Optimize Venous Stenting Outcomes
24-Month Vernacular Trial Results & Lessons Learned from the Expert on Venous Stenting
Originally Broadcast: June 25, 2020
Paul Gagne, MD, FACS, RVT The Vascular Experts Darien, CT
BD Peripheral Intervention educational program, ADVANCE invites you to a one-hour, interactive session on venous disease. Treating the venous patient for over thirteen years and Global Principal Investigator of the VIDIO trial, Dr. Gagne will discuss best practices for venous stenting and optimizing your outcomes.
Product features of the Venovo™ Venous Stent System
Stenting consideration for good long-term outcomes
Marketing your practice
Identify steps on appropriate venous stenting
Apply the latest clinical data into patient care
Given case reviews, identify appropriate stent placement for optimal outcomes
Discuss developing and locating, existing venous patients in current practice
is a board certified vascular surgeon. He attended NYU School of Medicine, and did his residency in General Surgery at NYU Medical Center. After residency, he served as a vascular surgeon in the US Navy. His vascular fellowship was at the University of Arkansas for Medical Science. Dr. Gagne was faculty of NYU School of Medicine for 8 years before joining The Vascular Experts. He heads vascular surgery at Norwalk Hospital. He is also president of the Vascular Health Forum, a non-profit educational forum focused on vascular disease for primary care providers. He is a Distinguished Member of the Society of Vascular Surgery, a member of the American Venous Forum and a member of Outpatient Endovascular and Interventional Society (OEIS). Dr. Gagne’s research focuses on the deep vein system 1) following acute DVT and 2) the use of IVUS for evaluating and treating chronic iliofemoral vein outflow obstruction. He was the Global Principal Investigator of the VIDIO trial and is currently the site Principal Investigator for the VIVO, VIRTUS, VERNACULAR, ABRE, VICARES, VIEW and Humacyte trial and a sub-investigator for the RANGER, REVEAL, Chocolate Touch, Torus 2 and Detour 2 trial Paul Gagne, MD
The opinions and clinical experiences presented in this webinar are for informational and educational purposes only. The results presented may not be predictive for all studies and patients as individual results may vary depending on a variety of patient specific attributes.
The Venovo™ Venous Stent System is indicated for the treatment of symptomatic iliofemoral venous outflow obstruction. Please consult product labels and instructions for use for indications, contraindications, hazards, warnings, and precautions. BD, the BD logo, and Venovo are trademarks of Becton, Dickinson and Company or its affiliates. © 2020 BD. All rights reserved. Illustrations by Mike Austin. Copyright © 2020. All rights reserved. Bard Peripheral Vascular, Inc. | www.bardpv.com | 1 800 321 4254 | 1625 W. 3rd Street Tempe, AZ 85281 BD-17807 thank you everyone for joining us this evening. My name is Maria Vega. I am the senior product manager for the Vinovo Venus system. This evening, Dr Paul Gagne will be presenting on his experience using Vinovo stent and on how he can optimize the stenting outcomes. But before we get started, here is a brief introduction on our percenter. Dr. Paul Gagne is a world renowned vascular surgeon who specializes in vascular and endovascular techniques for the treatment of arterial and venous disease. He joined the vascular experts in 2007, is the president of the Vascular Health Forum and it's a distinguished member off the Society of Vascular Surgery and of the American Venus Forum. Dr. Ghani also served in the U. S. Navy as both general and vascular surgeon. His research focuses on deep thing system and he was part of the Vinovo stand vernacular clinical trial which allowed him to gain significant insight and knowledge into the Villanova being a stent. And since if the approval in March of 2019, he has had extensive experience using the VINOVO stat. With that said, I would like to invite Dr Gagne to present on his experience using vinovo and how to optimize Venus sensing outcomes. Also, please do not hesitate to ask questions in the chat box below the screen and use the adjacent polling tool to submit your answers during the polling questions throughout the presentation. So with that set, Doctor Gagne thank you, Maria, it's a real pleasure. Thio participate in this broadcast tonight. The world of Venus disease and treatment for those who are suffering from the worst of crime, Venus hypertension has made big leaps in the last decade in the treatment of Venus outflow obstruction. And now that we have great new tools such as the Lenovo stand available to us commercially, it makes our life better, and it gives us better outcomes for our patients. So tonight we'll talk about the stent study that was published in its to your outcome data, and we'll also talk about some of the tips and tricks that I think of as I'm undertaking the treatment of these patients. So we'll go ahead and share my slides, share the screen, yeah, and I think we're a go. All right, So the number of being a stent was approved as Maria said in March of last year for the treatment of symptomatic geothermal vein outflow tract obstruction. It's a self expanding nightmare, all sent specifically designed for the deep veins. It has a player. Ends designed thio ensure that there's good wall opposition between the stent and the vein to prevent migration. There's a try acts of livery system and copious amount of markers so that the stent disease we've seen comes in a broad range of diameters. 10 to 20 millimeters in two millimeter increments, and it goes from 4200 and 60 millimeters long on it is deployed in an eight through 10 French system. The vernacular study was the pivotal I D study that led Thio commercialization. Three. Objective. The study was to assess the performance of the stent for iliac in common Federal vein outflow tract obstruction treatment. It was a prospective multi center study, non random. My single arm. 170 patients at 21 sites around the world were enrolled and there was independent analysis on the Vita Grams with core lab evaluation of thievy anagrams and radiologic imaging to look for problems such as stent fracture and also on the duplex. Ultrasound imaging used in pre and post up evaluation. The inclusion and exclusion criteria are is shown. Uh, inclusion was unilateral common Farmall common or external iliac vein disease Patients had to be symptomatic on, therefore had to have at least three clinical disease or a Dema and the VCs s pain score of greater than two and a greater than 50% diameter reduction by geography was the bar for inclusion. Radiographic Lee. The reference vessel diameter had to be between seven millimeters and 19 millimeters so that the stent was used within its I. If you the exclusion criteria was by bilateral disease or un correctable bleeding the emphasis prior stents in the target vessel or inability to cross the total inclusion. You can see here that the mean age was 52. There were slightly more women than men in a 2 to 1 ratio on If you look at the types of lesions that were treated, about a little less than half had post traumatic syndrome. On the rest were nivel or compression regions on. You can see that there was a lot more, uh, men represented in the Pts group than in the and then if you look at the lesion types that were treated. The common iliac vein was most commonly treated, followed closely thereafter by the extra elect vein and then the common federal vein. And if you look at the Pts Group, the common federal being was much more commonly treated due to the nature of these lesions, which are much more lengthy than is a nivel lesion, where it was rare that the common formal vein had to be extended. If you look at the main lesion length, it was 80 millimeters in the PDS group versus 55 millimeters in the compression group. Not surprising, Travis presence was more common in the post robotic group than in the compression group. Again, Not surprising, and then finally, the mean scented length was longer at just over 10 centimeters in the PTSD group versus the compression or nibble group. But it's important to note here that in general and the Venus system, we use long steps. If you look at the 24 month outcome data, you can see that the primary Peyton's he was excellent. 