PI-1268203-AB IVUS Case Collection Interactive FINAL

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Advanced IVUS Peripheral Imaging Solutions | Case Collection
Acute left subclavian arterial occlusion – thoracic outlet syndrome

Mr Taha Khan
Lower-limb claudication due to iliac atherosclerosis

Mr Taha Khan
Lower-limb claudication due to aorto-iliac disease

Mr Taha Khan Mr Taha Khan
Consultant Vascular Surgeon,
Guy's and St Thomas' NHS
Rutherford IV left, SFA occlusion, recanalisation Foundation Trust, London, UK
Dr Arun Kumarasamy
Rutherford II left, long ATA, Afib, ATP occlusions, JetStream™ 1.6mm

Dr Arun Kumarasamy
Rutherford IV both legs, left tibiofibular tract stenosis

Dr Arun Kumarasamy
Rutherford IV, long SFA occlusion (left)

Dr Arun Kumarasamy Dr Arun Kumarasamy
Interventional Radiologist,
Rutherford IV ruled out dissection or restenosis after recanalisation Krankenhaus Sachsenhausen,
Dr Arun Kumarasamy Frankfurt, Germany
Post-thrombotic syndrome resulting in tissue loss

Mr Taha Khan
Acute right iliofemoral deep vein thrombosis

Mr Taha Khan
Bilateral lower-limb post-thrombotic syndrome due to iliocaval disease

Mr Taha Khan
Dr Rutger Brans
Nutcracker Syndrome Interventional Radiologist,
Maastricht University Medical Center,
Dr Rutger Brans
Maastricht, The Netherlands
Results from case studies are not necessarily predictive of results in other cases. Results in other cases may vary. ATA: Anterior tibial artery
Afib: Atrial fibrillation IVUS: Intra-vascular Ultrasound
A New Depth of Insight. A New Level of Clarity. ATP: Arteria tibialis posterior
CVD: Chronic venous disease
PAD: Peripheral arterial disease
SFA: Superficial femoral artery
Mr Taha Khan, Consultant Vascular & Endovascular Surgeon, Guy's and St Thomas' NHS Foundation Trust, London, UK
PRESENTATION VIEW IMAGING TREATMENT OUTCOME VIEW IMAGING

• 52-year-old male right-handed baker • The morning after admission, operative intervention involving: • Left upper-limb pulse palpable
• No previous illness and no regular – Left 1st rib resection immediately after the procedure
medication – Left brachial embolectomy
– Left subclavian and upper-limb angiogram CONCLUSION
• Five-day history of left upper-limb
forearm discomfort and fatigue • IVUS enabled early identification
– Left subclavian and upper-limb IVUS
of residual intraarterial disease
• On examination: – Left subclavian artery stenting and angioplasty which may have been
– Absence of left upper-limb pulses • IVUS enabled: ambiguous on DSA alone
– Pallor – Recognition of residual subclavian artery stenosis
– Sensation intact (power 4/5) and thrombus
– Identification of the segment of the subclavian artery
requiring treatment with a stent
RATIONALE FOR IVUS

• IVUS in combination with angiography has greater sensitivity for identifying residual disease
• In this case, IVUS demonstrated residual stenosis and thrombosis despite surgical intervention and therefore supported the need
for subclavian artery stenting
ENLARGE IVUS IMAGES
Residual Stented, patent SA

thrombus in SA
Stenosed SA
Pre-stenting IVUS
(post embolectomy and
post 1st rib resection) Post-stenting IVUS
DSA: Digital subtraction angiography SA: Subclavian artery

IVUS: Intravascular ultrasound
PRESENTATION
Clavicle
Axillary
RATIONALE FOR IVUS artery
Occluded SA
Proximal SA
First rib
Aorta

OUTCOME
Post balloon-expandable
endoprosthesis stent
8mm x 5mm

IVUS
IMAGES
Residual
Stenosed thrombus in SA
SA
Pre-stenting IVUS
(post embolectomy and post 1st rib resection)
Stented, patent
SA
Post-stenting IVUS


