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Periprocedural Pearls in Iliofemoral Stenting: Focus on Pre- & Post-Care
Manisha Naganatanahalli • Jan 24, 2024 • 89 hits
Periprocedural care is critical in iliofemoral vein stenting. Success demands a meticulous approach, focusing on patient preparation and nuanced post-procedural care. Venous stenting specialists Dr. Steven Abramowitz and Dr. Kush Desai share their approaches to pre-procedure and post-procedure care for iliofemoral stenting, and the techniques that they deploy to to optimize outcomes in different clinical scenarios
This article features transcripts for the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• In iliofemoral procedures, medication adherence is crucial, especially to antiplatelet and anticoagulation agents after stent placement to prevent stent occlusion in thrombotic patients.
• For post-procedural care, non-thrombotic cases typically do not require anticoagulation, a practice supported by outcomes of various trials according to Dr. Desai.
• Acute and post-thrombotic cases are treated with low-molecular-weight heparin due to its polytrophic, anti-inflammatory, and anticoagulant properties.
• Post-procedure, patients undergo leg wrapping and are scheduled for early follow-up visits for suture removal and site checking.
• The first post-procedure imaging is generally a CT venogram conducted at one month, with subsequent long-term surveillance involving duplex ultrasound, considering the patient's body habitus.
• An aggressive surveillance algorithm is recommended, especially for complex reconstructions, involving regular three-month checks with either duplex or CT venography.
• Patients are encouraged to be self-aware and report any changes in symptoms promptly, as early intervention in cases of stent issues is crucial.
Table of Contents
(1) Patient Preparation for Iliofemoral Intervention
(2) Access in Iliofemoral Venous Interventions
(3) Key Anatomical Landmarks & Crossing Strategies for Iliofemoral Interventions
(4) Post-Procedural Care in Iliofemoral Venous Stenting
Patient Preparation for Iliofemoral Intervention
In preparing patients for iliofemoral procedures, emphasis is placed on medication adherence, especially the need for antiplatelet and anticoagulation agents post-stent placement. Patients are informed about potential discomfort, such as lower back spasms, and the possible need for medications like Valium or Diazepam. The necessity of regular follow-up and anticoagulation compliance is highlighted, with many patients requiring ongoing medication management. Procedure preparation involves thorough review of clinic notes and imaging, and readiness with appropriate tools, particularly for complex cases like obstructed stents or filters. Collaboration with local healthcare providers is crucial for patients from distant areas to ensure continuous care. Additionally, transitioning patients to low molecular heparin for its anti-inflammatory effects, supplemented with unfractionated heparin during the procedure, is a standard practice.
[Dr. Steven Abramowitz]
One of the big things that I emphasize with the patient in the preoperative conversation is the importance of that medication adherence in the post-intervention period. I am aggressive because I think that it is very challenging to deal with an occluded stent.
At minimum, I remind the patients that they will be on an antiplatelet and an anticoagulation agent if they weren't on one prior to the placement of their stent... The other thing I really remind patients of is that there can be just some discomfort both during the procedure when ballooning and doing vessel prep, then also afterwards.
I would say the vast majority of people who experience lower back discomfort, spasms, cramping, that generally resolves in 24 to 48 hours. I have had the occasional outlier with usually severe compression or severe post-thrombotic syndrome who's four to six weeks of Valium or Diazepam therapy with their spasms…
[Dr. Kush Desai]
... It's reviewing the clinic note, it's reviewing the imaging, ensuring I know my access site, ensuring what tools I need. This is where I think axial imaging is really helpful... Making sure all those tools are available and I'm prepared to take on that case.
In addition to the expectation setting, it's the post-management that's important, regular follow-up, see these patients in a month, six months, a year, and then at some point bi-annually, but that's usually after two years, ensuring compliance with their anticoagulation…
if you're in a referral practice and a lot of your patients are coming from outside of your area... you really need a willing partner on the other end that's going to be the patient's advocate and make sure that they're going to take care of the patient when they go back because you simply can't do it from a distance…
what I typically do is have them transition to low molecular heparin if they're on some other anticoagulant just largely because of the anti-inflammatory effect associated with heparinoids. Then I supplement on the table with unfractionated heparin provided it's not a hip patient.