24 months. You have 83% Peyton see as an aggregate. There have been no stent fractures noted within this I d trial. If you look at the Peyton, see rates for the post robotic group versus the compression group again consistent with literature experience. In this field, there was 73% Peyton C at 24 months, which is quite robust, okay? And 95% Peyton C and the compression group. So again, through both groups doing quite well as Faras Primary Peyton C. Now the Orangeburg Registry was another data set on the Vinovo Venus Dent. And this is a real world study. It's a registry, uh, that the Doctor Lichtenberg and Dr Graf have been maintaining on. They looked at primary patents. He had 12 months with clinical outcomes of 12 months in patients that they treated who had iliac and, um, common formal, both post robotic and non traumatic disease in their clinic. On using the Vinovo stepped, and what they found was that they used C 345 and six patients about half their patients, where the more severe seat four through six on 20% of these were extending from the common federal bein up through the common iliac vein on another 4%. Another another, another 10% under the ankle ligament to the common firm of Vein on the left and then about 15% on the right. So large group under the inguinal ligament. And what you see here is they had excellent primary pay agency for all patients. At 12 months, they had primary Peyton C. That was 96% and it was not much different or compression legions versus post robotic disease. And so, in the hands of very experienced investigators, you can see excellent long term results irrelevant of the lesion type using this stent. So in conclusion, the i. D trial, the vernacular study showed excellent primary Peyton C of 84% with zero stent fractures on improvement in the V. C. S s pain score in the civic quality of life score, which were the two clinical parameters that were tracked and then mirroring. This is the results from the Orangeburg Registry showing a significant VCs s improvement in over half the patients on the C T scores increasing on average from 4.3 down to 2.7 after treatment. So how do you get these excellent outcomes with the patients who present with some complicated problems using the new technology that we now have available. Well, the first question is, when the step and we have a question, we're gonna go to question number one. So on your chat box, a question will pop up. And the first question is what clinical seat categories have the best clinical response to earlier. For moral vein, I've s image ing and stenting off a 50% cross section area reduction. You'll see the options there on your screen. Please go ahead and start clicking your answers. We'll give you about 30 seconds. I think for now we can While people put in the answers, we can move on to the next slide. So this is what I call my persons of interest. Slide these air the patients that I think about when I'm focusing on patients who are most likely tohave uh Elio federal outflow obstruction That would be amenable. Thio balloon angioplasty and stent treatment. If you look on the left, you can see this patient has unilateral swelling and the hyperpigmentation on his leg with some erosions on the back of the ankle, you see in the middle slide middle picture swelling that in duration of the skin and Stasis dermatitis on, even though it's bilateral, the feeder spared in these patients, often time have iliac vein outflow obstruction. Then you can see on the right panel the patient who has skin damage starting to wrap around the leg. It's not just focal to the media moralist, even though the ulcer is present. So patients that have skin damage wrapping around the leg with or without active re healed ulcer. If you've treated all their superficial disease and they've still got skin damaged skin in duration inflammation, they probably have some outflow obstruction. So Dr Gagne, we got the answer for the first question. What clinical sleep categories have the best clinical response to really femoral Vein IV's image ing and stenting off a 50% conception area reduction? The majority of the people answered C C. P 456 but 52%. And then the second answer was the CP three for five with 31%. What do you think about those results? Well, I I favor the answer. I think the patients who have anak tive, ulcer or healed ulcer the patients who have a healed ulcer oftentimes have ongoing skin damage they've got in duration in the skin. It's fragile. There could be inflammation. I think that's unresolved. Chronic venous hypertension. And I think a lot of those patients about for obstruction the ulcers. I think, uh, those patients, especially you'll find, have treated their superficial disease. Maybe they're perforate er's and they're just not getting better. And those patients often times about for obstruction. Um, the C four patients again, they're kind of pre ulcerative. There's a lot of skin damage they've got in duration. The skin is thick and it's fragile, and it's cracking and it's prone to ulceration. C three patients may improve, but it's 50 50. That's what the data would tell us. And so, if you're really looking for the patients that seem to respond best, uh, Thio evaluating as a group, it's really 45 and six. Thank you for a living. Put. Yeah. All right. So let's talk a little bit about what this pathology looks like. S So this is what a non traumatic, uh, iliac vein. Compression. Looks like you can see a Z. We all know you have the spine. You have the iliac vessels confluence ing to the Vienna cameras you see on the left. And then you have the order bifurcating into the comedy lack arteries. Uh, over that, and depending on the orientation in the body. And this is everybody's unique anatomy. Sometimes the common iliac artery on the right historically has been identified as compressing the left common iliac vein. But we know that the right common iliac artery can also cross over. A zit does to go down to the right leg and compressed the right common iliac vein on. We also know that these arteries can compress the veins along the length of the they not just at one focal spot, so there's a lot of variability. We also know that where the internal iliac artery, uh, by advocates off of the common iliac artery in the pelvis, both on the right and the left, it can compress the cranial portion of the external iliac vein and causes stenosis. At that point, there are multiple points in the pelvis where the veins can be compressed, leading to significant stenosis and outflow obstruction. This has been a big advance in our understanding in the last decade. This is the other problem that we are often treating, and this is post robotic disease. This is a slide courtesy of Dr Cammarata, where you see this dense scar within a common federal vein. And this is what we're fighting through when we're dealing with a long segment occlusion trying to get from the common formal vein up to the Vienna Cavour in many of these patients, What you see is sort of this Swiss cheese Lumen, where you can get a wire. You could get a catheter through there, but once you do that, you have to expand this lump of collagen with a balloon and stent, and you can tear the college and with the balloon. But if it's not supported by a by a stent with good outward force, it's going to not stay open. It's gonna compress. And so that's been the big leap forward with the new knight in all stent, that vinovo, that Bart is now made available to us. The bonobo stent is that it does keep this college and plug open eso that we get better Peyton C and better looming game. Okay, question number two. Question number two. The question is going to pop up in a few seconds. In the meantime, I'm going to read the question to you. What did the video trial teach us about Ilia femoral vein image ing and see 4 to 6 patients. So that's gonna be the question that is gonna come back. Oh, another question that we asked and is more, a little bit more relevant to this question as well. We asked the audience, Do you currently use I vis in Venus interventions? It was a yes, always use Sivas, and that was the majority of them with 46% and then followed by 31% with intermittently. They use itis, and 23% said no. What do your thoughts on that? So 23% aren't using I this at all Correct. Yeah, So I used ideas routinely, and there's two reasons for that. One is. The more I've done this, the more I've seen detail with IBIs that you just aren't going to see anywhere anyway. Anyway. Else you're not going to see it on a venogram. You're not going to see it on M R. Geography. You're not going to see it on a C. T. V anagram. There's there's Trebek relations. There's subtle changes across the Lumen. You see a scar in the Lumen that tells you that this patient may have a sclerotic wall. There is just detail that you pick up on I vis that give you little clues that there are points of compression. There are points of narrowing that are limiting flow through these systems, so thes other imaging modalities could be helpful. But you need I vis to not miss disease because if you go ahead and do an intervention or an evaluation on the patient and you send them away and they've got an active Venus ulcer, they've got C four disease, and you say you're you're fine. There's something wrong with you. And you've missed the diagnosis because you didn't use I vis. Then you've probably not served that patient Well, the second reason is you need to stent safely. And if you don't want these stents, toe m belies. You need to be able to measure the size of the vein, and these veins can change with respiration. And so you need to do a real time evaluation of the vein size to make sure you know how big that vein can get when that patient is taking a deep breath about Sovereign so that that stent is not undersized and doesn't emb allies to the Hartmarx. So I use IBIs routinely. They also cuts down on radiation. Yeah, yeah. Eso We get the answer for the question. The question was, what is the video? Child teaches about Italy for moral vain image ing and sleep for through six patients, the majority of them with 95% answered b and C, which is multiplied plainer. Venogram is adequate for identifying significant iliac and common moral vein inclusive disease. Um, and so sorry, I red the wrong one. The intravascular ultrasound, the text and diagnose