• 80-year-old male Therapeutic dilemma: • Palpable left pedal pulses
• Bilateral lower-limb claudication • Option 1: Treat peripheral arterial disease (PAD) alone • Claudication resolved
(left worse than right) (left CFA endarterectomy and left Iliac stenting) • Patient is now able to walk for 0.5 mile (0.8
• Medical history: • Option 2: Treat PAD and aortic aneurysm km) before his mobility is restricted by fatigue
– Current smoker (endovascular repair) • Atorvastatin continued
– Coronary artery bypass 2016 • Treatment of choice: Left CFA endarterectomy • Secondary prevention with dual
– Right external iliac and superficial and left iliac stenting, chosen for two reasons: antiplatelet therapy for six weeks and
femoral artery angioplasty 2011 1. AAA was sub-threshold then Clopidogrel 75mg once a day
– Known 5.1cm asymptomatic 2. Patient had significant comorbidities as a
abdominal aortic aneurysm (AAA) result of PAD
• Drug history:
– Aspirin – Lansoprazole CONCLUSION
– Atorvastatin – Bisoprolol • IVUS enabled accurate recognition of the diseased left iliac segments despite challenges
– Ramipril with DSA
ENLARGE IVUS IMAGES

RATIONALE FOR IVUS
• Recognition of residual
stenosis or thrombosis with
greater sensitivity when
used in conjunction with
DSA angiography
Stented, patent • Accurate identification of the
EIA
diseased arterial segments,
even in the absence of flow
Stenosed
EIA • Assessment of individual
vessels without the need for
changing orientation of the
image intensifier
Initial pre-treatment IVUS Post-stenting IVUS
AAA: Abdominal aortic aneurysm CFA: Common femoral artery DSA: Digital Subtraction Angiography SFA: Superficial femoral artery
CIA: Common iliac artery EIA: External iliac artery IVUS: Intravascular ultrasound
PRESENTATION
Aortic aneurysm
Left CIA
RATIONALE FOR IVUS

Occluded left EIA
Left CFA
atherosclerosis
Occluded
right SFA
Patent
left SFA
OUTCOME
Stent graft 8mm x 57mm
IVUS IMAGES
Stented, patent EIA
Stenosed EIA
Initial pre-treatment IVUS Post-stenting IVUS

• 57-year-old lady who works as a cleaner • Medical management: Aspirin commenced • Palpable bilateral pedal pulses
• Bilateral lower-limb claudication (distance: 10m) at 75mg once a day • Claudication resolved
• Medical history: • Suitable surgical/endovascular options: • No significant limitation in mobility and
– Current smoker – Aorto bi-iliac bypass patient returned to full-time work
– Hypertension – CERAB • Atorvastatin continued
– Diabetes • Risks vs benefit discussion with the patient led • Secondary prevention with dual
• Drug history: to the decision to proceed with CERAB antiplatelet therapy for six weeks and
– Atorvastatin then Clopidogrel 75mg once a day
• No infra-inguinal pulses were palpable
CONCLUSION
• CTA showed severe stenosis of the aortic • IVUS enabled accurate recognition of the diseased arterial segments despite challenges
bifurcation with severe right CIA stenosis and with DSA
left CIA occlusion. No further run-off disease
• Furthermore, IVUS demonstrated a residual dissection flap not seen on DSA
ENLARGE IVUS IMAGES

