Tips and Tricks in IVC Reconstruction

Inferior vena cava (IVC) reconstruction is a delicate balance of physiology, geometry and discipline, where success depends as much on planning and inflow as it does on technical crossing and stent deployment. So will be the message of Gerard O’Sullivan (Galway University Hospitals, Galway, Ireland) who will elaborate on approaches shaped by common pitfalls and their prevention. 

In his practice, the indications that most commonly lead to iliocaval and IVC reconstruction fall into two broad categories. Malignant compression tends to be the more forgiving scenario. These patients are often technically easier to treat, and the symptomatic benefit can be rapid. Post-thrombotic iliocaval disease, by contrast, is slower, more complex and more demanding, but the payoff can be substantial and durable. The work takes longer, he noted, yet the relief is “so, so worth it”. 

For Dr O’Sullivan, the case is won or lost before the first puncture. Cross-sectional venous imaging is essential before all cases, and he advocates direct computed tomography (CT) venography or magnetic resonance venography to ensure clarity on inflow and outflow. 

That planning mindset extends to access. Rather than deciding jugular versus femoral on a case-by-case basis, he has adopted a consistent strategy for long iliocaval occlusions: “I go double jugular (a.k.a. ‘snakebite’) on all cases now and place a small sheath in any vein in both groins to act as a target, and make sure I am able to snare across,” he said. 

Crossing chronic IVC occlusions is where small technical habits are most important, he continued. Dr O’Sullivan warned how easy it is to drift into the wrong space, including the lumbar veins and even the spinal canal. His safeguard is the routine use of lateral projections. On the anteroposterior view, he looks for a wire and catheter course that stays relatively straight and just to the right of the spinous processes. 

In terms of his ‘crossing checklist’, Dr O’Sullivan was explicit that reconstruction should not be treated as an automatic next step once a channel is found. His approach increasingly includes disobliteration techniques (RECANA) and kinetic modification to optimize inflow before committing. He highlights the value of classification systems, including Jalaie et al., to help distinguish patients who are likely to be relatively straightforward from those who may be exceptionally difficult. 

When it comes to ballooning and stent optimization, his philosophy is methodical rather than aggressive for its own sake. He balloons to the nominal diameter of the stents at high pressure, typically for 20 seconds, and emphasizes the importance of treating every centimeter of the target vein. 

One topic that continues to raise eyebrows is the renal confluence. Dr O’Sullivan’s stance is unambiguous and reflects a growing comfort with modern constructs. Where earlier practice often treated renal vein ostia as a boundary, he now states that he is comfortable covering the renal vein ostia “with impunity”. 

On imaging, he draws a clear division of labor between intravascular ultrasound (IVUS) and venography. IVUS helps him define distal landing zones, delineate the true extent of diseased segments, and confirm adequate stent expansion at the end of the case. Venography remains useful for what it shows best: flow dynamics and the abolition of collaterals. 

For challenging or niche scenarios, he is also candid about boundaries. In filter-related occlusion and embedded filter disease, he involves specialist expertise rather than improvising. “Just ask Kush Desai,” he joked, reflecting a broader point about knowing when a case crosses from difficult into subspecialist territory. 

Aftercare, in his view, is not an afterthought but part of the procedure. He describes a minimum nonnegotiable regimen built around full anticoagulation before, during and after the intervention, pneumatic compression boots for 24 hours, and early imaging surveillance. He performs Day 1 color duplex ultrasound, and if the result is anything less than completely reassuring, he escalates to day 1 CT venography. Follow-up ultrasound at two and four weeks is part of his structured pathway, with reassessment thereafter. 

Finally, Dr O’Sullivan argued that procedural metrics alone do not define success. Patency and reintervention rates matter, but they are not so tangible to patients. The outcomes he wants teams to track are patient-centered and functional, including ulcer healing, walking distance, and quality of life. Ideally, he says, the goal is not merely walking, but “jogging up a hill”.