significant Elliot can come with a moral inclusive disease more frequently than MPV in the same patients. And I was imaging changes the treatment plan of patients with early femoral vein inclusive disease compared to MPV. So both the majority of them got it right. Sounds good. I'm glad. I'm glad that information is now well absorbed into our community. Yeah, exactly. All right. So what is What do we need to know in the literature? So we touched on the video trial on it was looking at the role of intravascular ultrasound versus three view multiplayer pornography for diagnosing and guiding treatment of illegal thermal vein obstruction. It was a prospective single arm study 100 patients, 14 sites in the U. S. And Europe with independent core lab adjudication of the intravascular ultrasound images and the Vienna Grams. And what it showed is we talked about in the question is that I've had superior diagnostic accuracy, the multi plane of pornography and more importantly, it changed the treatment plan in 57% of the cases. And then we did a post talk analysis of outcomes at six months looking at V. C. S s scores and patients who were treated based on itis versus how they would have been treated with multi plane of pornography. And what we found is that the measurement of stenosis based on intravascular ultrasound pre stent, uh, was able to predict ah, statistically clinical improvement when that cross sectional area was greater than 50% whereas a venogram diagnosis of a 50% diameter reduction or greater did not predict clinical improvement after stenting, so you could identify a lesion potentially on being a gram. But if you scented that lesion they did not necessarily get better versus stenting after I vis tended to predict clinical improvement. So that's a powerful statement. Now one of the criteria for intervention. As I mentioned, it's been, uh, used for a long time for non from biotic regions of 50% cross sectional area. Reduction on it seems to correlate reasonably well with clinical improvement. This is, ah, stenosis that's referenced to the adjacent normal vein, Andi, and the question comes up sometimes. Well, you know, in arteries of 50% cross sectional area reduction isn't much of a diameter stenosis. The problem is, veins don't exist is like arteries of circles. They existed in the lips. And when you do the math, 50% cross sectional area reduction actually correlates to a greater than 60% diameter stenosis if the circumference of the vein is fixed. And so that is why a 50% cross sexual area action in veins actually makes some sense. Um, but in post traumatic patients where you may not have a normal vein for reference or where the vein maybe nearly included think how do you know what the size of the true vein is? Well, there's a couple of strategies, you can look for Jason segments on the bilateral leg. Maybe your common formal vein is measuring 14, and your external and common iliac veins are included. Well, that means that you're probably your external and your common need to be 14 to 16. Or or at least that, um, But if you can always look at the contra lateral leg if it's normal and see what the size of the veins are there and then if all else fails. Theoretically, some studies that have been done and published previously have shown that on average, the common formal vein should be about 12 millimeters. Three external iliac vein should be about 14 millimeters, and the common iliac vein has should be about 16 millimeters. Obviously, there's a lot of variation in that in patients pending on their body habits and their size on dso. Excuse me. And so there is some variation on your initial intravascular ultrasound imaging, but this is a guideline for choosing the correct size stent in the post robotic patients. Now, how do you get started? So there are There are several options for access to the deep venous system to do these evaluations. Personally, the Papa Till vein is my favorite. Three. Access is fairly simple, although the patient does have to be in the problem position to not every patient is able to do that on, uh, patients. I find that a particular problems with that position, or those that have chronic back pain. COPD the grossly obese on then sometimes the post in patients who have severe post robotic disease, the federal papa till veins are included or markedly disease. And it's not a great place to get started. The mid thigh federal vein is actually one of the more common places to access. It's not the common federal vein, and it's not the staff in this vein. It's the mid thigh federal vein, and the reason you want to go here rather than the common formal vein or the greater staff in Spain is it allows you to evaluate the entirety of the common federal vein and the confluence of the deep thermal vein and the federal vein so that you know your landing site. Caudalie is a patent and is wide open. So you have good inflow because if you don't have good inflow on your stent, it's not going to stay open. And so you really want to be inferior and peripheral to the lesser stroke cancer of the of the femur to make sure you're below the confidence of the profundity, memories and federal vein. Three other thing you want to be careful about is avoid a 90 degree sheets so sometimes an extremely obese or large thighs on 11 centimeters. Chief. Maybe too short as maybe the access needle. And if you have to deal with the thigh that's large like that going in at 90 degrees can make the subsequent intervention difficult. And so then you may want to think about a different access sites, such as the Papa Till Vein or the third most common option, which be the internal jugular vein. It's not my favorite, but it's actually quite functional, and a lot of people use it routinely. That gives you access to both legs, the iliac systems bilaterally down to the federal federal vein and most people. Sometimes it's hard to cross, um, lesions if you get and you don't get enough support even with the chief. But generally you can even cross the most complicated post robotic regions. Um, it's hard to work and deploy stents bilaterally at the confluence of the common iliac vein. And Kaveh, if you do have been kissing stents without doing a second puncture. But all these air technical challenges that air certainly overcome can be overcome now, as far as imaging is concerned, we always start with duplex ultrasound, but we don't just image thean for inguinal vessels. We also image the Elio capable vessels to look for any evidence of scar compression or chronic conclusion on. Then, most of the time we proceed to Viagra Fee and Intravascular ultrasound. We could do a venogram from our leg access side. It's not the internal jugular. So look at the entirety from the lesser tro cantor so that we see the confluence of the profundity and federal vein up to the Vienna Kaveh. And then we'll look at the IBIs imaging and pull through, typically from the level of the renal bangs down through the Kaveh through the common and extra iliac veins and the common federal vein we look at the cave of to see if it's distended, because some patients you'll find just have a big, um, dilated Vienna Vienna Kaveh and that means they probably got some fluid overload. They've got some right heart failure, and we've had a number of patients come to us with chronic problems in their legs that could be chronic venous hypertension. They've been cleared by their cardiologists saying there's no issues with their heart. And yet there being a K virus, uh, chockablock full and they just fluid overloaded either from right heart pressure, elevation or some renal issues. We used the 035 system with the Ivies catheter because it really is the only catheter size that gives you the proper field of view for these big vessels. The this is an 888 8.5 French system, the five and six, the five and six French systems just don't show you the entirety of the veins. We intimately we use actual image ing, especially if we have somebody who has extensive post robotic disease to help plan the procedure and the duration of the procedure. And sometimes whether we do this in an outpatient setting or at the operating room, patients who have a longstanding filter or have bilateral symptoms and a history of DVT, especially up in the, uh public veins will get a cat scan to help plan the procedure on, then finally, if we have a patient that has a rapid onset of symptoms in the last 6 to 12 months that will take a cats get a cat skin to make sure they don't have ah neo plasm as part of the problem. And now for our third question. Okay, so our third question is what chronic vein pathology can acute deep vein thrombosis resulting. So the question is gonna be up on the pole, and we're gonna give it a couple of seconds there. In the meantime, Doctor Gagne wanted to ask you, you said that the jugular accesses the least commonly use access site. Um, is there? I have met some physicians that do it all the time. Some that just shy away from it. Can you tell me why some positions air Just completely hesitant. And also, you know, you said the public still access. I think it is good, and it gives you full access to the lesion. Can you give a little bit more insight on, you know, choosing jugular access versus public? Teal access s so I think you know juggler access is not my favorite, but I do think for some people it's their preferred