RATIONALE FOR IVUS
• Greater sensitivity for
identifying residual arterial
disease when used in
conjunction with DSA
• Accurate identification of the
Stented,
patent distal diseased arterial segments,
aorta even in the absence of flow
• Precise assessment of
potential in-stent disease or
Contralateral external sent compression
wire
Stenosed distal
aorta
Pre-stenting IVUS Post-stenting IVUS
CERAB: Covered endovascular reconstruction of the aortic bifurcation CTA: Computed tomography angiogram IVUS: Intravascular ultrasound
CIA: Common iliac artery DSA: Digital subtraction angiography
PRESENTATION
Aorta
Right Left
CIA CIA
Lines indicate expected

location of vessels
OUTCOME
Aorta
Right Left
CIA CIA
IVUS IMAGES
Stented, patent
distal aorta
Contralateral wire
Stenosed distal aorta
Arun Kumarasamy, Interventional Radiologist, Krankenhaus Sachsenhausen, Frankfurt, Germany
PRESENTATION VIEW IMAGING TREATMENT VIEW IMAGING OUTCOME VIEW IMAGING

• 55-year-old male, left SFA Occlusion • SFA recanalisation and atherectomy • SFA recanalisation with patent flow
• Rutherford IV (ischaemic rest pain) left with JetStream™ 2.4mm/3.4mm • IVUS detected no residual stenosis, no
• Medical history: • SFA treatment with: dissection, no stent placement needed
– Diabetes – 4mm x 80mm DEB • Improved Rutherford Category (IV ➞ II)
– Arterial hypertension – 5mm x 80mm DEB
– Hypercholesterolemia – 4mm x 200mm POBA CONCLUSION
• IVUS revealed no dissection • IVUS ruled out dissection, no stent needed
– Adipositas
• Drug history:
– Aspirin 100mg 1-0-0 – Enalpril 10mg 1-0-0
– Clopidogrel 75mg 1-0-0 – Pantozol 40mg 1-0-0
– Atorvastatin 40mg 0-0-1
ENLARGE IVUS IMAGE

RATIONALE FOR IVUS
• Greater sensitivity in terms of identifying residual stenosis
when used in conjunction with DSA
• Accurate vessel sizing
• Accurate identification of dissections
• Assessment of individual vessels without the need for
changing orientation of the image intensifier
Post recanalisation: IVUS ruled out

dissection
DEB: Drug-eluting balloon IVUS: Intravascular ultrasound SFA: Superficial femoral artery
DSA: Digital subtraction angiography POBA: Plain old balloon angioplasty
PRESENTATION
RATIONALEFOR IVUS
DIAGNOSIS / TREATMENT
RATIONALEFOR IVUS
OUTCOME 1 2
OUTCOME 1 2 SMART PERFUSION
Before recanalisation - arrival time Post recanalisation - arrival time
IVUS IMAGE POST RECANALISATION
IVUS ruled out dissection

• 47-year-old male, left AFS • ATA recanalisation and atherectomy with • ATA recanalisation with patent flow
• Rutherford II (moderate claudication) JetStream™ 1.6mm • IVUS detected no residual stenosis,
• Medical history: • ATA PTA with: no dissection
– Arterial hypertension – 2.5mm x 150mm balloon • Improved Rutherford Category (II ➞ I)
– Hypercholesterolemia – 3.0mm x 150mm balloon
• Drug history: • IVUS revealed no dissection CONCLUSION
– Aspirin 100mg 1-0-0 • IVUS ruled out dissection and
residual stenosis/embolus
– Clopidogrel 75mg 1-0-0
– Atorvastatin 40mg 0-0-1
ENLARGE IVUS IMAGE

RATIONALE FOR IVUS
changing the orientation of the image intensifier
Afib: Atrial fibrillation ATA: Anterior tibial artery DSA: Digital subtraction angiography PTA: Percutaneous transluminal angioplasty
AFS: Arterial fermoral stenosis ATP: Arteria tibialis posterior IVUS: Intravascular ultrasound SFA: Superficial femoral artery
PRESENTATION
OUTCOME 1 2
IVUS IMAGE POST RECANALISATION

