Updated: Mar 8, 2019
Successful treatment of chronic venous obstruction requires operator skill and optimal equipment utilization. In episode 33 of the BackTable podcast, Dr. Brooke Spencer discusses her go-to catheter choice, techniques for catheter and guidewire manipulation, and tips for crossing difficult chronic venous obstructions.
The BackTable Brief
There are many catheter choices available, however a braided taper-tip catheter is the best option for treating chronic venous obstruction, says Dr. Brooke Spencer.
When treating chronic venous obstruction, the operator’s hands should be on top of the catheter, not around or under. Having the operator’s hands above the catheter allows for easier guidance and twisting of the catheter.
In treating chronic occlusions: keeping the guidewire 1-2 inches ahead of the catheter prevents buckling and misdirection of the guidewire, thereby decreasing the risk of complications such as dissection.
Limited catheter mobility due to a tight obstruction can be addressed with angioplasty; angioplasty with a 4 mm balloon creates a small pocket surrounding the catheter tip, which permits pushability until the lesion can be fully crossed.
Disclaimer: The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
What is the best type of catheter for treating chronic venous obstructions?
When it comes to treating chronic venous obstructions, numerous catheter options exist; Dr. Brooke Spencer suggests using a braided taper-tip catheter. She also notes the performance difference between expensive and inexpensive catheters is negligible. Therefore, fiscal responsibility is important when choosing from the various brands of braided taper-tip catheters available.
[Isabel Newton] Let's talk a little bit about some of your favorite tools. You do cases that would take a normal human either forever 'cause they would never get through it or 12 hours, and you do them in a record time. I've watched you do it, we've filmed you. What are some of your go-to tools and how you use them in a unique way to get through those difficult obstructions?
[Brooke Spencer] … I talk to people all the time and I say, "Okay, what is your algorithm of catheters that you use?" And they're like, "Well, I use a Berenstein first, and then I use this, and then I use this." And I say, "So just never use a Berenstein. You need to skip all regular diagnostic catheters. If you have a chronic occlusion, you go straight to a braided taper-tip catheter."
There are a lot on the market. Some of them are significantly more expensive than others, and I'm going to leave my biased discussion of specific companies' products out of this conversation. You can look it up for yourself, but there are innumerable crossing catheters. I will tell you that some of them are $50 to $80 a catheter or more, and when you do five or ten a week, it starts to add up. So if you want to be fiscally responsible, find out what the cheap ones are because they work just as well as the expensive ones.
What is the best way to control your guidewire when navigating chronic venous obstructions?
Placement of the operator’s hands on top of the catheter is ideal for spinning the catheter in a drill-like motion across the venous lesion. Controlling the wire at the level of the obstruction is also crucial. Advancing the guidewire 1-2 inches ahead of the catheter tip will prevent buckling of the guidewire and decrease the risk of complications such as dissection.
[Brooke Spencer] … And then it's a technique where you want your wire in a chronic venous occlusion only to be an inch or two ahead of your catheter, and you don't want to buckle the wire. So you can do that, if you have an acute DVT, you can roll the wire over and push it up. You don't hurt the valves, it goes through easily, you know you're not poking holes in things or selecting branches. You don't want to do that in a chronic DVT. You want to keep your guidewire tip straight. Otherwise, you will dissect, and then you've gotta pull down below the dissection to get back up through.
And then you want your hands on top of the catheter. So I see people with them under or around. It's the same thing when you're - I was a surgery resident before IR - and they put a clamp in your hand, and they try to teach you how to barely put your fingers in so you can move it, you can twist it so you can do things. It takes a while to figure out how to do that, right? And everyone's clumsy at first, but you want both of your hands on top of the catheter, and then it's a clockwise motion and then a counterclockwise motion, and you're spinning the catheter forward and backward like a drill across the wire.
And then the amount of tension that you want to push to get through the lesion is often less than you would think. So you want to keep the wire system straight and have a little bit of back tension without losing your wire in the patient. So the skills that it takes to get through these are definitely acquired skills, and it takes more skill than you would think than just cramming something through an obstruction.
What techniques can be used to treat difficult venous obstructions?
Chronic venous obstructions are difficult to treat when tight obstructions prevent catheter tip mobility. Dr. Brooke Spencer performs angioplasty with a 4 mm balloon when crossing tight obstructions to create a small pocket of space surrounding the catheter tip. The small space permits wire pushability, and may be the last step before crossing difficult lesions.
[Brooke Spencer] Once you're through (with the wire), the next tip that I would give is that sometimes the catheter can get three quarters of the way up through the obstruction, and you just cannot advance it anymore, and it's because the entire length of the catheter is being held on by a very tight obstruction. So at that point, you can go in with a four millimeter balloon and start angioplasting from behind to create a little bit of space around your catheter. You don't want to lose your pushability, so you want to keep that balloon small, and you want to keep your tract fairly small and tight until you can get up. Eventually, over time, you learn to get through anything.
Podcast Participants: Dr. Brooke Spencer is a practicing interventional radiologist at Minimally Invasive Procedure Specialists group in Denver, CO. Dr. Isabel Newton is a practicing interventional radiologist at UC San Diego Health in San Diego, CA. Cite this podcast: BackTable, LLC (Producer). (2018, October 9). Ep 33 – Building a Comprehensive Vein Practice [Audio podcast]. Retrieved from http://www.backtable.com/podcasts Medical Disclaimer: The Materials available on the BackTable Blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable. Disclosures: None.