technique S. So I think there's a lot of dealer's choice in that physician choice as to whether it's papa, teal or jugular. I used to tell people that I used to judge the papa till access preferentially and most of the time accepting patients. I wouldn't tolerate it. But then I looked at my data, and I was actually used in the mid family vein 55% of the time, Papa till 35 or 7% of the time and the juggler 15% of the time. So, you know, I think that the reality is that the property can't be used in a lot of patients. Um, I think that the jugular is great access because the vein is relatively superficial. It's easy to get him a Stasis at the end of the procedure. You just sit the patient up the 30 40 degrees and you've got him a Stasis. The five could be a deep place to work. In some patients, you get some hematomas and some bruising, although it's usually not something that requires anything more than conservative treatment. I think the most important thing is that you need to be able to evaluate and treat the entirety of the common federal vein from the refund, uh, up to the Kaveh on. And if you have a tall person coming in from the jugular, in some cases may limit what technologies you have available to use. One of the advantages of the jugular is that if you have a disease, the federal vein with a lot of scar and you've got some disease in the profound ephemera. Spain. But in general it's open. You have the ability to stent down into the profundity femur. Spain Onda improve the flow directly from the deep vein into your common federal vein and through your iliac vein system. So there is an advantage in that point in that setting to be able to come in from the jugular vein. Thank you for that. We do have the answers for the question. What chronic vein pathology can acute Deep vein thrombosis? Resulting the correct answer is EALA fee above, which is intra Luminal Web intramural scars, Clorox sclerotic vein and, if usually, small women, occluded vein, intra Luminal scar and Luminal stenosis So the majority 92% got it right. We have a smart group tonight. All right, so this is an example of what you'd be looking for. This was a patient who azi young woman at the time of pregnancy. I got a D V t and then had a swollen left, like for the next 40 years. And we got this cat scan to see what was going on because 40 years ago, there was some interesting treatments for DVT we including legation of vessels. And what we saw was this very sclerotic. As you can see, what the pointer is very sclerotic vein underneath the iliac arteries across the front of the spine. You can see here it's just really a wisp of scar tissue. You don't really see any Lumet, and you can see it here is well. And then if you look over here, you can see the small, uh, partially open external iliac vein on the normal contra lateral vein. These are the types of things you want to check on cat scan because sometimes when you order a cat scan, especially at out center, that has a lot of special general radiologists who aren't used to looking at this type of pathology. You don't necessarily get it reported in your in your report. So you want to look at these things yourself in order to see if there's abnormalities. I found CAT scan can be very specific when you see an abnormality, but it misses us a fair amount of disease. Now, this is, I think, as we talked about I this is really the primary imaging modality for diagnosing a disease and then measuring the size of the vein. You can see here on the left is very severe. External iliac vein compression stenosis. You can see the cross sectional area only 37 millimeters. We're really looking for something between 101 150 millimeters. But on the right, you can see ah much more normal adjacent segment measuring 135 millimeters squared. Uh, and this was the inferior, externally like fan of the same patient. And so this was calculates out to a 75 to 80% cross sectional area reduction and you can see on the right panel on the lower left of the picture. The area is 135 millimeters square in the middle of diameter is 10.6. The maximum diameter is 17.4. In order to get a sense of what you're vain diameter is, you add the two up divide by two. So that's 28. Divided by two is 14. So that's a 14 millimeter vein. And assuming when you have your eye vis and the patient take some deep breaths, there's no phase. It changes with the vein opening and closing, and I've seen a 30% change with respiration. So you do want to do that. But assuming this is the fixed size of the vein that if you were going to stand here, you want to get a stent that's larger than 14 millimeters and three i f. You for vinovo was 13 millimeters and and that's your range of either out. Either a 16 millimeter stent would probably appropriate here. Now here's some other pathology that you'll pick up on IBIs. You can see here on Panel one, this white echo coming through the center of the Lumet. Here's the Artery. Here's the vein. Here's a Web coming up through the vein, and you can see that the vein itself is in fact, the same size or smaller than the artery. And we know that the veins should be much bigger, uh, than the artery, as you see here, a normal vein next to a normal artery. So the fact that this vain is shrunken, it's got this Hypercar echo right through the middle of the Lumen. This is post robotic scar and sclerosis of the wall. You can see here these little chunks, like little rocks on the edges, this irregular border again. This is post robotic disease. The vein is open, but the vein is not as big a zit should be. It should be much larger compared to the artery. This is a small, shrunken vein. You pick up these abnormalities on I vis it will be an open vein on venogram. It will be an open vein on cat scan, but if you see these abnormalities, this is not a compliant thing. This is a stiff thing that does not conduct blood normally. And this is the type of abnormalities that you can treat that stenting. And then finally, this is a very subtle web that you pick up on I vis and in fact, it's so subtle on this is a patient that had no stenosis, patient and no history of DVT and has this web in here and this web here you look at you go well, is that really something? And then you put a balloon up and I will tell you that I took my foot off the pedal because it started the way started right about over here. This was a bow tie, and you can see this tight narrowing and you treat these patients and their Stasis dermatitis and their Dema and they're in duration goes away. So So if I This is so helpful, why do you want to do a venogram? Well, if you see collaterals, it's a pretty good tip off that you have a pressure grading, So it's always nice to see those. When you start your intervention, you make sure you put your wire in the right place. You know exactly where you are, and then, especially after stenting, you want to see what the flow through the stent is. Is there spontaneous wash out of contrast as the patient breathes, you can push the contrast out with bullets of sailing. That's not going to tell you whether the stents going to stay open or not. If you have spontaneous drainage of washout. Excuse me. If you have spontaneous drainage of contrast in good wash out with just deep breath, then you know that stent is good info. Good outflow, and it's likely going to stay open in the post procedure period. Now, my protocol for evaluating for a non traumatic iliac vein lesions nibbles is I put my catheter up with the renal vein and I do a pull back down to the level of the federal vein, and that allows me to assess the the inferior vena cava for any phase. It changes to see if the patient is fluid overloaded. I got a good look at the common iliac vein. The confluence of the right and left common leg vein with the Kaveh, sometimes the inferior vena cava at that level is small. And sometimes the common iliac vein is actually larger than the period of una Cavour just above the confluence. It's good to know about that. If you're stepping into the I V c on, then I want to see what the vein segments of the common extra like they look like. And I want to see what the origins of the federal and deep formal veins look like and where they are, so that if I am standing into the common federal vein, I try not to stay to jail. That inflow into my step. I also see the pathology we've shown in the preceding slides on. Then I look for the compression that we've talked about. If I do my initial pull back and I don't really see much of anything. I put the catheter back up at the cable iliac confidence into a very slow, steady, tedious pull back, looking for discrepancies in vain size that could suggest a pressure grading areas of hyper dense echo in the wall that might suggest prior scar and then the occasional web that you see, uh, and then if you if you go ahead and you don't see anything, and let's say the extra in the like vein is measuring 90 millimeters, you know there's some discussion about whether it needs to be 125 millimeters squared, and I think in general we don't have good data to support those kind of numbers, so I would say that if the veins in general look normal and you can't really find any pathology, especially if the vein seems to match the body habits of the patient, stenting may not be the right thing to do now. This is what post robotic imaging could look like. You start