• 80-year-old male, ischaemic multiple • Femoropopliteal treatment with: • Improved outflow through tibiofibular
prior interventions – 6mm x 80mm DEB tract and fibular artery
• Rutherford IV (ischaemic rest pain) on both sides – 6mm x 80mm DEB • Improved Rutherford Category (IV ➞ II)
• Medical history: – 5mm x 80mm DEB
– Diabetes – 4mm x 80mm DEB
CONCLUSION
– Arterial hypertension • Artherectomy of the tibiofibular tract
with JetStream™ 2.1mm/3.1mm • IVUS delivered accurate vessel sizing
– Rheumatoid arthrosis and ruled out dissection
• Drug history: • PTA of tibiofibular tract using 2 balloons:
– Aspirin 100mg – Lercanidipin 20mg – 3.0mm x 150mm
– Eliquis 5mg – Ramipril HCT 5/25mg – 3.5mm x 80mm
– Metformin 1000mg – Bisoprolol 2.5mg
• On the basis of vessel sizing of the tibiofibular
– Atorvastatin 80mg – Torasemid 10mg tract with IVUS, we performed a further
dilatation using a 3.5mm x 150mm balloon
ENLARGE IVUS IMAGES

RATIONALE FOR IVUS
• Recognition of residual
Left stenosis with greater
CIA sensitivity when used in
angiography
• Accurate identification
of dissections
• Assessment of individual
vessels without the need
for changing orientation
of the image intensifier
Lumen gain pre-dilatation Lumen gain post dilatation
ATA: Anterior tibial artery DSA: Digital subtraction angiography PTA: Percutaneous transluminal angioplasty
DEB: Drug-eluting balloon IVUS: Intravascular ultrasound
PRESENTATION
RATIONALEFOR IVUS
RATIONALEFOR IVUS
OUTCOME 1 2
IVUS IMAGES
Left CIA
Lumen gain pre-dilatation Lumen gain post dilatation

• 73-year-old male Long SFA Occlusion • Palpable left pedal pulses
• Rutherford IV (ischaemic rest pain) on both sides • Recanalisation SFA, JetStream™ • Ischaemic rest pain resolved
2.4mm/3.4mm, treatment: • Improved walking distance
• Medical history:
– 6mm x 80mm DEB – 5mm x 80mm DEB
– Current smoker • Aspirin 100mg once a day continued
– 5mm x 80mm DEB – 4mm x 80mm DEB
– Hypertension • Secondary prevention with Clopidogrel
Therapeutic dilemma:
– COPD 75mg once a day for 6 weeks
• Option 1: Stent
– Coronary artery disease • Improved Rutherford Category (IV ➞ II)
• Option 2: No stent
• Drug history:
– Aspirin • Decision: Stent placement due to high-
grade dissection detected on IVUS: CONCLUSION
– Atorvastatin
– 8mm x 100mm • IVUS enabled accurate identification
– Ramipril
– 8mm x 10mm of high-grade dissection
– Bisoprolol
ENLARGE IVUS IMAGE

RATIONALE FOR IVUS
changing orientation of the image intensifier
IVUS after DEB treatment - dissection
COPD: Chronic occlusive pulmonary disease DSA: Digital subtraction angiography SFA: Superficial femoral artery
PRESENTATION
DIAGNOSIS
Angiography after DEB treatment
OUTCOME
IVUS IMAGE
IVUS after DEBtreatment - dissection

• 79-year-old female, popliteal occlusion • Recanalisation of the popliteal artery and • Rutherford II after a couple of weeks,
(acute onset) Artherectomy with JetStream™ 2.4mm/3.4mm healed ulcera
• Rutherford V left, interdigital ulcera D2/D3 • Treatment with 5mm x 80mm DEB • Patient is pain free
• Medical history: • IVUS revealed no dissection, no restenosis, • Improved ABI
– Diabetes no embolus – patent flow
– Arterial hypertension CONCLUSION
– Arterial fibrillation • IVUS delivered accurate vessel sizing
– CVI and ruled out dissection and showed
• Drug history: patent flow
– Xarelto 20mg 1-0-0
– Bisoprolol 5mg 1-0-1
– Ramipril 2.5mg ½-0-0
ENLARGE IVUS IMAGES

