Now, all the stents generally are deployed
using the standard system, so they get deployed from the top and work their way down. So they're in their sheath and they get unsheathed this way. But there's this new device or new deployment system which a reversed guidance system. The intention is that you deploy at the bottom
and work your way up to the top. And that's what I'm gonna go through today. So this is the protocol of it. Essentially, rather than before where'd you go left hand to right hand like that, this one is more about right hand to left hand.
- [Doctor] Okay, so it's probably even more convenient than the previous system. - [Vendor] Exactly, exactly. - [Doctor] Especially for the right handed people. - Yes, exactly for the right handed people. Best not to hold it at the bottom there.
It's best to hold it closer here to start with. And essentially just pull it. Push, push, push, push, push. - Push, yeah. - Push, push, push, push, push, until you get to the bottom there, and then you should click into place.
- [Doctor] So you have to click it, okay. - And then it just pulls out. - All the device. - All the way out. Keep the safety on until you're in the patient.
Keep the safety on until you're in the patient. Obviously, it will move around a bit 'cause it's a model. We don't have a guide wire on top here.
- [Doctor] Of course. So can we go inside him? - Yeah so go inside to the vein there. The peripheral zone of landing is where we want to be. It's the confluence of the profunda. - [Doctor] Profunda, yes.
If I may see, yes. Perfect. - So it's around there. Generally speaking, start off a little bit beyond where you wanna be. Okay, that's fine. And you can take your safety off.
Excellent, and then just open up the first couple of millimeters of stent. Got scared. You just place it there. And that's your martini glass essentially, your so-called martini glass.
And just slowly deploy it up, beautiful. And it should just gently come out the top there. - [Doctor] It's moving. - And that's great, and now you just click it in place. - [Doctor] It is coming. - Now over a wire, it should just retract back.
- [Doctor] Okay, one moment. - Don't worry, there's no wires. It's just catching a little bit. Essentially over a wire, that shouldn't, to go once this thing is fixated in place. - Yes, perfect.
- And that's - Great. - Is your reversed deployment. - That's fantastic. - Yeah, it's a fairly straightforward procedure. - It is, and it's probably in the normal venous system. I mean, we have experience with the Wallstent.
Unfortunately, not with this one, but we know that when we deploy the stent here, it usually fits very nice into the surface of the vein, and it does not slip like this one here in the plastic tube, yes. So I think the feature of this is the same, yeah?
that you've got this confidence (speaks faintly). - [Doctor] Okay, tell me one thing. If we deploy the stent like this, do we have to go with the balloon and position more, or you know, to even expand a little bit
of the stent like this one? - So, that's a very good question. So ballooning, you should do balloon - [Both] Before. - [Doctor] Let's do the pre-ballooning first. - Exactly. - And then?
- And then you do it to the diameter of the stent. Place the stent in and then place the balloon back again to the diameter of the stent. Not overinflation or underinflation, but the diameter of the stent. This is a 40 millimeter, so you do a 40 millimeter balloon.
- And obviously, I have to use these balloons up to the 20 bars or even, - So, higher atmosphere and noncompliant balloons are the way to go with this cause-- - And tell me, what is your recommendation for Veniti, should we use the balloon
which is the same length as the stent or we can just go a shorter balloon because when you do the phlebography, and you see where you have the stenosis, and the stenosis is not always is on the full length of the deployed stent.
So is it indicated to use a short balloons or should we go with the big balloons, and balloon the whole stent inside of the vein? - I do short balloons all the way through the stents. I force that to be ballooned all the way down the edge of everything down there.
And sometimes you'll notice that particularly when you've got post-thrombotic lesions, when you start to balloon it up, it can move a little bit because the tissue is so strong. So you just need to be careful about that factor and to understand that that may happen,
that the balloon can advance or come back again. - Yeah, but you know, our experience, especially in the thrombolytic therapy first with the May-Thurner syndrome, when you have the impression of the artery on the vein here, what we do if we realize the thrombose
and we see the stenosis of the iliac vein, and we go with the guide wire. And then we place the stent. And then, with the balloon we go and dilate the part of the vein like this? - Then do you dilate larger than the vessel?
- No. - Or the size of the stent? - The stent no, I'm just trying to use the short one, just focus exactly on the place where the stenosis is. Just to avoid additional dilatation of the vein because honestly speaking, I do not know if the vein is going to behave in the same way as artery,
and that's why I'd rather preserve the stent which is fitting well to the rest of the vein and only trying to dilate the stenosed vein. - So I mean, in our practice, we will do the entire stent to the entire dilatation to ensure that the stent is fully expanded.
With the Veniti stents, they're quite good. They do actually, you know. - Yes because this is nitinol stent, so it is working even after implantation for certain period of time. - It is yeah. - Just reaching the diameter of the stent.
- But unlike the arterial stents which have been designed specifically to have good radial force, these stents, while they do have that, have been designed to have crush resistance. So it's a slightly different concept. In the thrombotic tissue is pushing in like this,
whereas in on the arterial side, you want force to be going out that way to make sure that you have good seal zones, on either way or you have force. So it's a very subtle difference in design. But that's the additional of the bridges, essentially.
They act with that.
If your stent, the Veniti stent, can be also good for the occlusion of the vein which is lasting more than, let's say, two, three years after the first thrombotic episode?
- [Vendor] So post thrombotic patients? - [Doctor] Post thrombotic patients. - Yeah, so they're our main group of patients that we treat. Due to our arthero practice, we tend to treat more of those patients than a patient with non-thrombotic conditions.
And it's a good stent to use in those cases because they have a lot of fibrotic tissue. When you look at their, histologically when you look the tissue there, it's rich with collagen. It's rich with tissue that is hard to treat.
- You're totally right because we were trying in some of our patients, go into the vessel, to the vein, and remove this fibrotic tissue. And unless in the arterial side doing an - [Both] Arterectomy. - In the vein, it is much more difficult,
and this fibrotic tissue is much more harder, - Indeed. - Than that. So I can imagine that, obviously, with a stent like this one, the force of the stent has to be much bigger. - So in my experience of endophlebectomies
in our series, it's small, but they're challenging cases. - [Doctor] Yeah, those are very challenging. - We tend to now try to avoid it if we actually can. It's all about this confluence. It's all about making sure we have adequate inflow from the profunda and the femoral.
If this vein is gone, and there isn't adequate inflow, then doing the endophlebectomy is a sort of way out.
If you do the endophlebectomy and you get like in the arterial side,
you are not sure what is the ending point. Okay, you are removing something. And there is a flap or something like that. Then you can use the Veniti stent, just you know, like in the arterial (mumbles) to cover that place and secure the place
to having a good outflow of the vein? - Absolutely. I think the hybrid approach is the way to go because it keeps the vein patent. And certainly when we've been doing the endophlebectomies, similar to how sometimes you could do
with an endarterectomy on the arterial side, you get to the stent, and your patch is just at the intersection between the two. The same with these. You've almost stent through the endophlebectomy section to keep that patent and open.
- And my really last question. With the stent which is positioned here, it goes down through the groin.
Disclaimer: Content and materials on Medlantis are provided for educational purposes only, and are intended for use by medical professionals, not to be used self-diagnosis or self-treatment. It is not intended as, nor should it be, a substitute for independent professional medical care. Medical practitioners must make their own independent assessment before suggesting a diagnosis or recommending or instituting a course of treatment. The content and materials on Medlantis should not in any way be seen as a replacement for consultation with colleagues or other sources, or as a substitute for conventional training and study.