off with a venogram, the collaterals will be evident. You can then see where the normal vein ends. And a lot of times as you can see here, in this little risk of the common formal and externally like vein, attract that you can then feed a wire up through on. Once you get your wire through, you can start to balloon dilate. I typically would start with a 46 millimeter long, 15 or 20 millimeter balloon to create a channel. And then I just start going up to my larger balloons. And usually I'll go up to a 14 and 16 atlas balloon in order to disrupt the scar in that in that track, and once you've dilated to the size that you want, then go ahead and deliver your stent from a part of the vein that's open. So you have good inflow to a part of the vein that's open up above. So you get good outflow. Aan den you post dilate up to the size. You want that vessel to bait. And then I do an intravascular ultrasound image to make sure the vein has opened up adequately. Eso that I don't have any persistent narrowing that could threaten the paciencia that stent on. Then I do a venogram to make sure I could have good, spontaneous washout, because if the contrast is just sitting there, it's not going to be a successful revascularization. And we'll look at some case a case of this little later on where we had a great result with the new VINOVO system. When we do treat the post robotic patients, we wanna treat the entirety of the disease segment. If we overlap stents, it's usually two centimeters minimums that in the tortuous anatomy of the pelvis, it doesn't. You don't get stents separation that could then lead to stenosis and thrombosis. Way talked about info we talked about post dilating, Uh, you really want your stent to be 12 to 14 millimeters in size or bigger after it's been deployed and post dilated. All right, so the Venus anatomy. The comes in a variety of flavors on you can see here different anatomy, so you have, Ah, short common iliac vein. You could have a long common iliac vein, and that's relative between the confluence and the take off of the internal. Really like vein, you can see Thea External Iliac vein coming down to the common. Sometimes there's a duplicated, deep federal vein coming off of the common or joining the common rather than ah, single vein, as is taught in the anatomy books. Identifying these nuances and differences in anatomy is important in planning your stenting Andi, although we think that the average size of these veins based on anatomy studies is 12 14 and 16 millimeters, not everybody's veins of those size, and so they do not have to be that size if they otherwise appear to be normal. So how does the anatomy play into how you place a step? Well, if you've got a classic May 3rd a legion, oftentimes you have some priest cyanotic Gillet ation, so you could have a vein here that measures aluminum eight millimeters at the top of the common iliac. You may have a vein here that measures 23 millimeters. And you're thinking, Well, this is supposed to be about a 16 millimeter common iliac vein. If you go ahead and stent here, you're only gonna have wall opposition here. So what we oftentimes will do is we can you can either Extend stepped down from the from the extra Elliott external iliac vein all the way through the stenosis and just into the I V c. And this is where the flared end on the on the nova stand is nice because you don't have to extend too far. The flare will help not only to oppose the stent down here and give you good anchoring, but up here, it can keep the artery from rolling over the end of the stent and make sure that you open up the vein and don't have a late restenosis. Uh, but but you could put a smaller stent here and extend a bigger stent telescoping in size eso that you fill this up on, get a proper sizing, say, 14 here in 16 here. You don't want to put a 20 or 23 millimeters stent in here because it's gonna be too big in the Kaveh and it's going to threaten the outfall from the other. Like if you have a long, common iliac vein like this, then you can anchor it down here. Onda, come up through the stenosis here on if you have a narrowing in this section of your right common iliac vein, and you don't have to extend all the way down into the external iliac vein. So depending on the length of the common iliac vein your different strategies for stenting. If you look here the extra money like vein, especially as a very tortuous course in the pelvis, it starts a little straight. Then it dips down deep into the pelvis, and then it flattens out and comes up superficial again at the level of the inguinal ligament. And so there's really three parts. There's this initial straighter part. There's dipping deep part, and then this later, um, superficial, part of the common form of an injunction. And so I call it the rule of thirds, because if you go ahead and you stent in this dipping part at the end of your stent, either the codel or the cranial end of your stent ends down here in the dipping part of the external iliac vein you can see on this ladder review? Uh, this the vein down here, then what's gonna happen is the stent is gonna want to straighten out, and you may get a little narrowing, created just by attention on the vein wall. So when you spent, you want to stay in the upper third, 2 to 3 centimeters of the external iliac vein or the lower 2 to 3 centimeters of the external elect vein. And sometimes I mean to extend the step longer if you need to come all the way down to here or you go off from the common femoral. And sometimes you may need to extend all the way up here trying to avoid ending your stent either cranial cottage cuddly in this middle third, and it will make your stenting easier. And there's really not any consequence to having a longer step. Now, this is again just emphasizing if you have a common family legion and you've got disease extending across the inguinal ligament and you need to stand north, you don't want to end up in the middle here. You want to stay in the lower third of the external iliac vein or extended up higher and again. This is an example of extending it up higher past the middle third of the external iliac vein. You can you can avoid complications of tenting and narrowing the vein. And then here you typically you wanna oversize your your stent. So let's say this is Ah, 14 millimeter extra iliac vein. You've got eight millimeter now in here, you've got a 23 millimeter priest amount debilitation. If you take a 16 millimeter stent, you extended 2 to 3 centimeters into the external iliac vein that will anchor in the external iliac vein. And even if it's free floating here in the priest's knotted debilitation and fixed here, this tent not only will not go anywhere, but it will give you the 16 millimeter loom in here that you need to get good human dynamic flow and get rid of your chronic venous hypertension. So in some cases you wanna anchor your stent down here, especially with a short, common iliac vein that's dilated over here. You can see again if you wanna. If this is a 12 millimeter vein extra iliac vein, you may want to stent up with the 14 millimeter stent Thio here and then telescope out of that, putting the 16 millimeter stand inside the 14 that anchors the 16 and 2 to 3 centimeters of the 14 millimeter stent. So it's not traveling anywhere, and it gives you a good scaffold to open up the compression point, which maybe eight. And that will be 16. And you don't have to have wall at position here and you'll get a good outcome and that stent won't migrate. You never want to size the stent oneto one to the vein. You need to oversize at least 123 millimeters. So here's an example of what you don't want to do. Here's a patient with a high grade lesion priest, not a debilitation. If you say this is supposed to be 16 millimeters and this is eight millimeters. So if I put a short stent here, it's not gonna go anywhere because there's eight millimeter narrowing is gonna hold it. Well, I wouldn't do that because we've seen a number of steps now migrate up into the heart and lungs and require open heart surgery to remove. We never want to use the short, unanchored stents in the Venus system. It's different than the arterial system. In this case, you want to extend that stent down, anchor that 16 millimeter stent in a 14 millimeter external iliac vein, 2 to 3 centimeters so that you know it's not going anywhere. And then you'll have a nice scaffold for your stenosis. Now how do we see the patients post procedure While you always want to see him early, you want to see him in the first few weeks, and the reason is because if you do happen to have a thrombosis, opening up that stent early is much easier. If you wait till after four weeks for that initial follow up in the stent goes down, then you may not be able to open that stent again. Some of the common techniques has thrown the license, and such may not work as that clots. That trauma starts to mature, so we always want to see our patients early, at least less than at least within the first four weeks. I typically get an ultrasound and see the patient in the first week to make sure my reconstruction is fine and typically, if I have no problems at a week. I don't have a problem in six months or a year, which is my second two time points for follow up. If everything is looking good at a year that I see the patients annually, I do tell