047 - Supraclavicular Percutaneous Extra-Anatomic Recanalization (SPEAR) For Central Venous Occlusion
Robert Ford, M.D. – Attending, Interventional Radiology, Thomas Jefferson University; Sean Maratto, M.D. – Attending, Interventional Radiology, Thomas Jefferson University -; Ronald Winokur, M.D. – Director, Interventional Radiology, Weil Cornell Medicine Vein Center
Purpose: To describe a novel endovascular technique for treating central venous occlusions while mitigating risk seen in traditional sharp recanalization techniques.
Material and Methods: Define the occlusion: a.) Obtain femoral and brachial venous access; b.) Traverse wire and catheter towards the occlusion; c.) Perform simultaneous venography to define the occlusion. Ultrasound access window: a.) Linear ultrasound transducer is placed at a steep craniocaudal angle in the supraclavicular fossa; b.) Visualize the patent lumens both central and peripheral to the occlusion; c.) Take note of arterial orientation to avoid the potential of creating a transarterial path. Percutaneous access: a.) 20-gauge needle is advanced percutaneously into the peripheral patent lumen, towards the occlusion; b.) Convert to fluoroscopic imaging when unable to further visualize with ultrasound; c.) Target previously deployed balloon in the central patent lumen and traverse the occlusion; d.) Advance wire centrally into the inferior vena cava. Access evaluation: a.) Confirm safe and successful veno-venous access via tractography from the percutaneous access site, which additionally excludes trans-arterial path. Endovascular conversion: a.) Achieve percutaneous to groin through and through wire access with action wire and safety wire; b.) Establish endovascular conversion while carefully withdrawing catheter from the groin and simultaneously advancing the wire through the tip of the catheter until it flops into the peripheral lumen; c.) Use intravascular ultrasound (IVUS) to further evaluate trajectory and measure for stenting; d.) Perform venoplasty for wall prep and complete with stenting; e.) Perform post stenting venography to ensure adequate successful treatment.
Results: To date, this technique has been used successfully to treat three patients with CVO. Device selection varied slightly between each case, however, the standard protocol was reproduced with each case. Success was achieved in 100% of patients and defined as recanalization with patent flow through the previous occlusion. All three patients showed marked clinical improvement in the acute follow up period. Unfortunately, they were lost to long term follow up.
Conclusions: SPEAR technique allows for safe, controlled access with continuous visualization of surrounding structures and increased confidence of appropriate access points across even the most severe CVO’s.