Chapters Transcript Lecture Video: Optimal Approch to Venous Stenting (July 18, 2025) Featuring: Dr. Stephen Black; Duration: 26 Minutes; Language: English (Japanese subtitles available) My name is Stephen Black. I'm a, uh, professor of venous surgery at King's College Hospital and a consultant vascular surgeon at Geys and Saint Thomas's, uh, where I I'm also the, uh, Chief of Surgery, uh, for the hospital. Uh, today's, uh, we're gonna talk about the optimal approach to, uh, venous stenting. Um, uh, these are some disclosures I have, um, uh, for this presentation. Uh, before you start building a Venus practice, it's really important to learn and, and this, uh, talk is obviously aimed at, uh, that, uh, but the basis of building any practice that is new and particularly in a field where you haven't done anything before is to really understand the data. Uh, to know what your subject matter is, uh, to understand the techniques available to treat patients, and particularly with Venus, it's recognizing that, uh, arteries and veins are not the same thing. Uh, and the, uh, example I always give of, uh, is it's like playing, uh, squash and, uh, tennis. Uh, both racket sports with a ball, but the rules are different. And it's important to understand that difference in rules so that you, uh, approach the two fields. Uh, it's very helpful to spend time talking to people who've done it. And of course, in a new field, uh, and I certainly found this when I was growing my practice, uh, where, where the experience was very different from, uh, doing, uh, arterial cases, I needed to find those people. And in finding those people, I could utilize their skill and that process has been ongoing over many years. I spoke to, uh, a number of my colleagues and, and you continue to do that with each meeting and events that I go to, I learn more. It's also important in the hospital to build a team of people who are going to help you to treat, uh, these patients. Um, uh, I have, uh, a big team of colleagues, uh, who not only help me to make good decisions around the patients, but also help us to get patients that we're going to treat and to make sure we look after them properly. And this includes, uh, hematology, interventional radiology, uh, ultrasound technicians, research nurses. Research fellows and my vascular colleagues. Uh, hematology in particular are vital because a lot of the patients that you treat with venous disease have complex hematological conditions and they need, uh, significant input, uh, to manage, uh, their anticoagulation strategies, uh, both, uh, before and after treatment. Uh, then you need to focus on, uh, pathways and decisions to get patients to intervention. Uh, the pathway for venous patients is much more difficult than the pathway for arterial patients. It's pretty clear when an arterial patient has chronic limb ischemia that they end up with a physician who offers intervention, but that's not always the case with venous disease and particularly with DVT patients where Uh, the first choice of a physician is often an intervention, uh, uh, uh, an intervention person who is going to give them anticoagulation, but not necessarily offer them treatment. So we had to spend a lot of time in our hospitals ensuring that we had standard pathways that got the patients, uh, to us to offer them the option of treatment. Uh, you also can't be there all the time, so you need to make sure that, uh, particularly with DVT patients where there is a window of 2 weeks to treat them, that you capture those patients, uh, and they get referred to you for options for treatment. And then the decision making of who to treat and who not to treat is really, really critical, and we'll go into, uh, some of those decisions in a little bit more detail. But the art of medicine sometimes is to do as much, nothing as possible, uh, and we've got to be careful about trying to treat people where, uh, there will be inevitable failure or making good decisions in that treatment so that we optimize the chance of success. Uh, so interventionists can, can do quite a lot to change these pathways. Uh, we focused a lot on ulcer care pathways, uh, where a lot of venous ulcer patients, uh, may have underlying deep disease that needs treatment, and this can be in the context of post robotic syndrome. Where I've had many patients who may have had a DVT or a, a blood clot, uh, 20 or 30 years before, and what they actually have when they present with their venous leg ulcer is post thrombotic syndrome, uh, and by looking for deep venous disease in those patients, you will find it. Uh, we identified in my own hospital that about 30% of patients who presented to us with an ulcer had some form of deep component. Uh, that may require stenting. Uh, you need to look at the epidemiology of all the patients who present with venous disease. And once you start thinking of outflow obstruction as a component of deep venous disease, you add that to the pathway of superficial venous