There are several other “off-label” techniques that can be considered in more challenging chronic total venous occlusions. The use of a transjugular intrahepatic portosystemic shunt (TIPS) kit also known as the Rösch-Uchida Transjugular liver access set (Cook Medical, Bloomington, Indiana) (Fig. 36.2) has been reported to be a useful method of “sharp” recanalization [13, 14]. The curved 0.038 in. flexible catheter is used to orient the tip and allow the placement of a sharp trocar stylet. Using orthogonal fluoroscopic views, the trocar is then used to cross the CTO and then allow the passage of a Glidewire into the true lumen. In the report by Dou et al., the authors identified nine cases that required the use of a transjugular liver access cannula as a guiding instrument. The transjugular liver access cannula was used to traverse chronic occlusions in both the upper and lower central venous systems in these patients. The technical success rate was 100%. There were no clinically significant complications. One patient was lost to follow-up. Of the remaining eight patients, seven experienced symptomatic relief within 1 month of recanalization. The authors stated that the use of this TIPS needle technique may serve as a useful adjunctive tool during difficult venous recanalizations, especially when traditional guidewire and catheter techniques fail. Other authors have reported on using the cardiac Brockenbrough septal puncture needle (Medtronic, Dublin, Ireland) [15, 16] or Chiba Biopsy Needles (Cook Medical, Bloomington, Indiana) [17] to cross venous CTOs of the brachiocephalic veins. The Brockenbrough needle (Medtronic, Dublin, Ireland) (Fig. 36.3b) is a hollow tube which is 18 gauge tapering to 21 gauge. The proximal end has a flange with an arrow that points toward the needle tip. The Mullins sheath (Fig. 36.3a) is the most commonly used sheath used with the Brockenbrough needle. This is an 8 French 60 cm sheath that can be introduced over a 0.032 J-tipped guidewire.

The other needles available are the BRK, BRK-1, BRK-2, and BRK-XS needles, which are marketed by St. Jude Medical (St. Jude Medical, St. Paul, MN). The BRK is the standard needle with slight angulation between the tip and the shaft (19 F), which can be useful in directing the needle in any direction. The BRK-1 needle has a greater angulation between the shaft and the tip (53 degrees). The needle is available in two lengths (71 or 89 cm) [18]. The Chiba needle (Fig. 36.4) is straight and comes in 10, 15, and 20 cm length, which may limit its use to crossing shorter total occlusions in the common femoral or external iliac veins. To further facilitate this sharp recanalization technique , the interventionist can consider placing an open loop snare (10 mm) on the central side of the occlusion to use as a target to aim for with the needle or wire [19].

Another advanced technique reported has been the use of a radiofrequency guidewire [20–22]. In the report by Iafrati et al., the author discusses three patients with complicated central venous occlusions in whom conventional catheter and guidewire techniques were not successful and who were successfully treated using the PowerWire™ Radiofrequency Guidewire (Baylis Medical, Montreal, Canada). Occlusions were traversed using the radiofrequency wire, followed by angioplasty and stenting. The average length recanalized was 8.2 ± 3.6 cm. One patient required repeat angioplasty at 4 months. All stents were patent at 12–15 months. The radiofrequency wire is valuable in the management of patients with refractory central venous occlusions. It is a 4 Fr 0.035 compatible system that is 250 cm in length. The PowerWire™ has various straight and angled-tip models to adjust the wire trajectory to anatomical geography. Once across the lesion, it can be used as the guidewire on which to pass venoplasty balloons. It has an atraumatic radiopaque tip that delivers radiofrequency (RF) energy to vaporize a channel through lesions with minimal trauma to surrounding tissue. The PowerWire™ RF Guidewire has a torqueable, stiff proximal shaft with a smooth transition to a more flexible distal end. However, there have been reported complications attributed to this technique when used for the treatment of upper extremity central venous occlusions [23]. In this report, one of twelve patients treated using this technique (8.3%) experienced a major complication with tracheal perforation by the RF wire leading to the patient’s death.

