Unexpected major role for venous stenting in deep reflux disease

Expansion of WallStents® After Initial Deployment in Nonthrombotic Iliac Vein Lesions

OBJECTIVE

To determine the structural changes of Wallstents® (Boston Scientific, Natick, MA) in vivo following deployment in iliac veins.

METHODS

This retrospective single-center study was performed from September 2012 to April 2013 and included 100 office-based patients who underwent initial stent placement for nonthrombotic iliac vein lesions with Wallstent® as well as a second procedure for stenting of the contralateral iliac vein. Measurements were obtained with marker balloons and the diameters of the stents were compared at the time of the index procedure to the secondary procedure.

RESULTS

The average time between the two procedures was 28 days (range 3-237, SD ± 39.89). The overall average stent diameter after the index procedure was 16.38 mm (range 10.95-21.45, SD ± 2.24). The overall average stent diameter of the index stent when remeasured during the second intervention was 17.58 mm (range 12.84-24.11, SD ± 2.38, p=0.0003) which was significantly different from the initial measurements. There was no difference when comparing changes in stent diameter by gender or laterality of procedure. However, there was a significant difference in expansion of stents when placed in the common iliac vein vs the external iliac or common femoral veins.

CONCLUSIONS

This study shows that self-expanding Wallstents® can continue to expand days to weeks in vivo following initial deployment. Additionally, we found that the change in diameter from initial placement to follow up was more significant in stents placed in the proximal and middle segments of the common iliac vein.

CLINICAL RELEVANCE

Wallstents® are durable implants designed to last within a patient for the rest of their life, it is important to understand the structural changes occurring after their placement. This study allows for a better understanding of Wallstent® dynamics in vivo.

Percutaneous transluminal angioplasty of femoropopliteal veins for treatment of post-thrombotic syndrome

Background: Controversy persists concerning the endovascular treatment of the post-thrombotic syndrome (PTS), particularly if femoropopliteal veins are involved. Methods: We screened consecutive patients with PTS who underwent percutaneous transluminal angioplasty (PTA) of femoropopliteal veins using posterior tibial or popliteal vein access who had at least 3-month follow-up. Our assessment included the evaluation of primary and secondary patency of the treated segments by Doppler ultrasound (DUS) and clinical outcomes measured by the change in Villalta score as well as ulcer healing. Results: Among 29 patients, 8 (27.7%) were women and the mean (SD) age was 53.3 (13.6) years. Posterior tibial vein and popliteal access were used in 26 (89.7%) and 3 patients (10.3%), respectively. 13 (44.8%) patients had prior (n = 11, 37.9%) or concomitant (n = 9, 31.0%) endovascular treatment of the iliac or common femoral veins. At a median follow-up of 395 days (Q1: 205-Q3: 756 days), primary patency of femoropopliteal veins was 79.3% (95% CI 64.6-94.1%) and secondary patency was 82.8% (95% CI, 69.0-96.5%). The percentage of patients with moderate or severe PTS according to the Villalta score decreased from baseline to last follow-up from 34.5% to 18.5% and from 31% to 14.8%, respectively (p<0.003). Overall, the mean (SD) Villalta score decreased from 11.5 (1.7) to 8.0 (1.7) (p<0.0001). Postprocedural complete ulcer healing occurred in 4 out of 5 (80%) patients. Two (6.9%) patients developed new ulcers. No major bleeding, pulmonary embolism, stroke, or death occurred. Conclusion: PTA of femoropopliteal veins via posterior tibial or popliteal vein access appears to improve the severity of PTS with acceptable patency rates.

Pharmacomechanical Thrombectomy and Catheter-Directed Thrombolysis, with or without Iliac Vein Stenting, in the Treatment of Acute Iliofemoral Deep Vein Thrombosis

BACKGROUND

This study aims to evaluate and compare the outcomes and clinical efficacy of pharmacomechanical thrombectomy (PMCT) plus catheter-directed thrombolysis (CDT) and PMCT combined with CDT and venous stenting in managing acute iliofemoral deep vein thrombosis (DVT), while also assessing the long-term safety and efficacy of these interventions.

METHODS

A retrospective case-control study spanning 3 years involved 112 patients presenting with acute symptomatic iliofemoral deep vein thrombosis (DVT), each with a symptom duration of less than 14 days. Patients were consecutively categorized into two groups based on individual clinical indications: PMCT + CDT vs. PMCT + CDT + venous stent. Statistical analyses were conducted to compare clinical features and outcomes between the two groups. Additionally, patients were followed up for 24 months post-treatment, during which quality of life (QoL) and severity of post-thrombotic syndrome (PTS) were analyzed.

RESULTS

In this retrospective study, we analyzed a total of 112 consecutive patients, with 63 patients undergoing PMCT + CDT and 49 patients undergoing PMCT + CDT + venous stent. Between the two groups, regarding primary outcomes at 6 months, there was no difference in the observed cumulative patency rates, standing at 82.5% for PMCT + CDT and 81.6% for PMCT + CDT + stent. Survival analyses for primary, primary-assisted, and secondary patency yielded comparable results for PMCT + CDT, with p-values of 0.74, 0.58, and 0.72, respectively. The two-year patency rate was high in both groups (85.7% for PMCT + CDT vs. 83.7% for PMCT + CDT + stent). Additionally, during the follow-up period, there were no statistically significant differences observed in the incidence of PTS or the average Villalta score between the two groups. At 24 months post-intervention, the incidence of post-thrombotic syndrome (PTS) was 11.1% in the PMCT + CDT group and 22% in the PMCT + CDT + stent group (p = 0.381). Both treatment arms of the study groups experienced bleeding complications during the thrombolysis therapy; in the PMCT + CDT group, there were three cases of gastrointestinal bleeding, compared to two cases in the PMCT + CDT + stent group (p = 0.900). Additionally, there was one intracranial hemorrhage in the PMCT + CDT group and two in the PMCT + CDT + stent group.

CONCLUSIONS

Pharmacomechanical thrombectomy (PMCT) combined with catheter-directed thrombolysis (CDT) therapy has shown significant efficacy in alleviating leg symptoms and reducing the occurrence of post-thrombotic syndrome (PTS), including the incidence of moderate-to-severe PTS. On the other hand, the utilization of PMCT + CDT + stent therapy, tailored to individual patients' clinical and venous conditions, may enhance long-term venous patency and lead to superior outcomes, including improved quality of life parameters.

The clinical and economic impact of chronic venous insufficiency-associated lymphedema and the prevalence of persistent edema after venous intervention

OBJECTIVES

To determine the demographics, outcomes, and healthcare utilization of patients with chronic venous insufficiency-associated lymphedema (CVI-LED) and the prevalence of lymphedema-specific therapy use after venous intervention.

METHODS

The IBM MarketScan Commercial and Medicare Claims Databases were examined for patients with CVI-LED. Patient demographics and the use of lymphedema-specific therapy before and after venous intervention were collected.

RESULTS

Of 85,601 LED patients identified, 8,406 also had a diagnosis of CVI. In the CVI-LED group, 1051 underwent endovenous ablation or venous stent placement. The use of lymphedema-specific therapy before and after venous intervention was 52% and 39%, respectively (p < .05). The mean time of initiation of LED-specific therapy following venous intervention was 265 days after ablation and 347 days after stent placement.

CONCLUSION

Treating venous hypertension improves certain venous-related signs and symptoms of CVI. However, a significant proportion of patients have persistent edema which may reflect underlying, sub-optimally treated LED.

Risk factors for low back pain after iliac vein stenting for non-thrombotic iliac vein lesions

OBJECTIVE

Iliac vein stenting is an option being explored to treat chronic venous insufficiency. We have noted that our most common postoperative complication is low back pain after stent placement, which is occasionally quite severe. We wanted to investigate risk factors that are involved in this phenomenon and identify potentially modifiable factors.

