One of the questions that came up in the chat, and we've certainly heard a lot about this, it's no secret that we've had issues with stent migration the last few years, particularly with the introduction of self-expanding open-cell laser-cut nitinol stents. And the question is of hydration. How do we get around that? Hydration is not, unless I don't really remember my arterial physiology, not an issue as much on the arterial side, unless there are bigger problems to deal with, but on the venous side, it's a critical issue. And I'll start with Erin. What do you do in terms of a hydration protocol, and what do you do to prove that the lesion is actually something that's physiologically real? Yeah, so honestly, because I focus a lot more on the breathing maneuvers than I do on hydration status. I don't like to run my patients particularly dry. In post-thrombotic patients, it's not overly essential because it's so clear in the occlusions. In where the hydration, the breathing maneuvers matters in the non-thrombotics, I do think if you're treating patients with mild disease is where it comes in. I think we probably treat patients with more severe compression points. I'm not a 50-percenter. I'm closer to that 80-90 long segments. And if you're landing your stents with good landing zones, sizing by IVUS, there's less of a risk. But I like a semi-hydrated patient, I suppose, but I focus more on breath holds and Valsalva maneuvers with that IVUS right under lesion, making sure it's fixed. If it's not fixed, it's not a reason to stent. Yeah. Rob, real quick question for you since you did present some DVT cases. I find sizing in acute DVT challenging. I'm with Aaron. It's dealer's choice. He'd know what the normal is, 14, 16, 12 in the common femoral vein, 12 to 14 in the common femoral vein. But in acute DVT, you've just cleared it out. Maybe the vessel hasn't returned to its steady state. So talk me through that. What do you do for those acute DVT patients that need a stent? That's a great question. In short, I try to use the other side as much as humanly possible. Frequently, when you're working in the pelvis, you'll have cross-sectional imaging. I'm a firm believer of that and that I want to understand what the anatomy is. Is it a suggestion of an extrinsic lesion? Is there a cord? Is it dilated? And I'm able to use the other side as a reference. If I don't really have that luxury, I might even access the other side with an IVUS catheter and measure it that way. I will not err on the side of undersizing. I think deep venous is not where you want to go over 50%, but you really don't want to be erring on the underside of it. And obviously, once you are able to deploy your implant, you want to IVUS it afterwards and really get a sense of what the ratio is and whether you have full uniform circumferential wall position. So just as a sort of top 10 tips, use the other side, use the other side, use the other side, err on oversizing, and then IVUS afterwards. If there's any concern that, God forbid, you're undersized, I think Aaron alluded to this, extend your stent to trap it so that you don't have the concern about migration, which I think everybody's just very, very sensitive to. Yeah, perfect. And I completely agree with that. One thing to keep in mind, and we haven't really touched on it because this isn't a stent webinar, but the stents that people have been using for a long time in deep venous disease behave very differently than the current nitinol unlabeled stents. Of course, woven stents are also unlabeled for iliofemoral obstructive disease, but they behave differently. So you need to understand the properties of your stent, meaning that an 18mm nitinol stent will get to 18mm. An 18mm algebra stent will not get to 18mm, and they behave completely differently. So that has important procedural considerations for patients.

stent migration

vascular procedures

hydration protocols

stenting techniques

venous conditions