. So this is an 035. I think Ibis is really all telling. Uh, it tells you what kind of pathology you have, how extensive the pathology is. So, so this is a great picture here of the ibis. You can see on the ibis image, there's a fair amount of clot within that vein right all through there. And this is probably acute and subacute. And then that vein gets fairly significantly narrowed spot. And what I do is we're running a catheter up and we're correlating it. With the, the fluoroscopy. And so you can see there's a fair amount of clot right there. Riley, can you get the Apex? And then we get back into normal vessel, but as you can see here. It's a collapse, a fair amount of iliac venous compression spot. So that's a really spectacular image. You can see how collapsed that vein is. And then it opens up again, distal. So that's probably the reason this gentleman got a clot. Now, he was immobile to a certain extent, but look at how collapsed, even with a respiratory variation, there's a fair amount of collapse of that vein. And so we're gonna need to fix that after we clear out his clot to kind of help him have a long-term efficacy and prevent him from getting a clot in the future. That's kind of our thought process behind this. So we've taken the. And you see his IVCs even collapsed a little bit, but that's probably because he's a little dry, because he's been NPO things like that. So, would I do anything to that? No, I would not. Record. Would you have any protocols such as hydrating them prior to these procedures to avoid any sort of, it's a really, that's a really interesting question. Um, we don't, but I think we should see it. I could actually see there was a tactile sensation. Of the ibis catheter getting kind of caught right here in the very narrow portion of the vein. And it's really interesting. We'll take a, a better picture in a second, but that on venogram will be splayed out so it'll look wide open, um, but as you can tell on the ibis image, it's very, very collapsed. That's a really great image right there, pancaking on the imaging. I'm sorry, what's that? Stop caking. Yes, yes sir, yes sir, 100% would. Uh, can you say what the question was? And then there's also a question asked if that was a pancaking of the iliac that we see on the ibis, a classic kind of. Uh, uh, pancake image. Yes, it is a pancake image. And so since we, you can see in this Ibis image that Aaron is bringing up right now, uh, that there's a fair amount of clot in there. So I'd like to clean out as much of that clot as possible. So we're gonna use the 10 French Asperex device, um, which I've come to really like the Asperex device. We use a fair amount of the Rotorex product, which is also a Benton Dickinson product in our practice. It's the same drive unit. Um, and it goes up to 10 French. Um, you know, Asperex and Rotorex have been on the market in Europe for over 10 years, and we were only lucky enough to get it, um, in our hands in the last 2 years. And so, um, it's really changed our practice. The Rotorex is just a Really amazing product. I use it, well, arterial. But obvious, uh, uh, instant restenosis, I love it for that. Yeah. Um, I even use it in the iliacs in the thromb because it has a thrombectomy indication, um, and because it gets a lot of mass of the clot, um, you know, if there's a fair amount of soft clot in the iliac, so I don't shower distally. What's that? Right. And I've had to learn how to use the device. There's a fairly sharp learning curve, but once you get used to it and you use it appropriately, I think it's a wonderful device. I really, really like it and it's um Uh, you know, it's like anything else, it's trial and error. So if you start losing flow in it, it's really important to pull it out and flush it and then put it back in. If it starts heating up, it's really important to pull it out. Do you have a bird too? 65 B2. Doctor Harris, there was a question. When would you consider using a temporary filter? I don't use filters usually in these situations. That's a really great question. So the Society for Vascular Surgery, um, and, uh, Society, Society for Interventional Radiology a few years ago had a consensus paper that There's no real indication to use, you don't really have to use a filter for percutaneous thrombectomy of the venous space if the patient's adequately heronized. But, yeah, I mean, that's a good question. I know guys who do them all the time. It's not wrong, but you don't have to. And there hasn't been a, a really significant change and difference in outcomes and things like that. You're fine. You're doing great. So, this wire that comes with the 10 French device is an 025 wire. Um, it's really a great utilitarian wire. It's braided, um, but you can do a lot of things over this wire. I really like it. It's fairly stiff. Uh, the smaller devices go over an 018 system, but this 10 goes in over a A um 025. So on that clot, when you saw the picture, you saw a little bit of shadowing in there that suggests it's kind of It may not necessarily be in the acute phase anymore, but moving into the sub-acute phase, but that's OK. Um, I still think it's important to see if we can clean out some of that. Um, this device creates a certain amount of maceration to the clot too. So I think it works, it works fairly well for what we have available in the, um, office space, laboratory space. Um, and we've had good success with it. You