RATIONALE FOR IVUS
• Greater sensitivity in terms
of identifying residual
stenosis when used in
• Accurate identification of
dissections
• Assessment of individual
vessels without the need for
changing orientation of the
image intensifier
ABI: Ankle brachial index DEB: Drug-eluting balloon IVUS: Intravascular ultrasound
CVI: Chronic venous insufficiency DSA: Digital subtraction angiography
PRESENTATION
OUTCOME
IVUS IMAGES

• 48-year-old soldier who suffered a left lower- • Medical management with anticoagulation • Improvement in left lower-limb
limb gunshot wound in the Iraq war of 2003, and compression therapy had failed to resolve swelling over the next week
resulting left iliofemoral DVT in 2003 persistent symptoms and ulceration • Lower-limb discomfort improved
• Presented in 2020 with left lower-limb post- • Surgical option: Left iliofemoral deep venous over a period of 2-3 weeks
thrombotic syndrome (PTS): Tissue loss, stenting with RFA of the long saphenous vein • Ulceration healed after five weeks
haemosiderosis and lower-limb swelling
• Drug history: CONCLUSION
– Rivaroxaban • Medical management provides symptom control but does not cure PTS
– Omeprazole • IVUS enabled accurate recognition of the diseased left iliac segments despite challenges with DSV
– Pregabalin (for lower limb pain) • IVUS allowed precise assessment of both disease length and vessel calibre, thereby facilitating
• Venous duplex: appropriate stent choice
– Incomplete visualisation of CIV
– Patent but incompetent LSV, CFV, PFV, FV RATIONALE FOR IVUS
– EIV occluded distally
• Accurate identification of the diseased venous segments, even in the absence of flow
• Magnetic resonance venogram:
• Exact measurement of vessel calibre to guide stent choice
– May-Thurner Syndrome, chronic CIV disease
– Severe stenosis of the EIV
• Precise assessment of the length of deep venous disease
– Extensive superficial venous collaterals • Clear-cut demonstration of healthy deep veins and the location of the PFV
ENLARGE IVUS IMAGES
Right CIA
Right CIA
Patent,
stented
Compressed left CIV left CIV
Pre-stenting IVUS Determining iliac vessel Determining iliac vessel Post-stenting IVUS
(May-Thurner Syndrome) calibre with IVUS (i) calibre with IVUS (ii) (May-Thurner Syndrome)
CFV: Common femoral vein DSV: Digital subtraction venography EIV: External iliac vein IVUS: Intravascular ultrasound PFV: Profunda femoris vein RFA: Radiofrequency
CIV: Common iliac vein DVT: Deep vein thrombosis FV: Femoral vein LSV: Long saphenous vein PTS: Post-thrombotic syndrome ablation
PRESENTATION
Right EIV
Right CIV
Left CIV
Left EIV
CFV: Common
CFV: Common femoral
femoral vein vein DSV:
DSV: Digital subtraction
Digitalsubtraction venographyEIV: EIV:
venography External
External iliac vein IVUS:
iliacvein IVUS: Intravascular
Intravascular ultrasoundPFV: Profunda
ultrasound PFV: Profunda
femoris veinfemoris veinPTS: Post-thrombotic
RFA: Radiofrequency
syndrome
CIV: Common
CIV: Common iliac vein
iliacvein DVT:Deep
DVT: Deep vein thrombosis
vein thrombosis FV: FV: Femoral
Femoral vein vein LSV:LSV: Long saphenous
Longsaphenous vein vein RFA: Radiofrequency
PTS: Post-thrombotic
ablation syndrome ablation
OUTCOME
Pre-stenting venography Post-stenting venography
14mm x 120mm
stent
14mm x 80mm
stent
14mm x 150mm
stent
CFV: Common
CFV: Common femoral
venography External
RFA: Radiofrequency
syndrome
CIV: Common
iliacvein DVT:Deep
IVUS IMAGES
Right CIA
Right CIA
Patent,
stented
Compressed left CIV left CIV