METHODS

Patients who failed 3 months of conservative therapy had iliac vein interrogation performed. We limited the scope of this database to non-thrombotic iliac vein lesions treated in the office in which Wallstents were placed. Data were collected from September 2012 to August 2020 for 2308 consecutive outpatients who underwent 3747 procedures. Before August 2016, patients received pre-procedure oral valium (n = 2679) and thereafter, patients received intravenous (IV) sedation (n = 1068). A pain score, on a Likert scale ranging from 0 to 10, was assessed within 1 hour postoperatively. We analyzed the medications administered and correlated them with pain scores.

RESULTS

The average of all the pain scores was 0.86 (range, 0-10; standard deviation [SD], 2.00). Age had a slight inverse effect on pain scores (r = -0.12; P < .00001). Presenting signs (based upon CEAP) (P = .11) and body mass index (P = .88) did not have a significant effect on pain scores. Average pain score for females (0.96) was slightly higher than for males (0.70), with P < .0001. Average pain score for procedures on the right side (0.67) was lower than for procedures on the left side (1.01), with P < .0001. Average pain score for patients who received IV sedation (mean, 0.68; SD, 1.58) was lower than that for those who did not (mean, 0.93; SD, 2.15), with P = .0004. When using a single agent, propofol was associated with the lowest pain scores (P < .0001). Toradol displayed a dose-dependent effect on pain score (P < .0001). The best combination of agents for pain control was propofol and toradol together.

CONCLUSIONS

Overall, the vast majority of pain scores were low. Factors that were associated with lower pain scores were older age, male sex, procedures on the right side, and IV sedation, in particular with the use of propofol. These data may help us better target patients anticipated to have high pain scores and suggest the preferential use of propofol and toradol.

Intravascular Ultrasound Use in Peripheral Arterial and Deep Venous Interventions: Multidisciplinary Expert Opinion From SCAI/AVF/AVLS/SIR/SVM/SVS

Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable's aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.

Noninvasive and invasive imaging of lower-extremity acute and chronic venous thrombotic disease

The spectrum of venous thromboembolic (VTE) disease encompasses both acute deep venous thrombosis (DVT) and chronic postthrombotic changes (CPC). A large percentage of acute DVT patients experience recurrent VTE despite adequate anticoagulation, and may progress to CPC. Further, the role of iliocaval venous obstruction (ICVO) in lower-extremity VTE has been increasingly recognized in recent years. Imaging continues to play an important role in both acute and chronic venous disease. Venous duplex ultrasound remains the gold standard for diagnosing acute VTE. However, imaging of CPC is more complex and may involve computed tomography, magnetic resonance, contrast-enhanced ultrasound, or intravascular ultrasound. In this narrative review, we aim to discuss the full spectrum of venous disease imaging for both acute and chronic venous thrombotic disease.

Novel venous balloon for compliance measurement and stent sizing in a post-thrombotic swine model

Objective: Real-time accurate venous lesion characterization is needed during endovenous interventions for stent deployment. The goal of this study is to validate a novel device for venoplasty sizing and compliance measurements. Methods: A compliance measuring sizing balloon (CMSB) uses real-time electrical conductance measurements based on Ohm's Law to measure the venous size and compliance in conjunction with pressure measurement. The sizing accuracy and repeatability of the CMSB system were performed with phantoms on the bench and in a swine model with an induced post thrombotic (PT) stenosis in the common femoral vein of swine. Results: The accuracy and repeatability of the CMSB system were validated with phantom bench studies of known dimensions in the range of venous diameters. In 9 swine (6 experimental and 3 control animals), the luminal cross-sectional areas (CSA) increased heterogeneously along the PT stenosis when the CMSB system was inflated by stepwise pressures. The PT stenosis showed lower compliance compared to the non-PT vein segments (5 mm2 vs. 10 mm2 and 13 mm2 at a pressure change of 40 cm H2O). Compliance had no statistical difference between venous hypertension (VHT) and Control. Compliance at PT stenosis, however, was significantly smaller than that at Control and VHT (p < 0.05, ANOVA). Conclusion: The CMSB system provides accurate, repeatable, real-time measurements of CSA and compliance for assessment of venous lesions to guide interventions. These findings provide the impetus for future first-in-human studies.

Systematic review and meta-analysis of deep venous reflux correction in chronic venous insufficiency

OBJECTIVE

The aim of this study was to investigate the technical feasibility, operative techniques, safety, and efficacy outcomes of procedures aimed at correcting deep venous reflux, in patients with chronic venous insufficiency.

METHODS

We performed systematic literature searches in PubMed, Embase, and Web of Science from databases' inception to February 2022. We included systematic reviews, randomized controlled trials, and observational studies describing surgical procedures to treat patients with deep reflux due to primary and secondary incompetence, post-thrombotic syndrome (PTS). Proportion meta-analyses were performed for all the efficacy and safety outcomes.

RESULTS

We included 57 studies in the quantitative synthesis: three randomized controlled trials including 252 patients and 54 case series including 4004 patients. Studies included a median of 38 patients, with a mean age of 51 years; 52% of them were males. Forty percent of studies included 2291 patients with primary incompetence, 29% of studies included 595 patients with PTS, and 31% of studies included 1118 patients with both diseases. As for primary incompetence, pooled estimates for all procedures showed an 89% (95% confidence interval [CI], 82%-94%) of ulcer healing, 10% (95% CI, 4%-18%) ulcer recurrence, 98% (95% CI, 93%-100%) valve patency, 84% (95% CI, 78%-90%) valve competence, 0.05% (1/1904 patients) pulmonary embolism, 1% (95% CI, 0%-3%) wound infections, 5% (95% CI, 1%-9%) hematoma, 2% (95% CI, 0%-6%) lymphocele, 2% (95% CI, 1%-4%) thrombosis, 85% (95% CI, 74%-94%) pain improvement, 89% (95% CI, 65%-100%) edema improvement, and 85% (95% CI, 73%-93%) lipodermatosclerosis improvement. Patients with PTS showed less favorable outcomes: 82% (95% CI, 71%-91%) of ulcer healing, 18% (95% CI, 5%-36%) ulcer recurrence, 88% (95% CI, 78%-96%) valve patency, 78% (95% CI, 66%-88%) valve competence, no pulmonary embolism, 6% (95% CI, 0%-22%) wound infections, 6% (95% CI, 3%-10%) hematoma, 5% (95% CI, 1%-12%) lymphocele, 7% (95% CI, 1%-16%) thrombosis, 79% (95% CI, 59%-94%) pain improvement, 75% (95% CI, 61%-88%) edema improvement, and 64% (95% CI, 9%-100%) lipodermatosclerosis improvement.

CONCLUSIONS

The number of studies included in each meta-analysis are limited, and knowing how this element can affect the statistical power, as well as the absence of comparative control groups, it is not possible to draw definitive conclusions. Nevertheless, deep venous reconstructive surgery for reflux may increase the probability of clinical improvement in patients affected by chronic venous insufficiency. Outcomes appear to be satisfactory even if possible adjunctive procedures may be required over the course of the patient's lifetime. Consequently, a strict follow-up protocol is required to maintain outcomes. Further studies are required to evaluate deep venous reconstructive surgery for reflux particularly as to how it compares with the more recently introduced endovenous approaches.

Society of Interventional Radiology Position Statement on the Management of Chronic Iliofemoral Venous Obstruction with Endovascular Placement of Metallic Stents

PURPOSE

To state the position of the Society of Interventional Radiology (SIR) on the endovascular management of chronic iliofemoral venous obstruction with metallic stents.

