as if anyone really cares about my critiques. I have had all the complications i care to have in the beginning of my work. In the past six months, the only thromboses were two patients who stopped taking anticoagulation. Makes me wonder about the risks in those patients who are given no anticoagulation or just aspirin.
i am curious: in addition to the pradaxa, did you give an antiplatelet medication. I give both.
my general rule is i will increase size of balloon between 25-75% of size of the normal vein. 12 mm would have been over 100% increase. My experience, like your current one is that the vein cannot tolerate that much stress.
how long after the treatment did you discover the thrombosis? did you attempt to salvage?
without critiquing, there will be no learning.
when speaking about sizing, are we using area or diameter? i think we should stick to area measurements.
i hope we can stimulate discussion about what are appropriate end points for the procedure.
here is what i typically do....
size the IJ immediately distal (above) the valve plane. i do not believe we can change the size of this segment vein, so there is no point making the valves open more than this. this is the inflow. size at the valves - both the maximum opening of the valves and the area of the normal vein.
first ballooning is done using a balloon with an area about 10-20% greater than the vein immediately above the valves or the vein at the valve (which ever is smaller). in this case we did not have a 9mm balloon available and so we started at 10. we could have started at 8mm.
the question is what to do after the 10mm balloon with ivus still showing poorly opening leaflets. i can see a few options.
1. do nothing
2. repeat dilation with 10mm balloon
3. dilate with a cutting balloon
4. go bigger (we do not have an 11 mm balloon, so 12 was our next option).
since the waist in the balloon resolved at 5 atm, i don't think 2 or 3 would have offered anything.
so that leaves us with 1 or 4.
this will be great discussion for the workshop