(May-Thurner Syndrome) (May-Thurner Syndrome)
Determining iliac vessel Determining iliac vessel

calibre with IVUS (i) calibre with IVUS (ii)
CFV: Common
CFV: Common femoral
venography External
RFA: Radiofrequency
syndrome
CIV: Common
iliacvein DVT:Deep

• 26-year-old female, five weeks post partum • Medical option: Anticoagulation • Early resolution of venous congestion
• Three-day history of right lower-limb swelling with discomfort and compression • Improvement in swelling over 2-3 days
• Right lower-limb venous congestion to the calf and swelling • Surgical/endovenous option: thrombolysis • Lower limb discomfort improved
to the groin with pharmacomechanical therapy
(AngioJet™ in this case) with venoplasty • Patient was able to make a prompt
• Medical history: and deep venous stenting if required return to enjoying time with her
– Smoker new-born infant
• Risks vs benefit discussion with the patient
– No history of thrombophilia or previous miscarriage led to the decision to proceed with
– No regular medication endovenous intervention
• Venous duplex:
– Right iliofemoral DVT with thrombus extending into FV CONCLUSION
and popliteal vein • Intervention for early thrombus resolution can reduce risk of future PTS
– Patent PFV • IVUS enabled accurate identification of disease morphology
• Computed Tomography Venogram (CTV) • IVUS allowed focussed delivery of thrombolytic agents, thereby reducing
– Right iliofemoral DVT drug dose and improving thrombus resolution
– No compression of the deep veins or features of malignancy
RATIONALE FOR IVUS

• Accurate identification of the disease morphology enables • Assessment of which specific deep veins are involved
differentiation between acute thrombus and chronic disease • Exact demonstration of degree of thrombus resolution which
• Precise measurement of vessel calibre to guide stent choice facilitates targeted delivery of further thrombolysis if required
ENLARGE IVUS IMAGES
Thrombosed,
occluded CIV wall Patent, Stented
right CIV inflammation right CIV
Determining iliac vessel Determining iliac vessel

Pre-stenting IVUS calibre with IVUS (i) Post-stenting IVUS
calibre with IVUS (ii)
CTA: Computed tomography angiogram FV: Femoral vein PFV: Profunda femoris vein
DVT: Deep vein thrombosis IVUS: Intravascular ultrasound PTS: Post-thrombotic syndrome
PRESENTATION
Pre stenting (patient lying prone)
Thrombosed right CIV
Patent left CIV
OUTCOME
Post stenting (patient lying prone)
IVUS IMAGES
Thrombosed,
occluded CIV wall
right CIV inflammation
Determining iliac vessel

Pre-stenting IVUS calibre with IVUS (i)
Patent, stented
right CIV
Determining iliac vessel

calibre with IVUS (ii) Post-stenting IVUS

• 47-year-old female • Medical option: Anticoagulation and • Improvement in swelling over the next
• Four-year history of bilateral lower-limb swelling and pain compression (but patient has already 2-3 weeks
tried this with very limited benefit) • Lower-limb discomfort improved
• Deterioration 4 months before presentation
• Surgical/endovenous option: • Bilateral lower-limb venous claudication
• Bilateral lower-limb venous claudication
IVC reconstruction and bilateral also resolved over the next month
• Medical history: iliofemoral deep venous stenting
– Type 1 diabetes – patient has an insulin pump • Patient decided to proceed with
– Multiple episodes of DVTs over the past 11 years endovenous intervention
– No history of thrombophilia
• Drug history:
– Apixaban CONCLUSION
• Venous duplex: • Medical management provides symptom control but does not cure PTS
– No flow in the infrarenal IVC or the bilateral • IVUS enabled accurate identification of the disease segments
iliofemoral systems • Clear demonstration of PFV to ensure accurate stenting to preserve inflow
– Patent profunda femoris veins but stenotic
femoral veins
• Computed tomography venogram (CTV)
– Hypoplastic infrarenal IVC and chronic occlusive
disease of the bilateral iliofemoral venous systems
ENLARGE IVUS IMAGES

