Chapters Transcript Lecture Video: Optimal Patient Selection for Good Outcomes in Thrombotic Patients (June 11, 2025) Featuring: Dr. Erin Murphy, Duration: 30 Minutes ; Language: English only We're going to talk about patient selection, and focusing on these thrombotic patients since that's who you're currently enrolling and treating, and then highlighting the need, which we've already kind of pointed out on several cases, the need for good stent inflow. These are my disclosures. So, you know, we certainly can treat these patients with, um, you know, really good results. This is one of my patients who originally had a post thrombotic occlusion. Um, and you know, really, really bad leg disease. Um, she waited several years to get treatment because of insurance issues. There's her, you know, her post stent and her end result, and she's done really well long term. I will point out from some of the discussions already, um, you know, even though the vein, if you look here, is open down here, it's still not healthy down here. Um, so her stent did go, you know, all the way down to, to the level of the profunda there. Um, and then the, uh, you know, the outcomes tend to be better if you have clean, clean vein to that level. Um, all the stent trials have shown, even in our most challenging patients in the post thrombotic groups, that we do improve our quality of life in these patients, and we do improve their venous functional outcome scores, so they can do really well, um. So where do we, where do we see our, our challenges? Well, as you've pointed out, a lot of cases don't go as planned. Um, there's this common error that veins are more forgiving than arteries, but it's actually the opposite, um, because we don't have the high pressures to protect us like we do in the arteries. So while you won't. be, you know, as at risk if you have a bleeding complication, you are, um, significantly at risk if you leave any imperfections. So it's really treating deep venous disease, especially the throm thrombotic patients, is, uh, really a quest for perfection as much as you can get it in that inflow segment. Um, what we wind up happening is that our judgment and our technical errors wind up as the primary cause of these stent failures and complications, and a lot of it is just bringing over the years and years of training we have for our arterial patients, which are in some cases totally opposite thought process from how we have to approach these patients. Um, and so we wind up sometimes looking a little like this when we're dealing with problems like this. And this is why stent occlusions are so bad. Um, the ones you've been presenting, you kind of caught in the acute setting where you have an ability to potentially modify the result. Um, but once they get chronic, a lot of these stents, you know, I tell patients it's a 50/50 whether I can reopen them. And even if you can cross them, you've got, you know, 200 centimeters of solid core collagen. Even if you cross it, you may not be able to dilate it. Um, and bypasses don't do well. So it's really an unforgiving system that you need to kind of maximize upfront. So why are we seeing this in, we don't see that drop like that in our non-thrombotics, um, but the different, but the difference when we look at why stents occlude and where our troubles are quickly point to this, you know, the inflow issues. They all have the same conduit and a lot of Them have that same compression point, whether it's acute DVT, post thrombotic, or the non-thrombotics, um, and the stents seem to hold up pretty well there. Uh, there's, there's an occasional, um, exception, um, but most of the stents and certainly Bonovo are going to do well under that artery. Um, you have to make sure that you are sizing them correctly. Um, generally it's 14 in the common femoral area and I generally. Use sixteens up higher. Um, otherwise, if you use too small of a stent, you can leave them with a stenosis that's more prone to problems. Um, post dilating the stents to size, these are nightinal stents. So they're not the part of the nature of the nightinol is that you have to dilate it to size to get them as strong as they're supposed to be. Um, so making sure you pre and post dilate the stents. Um, and then, you know, the outflow. It seems like it's not usually an issue. You just got to make sure you're past, you know, any cranial lesions, um, for iliac disease, not as, not as common to miss that. Um, but when we're looking at inflow, what does this mean? It means the quality of those inflow vessels, the femoral and profunda, it means selecting the landing zone. So even if everything's open, if they're diseased, they are prone to clotting. The minute that patient lays down and has a pressure in their veins of. Um, and they're not moving their calf muscle or they missed a dose of anticoagulation, that what looked like was kind of OK is no longer OK. So, you know, in arteries, we say things like, oh, it's not flow limiting, um, so we're going to leave that