know, not all thrombectomies are created equal. Not all thrombectomy devices are created equal. There are a whole bunch of different ones on the market that are good for certain situations, but for this instance, I think this will be perfectly good and adequate. So this is a pretty big device for those of you watching at home. You can see there's two pretty good sized portholes. It's a 10 French device, um, it has a fair amount of aspiration power. It's really tremendous about as to how much aspiration it has and the ability to macerate the clot too. So, run it over the wire. It's a 80 centimeter length. It's 110, sorry. And so the wire comes out the end. There's that silver thing over there and then you pull that silver part back which tightens up the device on the wire and creates a seal. And what we do is dunk the tip into the bowl. It's exactly the same as the Rotorex device. We dump this into the bowl and then we uh engage the drive, and that runs heparinized saline through the system. Mhm. And we wait until we see fluid. Now, you can control this with a foot pedal or you can control it with a hand pedal. I used to like to shoot handguns before I had kids and couldn't, so I enjoy thinking that I'm at the, the shooting range, but no, I'm just kidding. But it, I like the control of the hand pedal, you know. My partner likes the foot pedal. It's whatever you feel comfortable using. Yep, so we're down here in the. Do you want me, you wanna mag up on that area. Spot That's perfect. You're good. All right, so give me some contrast. Um, oftentimes, some people will have a saline bag coming through here to keep continual flush while you're doing it. That's on the IFU. I don't typically do that. I think his inflow is pretty decent. DSI. So I've got an 11 French cheese, so I can shoot around this. So it's kind of nice. So what we'll do is. Start the device in the system, well, I'll just go really slowly and take my time. We put this marker on here, this white marker here, this kind of tells us where our wire is and makes sure every once in a while if the device heats up, it's an Archimedes screw system. And so it can, it can pull the wire out or something like that, so you just have to be careful with it. But I'm, as you can see on the, what's that? Yeah. On the fluoroscopy system, you can see me turning the, the, the holes around. So I'm, I'm spinning it with my left hand. And constantly getting. But there it goes. So we'll walk it out and wash it out, it a little closer. It's probably just caught in something. I guess. Yeah, I think there's some chronic clot in there. I mean there's flush. So when you have that situation, it's really important to go back in and flush it out and get to the point where you get sand again. Mhm. And is it divided. or It's, it's an Archimedes screw system, so it has to be over the wire. And that's on the IFU. Do not go wireless. Yes, yes. We'll go slow through the system again, and we may have been getting up into that narrowing, push the wire in a little bit. that and Getting a fair amount of clock. Why don't you walk that off? And sometimes what I'll do is I'll go and give me a, do you have a 12 atlas? No not at all. Spar Work. Yes, Yeah. True. It's spinning the wire a lot. I Stop. Can you get me a 12 ball. Perfect Spar That's fine. Pull this wire real quick. DSX. So we've gotten cleared out a fair amount of that clot, so I'm pretty pleased with that. So we'll go in and balloon that and macerate it some too. Yeah, that's great. But you can see that external iliac that we were looking at earlier on ibis. It's completely, like, it looks like it's wide open, but on ibis, it's clearly not. Yeah. Yes, ma'am. This is, this is 8 French system, right? Really? So this is an Atlas balloon that we're going up with. This is a 1240. It's 7 French allied, but you're in a Venus space, you don't really care. What I like to do is go in sometimes and macerate this with the Cause I think, you know, it's interesting, the more DVTs I do, the more I see that some of these, they have an acute component, but they almost all have a chronic component to it. It's rare. I'm lucky enough to get one with a really just cute, fresh. There's almost always some sort of reacy to it. Occasionally, it's the case, but You can almost that. Yeah, yeah, I probably will. Yes, sir. I agree with you. Yeah, so he was just saying that, um. There's a high likelihood that we'll have to stent down into the common femoral, and I'm OK with that with this stent system. Um, it's a very flexible, you know, with the bonovo stent system, it's a very, very flexible system. Let's go in with the aspect. You oversize by 15%, 20%, or roughly 10%, yeah. It depends on how I'm feeling that day. And smaller versions, um, I use it for fistul thrombectomies, the 6 inch device. And uh I talk with that for those. It's a little expensive, but it's still, it's fast, and I can do it all from the radial, and I don't have to have two accesses. And so that's kind of nice in that situation. And if I'm in a hurry and I'm trying to get my day going and things like that, it's a really nice thing. The other day I did it without one and I sent a clot down into the radial. And so I ended up having to open one and I went with a 6 French through the radial and sucked out the clot and the patient had a spot. So that was a really great, it was a great save, and I was really thankful to have the