RATIONALE FOR IVUS
• Accurate identification of the
diseased venous segments, even
in the absence of flow
• Clear demonstration of the
corresponding artery to ensure the
Stenosed IVC
Patent, stented correct anatomical path was followed
right limb
• Exact identification of the contralateral
Right renal artery
wire to confirm both the ipsilateral
and contralateral wires are in the
same fibrotic channel
Post-stenting Patent, stented • Precise measurement of vessel calibre
left limb
Pre-stenting IVUS IVUS in the IVC and disease length to guide stent choice
PRESENTATION
OUTCOME
IVUS IMAGES
Stenosed IVC
Patent, stented
right limb
Right renal artery
Post-stenting Patent, stented

left limb
Pre-stenting IVUS IVUS in the IVC
Dr Rutger Brans, Interventional Radiologist, Maastricht University Medical Center, Maastricht, The Netherlands

• 45-year-old female • Ultrasound-guided antegrade placement of a 6F sheath (15cm) • After stent treatment, the patient
• Long-lasting left-sided flank into the right common femoral vein under local anaesthesia was very well with no complaints
pain, dull abdominal pain • Fluoroscopy-guided 5F catheter placement into the left renal vein or other symptoms
and bilateral leg pain • Phlebography to confirm nutcracker compression. Sheath in right • Patient developed mild complaints
• Microscopic haematuria and groin exchanged over a stiff 260cm guidewire for a in the left leg after a few weeks,
pubic varicosities 55cm long 12F sheath. Latter placed into left renal vein which could not directly related
• Imaging findings to the nutcracker syndrome
• Intravascular ultrasound (IVUS) to visualise exact compression point,
(confirmed with phlebography): measure stent size/length and landing zone • Pain in left flank and abdominal
– Significant compression of area was resolved, as was the
• Pre-dilatation with 14mm balloon and a 14/60mm self- expanding
the left renal vein between haematuria
stent into the left renal vein. Post-dilatation with
the aorta and superior a 14mm balloon • Control ultrasound duplex at two
mesenteric artery weeks and six months showed a
• Completion phlebography and IVUS showed good result with smooth
– Dilated incompetent left patent stent with 0% lumen reduction
flow through the stent into the inferior vena cava
ovarian vein
• No significant retrograde filling of the left ovarian vein and paralumbar
• Other phlebography findings: CONCLUSION
collateral veins
– Left-sided paralumbar dilated • IVUS imaging provided additional
• Sheath removal and five minutes' manual compression to achieve information that was necessary to
collaterals haemostasis in the groin enable a successful procedure to
– Retrograde filling of the
• One single dose of 5000 IU intravenous infusion given during the procedure be performed
ovarian vein
ENLARGE IVUS IMAGES
RATIONALE FOR IVUS
• It was not clear from phlebology if
length of left renal vein would allow
a 6cm-long stent
• IVUS allowed us to:
– Determine renal vein length and
diameter and patency of lumen
Aorta
– I dentify exact location of
Aorta
compression/stenosis
SMA SMA
– Provide information about the
existence of webbing and
prothrombotic trabeculation
• IVUS was used at the end of the
endovascular treatment to check if there
were any stent- related complications,
such as early in-stent thrombosis, which
IU: International unit SMA: Superior mesenteric artery could be missed on phlebography
PRESENTATION
MRV (csTHRIVE sequence) shows compression (arrow) Phlebography shows compression of the left renal vein
of the left renal vein between aorta on the dorsal side (top arrow) with retrograde contrast filling of a dilated
and SMA anteriorly. left ovarian vein (bottom arrow).
IU: International unit SMA: Superior mesenteric artery

TREATMENT
Roadmap image of phlebography with angioplasty post stenting.

No indention of the balloon is seen at 6 atmospheric pressure.

OUTCOME
Completion phlebography shows nice stent position with good flow.

There are no paralumbar collaterals or retrograde filling of ovarian vein.

