In this interactive case, Dr. William Harris demonstrates the treatment of left common iliac venous compression using the Venovo™ Venous Stent System. This experience allows viewers to engage with the procedure while highlighting procedural approach, device deployment, and key clinical considerations in managing venous outflow obstruction.
Welcome back everybody. Again, we're at Vassar Institute. We're going to uh Look at this lady's, uh, venous system. By ultrasound measurements, we did a um ultrasound that suggested she had significant iliac venous compression. She has heaviness to both legs. Sticking to burn. 123, stick, man. So we're accessing the common femoral vein, you can see it sitting right next to the common femoral artery. Use a micropuncture for access. And I'm gonna, based on her ultrasound, she had iliac venous compression on both sides, and so when I see that on the ultrasound, I usually just put sheaths in both sides to give me a straight shot up to give me a more accurate um. Ibis measurement. Sometimes if I only see on the preoperative ultrasound, they only have symptoms on one side. Then I'll only get one access, and oftentimes I'll use a universal flush catheter to go up and over to interrogate, say, the right sided system. Without having put a sheath in, that's been pretty successful for us. Come then. DSA? Can you get 4000 heparin, please? Hey Erica, will you move that trash can at the end of my table? Let's do a venogram to make sure we're in the right spot. Thank you. Indeed, we've stuck the artery before we dilate it with an 11 front sheath. We go straight to an 11 front sheath. It accommodates, then we don't have to upsize shoaths later. It accommodates the 035 IIS system, which is an 8 French system. And then, you know, most of the stents are 10 print. Sorry ma'am, a little pressure. So I start off by getting access on both sides. Its along fairly efficiently that way. So she has had greater saphenous vein ablation before you can see the vein, it's a pretty good sized vein. With clot in it. So we'll stick the common femoral vein on this side, stick in a burn, man. Go above that anterior accessory branch coming in. Sorry, ma'am. You see the tip of my. Are going in OK. Could return. Give me a little more local, would you please? That Just giving you a little more local, OK? Nice. Like I said, I always start with a micropuncture, and all of our accesses are under ultrasound guidance. That just makes it safer. Come on. DSM Good. For this, I'm just putting in 2. Benson starter wires. It's all we seem to need for this sort of thing, usually. There is that. Uh, no, but I want contrast times 2, please. So we'll take pictures of both sides. Let's see what we have. DSA? Either I So that's, that's interesting. You can see how delayed that filling was coming from the left side. Definitely some respiratory variation contributes to that, but it kind of splays open approximately. I'm kind of. That may suggest that she has some significant iliac venous compression, so we're going up the left side first. With the Ibis, again, it's an 035 system. These are our typical settings for the Ibis are 60 of gain and go to 30 millimeter diameter. That's been our best spot. Again, I kind of reference, oh, that was just short enough, there it goes. Interesting, she has a little web, like a chronic webbing in their spot. And there it flattens out like a pancake. And so this is really a great image on the ibis, for those of you watching at home, you can see the artery sitting on top of the vein, and as somebody referenced earlier, pancakes the vein. That's really just a classic. Appearance of iliac venous compression. It looks like a wide open vein, and, and it's contributed to the, um, inferior vena cava being pretty collapsed as well. You can see the um other wire at the 4 o'clock position. Um, Sorry, 5 o'clock position depending on your. Your terms, so record. So what we'll do is record a setting going down. This kind of shows the confluence is right there, you can see the confluence of the veins coming together and then the artery sitting on top of the vein causing pretty significant compression. Don't move your leg. Then we'll move it down. She's got a webbing right here also that you can see that little web. Um, coming up from the bottom and the bottom of the ultrasound, so we'll definitely want to extend our stent down to exclude that, to preclude any issues down the road, and this is pretty normal, healthy external iliac vein right here. Stop recording. Go live and I was that's OK. You can stay asleep, ma'am, you're doing great. Live on X-ray. So what I do, and this is how I typically do it, and this is what I did in my last case, is I mark normal healthy vein where we want for a landing zone. Distally. And prox forms the spot. So I wanna get at least to here, to this location here, and I'll probably go lower than that, in all honesty. Um, I like to have a fair amount of healthy landing zone to prevent any, any chance of scent migration, even though if we size it appropriately, I think it's very low risk. So you can see up here, we're in the inferior vena cava, you can see the other wire up here. So I'm gonna want to extend into the inferior vena cava. Spot marketing. The other stunts coming up right there, or the other wires coming up, you can see the wire at the 6 o'clock position spot. So I want to get at least to that point there, because that excludes the portion of the compression. Um, you've gotten past the point of compression and you're to a point where you, you're probably gonna treat her appropriately. So we'll go look at the other side. Did you ever see a stem migration? Um, with the older stents, yes, not the bonobos, but like, say when we were putting in walls and things like that. So she's gonna measure a diameter, but typically in a female, I'll put in a 16. It's a very common things being common. So we're going up the right side now with Ibis. I think it's pretty normal, you know, that IVC is somewhat collapsed. You can see we're into the IVC right there. So this is the confluence right here, so you can see the other side coming around. I'm, I'm rotating the ibis around, but you can see the wire on the other side. So that's in IVC and that's the right common iliac vein right there and I don't see any really evidence of compression on that right side. Sorry, it's my fault. Record. Record. Oh, sorry. I was looking at this, the X-ray monitor and not the, so that's a pretty normal healthy system on that right side. Go live when I was. Make sure I'm not missing something. You agree, don't you? I do agree. That's a confluence, and of course it looks squished because it's under filmed spot. But I think the rest of it looks amazing. Yeah. Yeah, so, in this case, I'll take a 16, 120. Spot. So in this case, I'm only gonna stint that left side. Would you And again, I don't pre-dilate these. I don't usually post dilate them unless I think they need them. She's pretty tight. We may need to, but we'll post Ivis and see. left. Start the stand a little bit above and let it flare out. Settled perfectly exactly where I wanted it to. It lands into the external, which probably a little bit into the external, which I think is appropriate. Yeah, contrast, DSA. It's good, flows much more brisk through that system, doesn't hang up anymore, which is good. We see this often in patients with like pelvic congestion, um, Very frequently in pelvic congestion patients that they have like venous uh stenosis and so it's really underrecognized and probably undertreated. So good stent wall apposition. I'm really pleased with that. See the IVC how much the IVC propped up now that we've filled it better, so that's really, this is what we like to see. So record. So you can see we're in the IVC and pulling down. You've got good stent wall apposition. All the way around, I don't see any reason whatsoever to balloon that. And remember, it's a night and all stent, so it will continue to dilate over time. So same principle as you, you would if you say putting in a carotid stent or something like that, you get a certain amount, but it has a fair amount of radial force, stop recording, a fair amount of radial force that'll continue to dilate over time. As a matter of fact, they'll get some flank or back pain from that conca dilation. For a few days, but I think that's really, really good and I really like that result. That's exactly what I would expect, so pretty, uh, pretty simple, pretty great.
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