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Access in Iliofemoral Venous Interventions
The choice of access site is tailored to the specific case, with mid-thigh femoral access being common among vascular surgeons. For post-thrombotic cases with inflow lesions, prone access and small saphenous vein usage are typically preferred. The use of posterior tibial or popliteal veins may also be considered, albeit reluctantly due to potential complications. The need for improved venous closure devices, especially considering the high level of anticoagulation used, is highlighted. In hospital settings, most procedures are performed supine, primarily due to sedation policies and the need for comprehensive assessment of inflow, particularly in post-thrombotic patients. Internal jugular (IJ) access is reserved for complex cases like severe post-thrombotic syndrome or caval occlusive work, and it's adaptable depending on patient positioning and procedure complexity.
[Dr. Kush Desai]
There's a lot of different ways to do this... I think the way I was "raised" and the way I've done procedures is if it's a post-thrombotic and there's an inflow lesion, particularly the common femoral vein, I do it under prone access, and I access typically small saphenous... If there's a Saphenopopliteal junction. I like the small saphenous vein because... if I'm going to bag a vein, might as well bag the vein that people close for a living. Posterior tibial vein and then begrudgingly popliteal vein after that.
I will say that access management with closure and all that, that's probably where we need to come the furthest with venous. We have venous closure devices... particularly with the level of anticoagulation that we're using because access-like complications not frequently talked about, but they do occur.
[Dr. Steven Abramowitz]
My practice is predominantly based in the hospital environment and in the operating room... We are pretty much 100% supine, and it's because we have some very strict policies about who can be prone, and what type of sedation they can get when they are prone... I believe in frog legging and getting access to the popliteal vein... I think for post-thrombotic patients in particular, it can be challenging to truly assess your inflow if you are sticking in the mid-thigh femoral vein...
For most of my patients who do have trophic skin changes due to venous hypertension... I generally tend to be on a frog-legged supine approach.
[Dr. Christopher Beck]
Any need for IJ access or is that an option?...
[Dr. Steven Abramowitz]
Definitely much easier to get IJ access when you're supine already... It is nice to be able to snare the wires through and through, and have a real great body floss to work on that rail sometimes.
[Dr. Kush Desai]
... IJ access in my prone patients, let's say it's an atresia or a filter retrieval. If it's a filter retrieval and it's really complex, I usually turn them supine at some point... It's absolutely an adjunctive access for me.
Key Anatomical Landmarks & Crossing Strategies for Iliofemoral Interventions
In iliofemoral venous procedures, understanding the anatomy, particularly the confluence of the femoral and profunda veins, is paramount. Utilizing ascending venograms effectively identifies these vascular junctions, a critical step especially in post-thrombotic scenarios. Venography plays a key role in capturing dynamic flow information, influencing procedural decisions. Bony landmarks like L4, L5, and S1 are crucial for identifying the common iliac vein crossover point, which is essential in occlusive conditions. The 'string sign' in post-thrombotic patients directs the targeting of crossing catheters and wires. Employing multiple oblique imaging angles ensures precise navigation, while delicate handling of wires in sensitive vessels is crucial to prevent complications.
[Dr. Steven Abramowitz]
I think for me relevant anatomy for either in acute or a post-thrombotic patient really starts with the femoral and profunda confluence. You start with your ascending venogram... but you really want to make sure you understand where the profunda vein and where the femoral vein have that confluence, mark it out, give yourself that landmark...
...Really seeing how much dye comes in or is diluted by washout from the profunda vein... if you aren't seeing a pacification of the profunda vein in of itself, that's a good marker for profunda patency.
Then really thinking about where the inguinal ligament is, its potential impact on what your IVUS images may look like on the external iliac vein and femoral vein as it crosses under the inguinal ligament...
Where I choose to overlap stents... is a little bit different...