MATERIALS AND METHODS

A multidisciplinary writing group with expertise in treating venous disease was convened by SIR. A comprehensive literature search was conducted to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements.

RESULTS

A total of 41 studies, including randomized trials, systematic reviews and meta-analyses, prospective single-arm studies, and retrospective studies were identified. The expert writing group developed 15 recommendations on the use of endovascular stent placement.

CONCLUSIONS

SIR considers the use of endovascular stent placement for chronic iliofemoral venous obstruction to be likely to help selected patients, but the risks and benefits have not been fully quantified in well-designed randomized studies. SIR recommends urgent completion of such studies. In the meantime, careful patient selection and optimization of conservative therapy are recommended prior to stent placement, with attention to appropriate stent sizing and quality procedural technique. The use of multiplanar venography with intravascular ultrasound is suggested in diagnosing and characterizing obstructive iliac vein lesions and in guiding stent therapy. After stent placement, SIR recommends close patient follow-up to ensure optimal antithrombotic therapy, durable symptom response, and early identification of adverse events.

Association between the degree of iliac venous outflow obstruction by intravascular ultrasound and lower limb venous reflux

OBJECTIVE

The present study aims to evaluate the association between the degree of iliac venous outflow obstruction (IVOO) identified by intravascular ultrasound (IVUS) and venous reflux presentation in the lower limbs on duplex ultrasound (DU).

METHODS

Patients with bilateral chronic venous insufficiency, CEAP (clinical-etiology-anatomy-pathophysiology) C3 to C6, and a visual analog scale score for pain >5 underwent DU for reflux evaluation of the deep venous system (reflux ≥1 second); superficial system, great saphenous vein, and small saphenous vein (reflux ≥0.5 second); and perforator system (reflux ≥0.35 second). All patients underwent IVUS in the iliac venous territory. The area of the impaired venous segments was categorized as obstruction <50% (category 1), 50% to 79% (category 2), and ≥80% (category 3). The venous clinical severity score and reflux multisegment score (RMS) were assessed.

RESULTS

A total of 51 patients (n = 102 limbs; age, 50.53 ± 14.5 years; 6 men) were included. The predominant clinical severity CEAP class was C3 in 54 of 102 limbs (52.9%). The mean VCSS was 14.3 ± 6.7. A severe RMS (≥3) was registered in 63.4% of the limbs. Of the 102 limbs, 51 (50%) presented with category 1, 27 (26.5%) with category 2, and 24 (23.5%) with category 3. Previous deep vein thrombosis (DVT) was associated with critical obstruction (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.29-10.38; P = .015). The superficial and perforator venous systems had no association with the degree of IVOO. Deep venous reflux (DVR) had a significant association with significant IVOO (obstruction ≥50%; OR, 6.44; 95% CI, 2.19-18.93; P = .001) and critical IVOO (obstruction ≥80%; OR, 4.57; 95% CI, 1.70-12.27; P = .003) and a significant linear association with the IVOO degree and reflux in the femoral veins (P < .001) and popliteal vein (P = .008). Significant lesions were significantly more likely to develop in the left limb (OR, 5.76; 95% CI, 2.46-13.50; P < .001). After multivariate analysis, DVR remained a predictor for significant and critical obstruction (P < .003 and P < .012, respectively). Left limb and previous DVT remained as predictors for IVOO of ≥50% and ≥80% (P < .001 and P = .043, respectively).

CONCLUSIONS

We found a significant linear association between the degree of IVOO and reflux in the deep venous system on DU. Limbs with DVR, a severe RMS, loss of respiratory variation on DU, and previous DVT were more likely to be affected by IVOO of ≥50%, especially with left leg involvement.

Factors associated with difficulty in stenting the chronic iliofemoral venous obstruction

BACKGROUND

The main aim of this article is to investigate the causes of technical failure during endovascular recanalization in patients with post-thrombotic syndrome with occluded iliofemoral veins and to suggest alternative techniques to improve outcomes in such challenging cases.

METHODS

Between November 2015 and August 2020, 230 patients (274 limbs) treated in our institution with symptomatic chronic iliofemoral venous obstruction underwent endovascular recanalization with angioplasty and stent placement. Overall, the initial attempt was unsuccessful in 15 limbs. We retrospectively analyzed the basic demographic and health characteristics of the involved patients and evaluated the endovascular procedures and techniques that resulted in a successful second intervention.

RESULTS

The first attempts at endovascular intervention were unsuccessful in 15 of the 274 limbs (5.4%). Failures were attributed to hostile groin areas in intravenous drug abusers caused by multiple punctures in six cases. In addition, five interventions failed due to prior surgery at the site of venous occlusion and in retroperitoneal space, three patients due to severe stent deformity, and one patient due to congenital venous aplasia. Of the 15 patients, 11 underwent a subsequent attempt that included six successful recanalizations. The mean follow-up time of the six patients with successful recanalization was 27 months (5-62 months). The primary, assisted primary and secondary patency rates were 83.3%, 100%, and 100%, respectively. The remaining five patients, in whom the second recanalization attempt failed, received conservative treatment.

CONCLUSIONS

Recanalization failure is rare in chronic venous obstruction patients. Severe stent deformities have the lowest chance of successful second intervention. Patients with a hostile groin or prior open surgeries at the occlusion site may be considered for reintervention with a success rate of nearly 50%.

Relationship between iliofemoral venous stenting and femoropopliteal deep venous reflux

OBJECTIVE

Severe presentations of chronic venous insufficiency can result from reflux or obstruction at the deep venous, perforator, or superficial venous levels. Iliofemoral venous stenting can be used to address central venous obstruction; however, its effects on deep venous reflux (DVR) have remained unclear. The purpose of the present study was to evaluate the effects of iliac vein stenting on femoropopliteal DVR with the hypothesis that ultrasound evidence of DVR would remain absent or would have improved after iliac vein stenting.

METHODS

The present study was a retrospective review of patients who had undergone iliofemoral venous stenting from 2013 to 2018. The patients were divided into two cohorts according to the preprocedural presence (group A) or absence (group B) of femoropopliteal DVR. Baseline patient variables were collected, including age, gender, CEAP (clinical, etiologic, anatomic, pathophysiologic) class, presence of concomitant superficial or perforator reflux, deep vein thrombosis history, and additional venous interventions. The primary outcome evaluated was the persistent absence or resolution of DVR on the latest venous duplex ultrasound at follow-up. Other outcomes included the follow-up CEAP classification and the need for secondary deep venous interventions.

RESULTS

A total of 275 consecutive patients had undergone iliofemoral venous stenting. Of the 275 patients, 58 had presented with DVR (group A). A comparison of groups A and B revealed that group A had had a greater likelihood of prior deep vein thrombosis (P = .0001) and a higher frequency of superficial venous ablation. The remaining demographic variables did not differ significantly between the two groups. Of the 58 patients in group A, DVR had resolved at follow-up in 17 (P = .0001). When stratified by level, 7 of these 17 patients had had isolated popliteal reflux. In group B, DVR had developed at follow-up in 6 of the 217 patients. The CEAP class had improved from before intervention (C0, 1.1%; C1, 0.4%; C2, 1.8%; C3, 41.4%; C4, 24.9%; C5, 5.9%; C6, 24.5%) to the latest follow up (C0, 4.9%; C1, 1.9%; C2, 5.7%; C3, 34.2%; C4, 22.8%; C5, 17.1%; C6, 13.3%). Significant improvement had occurred in C6 disease within both groups (group A, 16 of 58 [27.6%; P = .0078]; group B, 19 of 217 [8.8%; P = .0203]).