device, so. Let's listen one more time. Boy, it just does not like that area. Yeah, that, that spot right there just does not want that could potentially be a valve leaflet right there. It could be potentially, yeah. So, we'll just walk it off from here and, and stop right there. We won't go through that space again. I think we're getting pretty good clearing in this area right here. And so you notice he's keeping the, the entire catheter in line and straight, which helps reduce the amount of friction that the Archimedes screw puts on the wire to help reduce the heat. Also, you can see she's squeezing the. The clear tube at the bottom of the handle, which lets them know that there is flow going through it. You want continuous flow going. It's just like the as the rotorex system in that you want to maintain continuous flow that does two things. Number 1, you know you're actually engaging something, and number 2, it cools down the system, which is really important. If you're not getting continuous flow, the system will overheat, and you can actually feel the catheter starting to yep. Let's go back in with Ibis. John, hey, they can, um. Uh, one of the questions that I get quite frequently with this device is how does it compare to some of the competitors in blood loss? Very minimal blood loss. It's not bad. It's really not terrible. I mean, you watch it obviously, but I think it's even less than, say. And that's really, I'm really happy with that. I mean, that's a fair amount of uh debulking. So that's a really pretty good system. Yeah. Usually we run that over the wire. Uh, it's funny, some of the old 035 systems from a competing company, uh, were wireless and they wanted you to use them, even like aortas and veins, and I'm like, are you guys? We do you wanted to revisit the old days, so. So you still got some burden in there. And like I said, that's a very chronic stuff. Um, but that may be something where we, we bring it down and actually tend to that, to that area. So there's that area that pancakes right there. The table just a little bit. Are you on a mag. Decrease the mag just a little bit, would you? You have marketing for? Spot So what I do is I track on Ibis where we're looking at that external iliac right there. So the confluence is a little bit higher, when we look at the external iliac where that pancaking is, and then we go above it to that area right there. Spot. And so I mark on the screen, that's normal healthy vein right there. And that's what we're looking at an ibis and we've correlated that with our X-ray. And now I pull it back, gone past that stenosis right there. And then I pull it back. Wendy's helping me walk it off. Gonna come from, we've got some disease there. And see, now I'm into the saphenous vein, so it's a little tricky because. Spot What I'll probably do is deliver it into part of the common femoral vein here where that chronic lesion is, but I can't go too far cause I don't wanna extend it in the saphenous vein and gel off that. You would lose points for that. So, spot, yes, exactly. So really, I think to Here is probably gonna be our safe, safe location if we have to. Maybe just a touch higher spot. So I marked the screen right there then, and then I use the IIS catheter. I can tell what kind of length we have. Spot 1234567. He had a uh 18,160. Each of those is a centimeter, right? Common iliac. I think Kaak looks pretty good. That's IVC up there. We're way high. Yeah, Kael acts fine. So you open so you can still get mhm yeah exactly and you know I'm if I land it right there you can go ahead and walk it off. If I land it right there, I'm still above the profunda, so there's gonna be flow coming in from the superficial frontal vein, flow coming in from the, um, saphenous vein. Do you have a question? When you're trying to do or figure out reference diameter, yes, how do you do it? Do you do it what it should be? Do you look above and below? Do you look at the opposite side? That's a, that's a really great question. So he's a big guy. Um, I would hate to go small on somebody like this. So I think doing a large size is appropriate in his indication, um, in his situation. Um, but also, I have, so Aaron's measuring a reference diameter right now. Go up higher, would you? Aaron's playing with it, but typically reference diameter, I, I go based off what it should be. Um, and, you know, for females, oftentimes it'll be like a 12 or 14 millimeter for males, it'll be 14 to 16, something like that. So I think an 18 is a nice, nice fit for this sort of thing. Yes, sir. Yes sir. So he was asking on the ibis catheter what each mark was, and each mark represents a centimeter. So the ibis catheter is also good because it uses, it's a, it's a reference tool to give you an idea as to length too. So this is the, uh, this is an 18,160 bonovo stent. So we really like the bonovas. This is a short, um, uh, short sheath. So coming from the poopal, this might have been kind of. Um, a little short, but probably would have actually made it. Um, this is a 10 French device. Um, I've got an 11 French sheath in. I just use 11 rees. I don't, I don't know why I use 11 Frenches. My partner uses 10 frenches. I just use 11. It just works for me. Um, but I can shoot around this if I want to, but it delivers pretty, pretty well. It doesn't foreshorten too much, you know, like the old technology. It's an open cell design, so it's designed and built for the