Pitfalls of IVUS Imaging

SESHADRI RAJU MD.FACSRANE CENTERJACKSON. MS.

Disclosure

Stock in Veniti, Inc.US Patent: IVUS use in venous diseaseVenous stenting is currently off label

GOT TO HAVE IVUS FOR STENT PRACTICE Diagnostic sensitivity of ≈85%

• Sensitivity of transfemoral venography is ≈50% to identify iliac vein lesions (Negus et al; Raju et al).

• Sensitivity of standard ascending venography worse.• Primary &Postthrombotic lesions are missed.• Venography not sensitive enough to pick up anomalies

in stent inflow/outflow and in the stent stack itself. Ie. to guide stent procedure.

• No radiation exposure• Can stent with fluroscopy and IVUS alone in renal

patients and those with contrast allergy

With IVUS, stentable obstructions are found in >90% of primary cases with advanced CVI

Non-thrombotic iliac vein lesion (NIVL)

Normal venogram but IVUS stenosis (PTS). Note trabaculae and perivenous fibrosis on IVUS but

not seen on venogram. IVUS area 72 sq mm.

Same case after stenting. Area now 164 sq mm.In adults CIV should measure ≥ 175 sq mm

Normal Lumen Size

• CIV: 16 mm Diameter; 200 sq mm Area• EIV: 14 mm Diameter; 150 sq mm Area• CFV: 12 mm Diameter; 125 sq mm AreaThe basis of symptoms in CVD is elevation of peripheral venous pressure.Peripheral venous pressure begins to rise with as little as 20% stenosis and becomes significant at 50% stenosis.

“Normal Venogram” with Residual Thrombus on IVUS after PMT

Venographic Sensitivity for complete clot lysis(PMT and CDT) n = 110 venograms

93/110 (85%) “Venographic Success” had residual thrombus on IVUS

Sensitivity of Venography for Complete Lysis = 20%

CLASSIC ROKITANSKI STENOSISDue to perivenous fibrosis

CIV 7mm

11mm

MRV: Unlike venography measurements are possible provided the radiologist gives measurements

Stent CompressionVenogram normal; IVUS shows compression

Missing BorderAt hypogastric orifice

CONCLUSIONSIVUS is “King” in the Endosuite

• With IVUS, you simply see more ‘stuff’ than is ever possible with venography. This will make a difference in improving outcome in cases at the margin.

• Lack of radiation and contrast hazards allow repeated use.

• IVUS is semi-quantitative, venography is not. Makes a difference in diffuse lesions and focal lesions that are borderline.

END

IVUS-MTS.MPG

Postthrombotic focal stenosisNote perivenous fibrosis and normal venogram

Balloon ‘Sizing’Proximal and distal NIVL

IVUS IN PRIMARY STENOSIS WITH WEB

IVUSTips and Tricks

Seshadri Raju MD.FACS.The Rane Center

Flowood, MS

TrabeculumCannot see in venograms

NIVL (MTS)

Malpositioning the stent behind the iliac artery.

• This was a 10 mm stent which thrombosed.