CONCLUSIONS

For patients who undergo iliofemoral venous stenting, DVR could improve if present initially and is unlikely to develop if not present before stenting. A cohort of patients had experienced persistent DVR and warranted further evaluation. Prospective studies are required to corroborate the safety, efficacy, and durability of iliofemoral venous stenting for patients with DVR.

Clinical tolerance of untreated reflux after iliac vein stent placement

BACKGROUND

We have recently demonstrated in a large patient cohort that the prevalence and severity of reflux will improve in most limbs after stenting and that most limbs will not develop new-onset reflux. In the present report, we have focused on the long-term clinical outcomes associated with untreated reflux in the same patient cohort who had undergone iliofemoral venous stenting without correction of residual reflux.

METHODS

The clinical outcomes data from 1379 limbs treated with only iliac vein stenting without correction of superficial or deep reflux from 1997 to 2018 were analyzed (23-year follow-up period). Of the 1379 limbs, 632 (46%) had had preexisting reflux before stenting and 747 (54%) had did not. The reflux data (reflux segmental score, air plethysmography, ambulatory venous pressure) for these patients have been previously reported in detail. The subsets were compared perioperatively with each other using the following variables: grade of swelling, visual analog scale for pain score, venous clinical severity score, venous stasis dermatitis, ulceration, and quality of life measures.

RESULTS

Both groups demonstrated improvements in the venous clinical severity score, grade of swelling, visual analog scale score, and quality of life. No differences were found in ulcer healing (5% vs 3% for limbs with and without prestent reflux, respectively) and resolution of dermatitis (6% vs 5% for limbs with and without prestent reflux, respectively) between the two groups. Of the 632 limbs with preexisting reflux, 218 (34%) had had axial reflux and 414 had had nonaxial reflux (66%). The clinical outcomes were similar between the two groups. Using a multisegment reflux score, the limbs with prestent reflux (n = 632) were divided into two groups. A segmental score of ≥3 indicated severe reflux and a score of <3 indicated moderate reflux. Of these 632 limbs, 161 (25%) had severe reflux and 471 (75%) had moderate reflux. The two groups demonstrated similar outcomes for most clinical parameters. The post-thrombotic limbs and nonthrombotic limbs also showed similar outcomes.

CONCLUSIONS

The long-term follow-up of patients after iliac vein stenting showed that uncorrected reflux is well tolerated by most patients across most clinical measures.

Patients with active venous leg ulcers at the time of iliac vein stenting require more reoperations

OBJECTIVE

An active venous leg ulcer (VLU) caused by lower extremity venous insufficiency is challenging to treat and will often recur after initially healing. In the present study, we compared the symptomatic outcomes and need for reoperation after iliac vein stenting (IVS) in patients with an active VLU (VLU+) and those without an active VLU (VLU-).

METHODS

A single-institution database of patients with chronic venous outflow obstruction who underwent IVS from August 2011 to June 2021 was analyzed. Symptoms were quantified using the venous clinical severity score. The patients were divided into two cohorts: those with (VLU+) and without (VLU-) VLUs.

RESULTS

A total of 872 patients (71 VLU+ and 801 VLU-) were identified. Many of the demographics and comorbidities differed between the two cohorts, and these variables were included in the multivariable analysis. On univariate analysis, the VLU+ cohort was more likely to need a major reoperation (odds ratio, 1.94; 95% confidence interval, 1.01-3.52; P = .036). However, on multivariable analysis, the difference was not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.55-2.40; P = .667). Additionally, the VLU+ cohort required a significantly greater mean total of reoperations (1.4 vs 1.0; P = .006) than the VLU- cohort. Comparatively, for patients who underwent at least one reoperation, the difference in the mean total number of reoperations was even greater for the VLU+ cohort (2.6 vs 1.8; P = .001). The results from the Kaplan-Meier log-rank test revealed no differences in the reintervention-free survival time (P = .980). Both cohorts experienced a durable mean reduction in the venous clinical severity score. The ulcer healing rates for the VLU+ cohort at 6, 12, 24, and 36 months were 38%, 47%, 52%, and 59%, respectively. The ulcer recurrence rates for the VLU+ cohort were 4%, 10%, 19%, and 30% at 6, 12, 24, and 36 months, respectively, with a median time to recurrence of 1.2 years.

CONCLUSIONS

Patients with active VLUs who underwent a first reintervention after initial IVS, on average, required an additional reintervention.

Options in the treatment of superficial and deep venous disease in patients with Klippel-Trenaunay syndrome

OBJECTIVE

Klippel-Trenaunay syndrome (KTS) is a congenital mixed mesenchymal malformation syndrome that includes varicose veins, capillary and venous malformations, lymphatic abnormalities, and hypertrophy of various connective tissue elements. The purpose of the present study was to describe the clinical characteristics and outcomes in a subset of patients with KTS in whom venous interventions, including iliofemoral venous stenting, were performed after failure of conservative therapy.

METHODS

A single-center retrospective data review of 34 patients with KTS who had undergone interventions for venous disease between January 2000 and December 2020 was performed.

RESULTS

Their mean age was 38.4 ± 17.5 years (range, 12-80 years). No gender predilection was found. Of the 34 patients, 61% had had all three features of the classic triad for KTS. Varicose veins were present in all 34 patients (100%), and 30% had had a history of bleeding varicosities. Most patients (79%) had CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class ≥C4. Of the 34 patients, 30% had a history of deep vein thrombosis and/or pulmonary embolism. Factor VIII elevation was the most common thrombophilia condition (12%). The venous filling index was elevated at baseline (5.9 ± 5.1 mL/s) and did not normalize despite intervention (3.5 ± 2.3 mL/s; P = .04). The superficial venous interventions (n = 35) included endovenous laser therapy; stripping of the great saphenous vein, small saphenous vein, anterior thigh vein, or marginal vein; ultrasound-guided sclerotherapy; and stab avulsion of varicose veins. One coil embolization of a perforator vein was performed. Deep interventions (n = 19) included endovenous stenting (n = 15), popliteal vein release (n = 3), and valvuloplasty (n = 1). The venous clinical severity score had improved from 9.4 ± 4.5 to 6.2 ± 5.6 (P = .04). The visual analog scale for pain score had improved from 5.5 ± 2.7 to 2.5 ± 3.3 (P = .008). Healing of ulceration was noted in 75% of the patients. Significant improvements in the total pain (P = .04) and total psychological (P = .03) domains were noted in the 20-item chronic venous disease quality of life questionnaire.

CONCLUSIONS

Superficial and deep venous interventions are safe and effective in patients with KTS when conservative therapy has failed. Iliofemoral venous stenting is a newer option that should be considered in the treatment of chronic deep venous obstructive disease in patients with KTS in the appropriate clinical context. An aggressive perioperative deep vein thrombosis prophylaxis protocol should be in place to reduce thromboembolic complications in these patients.

Appropriate Use of Intravascular Ultrasound During Arterial and Venous Lower Extremity Interventions

BACKGROUND

There has been growing use of intravascular ultrasound (IVUS) during lower extremity arterial and venous revascularization. Observational data suggest that the use of IVUS can improve periprocedural and long-term outcomes, but largescale prospective data remain limited. Consensus opinion regarding the appropriate use of IVUS during peripheral intervention is needed.

OBJECTIVES

The purpose of this consensus document is to provide guidance on the appropriate use of IVUS in various phases of peripheral arterial and venous interventions.

METHODS

A 12-member writing committee was convened to derive consensus regarding the appropriate clinical scenarios for use of peripheral IVUS. The group iteratively created a 72-question survey representing 12 lower extremity arterial interventional scenarios. Separately, a 40-question survey representing 8 iliofemoral venous interventional scenarios was constructed. Clinical scenarios were categorized by interventional phases: preintervention, intraprocedure, and postintervention optimization. Thirty international vascular experts (15 for each survey) anonymously completed the survey instrument. Results were categorized by appropriateness using the median value and disseminated to the voting panel to reevaluate for any disagreement.

