Systematic Review and Meta-Analysis of Iliofemoral Stenting for Post-thrombotic Syndrome

[Post-thrombotic syndrome - Prophylaxis, diagnostics and complication management]

The post-thrombotic syndrome PTS occurs when a relevant residual thrombus load remains after a deep vein thrombosis and/or the function of the venous valves is disturbed. The knowledge of the different types of PTS generates individualized therapeutic and secondary prophylactic approaches. Immediate compression, movement in compression garments and an effective anticoagulation are crucial for both the prevention and the outcome of post thrombotic syndromes.

Venous recanalisation in the setting of post-thrombotic syndrome: An expert consensus from the French Society of Vascular Medicine (SFMV) and the French Society of Cardiovascular Imaging and Interventional Radiology (SFICV)

Several aspects of the management of post-thrombotic syndrome (PTS) are still a matter of debate, or not yet addressed in international guidelines. The objective of this expert consensus from the French Society of Vascular Medicine (SFMV) and the French Society of Cardiovascular Imaging (SFICV) was to define the main elements of diagnosis and treatment of this syndrome, and to develop a proposal for its preoperative, procedural and follow-up management. In this consensus, the following issues were addressed: clinical and ultrasound diagnosis; pre-procedural workup; indications and contraindications to venous recanalisation; procedures; clinical and duplex ultrasound reports; follow-up; long-term treatment; management of great saphenous vein incompetency; anticoagulant and antiplatelet therapy after venous stenting.

A comprehensive study on venous endovascular management and stenting in deep veins occlusion and stenosis: A review study

Background

Patients with deep venous disease can be classified into two distinct categories: those with disease resulting from known deep vein thrombosis (DVT), which may subsequently lead to post-thrombotic syndrome (PTS), and those with disease caused by compressive factors or non-thrombotic iliac vein lesions (NIVL). The major factor causing the symptoms in patients with PTS and NIVL is venous hypertension which happens due to venous stenosis or venous obstruction. Nowadays Venous stenting offers a noninvasive approach for treatment of NIVL and PTS demonstrating high patency rate.

Methods

We comprehensively reviewed relevant published papers from 2008 to 2023 that surveyed various influencing factors including the site of occlusion and etiology of occlusions, proper diagnostic imaging, ideal characteristics of venous stents, different dedicated venous stents, pre-operative, concomitant, and post-operative interventions and factors that challenge stenting in both PTS and NIVL patients. The papers were identified by searching the keywords "venous stenting", "PTS", "NIVL", "occlusion", and "stenosis" in PubMed central library MEDLINE and Google Scholar.

Results

Patency rates, post-stent complications, and relevant data according to the patient's quality of life were included and analyzed from 476 identified studies. There is no validated protocol and guideline for using stents in patients with PTS and NIVL.

Conclusion

As there is no validated protocol and guideline for using stents in patients with PTS and NIVL, our study may provide comprehensive information to assist researchers interested in writing the protocol and give them insight.

Principles of Optimal Antithrombotic Therapy for Iliac VEnous Stenting (POATIVES): A national expert-based Delphi consensus study

OBJECTIVE

Management of antithrombotic therapy in patients undergoing venous stents has not yet reached consensus, and there are not any recommendations from published guidelines. We undertook a Delphi consensus from Chinese experts to develop recommendations regarding the preferred antithrombotic therapy in patients following venous stenting.

METHODS

The phase 1 questionnaire was comprised of three clinical scenarios of venous stenting for non-thrombotic iliac vein lesions (NIVL), acute deep vein thrombosis (DVT), and post-thrombotic syndrome (PTS) and was sent to venous practitioners across China. In phase 2, the results of phase 1 were distributed to a panel of experts for evaluation along with a questionnaire encompassing a series of statements produced during phase 1. A modified Delphi method was used to reach consensus on recommendations through two rounds of surveys.

RESULTS

The phase 1 questionnaire was completed by 283 respondents. In phase 2, an expert panel consisting of 28 vascular surgeons and interventional radiologists was assembled and voted 17 statements relating to antithrombotic management after venous stenting for NIVL (4 statements), DVT (6 statements), and PTS (7 statements). The majority of the statements about the antithrombotic agent selection received a high consensus strength.

CONCLUSIONS

Based on the national Delphi consensus of Chinese experts regarding antithrombotic therapy following iliac venous stenting in three common scenarios, most of the statements could be used to guide antithrombotic management following venous stenting. Further studies are required to clarify controversial issues including the dose and duration of anticoagulants, the role of antiplatelet agents, especially in patients with NIVL.

Ilio-femoral venous stenting for post-thrombotic syndrome in women of childbearing age: efficacy and impact of pregnancy-a multi-center study by the French Society of Cardiovascular Imaging

OBJECTIVE

We investigated the efficacy of iliofemoral venous stenting in women of childbearing age treated for post-thrombotic syndrome (PTS) and assessed the influence of pregnancy on stent occlusion.

METHODS

A retrospective analysis was conducted on women of childbearing age who underwent endovascular stenting for PTS due to chronic iliocava occlusion across 15 centers from 2009 to 2020. The study assessed pregnancy rates, primary patency rates, secondary patency rates, and clinical efficacy using the Villalta score for PTS severity and the Chronic Venous Disease Quality of Life Questionnaire - version 20 (CIVIQ-20), 6-12 months after the procedure. The impact of pregnancy on stent occlusion was analyzed using classical and multi-state survival analyses. Prophylactic low-molecular-weight heparin or fondaparinux was administered to patients during pregnancy until 6 weeks post-partum.

RESULTS

In total, 211 women with PTS underwent endovascular stenting, with a median age of 31 years (range: 16-42). Following recanalization, significant improvements were observed in the Villalta score (p < 0.0001) and the CIVIQ-20 score (p < 0.0001). Thirty-seven (17.6%) women became pregnant and 49 (23.2%) experienced stent occlusions. The 1-year and 5-year occlusion-free survival probabilities were 80.6% (95% confidence interval [CI]: 75.1-86.4%) and 66.6% (95% CI: 57.4-77.4%), respectively. There was no significant association between pregnancy and stent occlusion-free survival (hazard ratio = 1.00 [95% CI: 0.11-8.92], p = 0.9930).

CONCLUSION

Iliofemoral venous stenting in women of childbearing age was an effective treatment for post-thrombotic syndrome, and it did not increase the risk for stent occlusion during pregnancy when accompanied by appropriate anticoagulation.

CLINICAL RELEVANCE STATEMENT

This study demonstrates that pregnancy following iliofemoral venous stenting for post-thrombotic syndrome does not elevate the risk for stent occlusion.

KEY POINTS

• The severity of post-thrombotic syndrome and the quality of life, as measured using the Villalta score and Chronic Venous Disease Quality of Life Questionnaire - version 20, respectively, showed significant improvements 6-12 months after iliofemoral venous stenting. • The occurrence of pregnancy after recanalization in women of childbearing age did not lead to a significant increase in the risk for stent occlusion.