insufficiency, SVI, arterial, and others. And then trying to treat all those possible causes. And a good MDT team with wound care and follow-up will also help you to get those patients who come from, uh, multiple sources. One of the discussions in that pathway was speaking to my hematology colleagues to understand, to ask patients about symptoms in their legs after DVT so that you could then pick up the post thrombotic, uh, syndrome patients. Most hematologists focus entirely on DVT, uh, risk reduction and, uh, PE prevention, and they tend not to think about the leg because there really weren't treatment options in the past and so these may get ignored. So a treatment pathway for patients with C2 to C6 disease could look like this. Uh, this is a pathway that comes from Oscar Malletti and Marzia Lugli based in Italy who've been treating, uh, deep venous disease for, for many, many years. Uh, and what they're doing in each of these patients is looking for at both the deep and superficial. System, looking for disease in each of those, understanding which patients require a conservative management, and then working patients up for, uh, identification of proximal obstruction and deep venous reflux or a combination of the two. this ultimately may end up in a number of treatments, but you can see that endovascular treatment of ballooning and stenting, uh, fits in the pathway of proximal obstruction or combination of deep obstruction and reflux. And it is important when you're setting out these services to obsess about the detail for these patients. It's very, uh, easy to focus on the stent and be thinking only about placing the stent, but that is only one component of successful outcome. Uh, good stents obviously make a huge difference to the patients and the, the dedicated venous stents have really helped us. But what you have to think about is, uh, when you're building up to your treatment, is how are you're gonna access. Uh, do you have Ibis available? Particularly, you have to really think about profunda inflow. I can't stress enough how important profunda inflow is, uh, to good outcomes. Uh, be really clear on an anticoagulation strategy. That involves using. Uh, uh, full anticoagulation and potentially the addition of antiplatelets. Make sure when you finish treatment that all sheaths are out and the patients have stockings and intermittent pneumatic compression right from the very beginning. Really focus on where you land your stents. Missed inflow disease is the single biggest cause of failure. And then, of course, uh, be really clear on choosing your stent sizing and making decisions on. Landing zones, and we'll go into some of this in more detail. Uh, the classification of chronic venous obstruction, uh, which has now been published by Human, uh, Human July in the European Journal of Vascular and Vascular Surgery, uh, earlier on this year, is a really helpful framing of which patients to choose in terms of picking winners and losers, uh, for your treatment. Uh, if we go from left to right on this diagram, we go from type 1 patients, which are essentially, uh, non-thrombotic iliac vein lesions. And in those patients at 12 months, the primary patency is 95%. Uh, whereas if we go to type 5 on the right of the screen, uh, the primary patency in those patients is 40%. So that's a substantial drop-off in expected patency in this patient group, and that is all related to inflow. So the real target for post-thrombotic patients at the start to really ensure that you get good results is type 2 and type 3, where we can expect high patency rates with a low rate of re-intervention. In those patient groups, uh, and then of course you can predict, progress to type 4 patients, uh, as you become more experienced and clearer in, uh, the decision making. And then finally, after all of these things, you get to really the procedural tips which, uh, uh, make the mainstay of the procedure. So the first thing when you're thinking about, uh, treating venous patients is where are you gonna access the patient. And my standard practice, which you can see in the picture on the left, is to access in the mid-thigh, uh, where, um, I access the femoral vein. Uh, and you typically try to find a reasonable bit of femoral vein, uh, immediately behind the adjacent artery, uh, and this puncture is, uh, relatively straightforward with a stiff micropuncture access kit. You can access the popliteal, you can access the jugular to treat patients, uh, and that, uh, those access sites are in order of preference. I would absolutely avoid accessing the common femoral vein or the great saphenous vein on the ipsilateral side, uh, for the principal reason that you'll end up missing inflow disease if you start accessing those points as tempting as they are. So, uh, those sites should be avoided in treating these patients. But other than that, in some of the chronic patients, often I'll have access from both femoral vein and from, uh, uh, the jugular vein when we're trying to cross complex