Case report of concomitant iliac vein intravascular ultrasound imaging using the great saphenous vein access site for planned endovenous ablation

By: Luis Suarez, MD and Noah Rosen*, MD
Tufts Medical Center
800 Washington Street
Boston, MA 02111

Abstract:

Patients with advanced venous hypertension with venous ulceration often suffer from multilevel venous reflux and/or obstruction.  In the past, duplex venous reflux imaging has focused diagnostic evaluation and treatment on infrainguinal causes of venous hypertension, but recent publications have shown the importance of occult iliac vein outflow obstruction in contributing significantly to venous hypertension.  The detection of these iliac vein obstructions requires CT venogram, MR venogram, conventional venogram or IVUS imaging, often delaying their detection.  Axial superficial venous reflux is often present in these patients and ablation is recommended to reduce venous ulcer recurrence rate.  This case reports the novel use of the great saphenous vein access site used for GSV ablation as the access site for concomitant diagnostic ipsilateral intravascular iliac vein imaging.  No fluoroscopy, radiation or iodinated contrast is needed.  If an occult iliac vein stenosis is found, if warranted, it can be treated at a later date.  

Introduction

Iliac vein outflow obstruction is a frequent and underappreciated contributor to venous hypertension in patients with healed or active venous ulceration (CEAP C5 or C6).1,2  These patients often demonstrate great saphenous vein (GSV) reflux for which treatment is recommended to reduce the rate of venous ulcer recurrence.3 We hypothesize that ipsilateral iliac vein intravascular ultrasound (IVUS) evaluation can be performed using IVUS during planned GSV endovenous ablation with a single access site with no fluoroscopy, radiation or iodinated contrast. 

Case:

A 53 year old male presented with a 4 year history of now healed recurrent left medial malleolus venous ulcer (C5), stasis dermatitis and symptomatic varicosities with multiple episodes of superficial thrombophlebitis. He had no history of deep venous thrombosis. Left leg duplex venous reflux study showed normal phasicity of the left common femoral vein; deep venous reflux within the left common femoral vein, femoral vein and popliteal; and significant axial superficial venous reflux within a dilated GSV: 10.1 cm at the left saphenofemoral junction, 8.1cm diameter at the midcalf; with 4 secs of reflux. The patient had no prior imaging of the ipsilateral iliac veins. The patient was recommended to undergo left GSV ablation and left leg stab phlebectomies.

Informed written consent was obtained from the patient for these procedures along with concomitant diagnostic left iliac vein IVUS evaluation. He also gave informed written consent for this care report. In the operating room, under general anesthesia, the left GSV was punctured at the knee under ultrasound guidance and an 8 Fr x 11cm sheath was placed.  The patient was given 3,000 unit of intravenous heparin.  A 15 MHz IVUS Volcano catheter was advanced up the great saphenous vein, through the saphenofemoral junction and into the IVC over a Bentson wire using external ultrasound guidance.  No fluoroscopy or radiation was used and no iodinated contrast was administered.  Pullback IVUS imaging of the IVC, left common iliac vein, left external iliac vein, and left common femoral vein was performed (see images).  No significant ipsilateral iliac vein stenosis was identified. Using a 0.018 V-18 wire, the IVUS catheter was exchanged for a VNUS catheter.  Using external ultrasound imaging, the tip of the VNUS catheter was positioned 2.8 cm from the left saphenofemoral junction. Tumescent anesthesia was instilled and the left GSV was ablated in the usual fashion. Left calf and ankle stab phlebectomies were then performed.

Postoperatively, the patient did well and ultrasound performed on POD #2 showed no evidence of DVT and successful closure of the left GSV to within 0.9cm of the left saphenofemoral junction.

Discussion

Patients with advanced venous disease often harbor occult iliac vein stenosis.  It has been suggested that these patient undergo CT venogram, MR venogram, conventional venogram or IVUS imaging to find these stenoses.  IVUS iliac vein imaging is the gold standard imaging tool and does not involve the use of radiation or iodinated contrast.2,4

In this case report, we show that during GSV ablation, the GSV puncture at the level of the knee can be used as a convenient access site for ipsilateral iliac vein IVUS imaging. Since the GSV is destined for ablation in these cases, the potential for the large sheath to damage the intima of this potentially small access vessel is not a concern. Successful placement of the IVUS catheter in the IVC was achieved without the use of fluoroscopy, radiation or contrast.  In this case, regardless of the findings on iliac vein IVUS imaging, no endovascular iliac vein treatment was planned to be performed during this procedure.  In a previous series of patients, if an iliac vein outflow stenosis was found during planned GSV ablation, it was treated using the GSV puncture access site with Wallstents. These procedures required fluoroscopy, radiation and iodinated contrast (unpublished case series).  Our current practice is to treat axial superficial venous reflux first and if venous ulcerations continue or recur, an identified ipsilateral iliac vein outflow stenosis can be treated endovascularly at a later date.

Conclusion:

The addition of iliac vein IVUS imaging to planned GSV ablation was a technically simple procedure with no added morbidity. No fluoroscopy, radiation or iodinated contrast is needed.  This is the first report of using the single access site used routinely during GSV ablation as a pathway to perform IVUS iliac vein evaluation.  As most GSV ablations are performed in the outpatient setting, future studies should investigate the performance of iliac vein IVUS in the office during great saphenous vein ablation to screen for iliac vein outflow obstruction in patients with C5 and C6 disease. 

Images:

#1: Infrarenal IVC

#2: Cranial Left Common Iliac Vein

#3: Mid Left Common Iliac Vein

#4: Mid Left External Iliac Vein

#5: Left Common Femoral Vein at left saphenofemoral junction

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