Perioperative management of venous recanalization in a patient with inherited antithrombin deficiency: case report

Background

Inherited antithrombin (AT) deficiency (ATD) is a severe thrombophilia causing venous thromboembolism, which can be complicated by postthrombotic syndrome (PTS). Venous recanalization, used to treat PTS, often requires a temporary withdrawal of anticoagulant therapy. In ATD patients, there is a risk of insufficient perioperative anticoagulation due to altered heparin response.

Key Clinical Question

There is no consensus on how to manage perioperative anticoagulation in ATD patients.

Clinical Approach

Warfarin-unfractionated heparin transition could be a more reliable strategy than low-molecular-weight heparin transition because unfractionated heparin anti-Xa activity not only reflects heparin-bound AT but also AT's activity, which correlates strongly with therapeutic anticoagulation. Biological monitoring could thus decrease the number of plasma-derived AT supplementation.

Conclusion

This study describes a successful perioperative management of anticoagulation for venous recanalization that could be suggested to type 1 ATD patients with PTS.

Clinical Outcomes at 3 Years After Stenting for Thrombotic and Non-thrombotic Iliac Vein Compression Syndrome Patients

Iliac vein stenting for the treatment of iliac vein compression syndrome (IVCS) has been gradually developed. This article investigated the long-term patency and improvement of clinical symptoms after endovascular stenting for iliac vein obstruction patients. From 2020 to 2022, 83 patients at a single institution with IVCS underwent venous stent implantation and were divided into two groups: non-thrombotic IVCS (n = 55) and thrombotic IVCS (n = 28). The main stent-related outcomes include technical success, long-term patency, and thrombotic events. The technical success rate of all stent implantation was 100%. The mean length of hospital stay and cost were higher in the thrombotic IVCS group than in the non-thrombotic ICVS group, as well as the length of diseased vessel segment and the number of stents implanted were higher than in the control non-thrombotic group. The 1-, 2-, and 3-year patency rates were 85.4%, 80% and 66.7% in the thrombosis group, which were lower than 93.6%, 88.7%, and 87.5% in the control group (P = .0135, hazard ratio = 2.644). In addition, patients in both groups had a foreign body sensation after stent implantation, which resolved spontaneously within 1 year after surgery. Overall, there were statistically significant differences in long-term patency rate outcome between patients with thrombotic and non-thrombotic IVCS, the 1-, 2-, and 3-year patency rates in non-thrombotic IVCS patients were higher than those in thrombotic IVCS patients.

Long Term Follow Up, Causes for Re-intervention, and Consequences for Surveillance After Stenting for Proximal Deep Vein Obstruction

OBJECTIVE

Venous stenting is performed increasingly for acute deep vein thrombosis (DVT) and post-thrombotic syndrome (PTS) with good short term patency results, but long term data are scarce. The purpose of this study was to evaluate long term outcome of stenting for acute DVT and PTS and to study causes of re-intervention.

METHODS

All patients stented for acute DVT and PTS between May 2006 and November 2021 were included retrospectively in this single centre cohort study. Patency was studied by duplex ultrasound (DUS) or computed tomography. The primary endpoint was stent patency. Re-intervention free survival was calculated using Kaplan-Meier methods. Secondary endpoints were causes of re-intervention, using the Pouncey classification system (2022). Binary logistic regression was used to calculate odds ratios for predictors of re-intervention.

RESULTS

A total of 114 patients were included, with 129 limbs involved (acute DVT n = 53; 41%), PTS n = 76; 59%). Median follow up was 2.3 years (interquartile range [IQR] 2.3) for acute DVT and 5.2 years (IQR 7.1) for PTS. Primary patency, secondary patency, and permanent occlusion were 73.5%, 98.1%, and 1.9% for acute DVT, and 63.2%, 92.1%, and 7.9% for PTS limbs. Overall, 41 limbs underwent at least one re-intervention: 14 in the acute DVT group and 27 for PTS. Most re-interventions (82.9%) were performed within the first year after stenting. Missed inflow, insufficient flow, and thrombosis despite anticoagulation were the most common causes of re-intervention. The strongest predictor for re-intervention for PTS was inflow disease (odds ratio 3.57, 95% confidence interval 1.26 - 10.13, p= .017).

CONCLUSION

Long term patency of deep venous stenting is good. Re-interventions are typically performed in the first year and are potentially preventable by improving the procedure and patient selection. Since secondary patency rates are excellent, selected patients may be considered for discharge from long term surveillance.

Patient-Reported Outcomes of Endovascular Treatment of Post-Thrombotic Syndrome: Ancillary Study of a French Cohort

Excellent outcomes of angioplasty/stenting for the post-thrombotic syndrome (PTS) have been reported, notably regarding objective criteria in the vast French SFICV cohort. Differences may exist between patient-reported and objective outcomes. We investigated this possibility by using validated scales because significative correlations are discordant in the literature between patency and patient-reported characteristics. Patient-reported outcomes seem to be a more consistent tool than radiologic patency for the diagnosis and follow-up of patients displaying PTS. We retrospectively reviewed the Villalta scale and 20-item ChronIc Venous dIsease quality-of-life Questionnaire (CIVIQ-20) scores recorded after endovascular stenting for PTS at 14 centres in France in 2009-2019. We also collected patency rates, pre-operative post-thrombotic lesion severity, and the extent of stenting. We performed multivariate analyses to identify factors independently associated with improvements in each of the two scores. The 539 patients, including 324 women and 235 men, had a mean age of 44.7 years. The mean Villalta scale improvement was 7.0 ± 4.7 (p < 0.0001) and correlated with the thrombosis sequelae grade and time from thrombosis to stenting. The CIVIQ-20 score was available for 298 patients; the mean improvement was 19.2 ± 14.8 (p < 0.0001) and correlated with bilateral stenting, single thrombosis recurrence, and single stented segment. The objective gains demonstrated in earlier work after stenting were accompanied by patient-reported improvements. The factors associated with these improvements differed between the Villalta scale and the CIVIQ-20 score. These results proved that clinical follow-up with validated scores is gainful in patients treated for PTS thanks to a mini-invasive procedure.

A practice audit of short-term outcomes of Wallstents versus Venovo stents for the treatment of nonthrombotic iliac vein outflow stenoses

OBJECTIVE

The Wallstent (WS; Boston Scientific, Malborough, MA) is currently the standard of care for comparisons of clinical efficacy for new stent devices in the treatment of iliac vein outflow disease. Many vein-specific Nitinol-based stents have been now approved by the Food and Drug Administration for use in the iliofemoral venous system. However, few comparisons of these devices to the current standard have been reported. The purpose of this investigation was to compare the complication and reintervention rates between the WS and Venovo stent (VS; BD, Franklin Lakes, NJ).