RESULTS

Consensus opinion concluded that IVUS use may be appropriate during the preintervention phase for evaluating the etiology of vessel occlusion and plaque morphology in the iliac and femoropopliteal arteries. IVUS was otherwise rated as appropriate during iliac and femoropopliteal revascularization in most other preintervention scenarios, as well as intraprocedural and postprocedural optimization phases. IVUS was rated appropriate in all interventional phases for the tibial arteries. For iliofemoral venous interventions, IVUS was rated as appropriate in all interventional phases.

CONCLUSIONS

Expert consensus can help define clinical procedural scenarios in which peripheral IVUS may have value during lower extremity arterial and venous intervention while additional prospective data are collected.

Intravascular ultrasound in peripheral venous and arterial interventions: A contemporary systematic review and grading of the quality of evidence

Although angiography has been the primary imaging modality used in peripheral vascular intervention, this technique has major limitations due to the evaluation of three-dimensional vessels in two dimensions. Intravascular ultrasound (IVUS) is an important adjunctive tool that can address some of these limitations. This systematic review assesses the appropriateness of IVUS as an imaging modality for guiding peripheral intervention through evidence collection and clinical appraisal of studies. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a cohort of 48 studies (29 arterial; 19 venous) detailing IVUS use in peripheral vascular intervention were extracted. Qualitative assessment of the studies evaluated pre- and postprocedure efficacy of IVUS and revealed that IVUS-guided peripheral intervention in arterial and venous diagnosis and treatment was superior to other imaging techniques alone. Each study in the cohort was further assessed for reliability and validity using the Oxford Centre for Evidence Based Medicine (CEBM) level of evidence scale. The majority of both arterial (79.3%) and venous (73.7%) studies received a 2b rating, the second highest level of evidence rating. The evidence to date indicates that IVUS results in better clinical outcomes overall and should be more widely adopted as an adjunctive imaging modality during peripheral intervention. (PROSPERO Registration No.: CRD42021232353).

Quality of life after stenting for chronic iliocaval obstruction

Background

Iliocaval stenting is widely used for treatment of symptomatic iliocaval obstruction. The aim of our study was to compare quality of life before and after iliocaval stenting.

Method

Prospectively collected data using CIVIQ20 questionnaire, Venous Clinical Severity Score (rVCSS) and Villalta-Prandoni score (VP) of patients following iliocaval stenting for non-thrombotic and post-thrombotic venous obstruction were analysed.

Result

One hundred and one limbs (87 patients) were stented between May 2017 and May 2019. Baseline CIVIQ20 median value was 50 (34–66); 1 month after surgery CIVIQ20 value was 36 (26–58) and the scores then remained steady for the rest of the first year. Both rVCSS and VP scores decrease by 3.09 (95% CI: 2.39, 3.89; p < .001) and 5.21 (95% CI: 4.14, 6.48; p < .001) units, respectively, throughout the first year.

Conclusion

Quality of life of patients with iliocaval obstruction significantly improves after successful percutaneous reconstruction. Severity of symptoms measured by rVCSS and VP scores decreases.

The Clinical Problem of Pelvic Venous Disorders

Pelvic venous disorders are inter-related pathologic conditions caused by reflux and obstruction in the pelvic veins. It can present a spectrum of clinical features based on the route of transmission of venous hypertension to either distal or caudal venous reservoirs. Imaging can help to visualize pelvic vascular and visceral structures to rule out other gynecologic, gastrointestinal, and urologic diseases. Endovascular treatment, owing to its low invasive nature and high success rate, has become the mainstay in the management of pelvic venous disorders. This article reviews the pathophysiology, clinical presentations, and diagnostic and therapeutic approaches to pelvic venous disorders.

Treatment of Non-thrombotic Iliac Vein Stenosis: Where is the Evidence?

Non-thrombotic iliac vein lesions (NIVLs) refer to iliac vein lumen stenosis, usually secondary to extrinsic compression, without associated thrombosis. Clinical presentation varies; patients may be asymptomatic, have symptoms of lower extremity venous hypertension, or in women, may be associated with chronic pelvic pain. Given the significant variability in symptomatology, thorough history and physical examination are mandatory in excluding other causes of symptoms. Non-invasive imaging, such as venous duplex/insufficiency ultrasound examinations, and axial imaging aid in the diagnosis of a NIVL in the appropriate clinical context. Catheter venography and intravascular ultrasound remain the primary modalities for definitive diagnosis, treatment planning, and ultimately placement of self-expanding venous stents to resolve the causative iliofemoral venous obstruction. In appropriately selected patients, stent placement can lead to marked improvements in symptoms, heal stasis ulceration when present, and improve disease-specific and overall quality of life. Stents placed in patients with NIVL demonstrate high long-term primary patency. In this article, the authors discuss clinical presentation, diagnostic workup, endovascular interventions and outcomes of NIVL treatment.

Diagnosis of varicose veins

Background: Varicose veins refer to tortuous engorged veins on the lower extremities. Although this is a common condition observed in clinical practice, objective diagnosis is important for optimal treatment.Current Concepts: Thorough physical examination is the first key step for diagnosis of varicose veins. Both legs should be examined between the inguinal region and the feet with the patient in an erect position. The presence and location of venous reflux should be confirmed using duplex ultrasonography (DUS), which serves as a simple, non-invasive modality to assess both the anatomy and physiology of leg veins. Reflux is defined as duration of retrograde flow greater than 0.5 seconds in superficial veins, 0.35 seconds in perforating veins, and 1.0 seconds in deep veins. Computed tomography venography can be used in selective cases as a complementary tool to obtain objective images of all varicose veins; however, this imaging modality cannot confirm venous reflux.Discussion and Conclusion: DUS is a key diagnostic tool for varicose veins. However, DUS results are operator dependent; therefore, this procedure should be performed by experienced technologists or clinicians, based on guidelines. The location and duration of reflux should be recorded.

A systematic review of current trends in pharmacologic management after stent placement in nonthrombotic iliac vein lesions

Objective

Stenting of the iliac vein is increasingly recognized as a treatment for chronic venous insufficiency (CVI). However, the pharmacologic management after stent placement is unclear. This review was conducted to illustrate recent trends in anticoagulation and antiplatelet regimens following stent placement for nonthrombotic iliac vein lesions (NIVL).

Methods

The MEDLINE database was searched using the term “iliac vein stent.” Retrieval of articles was limited to studies conducted on humans and published in English between 2010 and 2020. Studies were included that described iliac vein stent placement. Studies were excluded that contained fewer than 25 patients, performed procedures other than stent placement, did not specify the postoperative anticoagulant used, or treated lesions of thrombotic origin.

Results

12 articles were included in this review, yielding a total of 2782 patients with a male-to-female ratio of 0.77. The predominant CEAP classification encountered was C3. The most common stent used in the included studies was the Wallstent (9/12), and the most common pharmacologic regimen was 3 months of clopidogrel (6/12). Warfarin, aspirin, cilostazol, and rivaroxaban were among other agents used. Primary stent patency ranged from 63.1 to 98.3%. There was no apparent correlation between pharmacologic agent used and stent patency or subjective patient outcomes.

Conclusion

Multiple different approaches are being taken to pharmacologically manage patients following stent placement for NIVL. There is no consensus on which agent is best, nor is there a formal algorithmic approach for making this decision. Additionally, the findings in this study call into question whether anticoagulation following stenting for NIVL is necessary at all, given the similar outcomes among the different agents utilized. This review underscores the potential value of undertaking a multi-institutional prospective study to determine what is the best pharmacologic therapy following venous stent placement for NIVL.

