European Conference on Interventional Oncology

April 24-27 | Vienna, Austria

April 24-27 | Vienna, Austria

April 24-27 | Vienna, Austria

April 24-27 | Vienna, Austria

April 24-27 | Vienna, Austria

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ProgrammeVenous emergencies

Venous emergencies

We spoke to Prof. Gerard O’Sullivan to learn more about his presentation at ECIO 2022.

You can now watch this session on demand! 

Most interventional radiologists and vascular specialists are familiar with arterial emergencies, as we perform arterial interventions frequently, and we see catastrophic events more commonly in arteries than in veins. Traumatic arterial cases, in particular, demand immediate action, and between coils, plugs, glue, stent grafts and occasionally open surgery, the problem can be swiftly dealt with –  and the intervention is usually life-saving.

By contrast, venous emergencies are less common, and as a result, most of us are less well prepared to deal with them.

Unfortunately, as I specialise in deep venous reconstruction, I have probably had more than my share of these, and experience can be a harsh mentor. The purpose of this lecture is to show you some examples of the problems you may face; how you need to prepare for them, in which of your patients they are more likely to occur, and how you have to react to rescue the situation.

Many of the basic tenets of venous interventions are similar to those in arteries; including good pre-operative imaging, secure access to the vascular tree, safe wire passage, balloon dilatation, stent implantation and so on. However, there are some critical differences: symptoms are harder to pin down, and thrombus may be more chronic than initially thought. The direction of flow is the opposite to that seen in the arterial circulation, and so objects (thrombus, coils – even stents) migrate to the right atrium or pulmonary arteries rather than peripherally. Vein walls are more resistant to balloon dilatation than arteries, requiring HIGHER rather than lower balloon inflation pressures, and the diameter of the balloons employed are often very different. Neo-intimal hyperplasia is not a factor, but still does occur in stent re-stenosis.

The CIRSE library has an extensive list of videos on this very topic, and readers are strongly encouraged to review them and learn from these experts.

My lecture at ECIO 2022 will cover the following points

  • Identification of potentially “problem patients”
  • How disaster-ready are you?
  • Central venous access disasters
  • Venous reconstruction disasters
  • Venous thrombectomy and thrombolysis disasters

Potentially problem patients:

Uncertain clinical history or poor historians; unexplained shortness of breath, remote history of DVT or PE; multiple miscarriages, abdominal scars with no explanation – all of these are potential banana skins. You need to prove that unexplained shortness of breath is NOT due to pulmonary hypertension.

Disaster readiness:

This is an integral part of airline pilot training. How ready are you and your team if something goes wrong?

What size IV line does the patient have?

Is the patient group and cross matched; or group and held?

Any allergies?

Are you ACLS certified?

Are you even BLS certified?

Do you know the numbers of your on-call arrest team/ blood bank/anaesthetic team?

Do you know where the stent grafts are kept?

Do you have the right size sheaths?

And so on….

The rest of the lecture is a series of disasters that have occurred to my patients or those of my colleagues; sometimes the situation was remediable – sometimes not. Why not learn from my mistakes rather than making them yourself?

References

  1. Mahnken AH, Thomson K, de Haan M, O’Sullivan GJ. CIRSE standards of practice guidelines on iliocaval stenting. Cardiovasc Intervent Radiol.2014;37(4):889-897.
  2. Adams MK, Anaya-Ayala JE, Davies MG, Bismuth J, Peden EK. Endovascular management of iliac vein rupture during percutaneous interventions for occlusive lesions. Ann Vasc Surg. 2012 May;26(4):575.e5-9. doi: 10.1016/j.avsg.2011.08.025. Epub 2012 Mar 19. PMID: 22437071.
  3. Ingram M, Miladore J, Gupta A, Maijub J, Wang K, Fajardo A, Motaganahalli R. Spontaneous Iliac Vein Rupture Due to May-Thurner Syndrome and Its Staged Management. Vasc Endovascular Surg. 2019 May;53(4):348-350. doi: 10.1177/1538574419831488. Epub 2019 Feb 19. PMID: 30782094.4
  4. Daub AC, Shin DS, Meissner MH, Ingraham CR, Monroe EJ, Chick JFB. Transient arterial insufficiency and neurologic deficit following external iliac vein stent reconstruction for malignant compression. J Vasc Surg Cases Innov Tech. 2021;7(3):469-473. Published 2021 May 21. doi:10.1016/j.jvscit.2021.05.007
  5. Haskal ZJ. Massage-induced delayed venous stent migration. J Vasc Interv Radiol.2008;19(6):945-949.
  6. Gabelmann A, Kramer S, Gorich J. Percutaneous retrieval of lost or misplaced intravascular objects. AJR Am J Roentgenol.2001;176(6):1509-1513.
  7. Morgan R, Walser E, eds. Handbook of Angioplasty and Stenting Procedures.London, England: Springer-Verlag London Limited; 2010
  8. Taylor JD, Lehmann ED, Belli AM, et al. Strategies for the management of SVC stent migration into the right atrium. Cardiovasc Intervent Radiol.2007;30(5):1003-1009.
  9. S. Kim, A. Patra, B.E. Paxton, J. Khan, M.B. Streiff Catheter-directed thrombolysis with percutaneous rheolytic thrombectomy versus thrombolysis alone in upper and lower extremity deep vein thrombosis
    Cardiovasc Intervent Radiol, 29 (6) (2006), pp. 1003-1007

Gerard O’Sullivan

University Hospital Galway, Galway/Ireland

Prof. Gerry O’Sullivan is a consultant interventional radiologist at the University Hospital, Galway. He completed his basic training in radiology in Plymouth and St. George’s, London, before completing an IR fellowship in Stanford under Mike Dake, and worked as a consultant in Chicago before moving to Galway in 2002. He specialises in vascular procedures, and is particularly well known for his expertise in the venous field, especially DVT. In this respect, Dr. O’Sullivan has been a regular faculty member at CIRSE meetings, actively participating in debates, lectures, panel discussions and workshops each year since 2006. He is currently the  Chairperson of the Membership Committee.