METHODS

A random sample of 100 WS and 100 VS cases performed from April 2018 through December 2020 were selected for retrospective analysis. The demographics, presenting symptoms, and CEAP (Clinical, Etiology, Anatomy, Pathophysiology) class were assessed. The complication logs and 90-day follow-up data were reviewed for every case to assess the incidence of postoperative deep vein thrombosis, stent thrombosis, in-stent restenosis, bleeding, and transient back pain.

RESULTS

WSs had been placed more often in the left common iliac vein segment (52 vs 1), and VSs had been placed more often in the left common iliac vein and external iliac vein segments (36 vs 63; P = .0069). The average diameter and length of the WSs and VSs were 19.7 ± 2.2 mm vs 15 ± 1.4 mm (P = 2.4∗10^-44) and 80.8 ± 9 mm vs 117.6 ± 20.4 mm (P = 2.4∗10^-38), respectively. The average number of stents per patient was 1.05 for the WSs and 1.03 for the VSs (P = .47). The reintervention rates were similar between the two groups: WS, n = 5; and VS, n = 4 (P = .74). Four of the five WS reinterventions were stent extensions to treat in-stent restenosis and recurrence of symptoms, and one was secondary to occlusion requiring ipsilateral venoplasty and stenting. Two of the four VS reinterventions were venoplasty for in-stent restenosis and two were stent extensions for symptom recurrence. Transient back pain was the most common complication (WS, 37%; VS, 47%; P = 0.28). Insertion site deep vein thrombosis had developed in the three patients in the WS group and four patients in the VS group (P = .71). No patient had experienced bleeding requiring hospitalization, and no stent fractures, stent migration, or deaths had occurred.

CONCLUSIONS

The complication and reintervention rates between the WS and VS groups were similar. Both stents demonstrated evidence of in-stent stenosis requiring reintervention. Implanted VSs tended to be smaller in diameter and longer in length and covered the common and external iliac veins more often compared with the WSs. Therefore, one VS can be used to cover two territories compared with the WS for which two stents will be required to cover the same vein territory length.

A systematic review of reported outcomes in people with lower limb chronic venous insufficiency of the deep veins

OBJECTIVE

The prevalence of lower limb chronic venous insufficiency (CVI) of the deep veins is increasing and presents a significant burden to patients and health care services. To improve the evaluation of interventions it is necessary to standardise their reporting. The aim of this study was to perform a systematic review of the outcomes of interventions delivered to people with CVI of the deep veins as part of the development of a novel core outcome set (COS).

METHODS

Following the Core Outcome Measures in Effectiveness Trials (COMET) framework for COS development, a systematic review was conducted to PRISMA guidance. The protocol was preregistered on PROSPERO (CRD42021236795). MEDLINE, Embase, Emcare, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews and Clinicaltrials.gov were searched from January 2018 to January 2021. Clinical trials and observational studies involving more than 20 participants, reporting outcomes for patients with CVI of the deep veins were eligible. Outcomes were extracted verbatim, condensed into agreed outcome terms and coded into domains using standard COMET taxonomy. Outcome reporting consistency, where outcomes were fully reported throughout the methods and results of their respective articles was also assessed.

RESULTS

Some 103 studies were eligible. There were 1183 verbatim outcomes extracted, spanning 22 domains. No outcome was reported unanimously, with the most widely reported outcome of primary patency featuring in 51 articles (<50%). There was a predominant focus on reporting clinical outcomes (n = 963 [81%]), with treatment durability (n = 278 [23%]) and clinical severity (n = 108 [9%]) reported frequently. Life impact outcomes were relatively under-reported (n = 60 [5%]). Outcome reporting consistency was poor, with just 50% of outcomes reported fully.

CONCLUSIONS

Outcome reporting in studies of people with CVI of the deep veins is currently heterogeneous. Life impact outcomes, which likely reflect patients' priorities are under-reported. This study provides the first step in the development of a COS for people with lower limb CVI of the deep veins.

Nitinol stents placed in iliac veins are not associated with prolonged back pain

INTRODUCTION

Endovascular stenting is the standard of care for the management of symptomatic chronic venous obstruction. The increased radial resistive force and longer lengths of Nitinol stents have led to questions over persistent post-operative back pain. The purpose of this investigation was to assess the incidence and severity of post-operative back pain of Nitinol stents compared to Wallstents.

METHODS

A retrospective review of data at the Center for Vascular Medicine was performed. Patient demographics, pre-operative, one week, three-, six,- and 12 month visual analog pain scores (VAS) for back pain, stent type, diameter, length, and vein locations were assessed.

RESULTS

From April 2014 to November 2021, 627 (412 women/215 men) patients were assessed for the presence of post-operative back pain after an initial iliac vein stent placement. Stents utilized were Wallstents (n = 114), Venovo (n = 342), and Abre (n = 171). The most common Nitinol stent diameter and lengths were 14 mm, 16 mm, and 120 mm, respectively (p ≤ .03). The incidence of back pain at one week was 66% (411/627). VAS scores at one week and one, three, and six months post-operatively were the following: Wallstents-2.6 ± 3 (n = 66), 1.7 ± 2.6 (n = 43) 0.7 ± 2 (n = 51), and 0 ± 0 (n = 27); Abre-3.5 ± 3 (n = 130), 3.8 ± 3 (n = 19), 1.2 ± 2.5 (n = 12), and 1 ± 2 (n = 5); and Venovo- 2.5 ± 3 (n = 216), 2.4 ± 3 (n = 70), 0.9 ± 2 (n = 68), and 0.6 ± 1.7 (n = 49). There was no difference in the severity of back pain at any time point (p ≥ .99). The development of back pain was unrelated to stent type, diameter, length, or covered vein territory.

CONCLUSIONS

Post-operative back pain was observed in 66% of patients at one week. The average pain score at one week for the entire cohort was three, which declined to less than one at one month. No difference in the severity of back pain between groups was observed at any time point, and the development of back pain is unrelated to stent type, diameter, length, or covered vein territory.

Comparison between a dedicated venous stent and standard composite Wallstent-Z stent approach to iliofemoral venous stenting: Intermediate-term outcomes

OBJECTIVE

Dedicated venous stents have not been used in the management of symptomatic chronic iliofemoral venous obstruction (CIVO) until recently. The Bard Venovo stent (Becton, Dickinson, and Co, Franklin Lakes, NJ) is one such stent noted to have an increased chronic outward force and radial resistive force compared with the Wallstent (Boston Scientific, Marlborough, MA). In the present study, we evaluated the outcomes following the use of the Bard Venovo stent vs a matched cohort of limbs that had undergone stenting with the Wallstent-Zenith (Z) stent (Cook Medical Inc, Bloomington, IN) composite configuration.

METHODS

A review of contemporaneously entered electronic medical record data for 167 patients (167 limbs) with initial iliofemoral stents placed from 2019 to 2020 for quality of life (QOL)-impairing CIVO that had failed conservative therapy was performed. The visual analog scale for pain score (score, 0-10), grade of swelling (score, 0-4), venous clinical severity score (score, 0-27), and the 20-item chronic venous insufficiency quality of life questionnaire instrument for QOL were evaluated before and after intervention to assess the effects of stenting. A Kaplan-Meier analysis was used to examine primary, primary-assisted and secondary stent patency, and analysis of variance with repeated measures was used to compare clinical outcomes.