there. We can't really get away with that so much in veins. Um, you might be able to get away with it with aggressive, no miss anticoagulation, but otherwise it's best to just treat it optimally. Um, and then the access location comes in really important because a lot of docs from our arterial experience are used to hitting that common femoral vein, but if you hit the common femoral vein, you're missing your profunda femoral confluence, and many of these patients have disease left there if you don't evaluate it. So anticoagulation decisions certainly come into play, um, and we'll talk about that a little bit, but I would say the vast majority, I would say almost all of my, um, post-thrombotic patients stay on indefinite anticoagulation. Um, they have persistent risk factors, but most importantly, they have inflow disease. So usually these people have occluded, as you've seen, all the way down their leg. So they have disease, and scarring in that femoral vein, sometimes in the popliteal vein. Um, and there, it's just not great, great flow in, in those patients. So then, and again, they have often had persistent risk factors and clotting disorders that are underneath. So those patients stay on anticoagulation. If you have somebody who's doing really well, who has, um, their, uh, everything looks pretty clear, like they're over 1 year out, sometimes with really good ultrasounds, if the patient is older, there's a reason to lower the dose. I'll put them on half dose prophylactic dosing. Um, the acute DVTs vary a little bit, depends on how clear they got. Some of those patients, you can get their fem pop and profunda and everything pretty crystal clear. Um, and that gives you a little more room long term with your anticoagulation decisions. Um. And we looked at the Abre study, um, was one of the device trials, ID trials, and we looked at all 12 patients that occluded their stents over the, uh, course of the study, uh, over 36 months, and there were 12 of the, uh, 200 that occluded. And what you see is there was a pretty significant and obvious uh trend towards these being post thrombotic patients. There was one acute DVT and one non-thrombotic. Um, Almost all of those patients that were post-thrombotic included, um, involvement of the common femoral vein, and most of them had involvement of the deep femoral and the femoral vein. Um, when we looked at them even closer, um, and looked at why we felt each case, you know, had a bad outcome. Um, under stenting, meaning that we left disease between the stent edge and the profunda that was not treated, um, was, was seen in over half, um, having inadequate inflow, meaning that they had, they were high risk patients with both femoral and profunda disease. Again, in about half. Um, there was one missed outflow lesion. There was, um, you know, a couple of technical errors which included things like stenting across the profunda into a femoral vein. Access of the common femoral vein, which caused, uh, missing of distal disease. Uh, and I don't know if I can remember the third one at the moment. Um, and then anticoagulation decision, decisions. What's interesting is the stent. So in this one here, this one, the major technical error was that they extended past the profunda into the femoral vein. And this patient actually had, um, a better profunda than femoral. The femoral was actually occluded. Um, so they basically stented into an occluded vessel. Um, and so then the, because the flow initially was preserved from the profunda and the stent looked good, the physician took them off their blood thinner. They didn't recognize this was an at-risk stent. Um, so, you know, we do. know that these inflow inflow itself is a huge predictor of outcomes. You know, Jelly has is published now, um, showing that as you go from involvement of the common femoral vein to involvement of the femoral to involvement of the profunda, the patency, you know, drops significantly down, um, in even in these first early years. Doctor Black did a similar paper, um, looking at device failure in his patients and showed that they were often, you know, technical. They were, um, hematologic or they were flow related. And when you looked at the stent factors, the, you know, most common similar we saw was inflow issues. Um, also patients who didn't have a stent, um, who probably, I'm guessing from this, probably needed one. Um, so what can we do? I'm gonna give you some kind of tips at looking at inflow, how to select these, the right people. Mm. In clinical standpoint, um, I think postthrombotics are a little bit easier to select than non-thrombotics. Um, you have to sort through so much more with them when you're trying to figure out if your non-thrombotic lesion is really significant. In your post thrombotics, it's usually pretty obvious. Um, I generally reserve treatment for patients who are CP 3 and higher. I'm, I'm not generally stenting for varicose veins, um, iliac obstruction that is enough to cause the symptoms. So, you know, those patients