E2012. Dual Aspiration Thrombectomy as a Viable Treatment for Iliac Vein In-Stent Occlusion Placed for Nonthrombotic Iliac Vein Lesions
  1. Christopher Yeisley; North Shore University Hospital
  2. Prasad Krishnakurup; WellSpan Health
Iliac vein stenting has emerged as a component of the treatment for May Thurner syndrome or nonthrombotic iliac vein lesions (NIVLs). It has been proposed that this leads to improved patency rates, pain, and swelling. However, stent thrombosis can occur in these patients postoperatively and the best treatment modality for stent thrombosis remains unclear. Treatment is critical given the risk of pulmonary emboli, phlegmasia caerulea dolens, and post-thrombotic syndrome. Previously, systemic anticoagulation or catheter directed thrombolysis have been the mainstays of treatment. However, these treatments carry a risk of hemorrhagic complications, including intracranial hemorrhage. A few prior studies have shown the efficacy of mechanical thrombectomy in deep venous thrombosis, but no studies have investigated the use of mechanical thrombectomy for iliac vein in-stent occlusion in the setting of NIVLs.

Educational Goals / Teaching Points
Brief overview of the treatment of NIVLs. Clinical presentation and significance of iliac vein in-stent occlusion. Management of iliac vein in-stent occlusion and associated deep vein thrombosis (DVT). Highlight challenges and complications of treatment options, including thrombolysis. Review current industry options for mechanical/aspiration thrombectomy. Multimodal case review of mechanical thrombectomy for iliac vein in-stent occlusion in the setting of NIVLs.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
The patient is positioned prone and popliteal vein access obtained with ultrasound (US guidance). A stiff guidewire is advanced into the central IVC. An IVUS catheter can be used to confirm CT findings. The skin tract is dilated and a Flowtriever T-20 catheter inserted without a sheath for aspiration thrombectomy. If there is difficulty advancing the T-20 catheter centrally, a Penumbra 12F Lightening catheter can be inserted coaxially through the T-20 catheter. Thrombectomy is performed into the peripheral IVC with a combination of both catheters. Following thrombectomy, the penumbra device is removed and balloon angioplasty performed throughout the venous stent. Post-angioplasty IVUS and venography are performed to demonstrate stent and venous patency.

Mechanical thrombectomy alone is a viable treatment strategy for patients with iliac vein in-stent occlusion in the setting of NIVLs. By avoiding catheter direct thrombolysis, this technique would avoid potentially significant bleeding complications.