RESULTS

A total of 167 limbs had undergone Bard Venovo stenting (56 men and 111 women). Their median age was 61 years. The laterality was right and left in 70 and 97 limbs, respectively. Post-thrombotic syndrome was seen in 84 limbs and nonthrombotic iliac vein lesions/May-Thurner syndrome in 83 limbs. At 6 months, the venous clinical severity score had improved from 7 to 4 in the limbs with a unilateral Venovo (UV) stent and from 5 to 4 in the composite Wallstent-Z stent group (P = .9). The grade of swelling had improved from 3 to 1 in the UV group and from 3 to 1 in the composite group (P = .6), and the visual analog scale for pain score had improved from 7 to 2 in the UV group and from 5 to 0 in the composite group (P = .007). At 12 months, ulcers had healed in 53% (8 of 15) of the UV group and 56% (5 of 9) of the composite group (P = .7). The global 20-item chronic venous insufficiency quality of life questionnaire scores had improved from 58 to 28 in the UV group and from 59 to 40 in the composite group (P = .6). The cumulative primary, primary-assisted, and secondary patency at 18 months was 81%, 97%, and 98% in the UV group and 87%, 98%, and 100% in the composite group, respectively (P > .4). No difference in the reintervention rates was noted between the two groups (P = .5).

CONCLUSIONS

For patients who had undergone stenting for QOL-impairing CIVO, the results with the Bard Venovo venous stent were comparable to those with the composite Wallstent-Z stent configuration for clinical outcomes, QOL improvement, and stent patency. Further study is, however, required to confirm this improvement in the long term.

Iliofemoral venous configurations from three-dimensional computed tomography venogram and their relevance to stent design

OBJECTIVE

Iliofemoral venous stenting has become the standard of care for patients presenting with quality-of-life impairing symptoms of chronic iliofemoral venous obstruction not responding to conservative measures. This has led to an increased use of venous stenting over the last several years. However, iliofemoral venous anatomy in patients requiring such intervention remains poorly elucidated. This study attempts to fill that gap.

METHODS

Twenty-two consecutive patients with intravascular ultrasound examination-confirmed chronic iliofemoral venous obstruction underwent three-dimensional reconstruction of their computed tomography venogram images. Relevant angles, tortuosity (tort index-ratio between centerline length, and straight line length), lengths, and diameters were computed and analyzed. We used t tests for comparisons between the right and left sides. A P value of .05 or less was considered significant.

RESULTS

Of the angles calculated, the median of the angles between the horizontal and common iliac vein (CIV) was 66° on the right and 60° on the left (P < .01). The median inferior vena cava-CIV angle was 172° on the right and 165° on the left (P < .0001). The CIV-EIV angle was 159° on the right and 151° on the L (P = .01). Overall, the median tortuosity was 1.07 on the right and 1.12 on the left (P = .007). The median centerline length of the CIV was 42mm on the right and 60mm on the left (P < .0001). The median external iliac vein length was 73 mm on the right and 88 mm on the left (P < .0001). The overall median iliac vein length was 220 mm on the right and 237 mm on the left (P < .01). The median diameters of the inferior vena cava at the iliocaval confluence, 20, 40, and 60 mm cranial to the confluence, were 23, 20, 22, and 23 mm, respectively.

CONCLUSIONS

Overall, the left side has steeper angles, greater tortuosity, and longer lengths than the right side. These disparities should be considered during femoroiliocaval stent construction.

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.

[Venous ulcus cruris-Surgical treatment]

Venous ulcus cruris is usually a chronic disease and an extreme burden for patients and their families. An analysis based on a random statutory health insurance sample of the AOK Hessen/KV Hessen estimated the number of affected people to be 400,000 in Germany. A venous ulcus cruris is always caused by an underlying chronic venous insufficiency (CVI). A spontaneous healing of this chronic disease without treatment is not to be expected. The conservative treatment includes an adequate compression treatment and exudate management. Surgical treatment is based on three pillars: an open surgical or endovenous approach to resolve the pathological venous reflux, uIcer surgery and in rare cases the various procedures of fascia surgery as well as defect coverage by a combination of negative pressure wound therapy and skin transplantation.

Short- and Mid-Term Outcomes of Endovascular Stenting for the Treatment of Post-Thrombotic Syndrome due to Iliofemoral and Caval Occlusive Disease: A Multi-Centric Study from the French Society of Diagnostic and Interventional Cardiovascular Imaging (SFICV)

PURPOSE

To assess the results of endovascular treatment in a large population of patients suffering from post-thrombotic syndrome (PTS) due to iliocaval occlusive disease.

METHODS

In this retrospective multi-center study, 698 patients treated by stenting for PTS in 15 French centers were analyzed. Primary, primary assisted, and secondary patency rates were assessed, and clinical efficacy was evaluated using Villalta and Chronic Venous Insufficiency Questionnaire in 20 questions (CIVIQ-20) scores. Outcomes were compared against pre-operative CT-based severity of the post-thrombotic lesions in the thigh (4 grades).

RESULTS

Technical success, defined as successful recanalization and stent deployment restoring rapid anterograde flow in the targeted vessel, was obtained in 668 (95.7%) patients with a complication rate of 3.9%. After a mean follow-up of 21.0 months, primary patency, primary assisted patency, and secondary patency were achieved in 537 (80.4%), 566 (84.7%), and 616 (92.2%) of the 668 patients, respectively. Venous patency was strongly correlated to the grade of post-thrombotic changes in the thigh, with secondary patency rates of 96.0%, 92.9%, 88.4%, and 78.9%, respectively, for grades 0 to 3 (p = .0008). The mean improvements of Villalta and CIVIQ-20 scores were 7.0 ± 4.7 points (p < .0001) and 19.1 ± 14.8 points (p < .0001), respectively.

CONCLUSION

Endovascular stenting as a treatment option for PTS due to chronic iliocaval venous occlusion generates a high technical success, low morbidity, high midterm patency rate, and clinical improvement. Venous patency was strongly correlated to the severity of post-thrombotic lesions in the thigh.

Three-Year Results from the Venovo Venous Stent Study for the Treatment of Iliac and Femoral Vein Obstruction

Purpose

To assess safety and patency of the Venovo venous stent for the treatment of iliofemoral vein obstruction.

Materials and Methods

Twenty-two international centers enrolled 170 patients in the VERNACULAR study (93 post-thrombotic syndrome; 77 non-thrombotic iliac vein lesions). Primary outcome measures were major adverse events at 30 days and 12-month primary patency (freedom from target vessel revascularization, thrombotic occlusion, or stenosis > 50%). Secondary outcomes included the Venous Clinical Severity Score Pain Assessment and Chronic Venous Quality-of-Life Questionnaire assessments (hypothesis tested). Secondary observations included primary patency, target vessel and lesion revascularization (TVR/TLR), and assessment of stent integrity through 36 months.

