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5min chapter
Ep. 370 Recan In Benign Venous Occlusions with Dr. Minhaj Khaja
BackTable Vascular & Interventional
Considerations for Sharp Recanalization of Occlusions in the Venous System
This chapter discusses the importance of experience in determining safe occlusion lengths for sharp recanalization in the venous system. It covers specific locations where a five centimeter occlusion is considered safe, precautions to ensure procedure safety, stent sizing and placement, concerns about perforation and the use of covered stents, balloon sizing, anticoagulation during the procedure, and cases where anticoagulation is stopped.
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Episode notes
Speaker 2
Is there a segment length that you're willing to sharp recan? Like what I'm trying to say is, have you ever come to an occlusion? And that is too long of an occlusion. I do not want to sharp recan that. Yeah.
Speaker 1
I think that that's a really important point and one about experience and just knowing your own limits and what's safe and what's not safe. And as a radiologist, we know what sort of structures are in the way. And so it depends on where you're doing the sharp recan. But I think around the most common location, which is around the cable confluence, around the sort of renal vein level where IVC filter may be in place or sort of the mather and her lesion, I think a five centimeter occlusion is sort of I feel very comfortable with anything above that. I want to make sure I'm doing some extra things. Those extra things are again, putting a catheter in the arterial system to make sure I'm not hitting the renal artery if I'm doing something at that area or putting into the iliacs or just putting it in there or not, just so I can make sure I know where those things are.
Speaker 2
Gotcha. Cool. Anything else about kind of the flavor number one recans that you want to talk about?
Speaker 1
I think stent sizing and ballooning is very, very important. So predilating before you put a stent in is really important. All the manufacturers recommend dilating to about the same size of your stent. And then figuring out with Intravascular Ultrasound or IVS, I think it should be the standard of care for these types of cases because you don't really know what your landing zones are. You get stalled with vinography, but that's single plane usually. So I think that using Intravascular Ultrasound appropriately sizing your stents and making sure that when you're placing the stents that you're placing them, so you're that in normal vein on both ends and that if you have compromised a landing zone on one of the edges, that you probably are going to need to do something edge-unctive, whether it's additional ballooning or extending the stent one way or another.
Speaker 2
For sure. I get concerned about perforating with your balloon before placing your stent in place. And I guess the edge-un question is how often do you have to switch to a covered stent?
Speaker 1
Yeah, those are always the toughest situations. And it doesn't happen very often or at least that we know because of the low pressure vena system. But I do get concerned for jumping straight to a large size balloon. And so one point would be if I have done sharp reconstruction where the wire didn't just fly through an occlusion, I generally go conservatively. I'll start with maybe an 8mm balloon in the IVC just through the track that you've created or the reconstruction recaneralized area. And then I upsize to a 12 and then probably go to a 16. But I go slow and steady because I think the vein opens up as you balloon it. But if you jump straight to the bigger size, I think that that is where I have more risks and you can't take it back. If I put in an 8mm balloon and inflate it, like you said, it perforated through, I went extravascular or something like that, I have an opportunity to maybe redirect while I'm still not fully anticoagulated. Or if I am anticoagulated to come down on the heparin or our gatroban, for example, and then fix it. So I do worry a little bit about that on every case. And that's why I kind of work my way out.
Speaker 2
For sure. You brought up the great point of anticoagulation again. I don't think we touched on how you like to anticoagulate during these procedures. Yeah.
Speaker 1
So whenever I start the case, I get a baseline ACT or activated clotting time, just see where it is. And then I always do part as part of our timeout. I say we're going to take, we'll get lots of ACTs and we're going to give lots of heparin. But we're not going to do it until we have confirmed that we've crossed the occluded areas safely and confirmed it with either vinography, rotational foroscopy. And in my case, generally intravascular ultrasound. At that point, I give a large bowl of heparin and I want my goal ACT is around 230 to 250 seconds during the ballooning and centing. And in general, I administer heparin and then I check an ACT five minutes later. And if it's a good amount, if the ACT is in a good place, then I'll ask to check every 15 to 20 minutes. And if it's not in a good place, I'll give a smaller dose and then check again after five minutes until I've sort of had a steady state in that 230 to 250 range. And then we'll check frequently throughout the procedure.
Speaker 2
Do you have folks stop their anticoagulation beforehand?
Speaker 1
That is a great question. One I hear frequently from trainees is whether to stop any anticoagulation. And if it's an occluded IVC, I like to stop it ahead of time for the appropriate amount. So most of the DOAX are 48 hours, come it in being five days and Lovanox is usually one or two doses. And the reason for that is that I feel more far more comfortable being aggressive with shark reconstruction of that five centimeter area when they're not on anticoagulation. In general, it's not going to be an issue to stop it for a couple of days. They've got a filter in place essentially. And most of these patients have chronic occlusions.
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