lesions and treat them. And particularly, jugular access for me allows good, uh, uh, easy access into the profunda vein, uh, if I need to plaster the profunda vein up at the end of the procedure. We do, of course, perform all these cases under general anesthetic when we're gonna place a stent, and that's for the simple reason that it is painful to balloon dilate up these patients and it is painful when you place a stent. So unless you have very good sedation, you need to focus on general anesthetic, and you also have to be aware that it's painful. And that's not like arterial disease where pain is a sign of impending rupture. You really do have to make sure that you pre-dilate properly, and we'll go into that. Uh, a little later in this talk. Once you are, uh, into a space of being able to, uh, access the vessel, uh, contrast is helpful to try and establish where you might find a tract, but oftentimes the contrast will only go into collateral vessels. Uh, so I'd, uh, be cautious about using too much. But once you have a catheter in the obstructed lesion, a contrast can give you a string sign to follow. Uh, but the mainstay of trying to cross in chronic occlusions and the picture on the right-hand side of the screen. Is the most important bit to tell you, um, what, uh, you need to, uh, do is try and get the tip of the wire to find the channel that will go through these chronic obstructive lesions. It is not like, um, uh, arterial disease where you are trying to access a sub-interval plane. What you're trying to do is allow the tip of the wire to go through the trabeculations that are formed by chronic scarring. And you can see in the picture on the left. Above the groin, there's a narrow, uh, string sign, which, uh, indicates where, uh, you need to try and access to cross. And oftentimes once you get into these, I use a straight stiff terrumo or any straight glide wire will be appropriate. And then you're trying to use the tip of the wire to drill through, uh, the lesion, uh, rather than try and form a loop. Uh, a loop is often an indication that you may be outside the vessel. Uh, many times in venous disease, you need additional support from catheters. Uh, we have, a, a, a system in, uh, the United Kingdom called the Tri-Force system, which is available to us, which is very helpful. In the absence of having that, what I typically would do is build up a platform of support using, uh, a mixture of, uh, catheters, uh, and supporting, uh, sheaths. Uh, and, uh, those may be destination or ansel type sheaths, uh, but what you're trying to do is make sure that you have enough support on the wire so that when you're pushing on the tip of the wire, which may often require force, that that force is directed through the lesion. You can see in this particular example, uh, there is a normal external iliac vein and I'm trying to get into an occlusion in the common iliac vein. And in order to do that, I needed a CXI and an ansel sheath to really create a rigid system that could then access the occlusion. And you can also see in the picture on the right that we've got access from the jugular, and we're working from both proximally and distally to get through, uh, this lesion. Once you start crossing typically from the left, the target that I have to get across are the spinous processes, which are a very good landmark of where the confluence of the common iliac veins is to form the inferior vena cava. And typically, you'll see in the picture on the left, uh, uh, we are crossing, uh, trying to work our way to the spinous process. And once we've crossed and I've placed my ivis catheter, you can see the tip of the ivis catheter in this case is at the confluence, and that is almost always just to the left of the spinous processes. And that's what you need to focus on, making your, uh, uh, and that's where you will want to land the proximal end of the stent. So once I have the IIS catheter in position of where I'm going to land a stent, I can work out where my stent landing zones are going to be and what length of stent I'm going to place in the patient. And in this case, using the IIS markers, I can see the window in the pelvis at the 1414 to 12 centimeter mark is where I want the stent to end. And if I'm going to extend the stent below the groin, I still do, uh, the same landing area because that's where I want stent overlap to be. And we want to really avoid overlapping any stents under the inguinal ligament and certainly around the femoral head, uh, because that can cause problems. So you can see these two examples. Uh, in the case on the left, we've placed a single stent, uh, into a normal external iliac vein, and you can see that the two red lines indicate that the size of the stent is matched to the size of the inflow vessel. So we have a very smooth transition from normal vessel into the stented segment, which means we're going to have good flow through that. And then on the right-hand side screen, you can see the landmarks that we've spoken