who have, that's more in the non-thrombotic category, but if they were completely lyced and everything's clean and all they have left is a mild Mathurner, that may not be causing full leg swelling. But, um, again, in post-thrombotic, it usually lines up pretty well. Um, I say no, uh, again, in these more non-thrombotic, not to bilateral edema where there's reason for the patient's edema. If they've got equal bilateral edema, then going after something on the left leg doesn't make a whole lot of sense. Um, and I don't treat patients with really excessive BMIs. I have a BMI cut off around 40. Um, that gets a little bit different when you're dealing with acute DVT, um, but in, uh, most of my post thrombotics or non-thrombotics, I, I have a cutoff. Um, and then I say no to noncompliant patients. Um, most, as I said, post thrombotic patients have to be anticoagulated indefinitely, and their stents at risk if they refuse to do that. So if you have patients who, you know, say that they won't do it unless they have like a like major situation in the acute DVT setting. Um, I don't, I don't offer the chronic patients intervention if they're not willing to do that or if they have a history of noncompliance until I, until they show me that they're going to be compliant. Um And so again, what you're looking for is symptomatic compliant patients with obstruction and uh adequate inflow and outflow. So when to think about the inflow, you think about this before you operate, while you operate, after you operate. This is the thing you're constantly evaluating that affects your outcomes more than anything. Um, so just always have this in your mind and your imaging. Um, preoperatively, when I'm looking at these patients, I'm getting an iliac duplex, and I focus very heavily on what those inflow vessels look like and where my landing zone is going to be. So, in this particular image, this is B flow imaging. I know the Phillips machine also has, um, I think it's, um, blank now, it's called, uh, but they have a setting, um, that's very similar color flow or something, not, not the routine color flow, color power Doppler or something. Um, so that's the femoral vein. This is the profunda. This is the kind of image you'd like to see that's clearly pretty perfect inflow. Um, but often you can see septations in there or scarring in there or clots sitting in there. Um, I also get DVT and reflux testing so you know that your access vessels are clear. Where you can access, um, set the patient's expectations, you know, you have disease below the inguinal, you know, the crease we, that we are, we are going to have difficulty treating. We may, I plan to balloon it if I'm, if I see really bad disease, um, in the femoral or profunda, and I'm still treating them. Um, and then I get a CT which I order, you know, as a rule out obstruction, stenosis. Um, and I, I take it to the top third of the femur and I'll show you why, um, but that's how I order it. Um, helps me to plan my operation. So for the ultrasounds, I, I get these kind of images. I do get color flow, but I rely most heavily on the B flow where you can see scarring and you can see how the flow truly is. The color flow bleeds too much to get too much data other than patency. Um, and then I use the gray scale to so that you can kind of compare. I go back and forth between the B flow and the gray scale and see if like what, where I'm seeing flow issues, what's it look like. And here, the thing that I look for most that I don't want to see is if there's any sort of, um, flap right over the profunda. If you have disease like flapping over the profunda that's impacting your flow, you've got to plan to handle that. Um, otherwise, that patient is super high risk. Um, when you're looking at candidacy, of course you want good, good inflow. Um, it's OK if you have minimal disease in both vessels, um, that still can support a stent. You just have to land right at it and you have to balloon them and get you the best outcome you can. Those patients are definitely blood thinner dependent. Um, if you see a patient who has a really big profunda, um, that can happen over time, uh, and a really small femoral, those patients still do fine. Um, if they have a tiny profunda, this is part of the reason I don't like to stent. Um, you know, if you miss your window with acute DVT, uh, I usually make them wait 3 to 6 months, um, because then over that time, the profunda generally reopens. It gets bigger, um, even if the femoral doesn't. Whereas if you try to stent it early, not only is it inflamed, but those vessels haven't had a chance to reestablish patency or enlarge. Um, on your Uh, higher risk side are patients with two vessel disease, that's more than 50%, that's clearly scarred. Anybody who has a flap over the profunda is high risk. Um, and certainly patients who have inflow. This was actually a patient that was stented in one of the trials. Um, they don't have femoral or profunda inflow, but a stent was landed in the occluded common