Answers: 1. B 2. D Through the right femoral vein a 5 Fr K | Figure 1

SIRRFS

Radiology

Answers:

  1. B
  2. D

Through the right femoral vein a 5 Fr KMP catheter and stiff Glidewire were used to cross the occluded IVC (Fig 1). However on the left central access was not obtained, despite numerous attempts the left popliteal vein was not canalized due to the presence of hard thrombus. The left pedal vein was cannulated instead and a 5 Fr KMP catheter placed.

Thrombolytics were initiated with heparin drip through the right femoral vein sheath at 300 units/hr and TPA through both right and left infusion catheters at 0.5 mg/hr.

The patient returned to the OR the next day and obtaining access on the left side still proved difficult. On ultrasound, no discernible popliteal vein was seen. A small superficial venous tributary was accessed and used to find a patent segment of the superficial femoral vein under fluoroscopy (Fig 2&3).

From this access point, a 0.035 in road runner wire was advanced through a support catheter to traverse the chronic occlusion in the left common femoral vein, external iliac vein, common iliac vein, and low IVC. Next kissing balloon angioplasty was performed on the infrarenal IVC with subsequent stent placement (Fig 4). Additional stents were placed inferiorly with good inline flow from the right and left lower extremity. (Fig 5).

Case courtesy of:

Student: Ben Varughese, BS

Attending(s): David Wynne, MD

Program/Dept(s): Baylor College of Medicine Department of Interventional Radiology



Patient with occlusive #DVT extending from IVC to the left external iliac vein (red arrow). The DVT is likely secondary to compression of the left common iliac vein secondary to the right common iliac artery (red arrow), known as May-Thurner syndrome.
The patient was brought to #InterventionalRadiology where they had thromblysis using Angiojet, angioplasty and stent placement utilizing IVUS for measurements (last slide).



Answer:\

  1. The caudate lobe has direct venous drainage into the IVC. Due to redistribution of venous drainage, the caudate lobe undergoes compensatory hypertrophy in half of Budd-Chiari syndrome cases. Caudate lobe hypertrophy can lead to IVC stenosis.\
  2. Decreases
    Procedure: DIPS utilizing intravascular ultrasound via right femoral vein and Rosch-Uchida TIPS set to IVC via left internal jugular vein. Portal vein accessed with 21-g Chiba needle (Figure 1). Hepatic parenchymal tract dilated with 3mm balloon. During removal the balloon catheter tore and the fragment remained on the 0.018 wire (Figure 2). 5mm gooseneck snare was used to successfully retrieve the fragment (Figure 3). Pre-DIPS portosystemic gradient of 24 mmHg (Figure 4). The parenchymal tract was dilated with 6mm balloons and 2 ViaTorr stents were placed and dilated with 10mm balloons (Figure 5). Post-DIPS gradient of 15mmHg. Patient’s symptoms resolved and ultrasound of DIPS demonstrated a flow of 125-133 cm/s.
    Case courtesy of University of Washington Dept. of Interventional Radiology – Student(s): Millie Liao, MS4; Residents: Brandon Perry, MD, Whitney Shofner-Michalsky, MD; Attendings: Guy Johnson, MD, PharmD, David Shin, MD.


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  1. IVC thrombosis has developed below indwelling Optease IVC filter, extending below the common iliac veins. A plethora of abdominopelvic collateral pathways have developed.\
  2. IVC thrombosis can lead to lower extremity DVT, chronic venous insufficiency, post-thrombotic syndrome, and limb ischemia.\
  3. Recurrent VTE after adequate anticoagulation, VTE with contraindications to anticoagulation, VTE with complications from anticoagulation, and inability maintain anticoagulation for VTE.
    Lower extremity symptoms from venous hypertension were treated with IVC filter retrieval followed by cavo-iliac reconstruction.
    Venography of the common iliac veins and IVC demonstrates occlusion at the cavo-iliac bifurcation with prominent collateral pathways. Note indwelling IVC filter.
    The IVC filter was successfully recaptured using a laser excimer sheath.
    Next, a Gianturco stent was deployed just inferior to the right renal vein, followed by an overlapping Gianturco stent in the peripheral IVC. Kissing Wall-stents were deployed at the cavo-iliac bifurcation.
    Completion venography demonstrates patent IVC and common iliac veins with preferential blood flow through the reconstructed iliocaval system.
    Case courtesy of Dr. Doug McDonald and Dr. Lauren Evans from Scott and White Medical Center, Department of Interventional Radiology, Texas A&M University.