IVUS IMAGES
Aorta Aorta
SMA SMA
IVUS images at presentation and after stent placement in left renal vein (LRV), outlined in blue. Pre treatment the LRV is flattened
due compression between aorta and superior mesenteric artery (SMA). After stent placement de LRV is fully opened with good
stent apposition and no intraluminal thrombus is seen.

Results from case studies are not necessarily predictive of results in other cases. Results in other cases may vary.
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A NEW depth of insight

A NEW range of flexibility

A NEW level of clarity

DISCOVER A New Depth of Insight. A New Level of Clarity.

Acute left subclavian arterial occlusion – thoracic outlet syndrome

Lower-limb claudication due to iliac atherosclerosis

Lower-limb claudication due to aorto-iliac disease

Rutherford II left, long ATA, Afib, ATP occlusions, JetStream™ 1.6mm

Rutherford IV both legs, left tibiofibular tract stenosis

Rutherford IV, long SFA occlusion (left)

Post-thrombotic syndrome resulting in tissue loss

Acute right iliofemoral deep vein thrombosis

Bilateral lower-limb post-thrombotic syndrome due to iliocaval disease

PRESENTATION VIEW IMAGING TREATMENT OUTCOME VIEW IMAGING

RATIONALE FOR IVUS

ENLARGE IVUS IMAGES

Residual Stented, patent SA

DSA: Digital subtraction angiography SA: Subclavian artery

DSA: Digital subtraction angiography SA: Subclavian artery

DSA: Digital subtraction angiography SA: Subclavian artery

DSA: Digital subtraction angiography SA: Subclavian artery

PRESENTATION VIEW IMAGING TREATMENT OUTCOME VIEW IMAGING

ENLARGE IVUS IMAGES

Initial pre-treatment IVUS Post-stenting IVUS

RATIONALE FOR IVUS

Stent graft 8mm x 57mm

Stented, patent EIA

Initial pre-treatment IVUS Post-stenting IVUS

PRESENTATION VIEW IMAGING TREATMENT OUTCOME VIEW IMAGING

ENLARGE IVUS IMAGES

Pre-stenting IVUS Post-stenting IVUS

Lines indicate expected

Pre-stenting IVUS Post-stenting IVUS

PRESENTATION VIEW IMAGING TREATMENT VIEW IMAGING OUTCOME VIEW IMAGING

ENLARGE IVUS IMAGE

Post recanalisation: IVUS ruled out

OUTCOME 1 2 SMART PERFUSION

Before recanalisation - arrival time Post recanalisation - arrival time

IVUS IMAGE POST RECANALISATION

IVUS ruled out dissection

PRESENTATION VIEW IMAGING TREATMENT VIEW IMAGING OUTCOME VIEW IMAGING

ENLARGE IVUS IMAGE

IVUS ruled out dissection

OUTCOME 1 2 SMART PERFUSION

Before recanalisation - arrival time Post recanalisation - arrival time

IVUS IMAGE POST RECANALISATION

IVUS ruled out dissection

PRESENTATION VIEW IMAGING TREATMENT VIEW IMAGING OUTCOME VIEW IMAGING

ENLARGE IVUS IMAGES

Lumen gain pre-dilatation Lumen gain post dilatation

OUTCOME 1 2 SMART PERFUSION

Before recanalisation - arrival time Post recanalisation - arrival time

Lumen gain pre-dilatation Lumen gain post dilatation

PRESENTATION VIEW IMAGING TREATMENT VIEW IMAGING OUTCOME VIEW IMAGING

ENLARGE IVUS IMAGE

IVUS after DEB treatment - dissection

Angiography after DEB treatment

IVUS after DEBtreatment - dissection

PRESENTATION VIEW IMAGING TREATMENT VIEW IMAGING OUTCOME VIEW IMAGING

ENLARGE IVUS IMAGES

PRESENTATION VIEW IMAGING TREATMENT OUTCOME VIEW IMAGING

ENLARGE IVUS IMAGES