them, however, that if they start to get new swelling, new paint, new heaviness that they shouldn't wait to come in. They should come in because recurrent symptoms is a good market, that there's something new going on, and they need to be re evaluated now as faras, anti coagulation and anti platelet therapy. For the patients who have compression alone, they have a normal vein that's being compressed externally. I use full dose and a coagulation during the procedure at a therapeutic level, usually in fractionated Hepburn. But after the procedure, I put the patients on anti platelet therapy. Now, how long to keep them on anti platelet therapy is debatable. I may put him on a baby aspirin indefinitely, I think for at least the first six weeks, uh, there are others to do it for three months. Unfortunately, we don't have any data or studies to show us what the proper timeframe is, but at least treating him for six weeks gives them potentially a chance to thio get post to get end of the realization. More important is the patient who has an acute DVT or post traumatic syndrome. If you're sending in the setting after an acute DVT license and you're putting a stent in, you need to treat that patient as if they were treating him for the D. V T. And so, if you would normally treat that patient for six months, you need to treat that patient for six months. If it's an unprovoked DVT and you're saying three months, that would be the minimum. If you have an extensive DVT with a lot of injury, especially if it's acute on chronic, you may want to treat them a little bit longer with anti coagulation. If it's a patient that has recurrent DVT s, then they may need indefinite lifelong in a coagulation. Or if they have a throne Ophelia, they may need lifelong into congratulations. Same thing with patients who have just pure chronic scar from Pts Post traumatic syndrome, typically right after the stent, will treat them with Lovenox, as we do with our cute DVT patients that we spent for 2 to 4 weeks at a milligram per kilogram. Q. 12 hours. That's to take advantage of not only the anticoagulant properties of Lovenox or knocks apparent, but also the anti inflammatory properties that seem to be associated with them. And then, after that first 2 to 4 weeks, then we'll start him on an aural anti coagulant. And if it's Coumadin or warfarin, we need to follow their iron. Are closely to make sure there's no big variation. And they don't lose their anti coagulation because that's ah, set up for re thrombosis. Now let's talk about being extending the next question, please. Okay, so question number four Critical considerations for successful Bain stent intervention always include a size of distant be type of anti coagulation. See adequate inflow and outflow, or d diameter of the balloon. Angioplasty on the question is now on the chat box, so please go ahead and start um, answering. And in the meantime, Doctor Gagne, we do have a couple of questions that have come up. The first question is, do you routinely have the patient ball Salva, when measuring with I vis? Also do you find knowing the patient is fully hydrated can make a measurable difference in your vessel. Measurements. Eso Ah, lot of people have raised the question about hydrating patients, and I think it's not a bad idea. I can't tell you that I've studied it systematically s so I can't really give a answer based on data. I think if they're more hydrated they are. The more likely you are to get a or the better hydrated they are, the more likely you are to get a more um uh, a more ah, better measurement of your veins. But I think what I found is that more important than Val Salva, which I actually find doesn't work a lot of times have the patient take deep breaths. And when they take deep breaths, I see a significant excursion. Sometimes in these patients, from a small, collapsed external iliac vein into a fairly large external iliac faith don't usually see it in the common iliac vein, although I have seen it a few times where you've got what looks like. It's sort of a diffuse Lee small vein that looks normal. You don't see any scar tissue, it doesn't look like this post robotic disease, and you have the patient. Take some deep breaths and you'll see that vein increase in size by 25 or 30% to a normal size. Main eso In that setting, there's no fixed gnosis. There's no reason Thio to treat them. The second question is, Do you find yourself using longer Spence for Venus cases or just treating true, healthy, too healthy? Well, I treat healthy too healthy, but I would say that in orderto anchor the stents, a tip of them using longer sense. I don't you really ever use anything less than 60 millimeters Onda typically using 80 and 100. I would rather over stent on make sure the standard anchored, then understand trying Thio, finesse it on, then worry about that sent becoming mobile and analyzing. So at times have not even allowed 40 millimeter Venus tents on the shelf because I don't want somebody to get attempted to use one. Yeah, I think that's what we've learned as well. With, you know, is, you know physicians are using longer, since as long as you know the anchoring the stents distantly, that's the most important thing as and also, you know, have good inflow and outflow. Um, so which is the correct answer for the question here, uh, critical considerations for successful vein spent interventions always include the majority. 87% answers see adequate inflow and outflow, which is the correct answer s surgery, vascular interventions. All right, so so these are some of the technical things to think about as you're doing these patients especially this is the post robotic case that we, uh, treated with vinovo stent. You can see the lesser tro cantor here, so we know that this is where our deep formal vein is gonna be and you could see it coming in here. You can see the federal vein is diffusing scarred. So this is our main inflow vessel. The question here Is there a lot of scar here or is this a healthy vein? Sometimes Hard to know if Veena Graham But when you put your intravascular ultrasound catheter here, you have a very clear idea of what this looks like and whether it will support the stent as an inflow vessel. Here's our inguinal ligament up here. So here's our common thermal vein disease. Here's our external iliac vein disease. So we need to get across all this in order to go from here where we think we have adequate inflow here to get up to the Ivies thing in order to get outflow in order to step. And then once we extended, here's our this is now the, uh the lesser tro cantor. Here, here is the head of the femur. This is Ah, a stent up in here and you don't see the contrast washing out very well down here. You see it washing out nicely up here. This Stasis down here, this relative Stasis should make you concerned of whether you have enough inflow to keep this stent open because you're not getting perhaps enough washout of contrast. In my experience, when you see something like this, that's that is doomed even within a coagulation, and they usually from both within the first few days or week. So another reason to bring the patients back in that first week or two to identify if this just doesn't hold up Mhm. So in this case, this patient here's our lower landing zone. We achieved outflow, and you can see here are stent with good evacuation of contrast spontaneously. This is not being pushed by sailing, but rather being fed by the collaterals and this patient did well, long term on then this is a patient goes to show the importance of keeping some of these patients on their anti congratulations and how you can get in trouble with non compliance. Here's a patient of the cute DVT from the lower leg up through the iliac. This is when we were using theme the trellis device which is no longer available on the market. This was bilateral, and then this is that is both stenting. This patient did very well for about five years, but then stopped there in a graduation and proceeded thio from both. And so patients who have recurrent DVT the patients have trouble filling. Unfortunately, they need to stay on my flying in a coagulation. Dr. Gone, You can ask you a question. We have one more. What measures can I take to prevent migration and perforation off sent? How long is the landing zone in the I V. C of a stent to treat Ilia cable Confluence Diagnosis. Um, I'm gonna go back here to use one of these diagrams to answer that question. So excuse me for a second, okay? Yeah. Mhm. so you can see here the insurer of unique Eva, the common iliac veins in this, In this case, there's a little bit of room above this diagnosis. The land, the step, if you're if you're if you're compression, say was right here, right at the confluence, you're going to need to get that stent up above it. Even with the flare configuration, you need to be up above that narrowing by probably a centimeter. And sometimes you end up going up a little higher. What you don't want to do is get it so that the standard laying along the side of the Vienna came out. If this edge happens to be close over here, and this stent is smaller than the cable, which is very important that the stent is smaller than the Cavor, if it's extending up like this, you don't jail the other side. But once you start laying that stand up against the wall of the cave or putting a stent that's