Results

Freedom from major adverse events through 30 days was 93.5%, statistically higher than a pre-specified performance goal of 89% (p = 0.032) while primary patency at 12 months was 88.6%, also statistically higher than a performance goal of 74% (p < 0.0001). Mean quality-of-life measures were statistically improved compared to baseline values at 12 months (p < 0.0001). Primary patency at 36 months was 84% (Kaplan–Meier analysis) while freedom from TVR/TLR was 88.1%. There was no stent embolization/migration, and no core laboratory assessed stent fractures reported through 36 months. Six deaths were reported; none adjudicated as device or procedure related.

Conclusion

The Venovo venous stent was successfully deployed in obstructive iliofemoral vein lesions and met the pre-specified primary outcome measures through 12 months. At 3 years, primary patency was 84%, reintervention rates were low, standardized quality-of-life and pain measures improved from baseline, and there was no stent migration or fractures.

Level of Evidence

Level 2—prospective, multicenter, controlled clinical study without a concurrent control or randomization. Pre-specified endpoints were hypothesis-tested to performance goals derived from peer-reviewed clinical literature.

Registration clinicaltrials.gov

Unique Identifier NCT02655887.

What are the ideal characteristics of a venous stent?

Historically, the stents used in the venous system were not dedicated scaffolds. They were largely adapted arterial stents. An essential feature of a venous stent is compliance, in order to adapt its crosssectional area to the vein. It should also be crush resistant, corrosion resistant and fatigue resistant. The material should be radiopaque, for follow-up. Another characteristic of the ideal venous stent is flexibility, to adapt its shape to the vein, not vice versa. The scaffold should be uncovered too, in order to avoid the occlusion of collaterals. The ideal venous stent should not migrate, so it is necessary a large diameter and a long length. The radial force is important to prevent migration. However, current stents derived from arterial use display high radial force, which could affect the patency of the thin venous wall. Alternatively, if the stent has an anchor point, that permits a passive anchoring, the radial force required to avoid migration will be lower. Dedicated venous stents were not available until very recently. Furthermore, there is a preclinical study about a new compliant nitinol stent, denominated Petalo CVS. Out of the commonest causes of large veins obstruction, dedicated venous stent could also treat other diseases described more recently, such as the jugular variant of the Eagle syndrome, JEDI syndrome and jugular lesions of the chronic cerebrospinal venous insufficiency that result unfavorable for angioplasty according to Giaquinta classification.

Utility of the 50% stenosis criterion for patients undergoing stenting for chronic iliofemoral venous obstruction

OBJECTIVE

The criterion for venous stenting in symptomatic chronic iliofemoral venous obstruction has been the arbitrary use of stenosis of ≥50%. In the present study, we evaluated the intravascular ultrasound (IVUS)-determined degree of stenosis in patients who had undergone stenting for quality of life (QOL)-impairing symptoms and assessed the utility of the 50% stenosis cutoff.

METHODS

A retrospective review of contemporaneously entered electronic medical record data from 480 continuous patients (480 limbs) with initial iliofemoral stents placed (2014 to 2017) for symptomatic chronic iliofemoral venous obstruction impairing their QOL was performed. The IVUS-determined normal minimal luminal areas for the common femoral vein (125 mm), external iliac vein (150 mm), and common iliac vein (200 mm) were used to group limbs as having <50% (low-grade stenosis [LGS]) or ≥50% (high-grade stenosis [HGS]) stenosis. The variables compared included the visual analog scale (VAS) for pain score, venous clinical severity score (VCSS; range, 0-27), ulcer healing, supine foot venous pressures, QOL (20-item chronic venous disease QOL questionnaire), and stent patency. A composite chronic venous insufficiency score (CCVIS) incorporating the VAS score, VCSS, and CIVIQ-20 score for predicting improvement after stenting was evaluated.

RESULTS

Of the 480 limbs, 283 and 197 were in the LGS and HGS groups, respectively. A preponderance of women, left laterality, and post-thrombotic syndrome were noted in both groups. At baseline, although no difference was found in the VAS for pain score between groups, the LGS group had a higher VCSS than did the HGS group (P = .05). The baseline median supine foot venous pressure was 15 and 14 mm Hg in the LGS and HGS groups, respectively (P = .17). At 24 months after stenting, the mean VCSS had improved from 6.3 to 4.4 (P < .0001) and from 5.7 to 3.7 (P < .0001) in the LGS and HGS groups, respectively, without significant differences between the two groups (P = .07). A greater prevalence of ulcers was found in the LGS group (18% vs 11%; P = .04), with no differences in healing (P = .41) or recurrence rates (P = .36). The QOL scores had improved in both groups (LGS, from 58 to 37 [P < .0001]; HGS, from 61 to 35 [P < .0001]), without differences between the two groups (P > .3). No significant differences in stent patency or reinterventions rates were found. A baseline CCVIS of ≥84.5, ≥86.9, or ≥105.3 was needed for a 30-, 40-, and 50-point improvement in most limbs after stenting.

CONCLUSIONS

The degree of IVUS-determined iliofemoral venous stenosis did not appear to affect the initial clinical presentation, CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical class, supine foot venous pressure, clinical improvement, QOL improvement, stent patency, or reintervention rates after stenting. Patients presenting with QOL-impairing symptoms in whom conservative treatment has failed merit consideration of correction of their obstruction even if the degree of stenosis is <50%. The use of a CCVIS might be helpful but requires further study.

A systematic review and meta-analysis of the treatment of obstructive chronic deep venous disease using dedicated venous stents

OBJECTIVES

This review aims to summarise the efficacy and safety of dedicated venous stenting for the treatment of obstructive chronic deep venous disease. The approaches to stenting and post-procedural management of different vascular units are also highlighted.

METHODS

MEDLINE and Embase were searched to identify relevant literature on dedicated venous stents published from January, 2010 to May, 2020. The patient population and study characteristics; procedural characteristics; and outcomes related to post-stenting symptoms, health-related quality of life, patency and complications were analysed.

RESULTS

Sixteen single-arm observational studies were included from 2,366 studies identified from key-word searches. In total, 1,688 patients were included, of which 70.5% had post-thrombotic syndrome and the remainder had non-thrombotic iliac vein lesions. Nine studies (n = 848), stated whether lesions were stenotic (36.6%) or occlusive (63.4%). Seven studies did not report the lesion characteristics (n = 840). Eight different dedicated venous stent brands were employed. 73.4% of ulcers healed at last follow-up. The remaining symptomatic changes were described narratively; sustained improvements in pain, venous claudication and oedema following stenting were observed. Significant post-stenting improvements in health-related quality of life were noted, as measured by the Chronic Venous Insufficiency Questionnaire-20 instrument. Overall, the most frequently reported complications were in-stent occlusion (n = 204), in-stent stenosis (n = 149) and minor bleeding (n = 77). At 12 months, the primary patency ranged from 59% to 94%, whilst the secondary patency ranged 87% to 100%. The pooled-primary and secondary stent patency rates at 12 months were 74.0% and 90.4%, respectively. The incidence of major and minor bleeding was 1.9% and 4.7%, respectively; bleeding complications were more common in patients undergoing hybrid intervention.