Chronic venous insufficiency: Part 2 Diagnosis and treatment

Chronic venous insufficiency (CVI) is a common medical condition that results from venous hypertension of the extremities, leading to significant morbidity. The diagnosis of CVI is quite straightforward from patient history and obvious clinical manifestations. In the recent past, availability of various invasive and non-invasive modalities have assisted in evaluation of such cases. Although compression therapy is the mainstay of management, newer surgical and other interventional techniques are now being considered for patients who do not respond to conventional medical management. This review article will outline a diagnostic approach in cases of CVI and discuss the management principles encompassing conservative, pharmacological, and interventional options.

Pivotal Study Evaluating the Safety and Effectiveness of the Abre Venous Self-Expanding Stent System in Patients With Symptomatic Iliofemoral Venous Outflow Obstruction

Supplemental Digital Content is available in the text.

Background:

Iliofemoral venous obstruction is recognized with increasing frequency as the underlying cause of lower extremity symptoms including edema, pain, skin changes, and, in advanced cases, ulceration. This study sought to evaluate the safety and effectiveness of the Abre venous self-expanding stent system for the treatment of symptomatic iliofemoral venous outflow obstruction.

Methods:

The ABRE Study (A Multi-Center, Non-Randomized Study to Evaluate the Safety and Effectiveness of the Abre Venous Self-Expanding Stent System in Patients With Symptomatic Iliofemoral Venous Outflow Obstruction) is a single-arm, multicenter, prospective study that included 200 subjects from 24 global sites. The primary end points were 12-month primary patency and major adverse events within 30 days. Secondary end points included lesion and procedure success, primary-assisted and secondary patency, major adverse events, stent migration, stent fracture, and quality of life changes. End point-related adverse events and imaging studies were adjudicated by independent clinical events committee and core laboratories, respectively.

Results:

Venous obstruction cause was classified as acute deep vein thrombosis (16.5%, 33/200), post-thrombotic syndrome (47.5%, 95/200), or nonthrombotic iliac vein lesion (36.0%, 72/200). The common iliac and external iliac veins were stented in 96.0% (192/200), 80.5% (161/200) of subjects, respectively. Stent implant into the common femoral vein was required in 44.0% (88/200). Primary patency at 12 months was 88.0% (162/184). Four (2.0%) major adverse events occurred within 30 days. Twelve-month primary-assisted and secondary patency were 91.8% (169/184) and 92.9% (171/184), respectively. No stent fractures or migrations were reported. Mean target limb Villalta score decreased from 11.2±5.6 at baseline to 4.1±4.8 at 12 months, and the mean target limb revised Venous Clinical Severity Score decreased from 8.8±4.7 at baseline to 4.3±3.6 at 12 months. Clinically meaningful improvements in quality of life and venous functional assessment scores from baseline were demonstrated through 12 months in all measures.

Conclusions:

Symptomatic iliofemoral venous obstruction can be successfully treated with an Abre venous stent. Study outcomes demonstrated a high patency rate with a good safety profile. Patients demonstrated a significant reduction in clinical symptoms and improvement in quality of life that was maintained through 12-month follow-up.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03038438.

Partial In-Stent Thrombosis After Iliac Vein Stenting in Non-Thrombotic Vein Lesions

OBJECTIVE

Iliac vein stenting is a safe and efficacious procedure for the correction of iliac vein stenosis. One of its known major complications is complete iliac vein stent thrombosis. However, we have noticed in our practice that a number of patients developed only early partial in-stent (<60%) thrombosis, within the first 30 days. In order to try to learn more about these lesions, we reviewed the data for possible causes of these lesions.

MATERIALS/METHODS

From September 2012 to August 2018, we obtained 3518 iliac vein venograms using intravascular ultrasound (IVUS) for patients with venous insufficiency who failed to respond to conservative therapy. Patients were followed up with transcutaneous duplex ultrasound (DUS) every 3 months for the first year and every 6 - 12 months thereafter. Patients were prescribed clopidogrel for 3 months or were told to continue their pre-existing anticoagulants.

RESULTS

There were 2234 women and 1284 men who received an iliac vein stent. The mean age was 65.7 ±14 years. Mean follow-up for this cohort was 17 months. Of 74 patients developed a full thrombosis, 38 developed a partial venous thrombosis and 3406 developed no thrombosis. When comparing those who developed a partial thrombus versus those who developed no thrombus/full thrombus, overall age, laterality, CEAP, gender, and whether the patient received clopidogrel prior to the procedure and after the procedure were not found to be statistically significant factors. However, patients with an ASA score of 2 or 3,were found to be at a higher risk of developing a partial thrombus(P = 0.0223) compared to those who had an ASA score of 1 or 4. CEAP Scores and ASA class breakdown can be seen in Table 1 and Table 2, respectively. Of the 38 partial venous thrombosis that developed,18 completely resolved within the first 3 months after the procedure and 20 remained chronic past 3 months after the procedure. Patients with partial venous thrombosis were asymptomatic upon clinical presentation, and none developed post thrombotic syndrome (PTS) or pulmonary embolism (PE). Male gender was associated with partial thrombus resolution(P = 0.0036) CONCLUSIONS: Patients with ASA scores of 2 or 3, seemed to be at a higher risk of developing a partial thrombus when compared to patients with ASA score of 1 or 4. Male gender was associated with partial thrombus resolution. All other factors appear to not be statistically significant in impacting the development of a partial thrombus. This has been the first attempt to look at this new clinical entity.

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.

Treatment of Nonthrombotic Iliac Vein Lesions

Nonthrombotic iliac vein lesions (NIVLs) most frequently result from extrinsic compression of various segments of the common or external iliac vein. Patients develop symptoms associated with chronic venous insufficiency (CVI); female patients may develop symptoms of pelvic venous disease. Given that iliac vein compression can be clinically silent, a thorough history and physical examination is mandatory to exclude other causes of a patient's symptoms. Venous duplex ultrasound, insufficiency examinations, and axial imaging are most commonly used to assess for the presence of a NIVL. Catheter venography and intravascular ultrasound (IVUS) are the mainstay for invasive assessment of NIVLs and planning prior to stent placement. IVUS in particular has become the primary modality by which NIVLs are evaluated; recent evidence has clarified the lesion threshold for stent placement, which is indicated in patients with moderate to severe symptoms. In appropriately selected patients, stent placement results in improved pain, swelling, quality of life, and, when present, healing of venous stasis ulcers. Stent patency is well preserved in the majority of cases, with a low incidence of clinically driven need for reintervention. In this article, we will discuss the clinical features, workup, endovascular management, and treatment outcomes of NIVL.

Contemporary treatment of May-Thurner Syndrome

Compression of the left common iliac vein by the overlying right common iliac artery is a benign anatomic abnormality in most individuals. However, in patients with significant vein compression, outflow obstruction and chronic intraluminal venous damage may lead to May-Thurner Syndrome. This syndrome commonly manifests as unilateral left leg swelling or acute iliofemoral deep venous thrombosis. In addition to clinical findings, diagnosis is made with ultrasound, computed tomography venography, or magnetic resonance venography. The extent of compression of the iliac vein is best determined by venography with intravascular ultrasound. Symptoms and hemodynamic significance of the compression guides the ideal treatment approach. Iliocaval stenting has become the standard treatment for this condition and has promising patency rates and clinical outcomes. This review paper provides an overview of pathophysiology, and utility and limitations of the existing diagnostic modalities and treatment options in the management of May-Thurner Syndrome.