Several different devices have been developed for the use of crossing arterial CTO. These devices have rarely been reported to be used off label for crossing venous CTO. The Wildcat catheter (Avinger, Redwood City, CA) is one such rotational atherectomy device. It is a 6 Fr 0.035 system that has a 110 cm working length and a 2 mm crossing profile. The device can be used in a passive mode rotating the catheter counterclockwise to cross softer lesions. In the active mode, the device deploys wedges at the tip, which corkscrew through tougher lesions. Once the lesion is crossed, a 0.035 guidewire can be passed into the true vessel lumen. A recent article by Smeds et al. reported on the use of a Wildcat catheter to cross an occluded iliac vein stent originally placed for deep venous thrombosis and May-Thurner syndrome [24]. The patient presented with complaints of left lower extremity pain and swelling. Multiple previous attempts had been made to cross this lesion with guidewire and catheter techniques without success. The authors reported crossing the lesion using the Wildcat catheter and then used directional laser atherectomy followed by balloon angioplasty and stenting with successful recanalization of the stent and resolution of the patient’s symptoms.

The Outback reentry catheter (Cordis, Milpitas, CA) is a 6 Fr compatible device designed for reentry in arterial chronic total occlusions (Fig. 36.5). In 2015, Adam et al. described using the Outback reentry catheter for endovascular stent reconstruction of a chronic total occlusion of the inferior vena cava [25]. In this report, the authors were successful in using bidirectional wire access and a balloon puncture utilizing the Outback reentry device. The device has visible markers, which help practitioners orient the reentry cannula toward the true lumen. An “L”-shaped radiopaque marker (visualized from 90° orthogonal view) provides confirmation of the desired alignment at the reentry site. Once across the lesion, the reentry needle is deployed into the true lumen allowing the passage of a 0.014 wire.

Once the CTO is crossed, predilation is usually necessary in order to allow delivery of the larger stents that are required to reestablish venous outflow. Unlike the artery, the vein tolerates extensive dilation without rupture. We use standard noncompliant angioplasty balloons for venous dilation. For angioplasty before stent delivery, we use small diameter balloons (e.g., 3–4 mm × 10 cm). After this, we place the stents. Stents are placed well into the inferior vena cava to avoid migration and early restenosis. Insertion of a large diameter stent is recommended with stent sizes: 18–24 mm for the cava, 16–18 mm for common iliac veins, and 14–16 mm for external iliac veins. Currently, we use the Wallstent (Boston Scientific, Marlborough, MA) to accommodate this range of sizes. Stents are delivered distally first in the external iliac and build proximally to and into the inferior vena cava . After delivery of the most distal stent, post-dilation is recommended before delivery of the next stent due to the foreshortening that occurs as lumen diameter increases. It should be noted that the disease is often more extensive than venography would suggest. It is essential that the entire diseased segment is treated as outlined by IVUS. Inadequate stenting has been shown to be the most common cause of restenosis. It is important to avoid short skip segments (<5 cm) in between two stents because they are also prone to secondary stenosis. Long-term patency rates of iliocaval stents have been reported in many series. In 2004, Neglen and Raju reported on their series of 324 iliac vein stents. In this large series, primary, primary-assisted, and secondary patency was 75%, 92%, and 93% at 3 years, respectively. Restenosis of iliocaval stents was a major cause of stent failure. At 3.5 years, more than 75% had some degree of in-stent restenosis with the highest in patients with post-thrombotic syndrome [26]. The reported early thrombosis rate (< 30 days) with iliocaval stenting is 11–15%, which is lowest in patients with chronic venous obstruction. Factors associated with early thrombosis may include patients with thrombophilia, stent length , extension below the inguinal ligament, and complete occlusions. In their retrospective analysis, Knipp et al. did find long stent length to be a significant risk factor for thrombosis in univariate analysis, as was thrombophilia; in multivariate analysis, however, neither was independently associated with decreased stent patency [27]. Inadequate stent dilation, inadequate inflow, and failure to stent entire diseased vein are the most common causes of stent thrombosis . Currently, there is no data comparing a single iliac vein stent to the use of multiple stents across the bifurcation of the iliac veins into the vena cava. In our experience, restenosis or stent thrombosis occurs commonly because of failure to stent across the lesion and into the inferior vena cava adequately . In these cases, salvage can be achieved using standard pharmacomechanical thrombolysis (PMT) to open an acutely thrombosed stent followed by restenting across the lesion and into the inferior vena cava. Due to poor experience with placing stents across joints, extension of venous stents below the inguinal ligament has long been avoided. However, Neglen et al. found no effect on patency rate or stent fracture when stenting across the inguinal ligament with the braided stainless steel Wallstent (Boston Scientific, Marlborough, MA) [9].