Endovascular Renal Vein Confluence Stenting Does Not Compromise Renal Function or Patency 2017 VASCULAR ANNUAL MEETING| SOCIETY OF VASCULAR SURGERY
Jeffrey Forris Beecham Chick, MD, MPH, DABR1; Steven D. Abramowitz, MD, RPVI2; Charles Brewerton, BS3; Jordan B. Fenlon, BS3; Dawn Coleman, MD4; David M. Williams, MD, FSIR1 1Division
of Vascular and Interventional Radiology, University of Michigan; 2Division of Vascular Surgery, Washington Hospital Center; 3Western Michigan University School of Medicine; 4Division of Vascular Surgery, University of Michigan
Disclosures • Jeffrey F. B. Chick – None
• Steven D. Abramowitz – None
• Charles H. Brewerton – None
• Jordan B. Fenlon – None
• Dawn Coleman – None
• David M. Williams – Boston Scientific
Background: Theory • Endovascular inferior vena cava stent reconstruction – Effective
– Safe
• Stent placement across renal vein confluence – Sometimes necessary – Safety unknown – “When positioning stents, the crossing of major branch vessels should be avoided”
Oudkerk M, Heystraten FMJ, Stoter G. Cancer. 1993;71(1):142-146; Zhang CQ, Fu LN, Xu L, et al. World J Gastroenterol. 2003;9(11):2587-2591; Iyer V, McKusick M, Friese J, et al. J Vasc Interv Radiol. 2016;27(3):S141.
Background: Animal Models • 1 animal model – Transrenal caval Gianturco Z-stents in 12 rabbits
– Evaluated 1 week, 2 weeks, 1 month, 3 months with serum laboratories and venography – No changes in renal function
– All stents patent – No pathologic abnormalities at autopsy
Oudkerk M, Kim JK, Park SJ, et al. Invest Radiol. 1996;31(6):311-3.
Background: Case Series • 1 case series – Transrenal caval Wallstents in 4 adults
– Evaluated with 3 follow-up serum creatinine measurements and computed tomography – No renal deterioration
– No evidence of renal vein dilatation or thrombus
O’Sullivan GJ, Lohan DA, Cronin CG, et al. J Vasc Interv Radiol. 2007;18(7):905-908.
Purpose • To determine if stent placement across the renal vein inflow in patients undergoing iliocaval reconstruction may affect kidney function and renal vein patency
Patient Population • 93 patients with caval stent reconstruction • Treatment group – Transrenal Wallstent (small lattice) – Transrenal Gianturco Z-stent (large lattice) – “Renal Gap”
• Control group – Iliac vein Wallstent
• June 2008 – September 2016
Patient Demographics
Patient Demographics Female
54 (58%)
Male
39 (42%)
Age
39 years (15-70 years)
Presenting Indications
Presenting Indications
N (%)
Lower extremity pain, swelling, or ulcers
48 (52%)
Deep venous thrombosis
42 (45%)
Mass compressing inferior vena cava
3 (3%)
Evaluated Outcomes • Renal confluence stenting technical success • Renal function evaluation – Glomerular filtration rate – Creatinine
• Renal vein patency • Complications
Treatment Groups Treatment
N (%)
Wallstent
15 (16%)
Gianturco Z-stent
24 (26%)
“Renal Gap”
12 (13%)
Control
N (%)
Wallstent
42 (45%)
Wallstent Technique A
B
C
D
Gianturco Z-Stent Technique A
B
C
“Renal Gap” Technique A
B
C
Stenting Technical Success Treatment
N (%)
Wallstent
15 (100%)
Gianturco Z-stent
24 (100%)
Control
N (%)
Wallstent
42 (100%)
Pre-Stenting Renal Function Wallstent Z-Stent Glomerular Filtration
“Renal Gap”
Control
All
60
59
60
59
60
P-Value Range
0.21
0.19
0.24
Creatinine
0.8
0.9
0.7
P-Value
0.4
0.24
0.09
51-60
Range *12
days before stenting (range: 0-62 days)
0.8
0.8 0.4-1.2
Post-Stenting Renal Function Wallstent Z-Stent
Glomerular Filtration Range Creatinine
60
60
“Renal Gap”
Control
All
60
59
59 42-60
0.9
0.8
0.7
Range *167
days after stenting (range: 1-932 days)
0.8
0.8 0.5-1.7
Overall Post-Stenting Function
Glomerular Filtration Creatinine
Pre-Stenting
Post-Stenting
59 (range: 51-60) 0.8 (range: 0.4-1.2)
59 (range: 42-60) 0.8 (range 0.5-1.7)
P-Value 0.32 0.41
Individual Post-Stenting Function Wallstent Z-Stent Glomerular Filtration P-Value Range
“Renal Gap”
Control
All
59
59
60
60
60
0.23
0.18
0.25 42-60
Creatinine
0.9
0.8
0.7
P-Value
0.27
0.32
0.15
Range
0.8
0.8 0.5-1.7
Renal Function Results •
No statistical difference in pre-stenting and poststenting renal functions cohorts
•
No statistical difference in post-stenting renal functions between individual treatment groups and control
Renal Vein Patency Renal Confluence Stent
Patency
26 (67%)
25 (96%)
Computed tomography only
10 (26%)
10 (100%)
At least 1 Both
30 (77%) 20 (51%)
29 (97%) 20 (100%)
Imaging Modality Venography only
*331
days after stenting (range: 3-652 days)
Complications •
3 (3%) minor and 1 (1%) major complications
•
3 minor access site hematomas
•
1 patient with transrenal Wallstent placement developed right renal vein thrombosis 7 days after stenting – Required thrombolysis, sharp recanalization through the stent interstices, and renal vein stenting
Conclusions •
Renal confluence stenting is technically successful
•
Stenting with small and large lattice stents does not compromise renal function
•
Due to a small risk of renal vein thrombosis, large lattice stents such as Gianturco Z-stents should be considered
References •
M, Heystraten FMJ, Stoter G. Stenting in malignant vena caval obstruction. Cancer. 1993;71(1):142-146.
•
Zhang CQ, Fu LN, Xu L, et al. Long-term effect of stent placement in 115 patients with Budd-Chiari syndrome. World J Gastroenterol. 2003;9(11):2587-2591.
•
Iyer V, McKusick M, Friese J, et al. Outcomes of IVC stenting with Gianturco-Z stents in non-thrombotic IVC stenosis: a 11-year experience. J Vasc Interv Radiol. 2016;27(3):S141.
•
Venbrux AC. Venous Angioplasty and Stents. J Vasc Interv Radiol. 1996;7(1):343-346.
•
Williams DM. Iliocaval reconstruction in chronic deep vein thrombosis. Tech Vasc Interv Radiol. 2014;17(2):109-113.
•
Kim JK, Park SJ, Kim YH, et al. Experimental study of self-expandable metallic inferior vena caval stent crossing the renal vein in rabbits. Radiologic-pathologic correlation. Invest Radiol. 1996;31(6):311-315.
•
O’Sullivan GJ, Lohan DA, Cronin CG, et al. Stent implantation across the ostia of the renal veins does not necessarily cause renal impairment when treating inferior vena cava occlusion. J Vasc Interv Radiol. 2007;18(7):905-908.
Thank You • Jeffrey Forris Beecham Chick, MD, MPH, DABR –
[email protected] – University of Michigan Medical Center
