Ep. 382 Iliofemoral Stenting: Decision-Making and Best Practices Explored with Dr. Kush Desai and Dr. Steven Abramowitz
Nov 6, 2023
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Dr. Kush Desai and Dr. Steven Abramowitz discuss iliofemoral venous stenting, including referral patterns, work-up of patients, procedural approach, best practices, and post-operative follow up. They also touch on the impact of venous disease, tools for complex crossings, stent selection, recognizing problems during procedures, and the rapid evolution of venous stenting.
When treating post-traumatic patients, the decision to use a permanent prosthetic should be carefully evaluated considering factors like quality of life and long-term implications.
Early intervention in iliofemoral venous obstructive disease is crucial to prevent venous hypertension, claudication, and significant skin changes and wounds.
The diagnostic workup for iliofemoral venous disease involves evaluating symptom burdens, imaging studies, and patient expectations. Tools like IVUS guide interventions beyond stent sizing.
Deep dives
Treatment Decision and Prosthetic Consideration for Post-Traumatic Patients
When considering the treatment of post-traumatic patients, the decision-making process can be challenging. It involves assessing factors such as compliance, inflow availability, and the long-term implications of using a permanent prosthetic. Treating a young patient with a permanent prosthetic raises serious questions about their quality of life for the next several decades. However, the decision ultimately depends on the individual patient and should be taken seriously.
Importance of Iliofemoral Venous Obstructive Disease
Iliofemoral venous obstructive disease has a significant impact on a patient's quality of life, affecting individuals across all age groups. It is crucial to take this condition seriously as it can lead to venous hypertension, venous claudication, and the development of significant skin changes and wounds. Treating iliofemoral deep vein thrombosis (DVT) early on has been shown to have positive outcomes, and there is ongoing research regarding its impact on post-thrombotic syndrome. Understanding the importance of early intervention and raising awareness among healthcare practitioners can help improve patient outcomes.
Diagnostic Workup and Intervention Approach
The diagnostic workup for iliofemoral venous disease typically involves evaluating symptom burdens, imaging studies such as CT venography, and assessing patient expectations and compliance. Interventional approaches depend on the type of venous condition being treated. For posterior traumatic cases, extending stents around the curve is preferred to avoid erosion. In non-thrombotic cases, a stent size is determined based on the average diameter of the anchoring segment in the external iliac vein. Tools such as IVUS (intravascular ultrasound) play a crucial role in guiding interventions and gathering additional information beyond stent sizing.
Importance of Medication Adherence and Post-Procedure Care
One important aspect emphasized in the podcast is the significance of medication adherence for patients undergoing stent placement. The speaker highlights the importance of adhering to antiplatelet and anticoagulation medications to prevent complications and ensure the long-term success of the procedure. Additionally, post-procedure care is discussed, including warning patients about potential discomfort, such as lower back discomfort, spasms, and cramping that may be experienced. The significance of walking, staying hydrated, and promptly communicating any sudden changes in lower extremity pain or swelling is also highlighted.
Considerations in Stent Placement and Follow-Up
The podcast episode delves into the various considerations when performing stent placements in venous interventions. The speakers discuss the importance of understanding relevant anatomy, such as the confluence of the femoral and profundic veins, careful delineation of inflow, and the impact of the inguinal ligament. Different stent options are mentioned, emphasizing the need to select stents based on specific qualities, including crush resistance, flexibility, and radial force, depending on the patient's condition. The necessity of clear planning, seeking advice from experienced practitioners if necessary, and avoiding irreversible errors are also highlighted. In terms of post-procedure follow-up, the importance of regular surveillance imaging, such as CTV and duplex scans, is emphasized, along with patient communication and timely intervention if adverse symptoms arise.
In this episode, host Dr. Chris Beck interviews interventional radiologist Dr. Kush Desai (Northwestern University Feinberg School of Medicine) and vascular surgeon Dr. Steve Abramowitz (MedStar Washington Health Center) about iliofemoral venous stenting.
We start this episode by reviewing the evolution of knowledge and treatment of venous disease over recent years. Dr. Desai and Dr. Abramowitz identify referral patterns that connect patients with vascular and interventional physicians, and they emphasize how most patients are diagnosed in primary care pathways rather than in the emergency room. The doctors also underscore the importance of educating referring physicians and patients on the impact of early intervention and how vascular and interventional physicians are well-equipped to provide specialized care and management of venous disease.
Dr. Desai and Dr. Abramowitz explain their work-up of patients with deep venous disease. The doctors cover necessary imaging studies and conservative treatments for clinic visits. They also explain their procedural approach, access sites, patient positioning preferences, and more.
The doctors share guiding anatomical landmarks and recommendations on tools for crossing, along with their decision-making process in treating post-thrombotic patients. They also discuss best practices in venous stenting and post-operative follow up algorithms. We conclude this episode with important advice on how to avoid dangerous life-threatening outcomes.
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RESOURCES
Society of Interventional Radiology Position Statement on the Endovascular Management of Acute Iliofemoral Deep Vein Thrombosis (2023):