Then the last one I'll throw out there before kicking it to Kush is focusing on L4, L5, S1... Getting some familiarity with where you actually think the crossover point is for the common iliac vein is really important...
[Dr. Kush Desai]
The profunda is absolutely the key. Femoral vein, my opinion, nice to have. Profunda, you don't have it, you're in trouble... The dynamic information of flow is venographic... Then I agree with him completely on the bony landmarks.
If we're talking about a post-thrombotic patient, what you're looking for is you're looking for that thin linear string... What that is is, if it's thin, linear, looks like gristle and it's coming off of a name vessel that you know you're in... Then you see this thin linear strand going up in the pelvis, and then a bunch of snakey windy collaterals, that's your true lumen...
Use your obliques because sometimes they can be obscured... You got to go in a couple of different obliques to find exactly the best one that's going to show you the way across.
Don't just keep pushing the wire because these are delicate vessels... For me, it's perching my crossing catheter, my crossing set there, and then taking that wire and just spinning and drilling all the way forward until you get across.
Post-Procedural Care in Iliofemoral Venous Stenting
For non-thrombotic cases, the post-procedural approach towards anticoagulation is more conservative, often omitting it entirely, supported by similar outcomes observed in various trials. The role of compression therapy is emphasized for all patients regardless of the underlying condition. In acute and post-thrombotic cases, low-molecular-weight heparin is preferred post-procedure for its polytrophic, anti-inflammatory, and anticoagulant effects. The immediate post-care involves leg wrapping and early follow-up for suture removal and site checking. Imaging schedules are typically set at one month post-procedure, usually with a CT venogram, and subsequent long-term surveillance with duplex ultrasound, considering patient body habitus. The aggressive surveillance algorithm involves regular three-month checks with either duplex or CT venography, particularly for complex reconstructions. Patient self-awareness and prompt reporting of symptom changes are encouraged, emphasizing the importance of early intervention in cases of stent issues.
[Dr. Kush Desai]
We'll just break it up, non-thrombotics, and then I think you could really lump acutes and posts in the immediate post-care the same way. Non-thrombotics, I don't anticoagulate them, just don't, don't need to... Some groups have done some work on that...
... Then of course, all the supportive care with compression, et cetera, depending upon what you treated that non-thrombotic for. On the acute and post-thrombotic side, low-molecular-weight heparin because of the polytrophic, anti-inflammatory and anticoagulant effect. Then compression, I wrap the leg afterwards and then we see them-- Particularly with post-throbiotics, I usually suture the excise, close, have them come back early the following week for suture removal and a site check.
[Dr. Christopher Beck]
Any imaging? Do you have it scheduled? What's their imaging interval?
[Dr. Kush Desai]
The first imaging typically is at one month... Occasionally, you'll hear some troubling signs that got better and it got worse again, and you're worried about re-thrombosis. At one month, typically a CT venogram... The only thing that limits duplex imaging is body habitus.
[Dr. Steven Abramowitz]
I think the only difference that I would highlight in terms of my follow-up algorithm... All of my patients get a compressive wrap... They get an SCD when they're in the holding area.
We have a very aggressive surveillance algorithm where we're seeing the patients every three months with duplex or CTV... I'm not getting a CTV every three months, but at least one CTV, maybe at the six month mark and a year, if they had a full iliocaval reconstruction or a very challenging post-thrombotic reconstruction or an agenesis reconstruction and really putting them into that follow-up algorithm.
I think one of the important things that I tell my patients is that they know their body best... If you have enough bad days in a row and you are having good days, come back sooner. Don't wait, don't sit on it because, again, some IST is much more easy to manage than a fully thrombosed reconstruction.
Podcast Contributors
Dr. Kush Desai
Dr. Kush Desai is an associate professor and the director of deep venous interventions at Northwestern University Feinberg School of Medicine in Chicago, Illinois.
Dr. Steven Abramowitz
Dr. Steven Abramowitz is a practicing vascular surgeon at MedStar Georgetown University Hospital in Washington, D.C.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2023, November 6). Ep. 382 – Iliofemoral Stenting: Decision-Making & Best Practices Explored [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com 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.
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