larger than the fury of you gave up into this area, you run a risk of having a problem on the other side. And with the flair. You have to remember that if you pull a 14 or 60. If you put a 16 millimeter sent here, it's going to flare out to 18 or 19. So I always measure the Vienna Kaveh before I extend, extend extend up into it to make sure that it's gonna be bigger. Then these cranial section off my step. That was the second question. The first question. Maria, I'm sorry. What measures can I take to prevent migration in preparation of a stent? Yeah, I think you know, we don't see a lot of perforation of the stent, Um, in these veins. You know, if you oversize it grossly by 4 to 6 millimeters, you may see some some erosion. But if you follow the i f. You 123 millimeters, that seems to be pretty accurate anchoring. And I think the key here is you need to measure the vein. So you're doing that with I've issue getting dynamic measurements, so you know how big the vein is. And then you're over sizing by I liked oversized by two two millimeters at least, But there are instances where I feel very comfortable over sizing by one millimeter, especially in the post robotic patient, because that scar tends to be a very reliable landing zone for anchoring the stent. All right, Thank you for that. Let me go back to where we were to the cases. Case one. Yeah. So this is most of these, uh, compression lesions. If you look at a population of 100 people, you'll find that you know, those patients who have no scientist symptoms of of chronic venous hypertension oftentimes have an element of compression. So the question is, when is compression pathological and when is it just a, uh, an atomic variant? And so again, we talked in the beginning about C 45 and six patients on those patients where I will look for compression because I think they're showing signs and symptoms of chronic venous hypertension, especially if all their superficial disease has already been treated. So I look for patients who have skin damage, Venus communication, pain, tightness in the skin and in the skin within duration as well. A swelling, I think patients who just have swelling may have compression, and they often times like I said before 50% of the time, if you sent them successfully, they don't get better. So that's a tougher group, but you have to have a careful conversation with so patients who have, uh, chronic venous hypertension. Treating their compression regions could be very helpful. And here's a great example of a 22 year old woman who played the act of hockey. She would exercise that gets severe left like tightness and pain and could only play 20 minutes. I could probably only play two minutes, but she could only play 20 minutes, and that was tough for her without taking a rest and letting the pain subsides. She was otherwise a very healthy young woman. Here's a beautiful three D rendition. You can see the cut off here of the common iliac vein with a pair of vertebral collaterals here, Here's the contra lateral iliac and the Vienna Kaveh. So you see this high grade compression? Ah, very classic may 3rd type lesion and here's a venogram. And again you could see the collaterals. You see, cross pelvic collaterals here to the contra lateral common iliac vein, and the common iliac vein is included rather compressed here and then you see some pair of October collaterals here. This is the I this image or in the Vienna Kaveh here for coming down into the common iliac vein. You see this very tight compression here. Now we're into normal common iliac vein and the extra neglect fame. A normal, a normal looking vessel. So this is a classic compression lesion. Here's the area stenosis. The area is less than 59 millimeters squared so very small we would expect that to be around 150 millimeters. Give or take. Here's the extra iliac. There's some compression here. A little bit of distortion 93 millimeters squared. Not particularly small. Uh, not sure if that's a significant lesion, so we go ahead and do a balloon debilitation. You may not see a waste with some of these lesions, or you may have a mild waste that opens up very easily. But if you could go back after this debilitation and re I this this you'll see on the intravascular ultrasound that this noses compression is right back. And so you go ahead and stent it. Here's a stent from the external iliac vein, anchoring it here. This is a vinovo stent going up through the common iliac vein compression. Here's the confluence, so we're up in the Vienna Kaveh here, just to the edge of the wall. Like we talked about. We'll have another view in a second, and this is the common iliac vein. Post steps you can see here we went from about 59 millimeters squared up to 188 millimeters squared. So excellent looming game. And what the second paper or from the video study showed, is that the amount of looming game is the best predictor of clinical improvement. And so this is, Ah, markedly improved. A common iliac vein post stent in this patient should do very well. Here's that external iliac vein going up from 90 millimeters squared or so up to 180 millimeters square. And then this is the venogram from the other side. You can see that this stent is going just to the wall. Here. The stent is smaller than the vena cava, and there's good Wash out from the contra lateral, uh, iliac vein. So there's no jailing in this scenario, but you never want to go higher up along the wall of the cave er, with this stent, you could even come a little lower, and that would be fine as well because of this nice flair that you have keeping the vein the artery from rolling on the step. Now post op, this patient is placed on anti platelet therapy. Follow up with duplex and clinically, she was doing great. I started playing hockey again on no longer had any pain with her athletic endeavors, and so she'll be checked annually to make sure she's doing well now. A. Z we talked about before. You want to size the stent to the vein, the vein is normal, and so it will have face. It changes with deep breathing in Val Salva and you don't want that's tend to move. So you need to know what the true size of that vein is under dynamic conditions. And then you oversized the scent dry. A few we talked about that on. You wanna have a good three or more centimeters of purchase between the stent in the deep venous system so it doesn't go anywhere. Um, now, here's the second case, which is opposed. Robotic lesion. We wanna be able to cross the lesion and we'll go through that. You gotta be careful when you're crossing the lesion. because you can get into these collaterals is a pair of vertebral collateral that we're in here trying to get it over here into the cave up. So you need to shoot little puffs of contrast. Periodically, we use a variety of crossing catheters, hydro filic, stiff catheters, tapered sheets, softbank of wide wires and then patients. So here's a 48 year old woman left leg swelling and aching. Chronic Venus skin changes do the hypertension. She had a really a formal DVT 10 years before still a manic coagulation using compression stockings regularly. This is her venogram. You can see conclusion here of the extra iliac vein collaterals. This is what it looks like getting a wire up through here. You have a pigtail catheter in the Kaveh showing your target for getting your wire from the common federal vein up to the Kaveh and then doing an oblique view to make sure that you're in the camera and you're not in the collateral. You see, things dip from the extra iliac thing, and now we're inflating. So we've confirmed we're in the native vessels axial vessels, inflating with the high pressure balloon, getting rid of the waste this. This is a 16 millimeter balloon from the external iliac vein up through into the Kaveh up here. And then this is post illit ation. You can see you have some gain of looming here but you still got compression inclusion up here. But you get cross, tell the collateral. So here's your confidence. You don't have flow through your commonly acts and now you need to step this. This is what the eye this looks like in the Kaveh. You can see compression here. Tight compression may 3rd a lesion. Here's a the vein opened up. You can see the scar in the wall And so this is delivery of the Vinovo stent and you can see we're treating room here where the 16 millimeter stent and then in 18 millimeter stent here you're overlapping the stents by two. We're extending up to the Kaveh. We've treated the common iliac external iliac down into the common federal vein. And then this is our completion venogram. You see the deep thermal vein down here? We're standing from just at the common for Mulvane. We preserve the inflow. Can we have good? Also, this is our completion I vis when the Kaveh here. We're now in the but common iliac vein. We've got great movement. See, here we're down in the external common federal, and then we should see the confidence the deep federal going off here and here. There's a double deep federal system there. Now. We talked a little bit about stents, sizing again as a rule of thumb. Your comedy leg pain wants to be 16 to 18 year externally, like saying wants to be a 14 to 16 millimeters. Your counter formal vein wants to be 12 to 14 million years. Um, you may have some very small patients who are all of 5 ft one in £90 and they may not need these veins