femoral. Um, that kind of patient, you know, it's just not going to stay open. Um, so it's just no stent for that patient. Um. And, looking at Jolly's classification, we're talking mostly about these 3 to 54 to 5, but these 3 patients too, because you can see that common femoral disease is below the inguinal ligament and from our arterial experience, people really hesitate to go past that, but in veins, um, it, it really is OK. Um. So again, things drop off in those higher disease patients. I also, the last thing that I look for on my ultrasounds are to have a really good landing zone and to know what it is. It helps you too with your access, feeling confident. If you see on here that you've got a really good landing zone in the common femoral, you know, you're going to be fine with your access kind of wherever you get it. You have got a good healthy vein from there down. If you see this kind of stuff with Thrombus and scar in the common femoral, in this case going into the femoral vein, then you know, OK, well I can do this case, but I'm going to have to land my stent right above the femoral profunda and maybe balloon the femoral flow a little. If you see something like this, there's septations in the common femoral. This is at the SFJ. There's septations here, so you're going to want to make sure you land below that. Um, some other things that are helpful if you see, you know, these septations or flaps, you know, you have to deal with them. It can be helpful to know you have a duplicated femoral vein. If one is open or one is closed, it can save you time sorting through that in the OR. Um, so for CT, I, I find them, um, unmissable. Like I, I think they add so much to the case. Um, so I think you guys do a bit of that. Um, even for the chronic patients, you can't really see flow, so I order them as CTVs, but I frequently get the, um, The comments that are, you know, well, yeah, but at my institution, I can't get contrast in the veins. They, they don't, they don't time it right anywhere. Um, and I tried to do, set up some protocols here, but kind of gave up because I realized I could see what I needed. Um, so what I, I'm gonna go through is what I can tell from the CT is that the CV CIV at the top is going to be really small. Um, the EIV is likely occluded. Uh, there's collaterals from GS to GSV. Uh, the common femoral vein opens back up, and I can tell where my profunda is, and it's on by the top of the lesser trochanter. So I already know going into the OR if I'm gonna see the GSV, the circ, the profunda, any other collaterals, I, there are other ways to tell, but I already know before going in where my profunda is. So, And if you're looking through here as we're coming down here, we're gonna go under the artery there. You can see the the common iliac is open there and then it starts to narrow under that actually under the left common iliac artery. It keeps going down and you see it's pretty small on that side. Now, your left EIV, you know, is, is in proximity here to your artery and that's occluded. And then it starts to kind of get a little bit bigger in caliber, probably still occluded. And then when you come down past the ligament, you can see it opens up, looks like it has some flow. Here's your GSV coming off and you see these collaterals here. And if you follow, um, I'm gonna go back a little bit. If you follow that collateral, it goes across the pubic bone, um, and that's a GSV to GSV collaterals that you see pretty frequently. If you follow down further, the, the branch that goes with the artery is your profunda. Um, and if you kind of move it up and down, you can see that there, it's totally on and that's by kind of upper end of the, of the, uh, trochanter. So, then how did we do? Well, I think pretty good. We showed that the, um, common femorals open, the externals occluded. You can see a little wisp of the common iliac that's open up here. Um, so we, we really did GSV to GSV collaterals. We really did see a lot of. Information already on that scan. And then again, this is stented to the profunda and we did pretty good figuring where that is as well, because there's the mark for the profunda and we're stented right above that and the CT we said, you know, it was right at the top. Um, this is just another quick example on this one. We can say the CIV is likely occluded as we go under here, um, the tiny vessel, and then it, it probably opens back up a little bit in the external. Uh, looking a little bit more normal caliber, does have some of those collaterals again. And in this case, the profunda looks more healthy and joins on, um, by the bottom of the lesser trochanter. It's kind of completely on. So then in this one, lining it up to that story, um, you can kind of see, you know, similar, um, similar presentation of the, of the venogram to the CT scan. So after you, you know, kind of what you're doing, you've set yourself up, you know what you're going to access, you know what your goals are from your preoperative imaging intraoperatively, um, access