Larger Sizes Matter More! Applying the Matteo Mathematics Method for Endovascular Aortic Bifurcation Reconstruction to Large Venous Vascular Repair

Figure 1. The non-intuitive nature of iliac stent placement Selecting the iliac stent diameter size is paradoxical since calculating the native vessel size (aorta or inferior vena cava) is not as intuitive as adding the diameters of the patient's iliac vessel lumens together. Doing so will lead to the infolding and endoleaking of the bifurcation graft, resulting in repair failure. As shown, iliac stent diameters of 16 mm will not result in a tight seal to accommodate a native vessel (aorta or inferior vena cava) or 32 mm. Instead, though the iliac stents will traverse the diameter of the native vessel (aorta or inferior vena cava) superfluous space will remain between the iliac stents and the native vessel (aorta or inferior vena cava) stent.

Figure 2. Initial cavogram accessed from the jugular vein Initial cavogram from the transjugular venous sheath demonstrates partial opacification of the inferior vena cava (red arrows), with large amount of extravasation into the pelvis (yellow arrows).

Figure 3. Initial venogram demonstrating reflux and extravasation into the pelvis A venogram performed through a transjugular venous catheter demonstrates partial reflux into the left common iliac vein and large amount of extravasation into the pelvis (yellow arrows).

Figure 4. Thrombus formation demonstrated by left external iliac venogram A left external iliac venogram through the right common femoral vein access demonstrates intraluminal filling defects consistent with the thrombus. The iliac vein was measured in preparation for covered stent placement.

Figure 5. Axial CT of the measured inferior vena cava An axial CT of the patient's measured inferior vena cava is shown, with the diameter being 24.1 mm. This is considered the native vessel diameter and can be used to calculate the side-by-side iliac stent diameters needed for adequate bifurcation repair. CT: computed tomography; IVC: inferior vena cava

Figure 6. Preparation for stent and IVC placement Bilateral iliac vein sheaths with wires were placed in the preparation for stent placement. A transjugular venous catheter was placed in the left renal vein as a reference for stent and filter placement. The venogram demonstrates reflux into the left gonadal vein (red arrow). IVC: inferior vena cava

Figure 7. Fluoroscopic view of the IVC before the deployment of a large stent Fluoroscopy is shown to verify the location of the largest (32 mm by 4.5 cm) stent (yellow arrow) within the IVC prior to deployment. The blue arrow indicates a transjugular catheter within the left renal vein as a reference point. The red arrows indicate the bilateral common iliac venous sheaths. IVC: inferior vena cava

Figure 8. Initial deployment of a large IVC sheath Deployment of the largest sheath (yellow arrow) within the IVC is shown. The blue arrow indicates a transjugular catheter within the left renal vein used as a reference point. IVC: inferior vena cava

Figure 9. Preparing for the deployment of the common iliac venous stents The fluoroscopic view shows the preparation of the bilateral common iliac venous stents (red arrows) for deployment, overlapping within the IVC stent (yellow arrow). The green arrows indicate the bilateral common iliac venous sheaths. The blue arrow indicates the transjugular venous catheter within the left renal vein. IVC: inferior vena cava

Figure 10. Live deployment of the bilateral common Iliac venous stents Preparing the bilateral common iliac venous stents (red arrows) for deployment within the IVC stent (yellow arrow); green arrows indicate the bilateral common iliac venous sheaths. IVC: inferior vena cava

Figure 11. Completed deployment of the bilateral common iliac venous stents The deployment of the bilateral common iliac venous stents (red arrows) within the IVC stent (yellow arrow) is shown. The green arrows indicate the bilateral common iliac venous sheaths. IVC: inferior vena cava

Figure 12. Post stent deployment venogram demonstrating iliocaval stent stenosis The venogram through the iliocaval stents demonstrates stenosis at the iliac confluence (red arrows) due to the nonabsorbable suture placed around the IVC during laparotomy. IVC: inferior vena cava