Clinical Outcomes of Stenting Extending Below the Inguinal Ligament for Treatment of Chronic Iliofemoral Venous Obstruction

Interventional treatment for post-thrombotic chronic venous obstruction: Progress and challenges

Chronic venous obstruction, including nonthrombotic iliac vein lesions and post-thrombotic syndrome, presents a significant burden on patients' quality of life and health care systems. Venous recanalization and stenting have emerged as promising minimally invasive approaches, yet challenges in patient selection, procedural techniques, and long-term outcomes persist. This review synthesizes current knowledge on the interventional treatment of post-thrombotic syndrome, focusing on the evolution of endovascular techniques and stenting. Patient selection criteria, procedural details, and the characteristics of dedicated venous stents are discussed. Particular emphasis is given to the role of inflow and other anatomical considerations, along with postoperative management protocols for an optimal long-term outcome.

Indications, technical aspects, and outcomes of stent placement in chronic iliofemoral venous obstruction

BACKGROUND

Iliofemoral Venous Stent Placement (IVS) has evolved to a well-established endovascular treatment modality for chronic iliofemoral venous obstruction (CIVO). Dedicated venous stents gained FDA approval in 2019 and solidified IVS as a defined intervention with clear indications, contraindications, risks, benefits, and procedural management principles. This review focuses on the indications, technical aspects and outcomes of stenting for CIVO. Other aspects pertaining to IVS are covered in manuscripts that are part of this series.

METHODS

This study conducted a literature search limited to English articles. Three search strategies were employed, and references were managed in Covidence software. Four investigators independently screened and evaluated articles, excluding meta-analyses, clinical trial protocols, and non-relevant studies. Eligible studies, focused on clinical outcomes and stent patencies, underwent thorough review.

RESULTS

The literature search yielded 1,704 studies, with 147 meeting eligibility criteria after screening and evaluation. Exclusions were based on duplicates, irrelevant content, and non-iliac vein stent placement.

CONCLUSION

Successful IVS for CIVO relies on meticulous patient selection, consistent use of IVUS during procedures, and attention to the technical details of IVS.

A meta-analysis of the medium- to long-term outcomes in patients with chronic deep venous disease treated with dedicated venous stents

OBJECTIVE

This review summarizes the safety profile, stent patency, and clinical effectiveness of dedicated venous stents for the treatment of chronic deep venous disease. The approaches to stenting and post-procedural management of different vascular units are also explored.

METHODS

The MEDLINE and Embase databases were searched for pertinent literature published from January 2010 to January 2023. Outcomes related to post-stenting symptoms and health-related quality of life were described narratively. A meta analysis was conducted to evaluate stent patency, ulcer healing, bleeding, and 30-day stent thrombosis, and these outcomes were presented as proportion event rates.

RESULTS

Seventeen studies were identified comprising of 2218 patients. 62.7% of individuals had post-thrombotic stenosis or occlusion. The majority of patients (78.6%) were noted to have complete occlusions of their deep veins before stenting. Eleven different dedicated venous stents were deployed. At 12 months, the primary patency rate was 83% (95% confidence interval [CI]: 76%-90%), the primary-assisted patency rate was 90% (95% CI: 85%-96%), and the secondary patency rate was 95% (95% CI: 92%-98%). A significant improvement in health-related quality of life was demonstrated after intervention. In total, 68.8% (95% CI: 52.0%-83.7%) of ulcers healed at the last follow-up. The remaining symptomatic changes were described narratively; improvements in pain, venous claudication, and edema after stenting were observed. Seventeen deaths occurred, but none were linked to the stenting procedures. A total of 159 cases (7.2% of patients) of in-stent stenosis were observed, whereas 110 stents (5.0% of patients) were occluded. The incidence of major and minor bleeding was 1.7% (95% CI: 1.0%-2.5%) and 3.2% (95% CI: 1.3%-5.6%), respectively, more commonly seen in patients undergoing hybrid intervention.

CONCLUSIONS

Deep venous stenting using dedicated venous stents is a safe technique to treat chronic deep venous stenosis and/or occlusion. Within the limitations of this study, deep venous stenting is associated with good patency rates and symptomatic improvement.

Stent patency rates and prognostic factors of endovascular intervention for iliofemoral vein occlusion in post-thrombotic syndrome

Objective

Post-thrombotic syndrome (PTS), an important complication of deep venous thrombosis (DVT), adversely affects patients’ quality of life. Endovascular intervention in PTS can relieve symptoms rapidly with high therapeutic value. This study mainly focuses on how to improve postoperative stent patency rates and aims to find prognostic factors impacting patency.

Methods

According to the specific inclusion and exclusion criteria, PTS patients who underwent endovascular intervention at the First Affiliated Hospital of Sun Yat-sen University from December 1, 2014, to December 31, 2019, were included in this single-center prospective study. Follow-up data were collected and analyzed regularly over 2 years.

Results

Overall, 31 PTS patients were enrolled in the study. The mean age of these patients was 55.39 ± 11.81, including 19 male patients. Stent implantation was successful in 22 PTS patients, with a technical success rate of 70.97%. The average Villalta scores of the stent-implanted group and the non-stent-implanted group were 5.95 ± 2.57 and 5.78 ± 2.95, respectively, with no significant difference observed. In the stent-implanted group, the perioperative patency rate was 81.81% (18/22), and the follow-up patency rates were 68.18% (15/22) within 3 months, 59.09% (13/22) within 6 months, 45.45% (10/22) within 1 year, and 36.36% (8/22) within 2 years. Based on the stent placement segments, the 22 PTS patients were divided into two subgroups: the iliofemoral vein balloon dilation + iliofemoral vein stent implantation (FV-S) subgroup and the iliofemoral vein balloon dilation + iliac vein stent implantation (FV-B) subgroup. In the FV-S subgroup, the perioperative patency rate was 100.00% (14/14), and the follow-up patency rates were 85.71% (12/14), 71.43% (10/14), 57.14% (8/14) and 50.00% (7/14), which were higher than those for overall stent patency of all patients. The postoperative patency rates in the FV-B subgroup were 50.00% (4/8), 37.50% (3/8), 37.50% (3/8), 25.00% (2/8), and 12.50% (1/8). The secondary postoperative patency rates in the FV-B subgroup were 100.00% (8/8), 87.50% (7/8), 75.00% (6/8), 62.50% (5/8) and 50.00% (4/8).

Conclusions

For PTS patients with iliofemoral vein occlusion but patent inflow, iliofemoral vein stent implantation is a more efficient therapeutic option than iliofemoral vein balloon dilation with iliac vein stent implantation for PTS patients.

Performance of Open and Closed Cell Laser Cut Nitinol Stents for the Treatment of Chronic Iliofemoral Venous Outflow Obstruction in Patients Treated at a Single Centre

OBJECTIVE

A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction.

METHODS

A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency.

RESULTS

A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 - 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 - 6.62, p < .001).

CONCLUSION

OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design.