about. So, Uh, Working from left to right, the upright left bar indicates the wall of the inferior vena cava. The second red line obliquely across the top of the stent shows the confluence, and you can see that stent is just to the left of the spinus process in this patient. Uh, and then the lower two red lines indicate the external iliac vein, uh, pointing up out of the pelvis, which is where we want the overlap zone of the stents to be. Uh, and also, uh, the last line indicates the inguinal ligament. And you can see I've crossed the ligament and placed the stent into normal common femoral vein below that. Again with a smooth transition from vessel into stent, but the overlap of these two stents is sitting up in the pelvis and not in the femoral head where I want to avoid any chance of overlap. Of course, before we place stents, we need to pre-dilate. And the main thing is to match your pre-dilation balloon to the size of your stent. So if I place a 14 stent, I choose a 14 balloon, and I always use the Atlas Gold balloon, uh, and we dilate that to 18 atmospheres before we place the stent. You cannot open these stents properly if you do not pre-dilate adequately. So, it is not good to pre-dilate with a 6 or an 8 balloon and hope that you will open the stent up after you have placed it. And again, as we mentioned before, if you get pain during the course of that, that is normal for venous patients and is not a sign of rupture, and you have to dilate up to the, the size that you want to place the stent. I also always post dilate with the balloons to the same size again, and that is important to allow Nanol to be fully transitioned into its strong state, and I do that as a routine in every single patient. So the main message is pre-dilate to the size of the stent that you want to place and make sure the balloon is fully open throughout the whole stented segment. The profunda is absolutely key to these patients, and you can see these pictures here. In the picture on the left at the start of the case, you cannot really see the profunda, but on the right when we finished the image, you can clearly see a profunda draining into the stent system. Uh, if I cannot see the profunda at the end of the case, I have a couple of techniques to try and help with that. One is to blow a balloon up in the stented segment and then do a run to see if I can see backfilling into the profunda. And if I'm really not clear that I can see a profunda, I will then access the profunda from the neck, come from the jugular, get a wire and a catheter into the profunda, and make sure that there is drainage from the profunda into the stented segment. If I need to, at that point, you can balloon the profunder up. It responds well to ballooning. Uh, sometimes I do kissing balloons in the femoral vein and the profunda to ensure that the confluence of the, the two is adequate into the stented segment. Uh, and in these cases, uh, that is really helpful to improve drainage from the stent. Uh, I try and avoid stenting into the femoral vein. I might on occasions, on very few occasions, extend the stent into the orifice of the profunda if it is the only inflow vessel, but you do not want to get into the habit of extending stents into the profunda vein or certainly into the femoral vein, which typically requires an additional stent, and that mandates a stent overlap in the common femoral vein, which is not good. Uh, for the long-term patency of patients. So ideally, we want to land the stent at the confluence of the profunder and femoral vein, and then simply balloon venoplasty, the profunder and the femoral vein if we need to. So what problems have we encountered so far with stenting? Well, migration was, uh, a problem, and this is really almost exclusively small diameter, short stents. So anything under 14 or anything less than 90, you'll have problems with migration. I don't have 60 millimeter stents in my hospital, and I really don't see the need for them on, uh, on many occasions. So I would suggest to most people try and aim for using the longer stent lengths, 90 plus, and avoiding, uh, small diameter stents, uh, in, uh, venous disease, uh, particularly in patients where you're treating a more, uh, nivel type lesion. Avoid oversizing too much. Uh, the algorithms based on wall stent tended to encourage people to put 18 or 20 stents into the common iliac vein. These lead to a lot of back pain. So the mainstay of what you're going to be treating is 14 or 16. It is very uncommon to need to go bigger than those two stents. I think I've placed in over 600 patients on one occasion, I've needed to place an 18 millimeter stent. Fractures are really hardly seen. So the main message is do not be worried about fractures by taking your stent below the inguinal ligament. If you need to stent the common femoral vein, you should do so. If there's disease in the common femoral vein, you have to stent it, and the risk of not stenting it is much, much greater than any risk of