Keywords
sharp - recanalization - chronic
Introduction
Endovascular revascularization of occluded iliac veins can be challenging, especially
if the occlusion is chronic, or associated with femoral venous occlusion or occlusion
of the inferior vena cava (IVC). Associated extrinsic compression abnormalities such
as May–Thurner syndrome or pelvic masses, and inflammatory disease-associated venous
occlusions, can add additional challenges to the procedure. An uncomplicated chronic
venous stenosis or short segment occlusion can be “crossed” with a soft, angled or
straight teflon-coated guide wire.[1] However, long-segment occlusions with large collateral veins are often hard to cross
due to buckling of the guidewire into the collaterals. Many techniques have been proposed
to achieve success in crossing such venous occlusions. These include use of a triaxial
system of catheters and sheaths to prevent buckling of the guidewire, intentional
use of a looped guidewire, use of back end of the guidewire for better support and
added force during guide wire manipulation, the use of sharp needles such as Rosch–Uchida
needle or Colapinto needle, and intentional passage of guidewire in the venous subintimal
space to reenter central to the venous occlusion using various assist devices such
as “Outback” or “Pioneer” catheters.[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10] Often times, many operators use these techniques in an incremental manner while
evaluating the immediate complications and risk-benefit ratio.
Revascularization with the use of sharp needles is usually the last resort after failure
of all other options.[1] Both Rosch–Uchida and Colapinto needles are designed for traversing the liver parenchyma
during transjugular intrahepatic portosystemic shunt (TIPS).[11]
[12] The Colapinto needle is a slightly curved long 16G needle that requires a 7F or
larger sheath and allows passage of a 0.035” guidewire through its central lumen.
The Rosch–Uchida needle system has an outer curved cannula that is placed through
a 10F sheath and a sheathed 19G needle that is inserted through the curved cannula.
It allows passage of a 0.035” guidewire through the sheath after removal of the needle.
The off-label use of such devices in vessels has been described with success but the
risks remain high due to the large size of the needles. The use of sharp needle devices
for venous recanalization can be supplemented by direct visualization of the needle
entry into the targeted central vein, such as the IVC, using intravascular ultrasound
(IVUS).[13] Additionally, the use of a balloon or a snare in the patent central vein can help
guide the trajectory of the needle pass. However, such guidance may not be available
or feasible, depending on the length of occlusion, and use of large needles in these
circumstances can be associated with bleeding or injury to adjacent arterial structures.
Unlike Rosch–Uchida or Colapinto needles, the transseptal needle is a small device
used for intravascular use to traverse the interatrial septum.[14] It requires a 6F sheath. The “needle” is not as sharp as the other needles described
and allows a 0.025” guidewire through its lumen. This needle is also routinely used
for crossing into the aorta during transcaval aortic valve repair. The occasional
use of this needle for revascularization of thoracic central venous occlusion has
been described.[15] In this report, we describe successful use of the combination of a transseptal needle
and balloon assistance for revascularization of a chronic iliac venous occlusion.
Case Report
A 30-year-old woman presented with progressively increasing left lower extremity swelling
and pain. She had prior history of deep venous thrombosis (DVT) of the distal IVC
and left iliac vein approximately 9 months prior to presentation. She was treated
initially with low-molecular weight heparin (LMWH, Lovenox) and transitioned to warfarin.
Three months after the episode of the DVT, an attempt by another provider to recanalize
the occluded left iliac vein was unsuccessful. She continued warfarin but progressive
lower extremity swelling prompted a referral to us. CT venography demonstrated a long-segment
occlusion of the left iliac vein with chronic, partially occlusive DVT in the left
common femoral vein. The IVC was patent.
The left common femoral vein was accessed under ultrasound guidance and a 10F short
sheath was placed. Venography confirmed occlusion of the left common iliac vein and
severe stenosis of the left external iliac vein, with multiple abdominal wall collaterals
([Fig. 1]). Using a combination of a 6F long sheath, 5F angled catheter and 0.035” angle Teflon-coated
guidewire, the stenosis in the left external iliac vein was crossed. Multiple attempts
to cross the left common iliac vein occlusion with angled guidewire, stiff angled
guidewire, and back end of the guidewire were unsuccessful. Through a right internal
jugular vein access, an IVUS catheter was advanced into the IVC to guide transseptal
needle entry into it. A transseptal needle was advanced through the left femoral sheath.