to be on the largest side. They may be quite normal at the smaller sites. You have to use a little judgment of this. This is just a big guy. Uh, if the vein is normal thing, you don't have to treat treat the vein. Um, when you're treating the post robotic patients, you do not need to see really dilate the vein. You can go ahead and make room with maybe a small balloon like a discussed before or 4 to 6. But then go biggest. Jerry O. Sullivan is fond of saying. Make room to the size you want 14 or 16 and then put your Stenton. And don't leave any gaps in these post robotic patients between stents because that's ah, set up for problems in the future. We talked about post op protocol previously, so I'm not going to spend more time on that. We do keep our patients with post revived disease and compression. We talked about overlapping the stent. I always telescope, the largest sent out of the smaller one. Others have done it differently. I think that's a great way to anchor the stent. I feel very comfortable with that on then. Finally, you know these patients have complex problems, especially the post robotic patients. Patient awareness is a challenge. The Mawr education We could give our patients, the better they will feel, and they can spread the word about what's possible in stenting, defeatist disease. And we can also educate our colleagues in the health professions. Thank you. Apple is an excellent presentation. Thank you so much. Dr Gagne. Really appreciate it. E wanted to discuss a little bit about your multi disciplinary approach on who you work with with other health care professionals, Uh, and how you raise awareness about this disease. Eso It's interesting. Um, when I first started down this road, I went to the wound care centers. That was fairly obvious because a lot of patients in wound care Venus ulcers of vascular ulcers are the most common cause of non healing wounds. And although there's a lot of arterial ulcers, uh, people check repulsive. And when they don't feel pulses they call vascular specialist, they don't necessarily have an awareness about the significance of Venus disease. And then a lot of these wounds centers, unaware of what we can do to open up the deep venous system and relieve Venus hypertension. So starting at the wound centers was kind of obvious, and that's been very successful in building that relationship. We have kind of people on speed dial. We could talk to the doctors and the wound center. The nurses, they call may I call them, have a close working relationship. The place that wasn't so obvious initially was cool looks at legs on a regular basis, and that's really your podiatrist in your orthopedist. Your primary care. Doctors will maybe once a year if they do a physical exam. But they're thinking about cholesterol. They're thinking about high blood pressure, thinking about weight loss and thinking about diabetes. And I found over the years, at least in the beginning, it took a little while For my primary care colleagues toe start thinking about chronic venous disease, but the orthopedists and the podiatrist, they're looking at legs all the time. They're looking at patients for total needs. They're looking at patients with ankle problems on, and it's also the same patient demographic that has chronic venous hypertension. The elderly get chronic venous hypertension as they get older, and so the same patients who need their need done also have chronic venous hypertension. And so I found that making those doctors aware of of what chronic Venus disease look like, what the skin changes look like patients at risk for ulceration and what we could do from an endovascular, minimally invasive approach to do to treat them has actually been a great effort on my part to bring them into the fold of what we can do and have found them to be vory helpful in referring these patients. We've also done the vascular health form, which is, uh, is educating doctors of every every ilk, every specialty about what we do. And then we spend a lot of time in the clinic talking to patients. Well, thank you so much for that. I really appreciate it way. Have any more questions? Let me see. There's one question, Um, which patients do you do as outpatient based lab vs in the hospital? So the two the two determinants of going way try to do everything in the office based lab of the two determinants that we use to go to the hospital? Are the patients just not particularly healthy patient patients who might be on supplemental oxygen? You have a Venus. Also, that's not healing patients who are severely obese on who are challenged, managing an airway when they're laying flat. Um, those are examples of patients where you just say they're more bit of these were such that they need toe be in a hospital where we have a few more resource is to help them should they need it. The patients who have very long post robotic disease when you balloon open that scar that you can have a fair amount of pain, and they may not tolerate it. So if you have ah, short segment that's scarred up or included, that's one thing. But especially if you're going from the common formal all the way up to the Cavour into the cave er up to the regionals, I found those patients need general anesthesia, and also those tend to be longer cases. And patients can get fidgety, laying on the table under local anesthesia with sedation. And so those patients, a lot of times, we'll bring them to the hospital for general anesthesia. Okay, perfect. We have another question here. If you have focused diagnosis of a mid left See ivy with normal size 16 millimeter adjacent central left. See ivy with priest cyanotic, dilated, peripheral left. See ivy and a normal side cited left E ivy measuring 14 millimeters. If you wanted to use of a novel and land approval portion of the stent in the healthy left E ivy, would you use a 16 millimeter diameter spent? I eat, Would you oversized external vein portion. So that was a long question. So I'm gonna ask you to say it one more time. Um eso if you have a focus stenosis of a mid left See ivy with normal size 16 millimeter Adjacent central left. See ivy with priest cyanotic, dilated, peripheral left. See ivy and a normal sighted left E ivy measuring 14. If you wanted to use of a noble and land the powerful portion of the stent in the healthy left E I d. Would you use a 16 millimeter diameter? Yeah. Oversized external portion. Right. So what I'm hearing here, is it za 14 millimeter external? As you go up towards the Kaveh, you have a priest, not debilitation. That's about 20. You have your area of stenosis, which is focal. And then you have, ah segment of normal 16 millimeter common iliac vein above that. So I would I would go ahead and land it. I was I would landed in the external iliac vein, the top 2 to 3 centimeters with a 16, and that would size perfectly to your to your common iliac. In this case, I would say the reference vessel is the cranial 16 millimeter normal common iliac vein. Not the priest, not debilitation. 20 or 23 millimeter common iliac thing. E answer that Yeah, And we have one more question. Does the sense for do stands for DVT passing the common femoral vein safe? We're bending the bending need of the hip joint the risk off coming from moral stand fracture Persistent. Yeah. So, uh, if you have to extend a stent above or below the inguinal ligament So if you're spending the iliac into the common federal or you're spending the common ephemeral up into the iliac, then there will be a chance of fracture. The good news is that fracture has been a relatively uncommon event, uh, in in stenting the deep veins and and sometimes when it happens, it doesn't have clinical manifestations. So the importance of stenting correction, the downside of stenting across the inguinal ligament from the point of view of fracture, it may happen, but the clinical consequences may not be all that significant. What's more important, though, is if you do, if you need the stent below the inguinal ligament in order to get good inflow and outflow, and you don't if you say well, I'm not going to extend the stent down there because I don't want it to fracture, and you don't have good inflow or you don't have good outflow. That's then is probably going to from both 100%. And that's going to be a failed reconstruction. So the consequences of stenting under the inguinal ligament seem to be ah, lot less than than than having a failed stent because you didn't secure good inflow and good outflow. Now, I will say that the one thing that I like to do is I try not to land. Land the stent, right? One end of the stent and usually it's the katelynn. I don't wanna land the stent right at the end of a ligament. I generally try to go to at least the mid federal head so that the inguinal ligament is crossing across the body of the stent and not the end of the state. Mhm. So, yeah, I do know in the vernacular trial at even at two years we had serious fractures as well had pretty good results with that. Yeah, the vernacular has has performed nicely in that position. Yeah, perfect. I don't think we have any more questions, so I want to thank you very much, Doctor Gagne, for your time to suspend very insightful and an excellent presentation. And I hope everybody found it very helpful as well. In education also. Thank you, everyone. Thank you. My pleasure. Have a good night. All fine.