Reconstruction of stenotic or occluded iliofemoral veins and inferior vena cava using intravascular stents: re-establishing access for future cardiac catheterization and cardiac surgery
Frank F. Ing, MD, FACC*,
Thomas E. Fagan, MD ,
Ronald G. Grifka, MD, FACC,
Sandra Clapp, MD,
Michael R. Nihill, MD, FACC,
Mark Cocalis, MD, FACC*,
James Perry, MD, FACC*,
James Mathewson, MD, FACC* and
Charles E. Mullins, MD, FACC
* Children’s Hospital of San Diego, San Diego, California, USA
Texas Children’s Hospital, Houston, Texas, USA
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Figure 1 (A) This 5.3-kg infant with hypoplastic left heart syndrome s/p Norwood I operation underwent a pre-Glenn catheterization. Hand injection of contrast demonstrated complete occlusion of the left iliofemoral venous system, with contrast entering the paravertebral venous collateral circulation. (B) Careful evaluation of the early phase of the same injection demonstrated a tiny superficial femoral vein remnant (arrow) before filling by the superimposed paravertebral venous collaterals. (C) The same injection on the lateral projection showed the anterior position of the femoral vein remnant (arrow) compared to the posterior paravertebral collateral veins.
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Figure 2 Through a 4F dilator, a stiff 0.018-in. (0.0457-cm) wire was carefully pushed into the occluded vessel in millimeter increments followed by advancement of the dilator. The wire and dilator should follow the expected course of the IFVs in both AP and lateral projections. Contrast was hand-injected into the dilator after the wire was removed, demonstrating no extravasation. Note the length of the occluded segment, which extended from the left superficial femoral vein to the midportion of the IVC just below the renal veins (arrows).
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Figure 3 The wire and dilator were advanced beyond the occluded segment. Contrast flowed freely into the patent IVC and the renal veins (arrow).
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Figure 4 An exchange guide wire was passed across the recanalized vessel, and balloon dilation of the entire occluded segment was carried out initially.
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Figure 5 Seven overlapping stents were implanted. A clamp was placed on the surface of the groin corresponding to the level of the inguinal ligament (dashed line), which defined the caudal limit for stent implant. The three most inferior overlapping stents are shown here.
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Figure 6 Post-stent implant angiogram demonstrated wide patency from the IFV system to the proximal IVC. Notice that the previously seen paravertebral collateral flow was no longer present.
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Figure 7 A percutaneous needle was placed on the skin surface parallel to the femoral vein in order to determine the level at which the most caudal stent must be implanted and still permit access into the stent by the needle. This strategy will permit recanalization of the stent by a needle (arrow) in the event that it is completely occluded in the future.
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Figure 8 At the end of the procedure, the hips were flexed (black arrow) under lateral fluoroscopy to evaluate for potential stent movement. In this patient, five overlapping stents were implanted from the right IFV to the IVC. Hip flexion did not change the position of the most caudal stent (white arrow).
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Figure 9 Contrast injection into the IVC was used to evaluate stent position relative to the renal vein orifices (arrows) to avoid overlap.
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