The needle could not be identified on IVUS due to its limited field of view. The IVUS
catheter was exchanged for a 12 mm × 40 mm (Mustang) balloon, which was used as a
target to advance the transseptal needle into the IVC. The trajectory of the transseptal
needle relative to the balloon was confirmed on two orthogonal planes, and the needle
was advanced into the balloon ([Fig. 2]). A 0.018” guidewire was advanced in to the IVC. A cone-beam CT confirmed intravenous
location of the wire. Serial angioplasty of left iliac veins was performed with 3
mm and 5 mm balloons. The 0.018” guidewire was exchanged for a 0.035” stiff Amplatz
wire. Two overlapping 14 mm × 90 mm wall stents were placed in the left iliac veins.
The stents were dilated to 12 mm using a 12 mm × 40 mm high pressure (Conquest) balloon.
Posttreatment venography confirmed brisk flow through the iliac veins ([Fig. 3]) The patient was discharged on a combination of acetyl salicylic acid (162 mg) and
therapeutic LMWH. At 1 month, CT venography and duplex ultrasound confirmed patent
iliac vein stent and residual nonobstructive chronic DVT in left common femoral vein.
The patient developed a small thigh hematoma at 1 month which was surgically evacuated.
At 2 month follow-up, the patient remained asymptomatic.
Fig. 1 Venogram through left common femoral vein access. Failure of contrast to progress
beyond the left common iliac vein (arrow) is noted. Later images demonstrated opacification
of abundant pelvic and abdominal wall collaterals.
Fig. 2 Intraoperative fluoroscopic image at the level of the inferior vena cava (IVC) confluence.
Transseptal needle placed through the left common femoral vein access is noted abutting
the target 12 mm balloon within the IVC, just prior to perforating the target balloon.
Fig. 3 Intraoperative fluoroscopic image centered on the left iliac veins. Venogram demonstrates
brisk flow within the left iliac veins after sharp recanalization, endovascular stent
placement, and subsequent balloon angioplasty.
Discussion
Chronic iliac or iliocaval occlusion leads to chronic venous hypertension and valvular
dysfunction. Patients present with symptoms of progressively worsening lower extremity
edema, varicosities, and exercise intolerance. Longstanding chronic venous hypertension
results in chronic venous stasis, lipodermosclerosis, and venous ulcer around the
ankle and lower leg. In addition, the abdominal wall collaterals and varicose veins
in lower extremities can be disfiguring and have the potential to bleed, owing to
high-venous pressure. Revascularization of the occluded iliocaval veins has been shown
to reduce symptoms and disease progression.
While traditional methods of crossing occluded vessels involved passing an angled
or straight teflon-coated guide wire, sharp recanalization is usually performed with
the back end of a guidewire or a long needle.[1] As venous occlusions tend to be more fibrotic, sharp recanalization is more often
used for veins rather than arteries. Occluded iliac veins are often more difficult
to revascularize due to their long-segment occlusions and three-dimensional course
of the vessels as well as close proximity to the arteries. Previous techniques for
revascularization of occluded iliac veins included unintentional subintimal or extraluminal
passage of a guidewire and subsequent reentry in to the lumen of a patent proximal
vein.[8]
[9] Using a target such as a snare or catheter or balloon while traversing the occlusion
with a rigid end of the guidewire or a sharp needle allows improved chances of target
vessel entry and decreased complications. Of all the targets used, an inflated balloon
allows superior targeting by providing a larger target and more dilated vein. In addition,
the entry of the needle or rigid wire into the vein can be confirmed when the balloon
deflates. The balloon can also allow safe capturing of the wire for subsequent advancement
into the target vein.
The use of a transseptal needle instead of Rosch–Uchida or Colapinto needles has distinct
advantages. The smaller size of the needle and small caliber of the lumen may help
decrease complications during accidental injury to the adjacent structures. Given
the smaller diameter of the needle, the shape of the needle can be more easily changed
to accommodate various venous configurations. The inner sharp wire can be changed
to various floppy or rigid wires for further modulation of the needle for a desired
outcome.
Despite the aggressive (use of rigid wire and needles) revascularization techniques
described for chronic venous occlusions, the outcomes of such recanalization appear
to be similar to those described without the use of these techniques for iliocaval
veins and central veins. The reported complications are also rare.
In conclusion, we report the use of a transseptal needle and balloon targeting technique
for revascularization of chronic iliac vein occlusion. This technique appears to be
safe. This can be applied after failure of conventional techniques for revascularization
and as an alternative to use of larger needles. As with any complex endovascular work,
a good understanding of anatomy, preoperative planning, and expertise are essential
to ensure good patient outcomes.
