Endoguide — Navigating Endovascular Surgery

ENDOGUIDE - MANAGING CENTRAL VENOUS OCCLUSIONS

Treating a stubborn central vein occlusion can be a daunting task 🥲 
 
On the one hand, you want to recanalise the channel to allow flow. On the other, you accept a small but very prescient risk of rupture into the pericardium or pleural cavity (ouch!) 🚨 

Some tips I like to use: 💡 

Never use the backend of a Terumo as your go-to strategy. I fancy a front of Stiff Terumo rather. 🙂 

Choose your support catheter based on anatomy of the occlusion. Could use a steady ol’ Vert or you may be more decisive with a straight angled rather. I prefer a 5 Fr, this nicely balances support and at the same time doesn’t compromise much on engagement of the nipple. 💪 

You need through and through wire support. You would be really fortunate to get away without this. 🤝 

Keep a covered stent standby. Remember to use the right femoral sheath size upfront in case of an emergency later on. 👖 

Prefer local anaesthesia. The reason not due to concomitent risks of a general. Rather, I like to perform inflation guided by patient tolerance primarily rather than any strict pressure cut-offs. 💉 

The inflation technique I use is (adopted observing a senior IR performimg a renal intervention) - focussed small bursts of inflations incrementally up & down the full length of the lesion to slowly make it yield. This fibrotic channel behaves very differently from say an eccentric nodular calcium in the SFA. 
Stab and scoot! 🏃‍♂️ 

Don’t forget the magic of the balloon shoulder before upsizing. s 🦾 

Typically use non-compliant balloons. Start with 6, progress to 10 and finish with a 14/16. 🗜️ 

Crank the pressure up by 1 each time I get a haptic feedback of a (mini)-yield. 🕐 

Collaterals are golden pointers. Their disappearance is a good indication to stop. Remember the old adage - ‘perfect be the enemy of good’. 😈 

What are your tips and tricks to manage these recalcitrant beasts? ☕ 

#venoplasty #centralveinocclusion #venoushypertension #cathlab