CONCLUSION

Deep venous stenting using dedicated venous stents is a safe technique to treat obstructive chronic deep venous disease and within the limitations of this study, is associated with good patency outcomes and symptomatic improvement.

A predictive model for postthrombotic syndrome in proximal deep vein thrombosis patients

Background

Postthrombotic syndrome (PTS) is the most common long-term complication of deep vein thrombosis (DVT). Predictive models for PTS after hospitalized DVT patients, especially those with proximal DVT for whom preventative intervention decisions need to be made, are rare. We aimed to develop and externally validate a clinical predictive model for PTS in patients with proximal DVT.

Methods

This study was a retrospective, single-center, case-control study. The data used in our model were retrospectively collected from a prospective registry database in which 210 (derivation) and 90 (validation) consecutive patients were first diagnosed with proximal DVT. We developed a nomogram using the multivariate logistic regression model. External validation of our predictive model and previous predictive models in our validation set was assessed by discrimination, calibration, and clinical utility.

Results

Of the 30 candidate predictors, 5 were significantly associated with PTS in our final multivariable model, including the number of signs and symptoms (OR 1.33, 95% CI: 1.17 to 1.53, P<0.001), male sex (OR 1.79, 95% CI: 1.07 to 3.06, P=0.028), varicose vein history (OR 3.02, 95% CI: 1.04 to 7.60, P<0.001), BMI (OR 1.06, 95% CI: 1.00 to 1.12, P=0.052), and chronic DVT (OR 2.66, 95% CI: 1.49 to 4.79, P<0.001). The area under the curve was 0.724 in our predictive model, indicating suitable external performance.

Conclusions

A simple-to-use nomogram effectively predicts the risk of PTS in patients with proximal DVT. This predictive model may be considered for use in clinical care.

Mid-term patency of iliac venous stenting for post-thrombotic syndrome

INTRODUCTION

Post-thrombotic syndrome (PTS) is the most common chronic complication of deep vein thrombosis. Recent studies suggested that iliac stenting in chronic obstructive venous disease is safe and effective. However, systematic reviews focusing on mid-term efficacy of iliac stenting in post-thrombotic syndrome are lacking. This systematic review aimed to analyze mid-term stent patency rates and clinical outcomes of iliac stenting in post-thrombotic syndrome.

EVIDENCE ACQUISITION

Two databases were searched: Pubmed/Medline and Scopus. Articles published between January 2000 and July 2020 were selected and titles and abstracts were independently reviewed. Eighteen articles were included for the qualitative analysis. From this initial set of articles, fourteen articles were included for the quantitative analysis.

EVIDENCE SYNTHESIS

Overall, 1008 patients were included in this study. The pooled technical success rate was 96%. The pooled primary and secondary patency rates were 98.2% and 100% at 30 days, 78.1% and 94.5% at 12 months and 66.3% and 89.4% at 36 months, respectively. The rates of ulcer healing, pain and edema relief were 78.1%, 53.4% and 48.8%, respectively. The pooled rate of complications including intraoperative venous injury, back pain and stent fracture were 28%, 57.1%, and 5.9%, respectively.

CONCLUSIONS

Iliac venous stenting in PTS presents durable mid-term patency rates, as well as significant symptomatic improvement. Therefore, endovascular treatment should be considered in symptomatic patients with PTS.

Clinical outcomes of venous self-expanding stent placement for iliofemoral venous outflow obstruction

OBJECTIVE

In the present study, we evaluated the feasibility of a self-expanding venous stent for treating iliofemoral venous obstruction.

METHODS

The present retrospective study reviewed the data from 49 patients who had undergone Zilver Vena (Cook Medical, Bloomington, Ind) stent placement for treatment of iliofemoral venous obstruction from September 2017 to March 2019. All patients had undergone received follow-up duplex ultrasound examinations to assess for stent patency. The Villalta scores and Venous Clinical Severity Scores (VCSSs) were also calculated to stratify the postoperative improvement in disease.

RESULTS

Of the 49 patients, 19 had had acute deep vein thrombosis, 7, nonthrombotic iliac venous lesions, and 23, post-thrombotic syndrome. At 1 year after Zilver Vena stent placement, the primary, assisted primary, and secondary patency rates were 93.8%, 95.9%, and 97.9%, respectively. The baseline median Villalta score before treatment for those with post-thrombotic syndrome was 19 (range, 11-30), and the median VCSS for the patients with post-thrombotic syndrome and nonthrombotic iliac venous lesions was 11 (range, 6-25). At 1 year after stent placement, the median Villalta score for the post-thrombotic syndrome patients was 4.0 (range, 2-18), and the median VCSS for the post-thrombotic syndrome and nonthrombotic iliac venous lesions patients was 3.0 (range, 2-12).

CONCLUSIONS

Venous placement of self-expanding stents offers excellent 1-year patency rates and improved the outcomes of patients with iliofemoral venous obstruction caused by acute deep vein thrombosis, nonthrombotic iliac venous lesions, and post-thrombotic syndrome.

Venovo venous stent for treatment of non-thrombotic or post-thrombotic iliac vein lesions – long-term efficacy and safety results from the Arnsberg venous registry

Summary: Background: Endovascular venous stenting with dedicated venous stents for the treatment of chronic venous outflow obstruction is developing as efficacious alternative to conservative therapy or open surgery. However, so far, mid- and long-term evidence on effectiveness and safety is poor. Patients and methods: The prospective, single-center, observational study enrolled consecutive patients with chronic non-thrombotic iliac vein lesions (NIVL) or post-thrombotic iliofemoral obstructions (PTO). From February 2016 to April 2017, patients underwent implantation of open cell, self-expandable dedicated venous stents. Short-term symptomatic improvement, patency, and complication rate were favorable. Evaluation at 2-years included improvement in the revised venous clinical severity score (rVCSS), patency, stent migration, major target limb events, clinically important pulmonary embolism, major bleeding, and all-cause mortality. Results: A total of 79 patients (57 ± 16 years, 44 female) were evaluated. At 2 years, rVCCS improved by 4.3 ± 2.7 (p < 0.001). Substantial clinical improvement of ≥ 2 score points was achieved in 86.4% (38 of 44) of patients. Improvement was not associated with thrombotic pathogenesis (regression coefficient [B] with PTO = 0.6 [95%CI: −1.1 to 2.3], p = 0.48). At 2 years, all ulcers (in 8 of 79 patients) were healed and none recurred. Two-year primary patency was 95.5% (95%CI: 86.5 to 98.5) with no difference between NIVL- and PTO-patients (log-rank p = 0.83). Target vessel revascularization was conducted in two PTO- and one NIVL-patients in the period of 34 days to 156 days from index procedure, resulting in a secondary patency of 100%. No stent migration, target limb deep vein thrombosis, major amputation, pulmonary embolism, or death occurred. Conclusions: Venovo venous open cell self-expanding stent implantation for chronic outflow obstruction was efficacious and provided a sufficient level of safety throughout 2 years.