venous system, and it's indicated for use in, um, stenotic lesions within the, uh, Uh, Venus system. So we'll start our deployment right there. Just above And I don't see a need in a lot of these patients to pre-dilate. Um, even in NIVL lesions, I don't necessarily post dilate much. You can see it, I can see it shortening just a little bit and that's what I expected. So when it'll end up, it'll probably end up right where I kinda want it. Yeah, that's nice. So, um, the other thing is, it's a very flexible stent design. So while this is a 2D representation, that vein is going posteriorly, uh, in the pelvic brim and shooting anteriorly, and then it's crossing underneath the inguinal ligament. Um, in the studies, uh, in the vernacular study, they didn't see any evidence of stent fractures. I've put in hundreds of these stents. I haven't seen any evidence of stent fractures. I think it's a really great system. TSA? And. The system was very. To s. Yes, sir, and Archer, you're 100% correct, but in this instance, in the venous system, I'm OK with it because the stent is very flexible. That's one question I ask all the time. OK, can I have the ibis? I don't know why I was looking down there for it. I was too. No. So there might be some people that would ask, you see right where it's coming out of the sheath, and then there there's like a little bit of streaming clot there, yeah, yeah, is that it's probably a little bit of residual clot there, but I think over time that'll, that'll close down like I said. Yeah, they can roll. I don't wanna go too low on him. Um, and he's got adequate inflow and it washes out pretty well. I don't wanna go too low on him because I don't want to jail off, you know, he's so heavy from our access and things like that. It's difficult to get any lower. If I was coming from the Um, from the popliteal vein, I might try and stent lower, but, so that's going in. I may balloon that area, the taper, but the stent looks pretty good. Can I get a 16, do you have a 16 atlas? I don't, I don't think I'm low enough cause I think the sainous comes in above that. But you can see where the um You can see where the uh. Um, the significant stenosis in the external iliac vein was, that's completely resolved. There's a tremendous amount of radial force on these bonovo stents. So, I find that in, um, in May Thurner type situations, it's very rare that I have to balloon these posts. Now, he has some, like I said, the chronic scarring. This is actually a pretty good image. You can see the vein, the stent of the vein, and you can see on top, on the ibis image, you can see the vein wall going across the top. There's probably some chronic stuff in there. So we've propped it open some. I'd like to prop it open even more if we can. Go ahead and lock this off. This is made of, is that right? It is. Yes, sir. Yes. So there are other stents on the market, um, venous stents. Um, I like the amount of radial force with this one. I've seen fractures and other venous stents on the market. Um, the deployment, I don't think is quite as good as this one. There is a flare at the top, which allows for better opposition, obviously. Excuse me, but there's um. Um, we can, we can land these with pretty, pretty precise. Um, And they flared. What Kind of like it hasn't. Or can it slide? It's, it can't really slide much. It doesn't really, it doesn't have hooks or anything else like a filter. It's not sharp. Um, it just has a little bit of apposition at those areas from the radial force. So I'm ballooning the area going into that area. Again, this is an Atlas balloon. So I don't wanna blow up the saphenous vein too much because it probably extends a little bit into the saphenous. So this question is for me. If after you treat this, send him home on a follow-up so he's on Eliquis, and we'll keep him on Eliquis for 6 months. He's on Xarelto. I'm wrong. He's on Xarelto. We'll keep him on Xarelto for 6 months. We'll do a repeat ultrasound probably in 6 weeks. But if you notice that this was kind of a recurrent spot here at the bottom just below the, I may come back in from the popliteal and the stent that even though you don't like it. Yes, sir. But part of the reason you stent this also is to prevent him from getting another DVT in the future too. You know, letting nature do its thing. Bye. Spot. Been watching enough. Come on. Yeah. TSA. A little bit of increased flow there in that area. And it washes out really well, so I'm pretty, pretty happy with that. I think he's got adequate flow to keep the stent open. He'll probably recantanalyze this very well over time. test At the top of the stent. Let's, we'll go up with Ibis and take a look. I didn't see it being specifically narrow, but we can definitely, there's a little bit of residual chronic stuff there in the groin, but that's OK. Like I said, I think it's fine enough to keep it open for right now. But going Yeah, it looks pretty open on Ibis. So I'm pretty pleased with that, and there's a confluence there. Record So inside the stent that looks pretty good. It's pretty uniform the whole way around. Going down into the femoral region. They said there's a little bit of stenosis right there, but I'm pretty happy with that. So, stop recording. So I think that's it. I, I, I wouldn't do anything else right now. I'd just wait, wait and see and see how he did. I ballooned it.
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