Hybrid CT-angiography to facilitate lower extremity sharp venous recanalization: a novel approach to a common procedure

Monica M Matsumoto,Chelsea Dorsey,Osman Ahmed,Karan Nijhawan,Jeffrey A Leef

doi:10.1186/s42155-020-00145-y

Monica M Matsumoto, Chelsea Dorsey + Show 3 more

Open Access

https://doi.org/10.1186/s42155-020-00145-y

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Abstract

BackgroundPost-thrombotic syndrome due to chronic venous occlusion is associated with high morbidity and healthcare costs. Sharp venous recanalization has been used with success when conventional techniques fail to cross the occlusion, permitting endovascular reconstruction with angioplasty and stenting. However, manipulation of a needle, especially in extra-anatomic locations, risks damage to adjacent structures, thus necessitating adequate imaging guidance.Case presentationThis report describes the novel use of hybrid CT-angiography in a successful recanalization of a complex iliofemoral chronic venous occlusion, after multiple failed attempts with traditional recanalization techniques. The procedure was performed without complications, and stent patency was confirmed at three-month follow-up with patient-reported improvement in severe post-thrombotic syndrome.ConclusionsThis case demonstrates effective incorporation of hybrid CT-angiography to facilitate complex sharp venous recanalization for chronic lower extremity thrombosis, as an alternative to standard fluoroscopic techniques requiring multiple projections with or without cone-beam CT. Further studies are needed to understand the implications of this strategy.

Highlights

Post-thrombotic syndrome due to chronic venous occlusion is associated with high morbidity and healthcare costs
For Post-thrombotic syndrome (PTS) secondary to chronic iliocaval thrombosis in which standard endovascular reconstruction techniques fail to cross the occlusion, sharp recanalization has been reported with high technical success (McDevitt et al 2019; Hage et al 2018; Ito et al 2012; Wadhwa et al 2018)
We present a case of severe PTS, in which hybrid Computed tomography (CT)-angiography permitted improved visualization for sharp recanalization and venous reconstruction of a complex chronic left common iliac vein (LCIV) occlusion

Summary

Conclusions

This case demonstrates strategic use of angio-CT to guide sharp recanalization of a chronic LCIV occlusion causing severe PTS in a patient with a complex surgical history and chronic occlusion refractory to prior recanalization attempts. Given the need for precision and safety, angio-CT integrating volumetric CT fluoroscopy with fan beam CT machinery in the same room, as opposed to C-arm cone-beam CT, was utilized (Tanaka et al 2014; Toyoda et al 2009). Similar techniques would have been difficult with conebeam CT, which requires either the C-arm to spin around the patient producing lower-quality images or fluoroscopy in multiple orthogonal planes. This case report demonstrates the utility and feasibility of incorporating angio-CT in complex sharp venous recanalization.

Background

Findings