Dimensional disparity between duplex and intravascular ultrasound in the assessment of iliac vein stenosis

Minimum iliac vein caliber necessary to maintain normal peripheral venous pressure can be derived by the Poiseuille equation. Duplex was compared to intravascular ultrasound (IVUS) in the assessment of iliac vein stenosis in this single center retrospective study. Parallel IVUS and duplex caliber data for common iliac vein (CIV) and external iliac vein (EIV) in 382 limbs were separately compared. One or both segments were stenotic by IVUS criteria in 213 limbs. Neither segment was stenotic by IVUS in 22 limbs. Bland-Altman analyses and Passing-Bablok linear regressions were used. Duplex calibers were dimensionally smaller than corresponding IVUS images of CIV and EIV segments in Bland-Altman comparison by a mean of 54 mm² and 34 mm², respectively. Passing-Bablok regression suggested the difference was due to a systematic bias and not proportional. Duplex yields a smaller cross-sectional image of CIV and EIV compared to IVUS. Duplex is not a reliable diagnostic test for iliac vein stenosis.

Post-thrombotic syndrome

Post-thrombotic syndrome (PTS) is a chronic venous insufficiency manifestation following an episode of deep-vein thrombosis (DVT). It is an important and frequent long-term adverse event of proximal DVT affecting 20-50% of patients. This position paper integrates data guiding clinicians in deciding PTS diagnosis, treatment and follow-up.

A systematic review on the treatment of nonhealing venous ulcers following successful elimination of superficial venous reflux

OBJECTIVE

Nonhealing leg ulcers are frequently associated with the saphenous vein reflux. Despite the success of endovascular ablations, there are patients who either fail to heal or develop recurrent ulcers. This systematic review aims to summarize the available evidence on how to treat these patients after successful elimination of superficial reflux.

METHODS

A systematic review was performed following the PRISMA guidelines. The MEDLINE and Embase databases were searched for full text articles in English from 1946 to July 31, 2020. All articles that did not specifically mention the treatment of persistent venous ulcers or superficial venous reflux associated with healed or active venous ulcers were eliminated. The remaining abstracts were read for mention of either recurrent or persistent venous ulcers and, if mentioned, the full article was reviewed. All study designs were included. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers.

RESULTS

Four eligible studies including a total of 161 patients (177 limbs) with C6 disease were included in the review after the screening of 546 identified articles. A total of 62 patients were treated for persistent or recurrent venous ulcers after treatment of superficial reflux. Treatments included four-layer compression dressings, repeat ablations of superficial veins, and endovenous ablation of incompetent perforator veins. Overall, successful healing was noted in 50% of patients undergoing repeat ablative procedures, 100% of patients treated solely with four-layer compression dressings, and 90% of patients treated with compression and successful ablation of incompetent perforator veins. Across all studies the presence of deep vein reflux was 31% (50 of 164 limbs), post-thrombotic (secondary) ulcers 13.7% (16 of 117), and proximal obstruction was present in a single patient. Superficial venous reflux was treated using endovenous ablation (either radiofrequency ablation or laser), foam sclerotherapy, and endovenous radiofrequency ablation with or without microphlebectomy procedures. The frequency of persistent ulcers after elimination of superficial reflux ranged from 2.3% at 2 years after the intervention to 21.1% at 1 year with follow-up ranging from 6 to 52 months.

CONCLUSIONS

Although further studies are warranted to improve the quality of evidence, it seems that additional ablative procedures to address incompetent perforating veins and persistent superficial reflux in combination with ongoing compression therapy is effective in healing persistent or recurrent venous ulcers after the elimination of superficial venous reflux.

DEep VEin Lesion OPtimisation (DEVELOP) trial: protocol for a randomised, assessor-blinded feasibility trial of iliac vein intervention for venous leg ulcers

BACKGROUND

Venous leg ulceration is a widespread, debilitating pathology with high recurrence rates. Conservative treatment using graduated compression dressings may be associated with unacceptable ulcer recurrence rates. Early superficial venous ablation encourages ulcer healing and reduces recurrence. However, many of this cohort display concomitant ilio-caval stenosis, which further contributes to lower limb venous hypertension and ulceration. An approach that combines early superficial venous ablation with early treatment of ilio-caval stenotic disease may significantly improve ulcer healing and recurrence rates. We question whether early iliac vein interrogation with intravascular ultrasound (IVUS), stenting of significant occlusive disease plus superficial venous ablation, in patients with active venous leg ulceration, will produce superior ulcer healing to standard therapy.

METHODS

This is a prospective, multi-centre, randomised controlled, feasibility trial recruiting patients with lower limb venous ulceration and saphenous venous incompetence. Patients will be randomised to undergo either truncal ablation and compression therapy or truncal ablation, simultaneous iliac interrogation with intravascular ultrasound and stenting of significant (> 50%) iliac vein lesions plus compression therapy. The primary feasibility outcome will be the rate of eligible patient participation while the primary clinical outcomes will be ulcer healing and procedural safety. Secondary outcomes include time to healing, quality of life and clinical scores, ulcer recurrence rates and rates of post-thrombotic syndrome. Follow-up will be over a 5-year period. This feasibility trial is designed to include 60 patients. Should it be practicable a total of 594 patients would be required to adequately power the trial to definitively address ulcer-healing rates.

DISCUSSION

This trial will be the first randomised trial to examine the role iliac interrogation and intervention in conjunction with standard operative therapy in the management of venous ulceration related to superficial truncal venous incompetence.

ETHICAL COMMITTEE REFERENCE

C.A. 2111 Galway Clinical Research Ethics Committee REGISTRATION: Clinical Trials.gov registration NCT03640689 , Registered on 21 August 2018.

[Case of endovenectomy and stenting with functioning arteriovenous fistula in extended post-thrombotic occlusion of deep veins]

We describe herein a case of surgical treatment of a 32-year-old female patient presenting with multilevel post-thrombotic occlusion of deep veins of the left lower limb. Laboratory study revealed high-risk hereditary thrombophilia (homozygous mutation of PAI-1, MTR, heterozygous mutation of MTHFR, MTRR, ITGA2). The first stage included endovenectomy from the common femoral vein with creation of an arteriovenous fistula between femoral vessels. An attempt of endovascular stenting of iliac veins was initially unsuccessful. After 3 months, the woman was rehospitalized to undergo successful endovascular operation with stenting of the iliac veins and common femoral artery on the background of the functioning arteriovenous fistula. The clinical outcome of the operation was good. Follow-up ultrasonographic examinations (ultrasound duplex scanning) were performed at 3, 6, 10 and 13 months after the second operation. The findings of ultrasound duplex scanning at 13 months showed that the stented segments of deep veins were freely patent, with the arteriovenous fistula functioning well. There were no signs of impairments of central haemodynamics, with significant regression of clinical symptoms. The total score by the Villalta scale as compared with the baseline values decreased from 13 to 5. Given the pattern of deep vein lesions, complexity of open and endovascular operations, and the presence of thrombophilia, we decided to abstain from disuniting the arteriovenous fistula. This case report demonstrates possibility, efficacy and safety of long functioning of an artificial arteriovenous fistula in a particular patient cohort.

Comparing Safety and Efficacy of Rivaroxaban with Warfarin for Patients after Successful Stent Placement for Chronic Iliofemoral Occlusion: A Retrospective Single Institution Study

OBJECTIVE

The aim was to compare the safety and effectiveness of rivaroxaban and warfarin as anticoagulants for treating patients with post-thrombotic syndrome (PTS) with chronic iliofemoral venous occlusion undergoing iliofemoral venous stenting.

METHODS

This single institution retrospective study analysed patients with PTS with chronic iliofemoral venous occlusion who were prescribed rivaroxaban or warfarin for one year after successfully undergoing iliofemoral venous stenting. The primary safety and efficacy endpoints were bleeding complication rate and primary patency rate at one year. Secondary outcomes included Villalta score, symptom recurrence rate, ulcer healing rate, and clinically driven target lesion revascularisation (CD-TLR) rate during follow up.