Medicine and Phlebolymphology: Time to Change?

Biomedical science is undergoing a reappraisal of its scientific advancement process and of the related healthcare management. Progress in medicine should combine improvements of knowledge, efficacy, and safety of diagnostic/therapeutic procedures, with adequate cost-effectiveness profiles. This narrative review is aimed at assessing in medicine, more specifically in phlebology and lymphology: (a) scientific literature possible biases, (b) the level of evidence, comprehensiveness, and cost-effectiveness of the main therapeutic options, and (c) the possible contribution of integrative and translational medicine. Current medical research may have cognitive biases, or industry-tied influences, which impacts clinical practice. Some reductionism, with an increasing use of drugs and technology, often neglecting the understanding and care of the root causative pathways of the diseases, is affecting biomedical science as well. Aging brings a relevant burden of chronic degenerative diseases and disabilities, with relevant socio-economic repercussions; thus, a major attention to cost-effectiveness and appropriateness of healthcare is warranted. In this scenario, costly and innovative but relatively validated therapies may tend to be adopted in venous and lymphatic diseases, such as varicose veins, leg venous ulcer, post-thrombotic syndrome, pelvic congestion syndrome, and lymphedema. Conversely, a more comprehensive approach to the basic pathophysiology of chronic venous and lymphatic insufficiency and the inclusion of pharmacoeconomics analyses would benefit overall patients' management. Erroneous lifestyle and nutrition, together with chronic stress-induced syndromes, significantly influence chronic degenerative phlebo-lymphatic diseases. The main active epigenetic socio-biologic factors are obesity, dysfunctions of musculo-respiratory-vascular pumps, pro-inflammatory nutrition, hyperactivation of stress axis, and sedentarism. An overall critical view of the scientific evidence and innovations in phebolymphology could be of help to improve efficacy, safety, and sustainability of current practice. Translational and integrative medicine may contribute to a patient-centered approach. Conversely, reductionism, eminence/reimbursement-based decisional processes, patients' lack of education, industry-influenced science, and physician's improvable awareness, may compromise efficacy, safety, appropriateness, and cost-effectiveness of future diagnostic and therapeutic patterns of phlebology and lymphology.

Effect of thrombophilia on clinical outcomes of chronic post-thrombotic patients after iliofemoral stenting with nitinol venous stents

OBJECTIVE

Thrombophilia is a prothrombotic condition that increases the risk of venous thromboembolism. It is unclear whether the presence of thrombophilia alters the clinical outcomes after deep venous stenting. The aim of the present study was to examine the relationship between thrombophilia and outcomes after stenting for post-thrombotic syndrome.

METHODS

Consecutive patients (2012-2017) receiving a nitinol venous stent for chronic post-thrombotic venous occlusive disease with a minimum of 18 months of follow-up in one center using the same anticoagulation protocol were included. The clinical history and thrombophilia testing results were reviewed. The outcomes were stent patency, which was assessed using duplex ultrasonography at 24 hours, 2 and 6 weeks, 3 months, 6 months, and annually thereafter; and reinterventions, which were performed when the stent diameter was <50% or occluded.

RESULTS

Of the 136 patients who had undergone intervention, 55 (40%) had had a provoked deep vein thrombosis (DVT) and 81 (60%) had had an unprovoked DVT and had therefore undergone thrombophilia testing. Of the 81 patients, 38 (47%) had had either inherited (n = 19; 50%) or acquired (n = 19; 50%) thrombophilia. Of the 136 patients who had undergone stenting, 68 had required reintervention (50%) during follow-up to maintain stent patency. Of the 55 patients with a provoked DVT, 29 (53%) had required reintervention. Of the 81 patients with an unprovoked DVT, 39 (48%) had required reintervention (P = .420). Of the 38 patients with unprovoked DVT and thrombophilia, 17 (45%) had required reintervention. Of the 43 patients with unprovoked DVT and no thrombophilia, 22 (51%) had required reintervention (P = .766). The cumulative patency rate was 80% for patients with provoked DVT and 88% for those with unprovoked DVT (P = .193). The presence of thrombophilia was not associated with patency loss (92% cumulative patency for patients with thrombophilia and 84% for patients without thrombophilia; P = .307).

CONCLUSIONS

Using our anticoagulation protocol, patients with and without thrombophilia had similar clinical outcomes after deep venous stenting and should not be excluded from iliofemoral venous stenting. We found no significant differences in outcomes in conjunction with appropriate postoperative anticoagulation therapy.

Stent characteristics of 32 patients with early (<14 days) iliofemoral stent occlusion

OBJECTIVE

Endovascular treatment with percutaneous transluminal angioplasty and stenting has quickly gained popularity for treatment of deep venous obstructive disease. Early thrombosis after stenting in iliofemoral veins is uncommon. The treatment and analysis of the underlying factors leading to the rethrombosis of stents placed in the previous 14 days are reported in this study.

METHODS

Patients diagnosed with early in-stent thrombosis after iliofemoral stenting were reviewed in this retrospective analysis. Patients with acute occlusion were routinely treated by catheter-directed thrombolysis (CDT), and the underlying causes of early occlusion were identified during the procedure. After successful CDT procedures, patients received additional interventions (percutaneous transluminal angioplasty with or without stenting) if indicated.

RESULTS

A total of 527 patients underwent stenting in the iliofemoral veins, and 32 patients (20 men [63%]) with acute thrombosis in iliofemoral venous stents placed in the previous 14 days were treated in our center from January 2015 to December 2018. The mean time from the onset of symptoms to the intervention was 6 days. Successful thrombolysis was achieved in 31 of the 32 patients, and additional stents were implanted in 16 patients. Patency was achieved in all cases. The underlying factors of early stent thrombosis were technical failure of the initial procedure, such as suboptimal positioning, failure owing to stent characteristics (stent kinking, compression, and angulation), in-stent residual thrombus, and inadequate anticoagulation. In all cases, recanalization was achieved through successful thrombolysis with or without restenting.

CONCLUSIONS

Treatment with CDT and stenting of early in-stent thrombosis is effective and feasible. Recanalization of stented segment(s) can be achieved in most cases of recent thrombosis (<14 days). Early stent-related occlusion is mainly caused by stent-related problems and technical inadequacies.

Long-term outcomes following use of a composite Wallstent-Z stent approach to iliofemoral venous stenting

OBJECTIVE

An endovascular approach has essentially replaced open surgery in the management of symptomatic chronic obstructive iliofemoral venous disease. In the last several years, such a minimally invasive approach has shifted from use of Wallstents alone to a combination of Wallstent-Z stent (composite stenting) to better deal with the iliocaval confluence. This study evaluates the clinical and stent related outcomes following use of composite stenting.