is your first major decision. I generally, you know, like you guys were doing for acute DVT, I'll go behind the knee. Um, but for all chronic cases, I go from, um, mid-thigh, and even for my stenting of acute DVT, I most often drip overnight. So if I left a sheath in from the pop and drip overnight, I'll often reaccess the femoral vein the next day. And I do it about the mid-upper thigh. I'll find the common femoral ultrasound down the leg, see where it kind of rolls. Out to the side like you see here, and that's where I'll access it. Um, then I do, um, you, what you want to do is you want to have your whole sheath in -10 centimeters long below the lesser trochanter because that's where the femoral and profunda come together. You want to know your landmarks. So, here's your GSV. Here's your femoral profunda, generally somewhere along the lesser trochanter. And that below that, you can have a profunda below that, but most commonly, it's a bifid femoral if you get too low. And so that just know those anatomical kind of landmarks to help you. Um, if they're not landed correctly, um, this is what a consequence can be. So they, this, this doc actually accessed the common femoral for an occluded iliac and did have it open. The stent looked pretty good, um, but pretty small. That's a pretty diseased common femoral as they're pulling into their sheath. And this patient had a pretty predictable stent occlusion, and we were unable to open that. stent when I got him, you know, he had been chronically occluded for a couple of years. Um, so now he has a permanent disability. Um, and what's really a shame about this is this is his current ultrasound when we last did it was his femoral and profunda are pretty clear. So if he had had access, you know, at a different location and was stented to right above that confluence, he probably would have stayed open and had pretty good results. Um, use your ibis for everything else. You're gonna use it to find your profunda, to access, uh, to assess the healthiest portion of your vein above the profunda. You don't want to leave any disease between the stent edge and that femoral profunda orifice, and then you want to assess your profunda orifice, and assure that it's unobstructed. Um, and the profunda identification, again, it's generally at the top of the lesser trochanter. Um, this particular patient, is this possible that a profunda is down here? It's possible. I've seen it a couple times. It's very rare, um, but in this case it wasn't. This was probably a bifid femoral, and this patient, no matter how many times you open that stent, they would re-occlude because femoral inflow alone cannot keep a stent open. Um, so just, just beware, and I'll see if I can show you on here. Um, the femoral or the profunda vein, you know, is gonna go off, so with the artery. So you see it kind of coming on and off at the top there. That's, that's going to be your profunda. If you see a branch above it, that's like a cirque or a collateral, um, but it's the one at like, you know, there at 11 o'clock that goes off the screen with the profunda artery, that's your profunda vein. Um, The, uh, I, I think Doctor Black already mentioned you can, um, do selective imaging. You put a balloon up and a hand injection, um, and you can force contrast into, um, into the profunda. You can put, um, you know, a specific catheter into the profunda, um, and, and, and look, um, that way. Uh, it is important to access it if needed. Um, designing this landing zone, um, is You know, uh, one of, another, one of the most important things you're going to do, um, there is a paper out of my last institution where we looked at the determining the landing zone with venogram versus just IIS, and IIS determined a lower landing zone in 63% of cases. Um, one of the things we see in veins sometimes is this diffuse narrowing. So this looks pretty normal on a venogram, um, but actually if you look at the areas, this is a 50% stenosis in the EIV and similar. In the, in the common femoral, and you can see all this bright echogenic scarring around the vessel indicative of, um, the prior DVT and scarring from that that the patient had. So if you landed that stent up here treating the compression and, you know, just maybe at the, at the internal, you're going to be leaving all this disease below and risking your stent. So don't leave anything below. You have to cross the ligament in almost every single PTS patient. It's a very rare occurrence where you don't. Um, the, there's fears about crossing the ligament. People, you know, docs concerned that it will result in stent fracture. Um, but that, that is a fiction. Uh, stent fracture is really uncommon with the dedicated stents and is much less concerning than an arterial disease. And in fact, um, you know, is, is so low. I mean, I would say that leaving disease is significantly more risky. Um, there's a fear that needing more metal. In the outcomes because we try to avoid stenting in the arterial system, but in fact