1. Prof. of Vascular Surgery
Double Balloon Angioplasty Technique Makes for Unavailable Large Size Venous Balloon
Mohamed El-Maadawy, MD
Prof. of Vascular Surgery
Faculty of Medicine
Cairo University
It came as no surprise that surgeons are confronted by situations that they are not prepared to

2. Clinical Vignette A 46 years old male patient
Has 4 years ago unprovoked SVC thrombosis
Non-tender face edema
Elevated non- pulsating EJVs
Gradually developed chest and abdomen collateral veins
He was kept on warfarin after 10 days of enoxaparin injection
Edema subsided over time
Chest and abdomen collateral veins enlarged over time
He was kept on Warfarin since
A 46 years old patient developed painless non tender fasial edema and proved to have un-provoked SVC obstruction. He received enoxaparin for the 1st followed by Warfarin. His fascial edema subsided gradually over time and large caliper collateral veins supervened over his chest and abdomen.

3. Decision Two months ago
After one week of having painless oedema of lower limbs
The collateral veins over the chest and abdomen became more prominent
Lower limbs were oedematous, non tender and supple
Duplex and CTV revealed IVC obstruction
Decision
Catheter directed thrombolytic therapy was the odd on favorite to treat the patient
Proponents for the decision:
Acute thrombus
Within the therapeutic window for thrombolysis
Two months age and after 10 days of having painless edema of lower limbs, the collateral veins over the chest and abdomen became more prominent. His lower limbs wee both supple and non tender and edema was pitting. Duplex U/S and CTV revealed IVC obstruction by a heterogenous thrombus mixed up of hypo- and hyperdense areas; in other words acute and chronic thrombus laden IVC. Catheter directed thrombolytic therapy was the odd on favorite to treat the patient.

4. Procedure Bilateral Duplex guided CFV access
Bilateral Duplex guided CFV access was established under local anesthetic

5. Crossing the lesion
The lower part of IVC was loaded by fresh thrombus while its middle & upper part were ostensibly chronically obstructed.
The lesion was too tight that the 4F fountain catheter could not be advanced through.
A 3 mm diameter balloon could pave the way for the Fountain catheter to be advanced.

6. Completion of the 1st session
Finally the Fountain catheter reached its desired destination thereafter, Alteplase at a rate of 1 ml /hour was administered.

7. The second session
On the next session, the over night administration of Alteplase was found to establish partial thrombus lysis, certainly in the lower part of the IVC.
A zilver vena 16 X 90 mm was deployed. Due to the large rewrap size of the previously used ATB balloon, it could not pass into the stent through the tightest part of the stenosis.
A new balloon certainly, could pass through that stenosis but would cost an additional extravagant price.

8. Second session, continue;
A 3 mm balloon was inadequate to pave the rewrapped ATB balloon, but two alongside balloons each was advanced over a separate balloon, could.
Finally the rewrapped ATB balloon could adequately post-dilate the stent

9. Completion
The completion angiogram

10. Left innominate vein stenosis
Similarly, during the insertion of permeacath, the peel off sheath could not be advanced through the diffusely stenosed left innominate vein due to the presence of fibrinous sheath which was formed around a previously inserted hemodialysis catheter. A balloon which matches the size of innominate vein was unavailable. Furthermore, the available 5 mm balloon inflation was unable to rupture the fibrinous sheath. Instead of aborting the procedure and squandering the opportunity to cross the lesion that often comes once, two wires were advanced alongside.

11. Left innominate vein stenosis; continue
Two 5 mm balloon were advanced, one over each wire, their inflation was effective and the peel off sheath could be advanced successfully.
In conclusion, Double balloon can solve the quandary when a large sized balloon is unavailable.

12. Thank You