METHODS

A retrospective review of contemporaneously entered EMR data on 535 patients (545 limbs) with initial iliofemoral stents placed over a 4-year period from 2014 to 2017 for symptomatic chronic iliofemoral venous obstruction was performed. Patients who underwent stenting after intervention for acute deep venous thrombosis were excluded. The impact of stenting on clinical outcomes before and after the intervention were evaluated through use of the visual analog scale pain score (0-10), grade of swelling (0-4), and Venous Clinical Severity Score (0-27). Quality of life was appraised using the Chronic Venous Disease quality of life Questionnaire 20 instrument. Kaplan-Meier analysis was used to assess primary, primary assisted and secondary stent patencies, and paired and unpaired t-tests were used to examine clinical outcomes.

RESULTS

Of the 545 limbs that underwent stenting, 183 were in men and 362 were in women. The median age was 60 years. Laterality was right in 205 limbs and left in 340 limbs. Post-thrombotic syndrome was seen in 441 limbs and nonthrombotic iliac vein lesions/May-Thurner syndrome in 104 limbs. At 24 months, visual analog scale pain score went from 5 to 2 (P < .0001), grade of swelling went from 3 to 1 (P < .0001), and Venous Clinical Severity Score went from 6 to 4 (P < .0001). Ulcers were present in 67 limbs and had healed in 49 limbs (73%) over a median follow-up of 26 months. Global Chronic Venous Disease quality of life Questionnaire scores improved from 60 to 36 (P < .0001) after stenting. Cumulative primary, primary-assisted, and secondary patencies at 60 months were 70%, 99% and 91%, respectively. Thirty limbs (5.5%) required contralateral stenting. There was only one instance (0.2%) of contralateral iliofemoral deep venous thrombosis. One hundred eleven limbs (20%) underwent reintervention, including for in-stent restenosis in 44 limbs, stent compression in 2 limbs, in-stent restenosis and stent compression in 48 limbs, and stent occlusion in 17 limbs.

CONCLUSIONS

In patients undergoing iliofemoral venous stenting for obstructive disease, clinical improvement, quality of life improvement, and stent patencies after use of a composite stent configuration are comparable with those seen after exclusive use of Wallstents. However, the use of a composite stent configuration not only decreases the need for contralateral stenting to relieve chronic obstruction, but also decreases the incidence of contralateral iliofemoral deep venous thrombosis.

Three-dimensional computed tomography venogram enables accurate diagnosis and treatment of patients presenting with symptomatic chronic iliofemoral venous obstruction

OBJECTIVE

The last several years has witnessed an increase in the diagnosis and treatment of chronic iliofemoral venous obstructive lesions. Although intravascular ultrasound (IVUS) examination has become the gold standard in the management of chronic iliofemoral venous obstruction (CIVO), it is an invasive technique. To ascertain the usefulness of noninvasive imaging technology in diagnosing and treating CIVO in symptomatic patients, we compared three-dimensional (3D) reconstructions from computed tomography venogram (CTV) with IVUS examination.

METHODS

Twenty-two continuous patients who underwent IVUS interrogation during intervention for CIVO formed the study cohort. Patients who had stenting performed in the setting of chronic total occlusion of the iliofemoral segment or acute iliofemoral deep venous thrombosis were excluded. All patients underwent CTV as part of their standard preoperative work up. Minimal (smallest) luminal areas of the common iliac vein (CIV), external iliac vein (EIV), common femoral vein (CFV) and the inflow channel (segment caudal to the CFV) were obtained from 3D CTV and IVUS. Centerline length measurements were obtained from 3D CTV to estimate the length of the venous stents necessary; the inflow channel luminal area was used to predict the required stent diameter. Pearson correlation was used to evaluate the association between the luminal areas obtained from the two techniques. Agreement was ascertained by use of Bland-Altman limits of agreement. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 3D CTV in predicting luminal areas was also determined. Predicted stent diameters and lengths were compared against actual stent diameters and lengths used.

RESULTS

Pearson correlation statistic for luminal areas between 3D CTV and IVUS for the CIV was 0.89 (P < .01), for EIV was 0.77 (P < .01), and for CFV was 0.69 (P < .01). The correlation statistic for the inflow channel luminal area was 0.90 (P < .01). The sensitivity of 3D CTV in diagnosing CIVO in the CIV, EIV, and CFV were 100%, 100% and 80%, respectively. The specificity was 67%, 57%, and 86%, respectively, in the CIV, EIV, and CFV segments. The positive predictive value of 3D CTV in determining CIVO in the CIV, EIV, and CFV segments was 89%, 83%, and 92%, and the negative predictive value was 100%, 100%, and 67%, respectively. The overall accuracy was 91%, 86%, and 82% in the CIV, EIV, and CFV segments. Thus, 3D CTV is able to predict stent length within 9.5 mm of the actual stent length used. With respect to stent diameter, 3D CTV was able to predict within 2 mm of the actual stent diameter used 91% (20/22) and within 4 mm of the actual stent diameter used 100% (22/22) of the time.

CONCLUSIONS

From a diagnostic standpoint 3D CTV does well with an overall accuracy ranging from 82% in the CFV to 91% in the CIV in predicting CIVO. It is also able to accurately predict venous stent diameter and lengths required, rendering it a good tool in the diagnosis and treatment of symptomatic CIVO.

Aiming for the Bottom Corner: How to Score a Field Goal When Landing Venous Stents in May-Thurner Syndrome

PURPOSE

To report an iliac venous stent landing technique using only fluoroscopy in patients with May-Thurner syndrome (MTS).

MATERIAL AND METHODS

Sixty-five patients (69% female) who had self-expanding nitinol stents deployed for symptomatic MTS were retrospectively analyzed. Mean age was 50 years (range 18-80). The cephalic stent right lower corner was deployed to the right of the lumbar vertebra spinous process (SP), but not as far to the right as the right pedicle lateral border. Mode stent diameter and length were 14 mm (range 12-18) and 120 cm (range 60-180), determined by venography, respectively. The anatomical positions of the right common iliac artery, inferior vena cava (IVC), and stent were assessed relative to these bony landmarks on computed tomography venography.

RESULTS

Position of the proximal right common iliac artery right lateral border lay a mean distance of 12 mm (±8 to the right of the SP and 13 mm (±7) left of the right pedicle lateral border. Mean position of the IVC right lateral wall lay 1 mm (±6) to the right of the right pedicle lateral border. Mean position of the cephalic stent right lower corner was 6 mm (±6) to the left of the right pedicle lateral border and 19 mm (±7) to the right of the SP. The mean space left between the cephalic stent right lower corner and the IVC right lateral wall was 5 mm (±5). Primary patency rate at 1 year was 88%.

CONCLUSIONS

Important vascular structures lie in predictable locations relative to bony landmarks, facilitating accurate venous stent placement using fluoroscopy only.