fractures. Uh, and all the data for the open-cell laser cutitinal stents and the Vinovo in particular are very, very few fractures have been seen, and those that have been have not caused problems for the patients. Uh, so it really is an uncommon problem now. In stent stenosis does occur. It's a problem for all stents. In venous disease, it is a slightly a part of life, but that's why we do follow-ups, uh, very rigorously and try to make sure that we intervene on the patients early if they do need anything. But, uh, as long as you choose patients with good inflow, in stent stenosis is very, very low risk. Uh, and we do need to work on outcome measures and, uh, uh, for, uh, you in Japan, uh, with the PMS system and the efforts that have been put into standardizing the, uh, data collection, uh, that will be enormously helpful. So where do we see where things go wrong, uh, from what we've talked about, this is a case that was sent to me where the stent hadn't worked, and you can see why did this fail. Uh, the, the inflow, um, and outflow have both been badly treated. On the left-hand side of the screen, we can see that the stent is not projecting to the left of the spinus processes. So in this case, the physician has not stented the Maurna compression point. And on the left-hand side, you can see that we can identify a profunda, but the stent has been taken down into the femoral vein, and this is jailed inflow into the stent from the profunda, which was actually reasonably good. So this patient was a 4A on the July classification, and what they needed was a stent landed at the red line, uh, to ensure that they, uh, uh, kept the profunda in circuit. And you can see the profunda comes in at the lesser trochanter. And the lesser trochanter is a very, very reliable landmark for where the profunder will be. And so oftentimes if I see somebody's landed a stent short, it will often be at the femoral head, and that typically means that inflow disease has been missed. So you really want to make sure you get your stents down as far as possible to, uh, capture the disease, but be wary of going below the lesser trochanter into the femoral vein, which does not work. It is important to follow up your patients. And I think the three main reasons for failure are technical issues, which we've spoken about extensively, flow, which is about patient selection, and clotting, which is making sure that you give the patients adequate anticoagulation after the procedure. My favorite approach. Uh, would be, um, pixaban, uh, 5 mg twice a day, and that needs to start immediately after you've completed the procedure. Uh, ensure that the patient finishes the procedure with an ACT above 200, and then transition them immediately to apixaban, uh, uh, as soon as possible after the procedure is completed. And then I would maintain that for the duration as specified by the underlying reasons for clotting in that patient. And typically we'd keep the anticoagulation for at least a year after stent placement. In some patients, we add an additional antiplatelets, uh, uh, to, uh, those patients where we are really concerned about high risk, and those would be patients where the inflow is potentially compromised. So the conclusion from today's discussion is that it's really important to build a team around you to make sure you work. And that team, apart from the hospital can also involve the people who are providing support. I've got significant and invaluable support from industry colleagues over the years in building my practice and making sure That I do the right thing and, uh, that involves some of these things of having people around who will help you and that may be remote, uh, mentors and, uh, people who can support, uh, your cases. Uh, start with simple patients. Start with patients where you've got really good inflow. So we'd say the main target to begin with is those type 2 and 3 patients where you have got good inflow vessels because that will build confidence and build success, and you can progress as you become more confident in decision making to the type 4, and type 5 potentially patients, although those are extremely high risk. Uh, really, really be clear that, if you need to extend below the ligament, you should do so. Fracture is not an issue, and it is far worse to leave untreated disease, uh, below the ligament. Where you need two stents, make sure that the stent overlap is above the ligament to avoid stent overlap in the region of the femoral head or the common femoral vein. Make sure you focus on the details and respect the fact that venous and arterial treatments are not the same. So just because you can do arteries, doesn't mean you can immediately do veins. Make sure that you learn the difference in the rules and you will have great success, uh, in doing that. So, uh, I wish you all, uh, wonderful success in treating uh venous patients and building the future for venous disease, uh, in Japan. Created by
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