it's not true. It's the residual unstented disease that causes stent occlusions in veins, not the amount of metal. Um, and then, you know, we, we say things like we do in arterial, like, oh, the disease is not flow limiting. I'll just balloon this. I'll revise it later if I need to. But in fact, disease that is not flow limiting is still a problem and means venoplasty alone is not effective, although I definitely use it. Um, and you often only get one shot. Uh, you're lucky if you get multiple attempts on these patients. You really want to get it right the first time. Um, this is the most common complication I see crossing the ligament, and, uh, I didn't have a picture to put there because I haven't seen a complication from crossing the ligaments. Um, the, uh, improper landings as an example, this patient had an occlusion. This is after, um, ballooning, and I made marks so you could see where the bony landmarks are. This is the top of the femoral head. That's a lesser trochanter. And so the, um, If you look at, you know, afterwards, they stented trying not to cross the ligaments, um, but this whole area was treated by venoplasty alone because it was all occluded previously. And what you were left with, um, afterwards was this ragged, you know, edge tears and, you know, um, old, uh, scar tissue in there that eventually led to the patient's, you know, stent occlusion. Um, here's another one. This was left below the stent, and again, a patient, they didn't want to cross the ligaments, um, which occluded just a little bit earlier than the last one. So even if they stay open a little bit, they still remain pretty at risk. Um, and the last part is to maximize your inflow, you may need to treat the inflow. So this is a patient that was more in the, um, more into that subacute setting, starting to get some scarring. Um, and this was the inflow vessel, you know, the femoral vein, uh, the profunda is not in these pictures, and, uh, you know, with ballooning, you, you can get something. It wasn't the best result. It's certainly better than this was. Um, this is a patient who had this flap across the profunda. Um, and then this is after ballooning. And in this case, you know, we actually put a balloon in there. It wasn't, it wasn't helping. So I wound up trying to do this to kind of tear that flap. Um, doesn't, none of this stuff works routinely, but you just got to try whatever you can to get that flow from the profunda unobstructed. Um, an acute DVT is what we're talking about. Shoot for resolution, not improvement. You really need all of the clot gone. If you've got a drip, then drip. Um, the DVT can involve the profunda. In this case, um, this is the, I wonder if I, yeah, here, this is a close up, but there's, uh, thrombus within the, uh, profunda vein, and this is, you know, a catheter going up and over to suck it out. Um, The, uh, cloth triever can actually drag thrombus into this vessel because as you're pulling it back, it'll, it'll just kind of flow in there naturally. Um, so even if you didn't have it at the start of the case, you still got to check it after. Femoral inflow alone is not enough. Um, so just make sure we're cleaning that out. Uh, this probably would not be included in a trial, but if you can't get adequate inflow and it's right. Especially in these post thrombotic patients. Sometimes we do, uh, like this case, I could not get that to dilate, so I didn't want to put a stent in there. Um, and so we wound up doing this endophlebectomy, um, my partner and I, and then, um, and then stenting it. So, remember, no inflow equals no stent. This is one of the cases I showed earlier, you know, they, they ballooned everything, um, but you can see the femoral vein was initially occluded. Um, and this was their inflow. Like that's in the common fold. This is the, there was no pheromone flow. This is the only profunda inflow, um, which basically is nothing. So when the stent occluded on day 5, you can see all of this stuff below there is chronic that wasn't new. So they basically put a stent above occluded veins. Um, so when not to stent is these patients with super poor info inflow. Um, non-compliant patients who aren't gonna take their blood thinner or people who are, you know, super high risk that are kind of out of your comfort zone or ability to address. Um, postoperatively, I think, um, Doctor Black's gonna talk about that next, but I do see the patients pretty frequently. Um, and generally again use indefinite and anticoagulation, those with inflow issues. So overall, you can get really good results in these people, um, but you know, make sure you, you, you pay attention to their, uh, profound ephemeral flow and compliance when considering candidacy and make every, uh, every move to optimize those factors, um. Avoid, uh, any remaining common femoral disease and assure unobstructed flow. Follow postoperatively with good thoughtful anticoagulation decisions. All right. Thank you. Created by
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