CIRSE 2023: Venous deep dive

October 3, 2023

CIRSE 2023 included a deep dive into venous interventions on the second day of the congress, featuring a full-day programme in auditorium 2 in compliment with a variety of venous-focused hands-on device trainings.

All you want to know about venous stents

The day began with an EBIR recommended session titled “All you want to know about venous stents.” In this session, presenters covered pre, intra, and post-procedural considerations, as well as how to avoid venous stent disasters.

N. Karunanity put an emphasis on how essential careful patient selection is to successful practice, as well as on what clinical and anatomical factors to consider, especially when dealing with chronic and acute DVT. “The key when treating venous disease is trying to identify the patient’s symptoms and identifying the impact of those symptoms on their quality of life.”

J. Abdal Villayandre spoke on intra-procedural considerations, and humorously concluded with a “venous stent mind map,” which was indeed food for thought (the map appears at 15:24 in his lecture!) R. de Graaf continued the session with post-procedural considerations. He underlined that it’s essential to be honest with patients; that they will often be in a great deal of back pain after stent implantation, and that implantation of a foreign body/large tube in a low flow/low info system induces thrombosis risk. This can be prevented with anticoagulation. He concluded with a checklist and several considerations to keep in mind in the case of a re-intervention.

H. Moriarty ended the session with a presentation on how to avoid venous stent disasters. She spoke on differences between arterial and venous stent designs and discussed factors with have led to recent stent withdrawals, such as VICI’s recent class 1 recall due to migration and VENOVO’s voluntary recall due to activation failure issues. “Stent disasters are rare.” She concluded. “Planning appropriately goes a long way to avoiding them. Know your patient, know your equipment.”

Acute iliofemoral DVT

The second session of the day focused on acute iliofemoral DVT. This controversy session included presentations both for and against several topical issues in DVT.

S. Siliopupulos presented the “pro” side of catheter-based therapy for acute high iliofemoral DVT. He stated that it’s safe, with no intracranial or fatal bleedings in all major trials, and effective in reducing the magnitude of PTS symptoms and improving quality of life. He attributed RTC controversies to suboptimal design, older technologies, and less experience. S. Konstantinides presented the “con” side of this topic. “It’s not about if it’s generally a nice thing, it’s about if its safer and more effective than anticoagulation alone… don’t forget, we’re recommending it to the broad medical community, not to the most specific hospital in the country. It has to be feasible in an adequate number of facilities.” He concluded that we are ‘not there yet’ and that there are simply too many questions left unanswered.

Other talks in the session focused on a “pro” stance on thrombolysis-based DVT treatment, and arguments for and against DVT for intravenous drug-users, for which there are many social considerations, but few solid pieces of clinical evidence to rely on. The session ended with a panel discussion.

Management of chronic lower extremity venous occlusion

The afternoon continued with a fundamental course on the management of lower extremity venous occlusion. M. Finas started the session out with a lecture on pre, peri, and post-procedural imaging. S. Lojo Lendoiro followed with an EBIR recommended talk on unilateral iliofemoral venous occlusions. She led viewers through what is considered chronic in venous obstructions, and which patients make the best candidates for endovascular treatment. She noted that treatment of asymptomatic patients is not supported by evidence and that quality-of-life improvement is a primary endpoint, before walking through technical considerations and causes of occlusions, such as May Thurner syndrome.

H. Jalaie continued with valuable information on IVC reconstruction, including the classifications of the different IVC occlusions based on inflow, procedural aspects, and the integration of IVC removal into IVC reconstruction. He concluded with the points that patient selection should be based on inflow, not on the severity of the cava pathology, and that experience in variable recanalization techniques and tricks is essential.

L. Hofmann closed out the session with a talk on the who, what, when, why and how of femoropopliteal venoplasty. He presented two exemplary cases with technical details, discussed his own findings, and explained a treatment regimen for femoropopliteal chronic venous occlusions. “Take home points – this really, really helps patients,” he concluded.

Mission impossible – there are no veins left!

The venous deep dive day concluded with an excitingly titled case-based discussion, “Mission impossible – there are no veins left!”

Moderated by D. Sze and U. Salati, this session featured specific presentations of difficult hepatic, ICV, and transrenal cases, as well as a presentation from M. Guimares on extreme recanalization of central veins.  Throughout these presentations, audience members had the opportunity to participate in live polls as to what they would do in each specific case. The results of the polls did not always agree with the presenter, illustrating the multifaceted considerations for each case and leading to interesting discussions with the audience at the end of the presentations.

Getting hands-on with venous devices

The venous deep dive day was complemented by a set of venous-focused hands-on device trainings. The morning started with a session led by C. Althoff and D. Tuitte giving attendees the opportunity to explore central lines and ports. After lunch, two sessions on percutaneous arteriovenous fistulas took place under the direction of P. Kitrou and G. Falcone. Concurrently, K. Minhas and J. Adu coordinated two training sessions on venous access in small children, underlining the need for education in adapting IR techniques to treat our youngest patients.

Further viewing: