Podcast Transcript: Iliofemoral Stenting: Decision-Making & Best Practices Explored

[Dr. Christopher Beck]
I feel like one thing that would resonate, I think a lot of these referring docs have seen that one out of nine patient who has terrible venous disease, whether it develops into a wound or just a longstanding chronic edema. I'm with Kush on this. I feel like they've seen those patients who can be very, very difficult patients to manage, and it's a lifelong process after that with not a ton of great options. I think we beat referral patterns to death, but workup. Let's just take it out of the inpatient realm and just say someone happens to be in your clinic. Can you talk about what that workup looks like just first time you walk in the door? Kush, we can start with you.

[Dr. Kush Desai]
Yes. Typically, if they're coming to my office, they're not coming with an acute DVT. It's typically a post-thrombotic case. What the workup means, what it consists of, I would say, is you start with, obviously, what are the symptom burdens. We have numerous scales, both the Villalta and the venous clinical severity score to inform how severe the symptoms are. We actually have a little bit of data to guide us on which patients are the most likely to benefit.

The next thing you're going to do is look at your imaging, and what that means at different places is based on local practice patterns, preferences, and expertise, really. We do a lot of axial imaging at Northwestern that consists of usually CT venography to assess the iliofemoral segment and then a duplex to look at what the inflow looks like as well as whether there's a concomitant superficial venous disease.

The reason we want to look at that is because if the patients are presenting with symptoms that we think are primarily due to the superficial venous disease, there's really no downside in trying to treat that first and then see if we get the outcome we want. Frequently, you don't. Numerous times over my career, it's been like you treat the problem that's really bothering the patient. Don't necessarily treat the problem that you're the expert in, right? Sometimes it's better to send that to somebody that does it, or if you do it, you do it. History taking, your imaging, and then you synthesize a plan.

I would say the next part, for me, and probably the most important part after those two things is ensure that you have a very clear, defined partnership with the patient. They have to know what to expect, and they have to know their part in the process, in the journey. Are they going to comply with the blood thinners? Are they going to comply with any additional stuff?

A lot of these patients have inflammable lymphedema. Are they going to comply with their compression with pneumatic compression devices at home if they need them? All those things. Because if they're not going to, I would argue, if a patient's not going to take their blood thinners, for example, probably not someone you should be super keen on treating because it's going to be all risk and really no benefit from that procedure. My opinion.

[Dr. Christopher Beck]
Steve, can you either add to that, or you can just talk about how your workup may either differ from Kush's

[Dr. Steven Abramowitz]
Yes. It's interesting. I would say, in our system right now, about 20% of the acute DVTs that I treat actually come in through the office. The interesting thing is they aren't people who show up with the expectation of being treated. This isn't to say that someone walks in my office door and I automatically give them an operating room time. I think that this has to do with a lot of the ultrasound protocols that exist out there. Kush and I have talked about this ad nauseam.

One of the things that generally tends to happen is people will get labeled as Femoro-popliteal DVT. Someone just threw a probe on them as part of a DVT algorithm that they're following and protocol. It'll show. It'll be labeled as femoral DVT. What it doesn't really show is that the common femoral is occlusive, and there's likely iliac extension. There's a good number of people who show up who are still profoundly symptomatic after two weeks of anticoagulation who were told, "Hey, go to the vascular surgeon, see what they say. See what they can offer."

Our ultrasound protocol is a little bit more, I would say, comprehensive in the management of acute DVT in our vascular lab, and we're looking at the external iliac. For those patients, we're finding that there is significant extension. Part of the education that we, I think, have to do is to encourage freestanding vascular labs, freestanding ultrasound facilities. The point of contact caregiver is to ask that next level question which is, "If this is a DVT, and you're saying it's femoral, did you look at the iliac? Can we look at the iliac?" I think that that would give us that patient pipeline more immediately to intervention as opposed to that delayed patient presentation in our office.

[Dr. Christopher Beck]
One of the things I wanted to ask you guys is whenever you're seeing a patient and teasing apart venous hypertension symptoms from other concurrent symptoms that may be going on, can you talk about either the difficulty or the tools that you use or your thought process and how to tease apart like lymphedema versus venous hypertension and which is which?

[Dr. Kush Desai]
This really strikes at what I said before which is managing expectations. If I have a swollen leg that waxes and wanes, but the features are there, I can see the malleoli, for example, there's no stemmer sign, they don't have the hump on the dorsum of their foot, they don't have prototypical cylindrical edema, they're not probably a significant lymphedema patient.

By distinction, if I have a post-thrombotic, and this is frequent, iliocaval or iliofemoral obstruction that has significant edema that is literally cylindrical, you can't see the ankles, you got the big hump on the dorsum of their foot, like floridly positive stemmers, the discussion is different. I am not going to improve your swelling significantly. Maybe in the thigh, probably not below the knee, and what other symptoms do you have? Stasis ulceration, we can get that better. Pain, venous claudication, absolutely, we can get that better.

Edema, and I've shown the cases a couple of times, I believe Steve's seen them, you're disappointed frequently. That's upfront discussion. I even tell them, you're probably going to see a very short-term improvement of the edema meaning I'll do the procedure. A week, maybe two weeks after the procedure, you're going to notice a big difference. It's going to come back.

I hope it doesn't, but I fear I'm probably going to be right. It's going to come back. That's the shift in the Starling principle and between the lymphangion and the venous side and all that kind of stuff. You're really looking for prototypical signs of lymphedema in the patient that has clear venous obstruction to help tease apart what's lymphatic, what's venous.

[Dr. Christopher Beck]
Steve, do you want to talk about anything about the imaging that you guys do, or is it very similar to what Kush said, like DVT study potentially, superficial venous reflux study, and then CTV?

[Dr. Steven Abramowitz]
Yes, it's very similar. We generally tend to gravitate towards CT venography at our institution and indirect CT venography primarily because getting MR is very challenging in our area. I think it is very valuable for delineating post-thrombotic syndrome or central compressive disorders. I will say, on the acute side, even this week, unfortunately, we diagnosed a pancreatic cancer and what's likely an ovarian cancer, and it's presenting symptoms as a DVT. If you have any suspicion as to what the potential underlying cause of the DVT may be, it's important to get some additional imaging.

[Dr. Christopher Beck]
Before we move on too far from the clinic visit, Kush talked about it, that upfront discussion about the patient's role, can we talk a little bit more about some of the conservative treatments that you may initiate during the clinic visit? Say they haven't been booked for either/or the cath lab, but some of the things you have the patient do, just leaving the hospital, either medication regimens that you tune up or compression therapy. Steve, let's start with you.

[Dr. Steven Abramowitz]
I'm a big believer in compression therapy, not for the treatment of post-thrombotic syndrome or the management or prevention thereof, but mostly because it makes people feel better. You see a lot of patients with their early onset edema after they're lying flat in the hospital. They seem decompressed, they go home, they're up on their feet, and then their swelling comes back, and it comes back in a very painful fashion.

Some sort of compressive therapy, whether it's pneumatic, non-pneumatic, mechanical, whether it's simply a wrap or a stocking, anything that the patient will use, I find to be very beneficial. Generally, on the order of medications, I would prefer Enoxaparin for the acute DVT patient because I do think that there are additional anti-inflammatory side effects, and patients generally, I think, have a better response earlier on while on Enoxaparin.

There are some barriers. It's prohibitive in terms of cost sometimes, in terms of insurance coverage, as well as early access, and it's painful. I have a lot of patients who don't like injecting themselves. The anticoagulation agent that someone will take is the best anticoagulation agent in my mind.

The other things that I'll tell people to do, and I don't know Kush if you've ever done this, but we do a lot of water walking recommendations in the summer months, especially if people have pools for people who want to stay active, but they're afraid to go and get back and running, and their legs swollen and heavy, resistance water walking has been very beneficial for them. Those are some of the early things we do to help people feel better even if they do undergo intervention.

[Dr. Kush Desai]
I agree on the anticoagulation, and I'll just add that same modifier to compression. Any compression that a patient wears is better than no compression. If they'll put on the famous sock brand that sells one to you and then donates one, if they put on those compression stockings or one from a mail order service and not the medical grade hose, I'm fine with it. Compliance is key. Then I agree on the anticoagulation.

The only other thing I would add is venoactives, but certainly none really FDA-approved, but the European colleagues have used them with great success. For those that can take them and can tolerate them, they can be really, really helpful. It's a subset of patients. It's not all patients.

[Dr. Kush Desai]
Venoactives: Like Diazepam, Pentoxifylline. I don't know how often you use them, Steve, but we've seen these patients that have complex wounds that you reconstruct them, you treat their axial reflux, you close the ulcer bed, they're still just trying to get the wound closed, and sometimes those venoactives can help. Actually, this is where-- I'm sure we'll get to this at some point, but multidisciplinary care. If you have wound providers that you really trust, they're worth their weight in gold. They're just so helpful in managing these patients because these patients are going to probably be coming back and forth for many, many years.

[Dr. Steven Abramowitz]
Yes, I agree. I generally only reserve Pentoxifylline for patients who have very difficult-to-manage venous ulcers. Otherwise, I agree. It's interesting, there's all the data that should be coming out soon from dexterity about the use of perivenous anti-inflammatory agents in mitigating the future of post-thrombotic syndrome. That could be an entirely separate conversation.

The only reason I bring this up is because I have not used oral anti-inflammatories in conjunction with anticoagulation like a Medrol dose pack or high-dose NSAIDs. I have heard of people who do that, but I don't think the data's there. I don't think the benefit to the patient is there, so I haven't adopted any additional pharmacologic treatment for the patients beyond the anticoagulation.