RESULTS

From January 2016 to December 2017, 154 legs from 154 patients were included in this study (69 in rivaroxaban group and 85 in warfarin group). The groups were well matched for patient demographics, clinical characteristics, and procedural details. There was no significant difference between the rivaroxaban group and warfarin group in bleeding complication rate (10% vs. 16%, p = .23, hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.25 - 1.37) at one year, as well as major bleeding complication rate (0% vs. 2%, p = .20, HR 0.16, 95% CI 0.01 - 2.61) and minor bleeding complication rate (10% vs. 14%, p = .40, HR 0.67, 95% CI 0.27 - 1.66). The primary patency rate was higher in the rivaroxaban group at one year (84% vs. 71%, p = .049, HR 0.50, 95% CI 0.26 - 0.96) and at two years (79% vs. 63%, p = .037, HR 0.52, 95% CI 0.29 - 0.93). At a mean follow up of 24 months (range 1 - 42 months), the rivaroxaban group had a significantly lower post-operative Villalta score (4.87 ± 3.51 vs. 6.88 ± 5.85, p = .010, t = 2.64, 95% CI 0.50 - 3.52), lower rate of symptom recurrence (4% vs. 32%, p < .001), lower CD-TLR rates (3% vs. 13%, p = .039), and higher ulcer healing rate (90% vs. 59%, p = .004) than the warfarin group.

CONCLUSION

For PTS patients with chronic iliofemoral venous occlusion undergoing iliofemoral venous stenting, rivaroxaban probably exhibited similar safety but superior efficacy to warfarin. However, further prospective control studies with large sample size are necessary to confirm the results.

Role of venous stenting for venous thromboembolism

Endovenous stenting has emerged as the method of choice to treat iliofemoral venous outflow obstruction. It is used in patients with established postthrombotic syndrome (PTS) after previous deep vein thrombosis (DVT) to reduce symptoms of chronic pain and swelling and to aid ulcer healing in severe cases. Venous stenting is used to alleviate symptoms of obstruction in patients presenting with acute DVT, with the aim of preventing development of PTS. There is a low risk of morbidity and mortality associated with the use of endovenous stenting, and although significant advances have been made, particularly improvements in stent design for use in the venous circulation, data are lacking on beneficial long-term outcomes. Unmet research needs include optimal patient selection, anticoagulant choice and duration, best practice for postoperative surveillance, and use of validated assessment tools to measure outcomes. In this article, I address the potential benefits, as well as the challenges, of endovenous stenting.

Dyeless iliac vein stenting

OBJECTIVE

Iliac vein stenting is increasingly being explored for the treatment of chronic venous insufficiency. While venography is considered the gold standard for assessing iliac veins, some have proposed that intravascular ultrasound should be utilized instead due to its greater sensitivity at detecting stenotic lesions. Routinely, our service uses both intravascular ultrasound and venography, but we have noted that some patients cannot tolerate dye due to allergy, renal insufficiency, or deemed high-risk by the interventionalist due to uncontrolled medical co-morbidities. This study aimed to investigate whether forgoing dye had an impact on iliac vein stent thrombosis.

METHODS

From 2012 to 2016, 1482 iliac vein procedures (91 intravascular ultrasound-only and 1391 intravascular ultrasound plus venography) were performed on 992 patients who failed conservative treatment for chronic venous insufficiency. Our mean patient age was 65.8 years (range 21-99; SD ± 14.3) with 347 male and 645 female patients. The clinical presenting symptoms per clinical-etiology-anatomy-pathophysiology classification for the intravascular ultrasound-only cohort were C1:0, C2:3, C3:31, C433, C5:5, C6:20 and for the intravascular ultrasound plus venography cohort were C1:0, C2:24, C3:566, C4:583, C5:30, C6:188. Stent thrombi that developed within or at 30 days of stenting were categorized as early and greater than 30 days as late. Transcutaneous duplex ultrasound classified stent thrombi as either partial or occlusive. Our average follow-up time was 19.4 months (0-42, SD ± 12.5).

RESULTS

A total of 2.2% intravascular ultrasound-only patients versus 2.75% intravascular ultrasound plus venogram patients developed early stent thrombosis, p = 0.35. Early partial stent thrombosis occurred in 1.1% of the intravascular ultrasound-only group versus 2.6% of the intravascular ultrasound plus venogram group, p = 0.38. Early occlusive stent thromboses occurred in 1.1% of intravascular ultrasound-only patients and 0.15% of intravascular ultrasound plus venogram patients, p = 0.06. Late stent thromboses developed in 4% of patients in the intravascular ultrasound-only cohort and 4% in the intravascular ultrasound plus venogram cohort, p = 0.97. Late partial stent thromboses occurred in 2.7% of intravascular ultrasound-only patients versus 2.6% in intravascular ultrasound plus venogram patients, p = 0.99. Late occlusive stent thromboses occurred in 1.3% of intravascular ultrasound-only patients versus 1.4% of intravascular ultrasound plus venogram patients, p = 0.95. Moreover, the formation of any stent was 6.2% in the intravascular ultrasound-only versus 6.75% in the intravascular ultrasound plus venogram group, p = 0.55.

CONCLUSION

Results of our study show no significant difference in stent thrombosis between the intravascular ultrasound-only and intravascular ultrasound plus venogram cohorts. This concludes that using intravascular ultrasound alone is safe for iliac vein stenting.

Ambulatory venous pressure, air plethysmography, and the role of calf venous pump in chronic venous disease

BACKGROUND

Ambulatory venous pressure (AMVP) records pressure dynamics with calf exercise. Air plethysmography (APG) measures related volume detail. APG has been suggested as a noninvasive surrogate for AMVP. We examine the correlations between APG and AMVP parameters and the role of "calf pump failure" in chronic venous disease (CVD).

METHODS

A total of 8456 limbs in 4610 patients investigated for CVD during a 20-year period were analyzed. APG and AMVP data were available in 4599 limbs for calculation of Pearson correlation coefficient; 1347 of these limbs had significant iliac vein stenosis, proven by intravascular ultrasound. Venn diagrams are used to explore overlapping incidence of APG and AMVP abnormalities.

RESULTS

APG calf volume and reflux (venous volume, venous filling index) showed progressively significant deterioration with advancing Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class, anatomic extent of reflux (superficial, deep, perforator), and reflux severity (axial reflux, segmental score). Notably, calf ejection volume increased in a nearly linear fashion (R = 0.71) to venous volume such that residual volume fraction (RVF) remained normal even in the worst of these categories. AMVP too progressively deteriorated with clinical disease and reflux severity. Venous filling time was the key parameter as the pressure drop alone was abnormal in only 4% of the limbs analyzed. There was no correlation between RVF and AMVP (R = 0.22) or between AMVP and many other APG parameters. Venn distribution showed only minor overlap (30%) between AMVP and key APG abnormalities overall, but the overlap increases from 40% to 70% in advanced clinical and reflux categories. AMVP was rarely abnormal (7%) when APG was normal. Median AMVP was normal in calf pump failure categories, however defined (subnormal ejection fraction, RVF, or both). Median AMVP is normal in venous obstruction without reflux, while AMVP abnormalities are associated three to seven times more with reflux than with obstruction.

CONCLUSIONS

APG (venous filling index) is a useful index of reflux. Calf pump ejection is a powerful and plastic compensatory mechanism, and calf pump failure is rare. Ambulatory venous hypertension is dominantly associated with reflux and less with obstruction. AMVP too worsens with clinical and reflux severity categories. However, there is little correlation between APG and AMVP parameters as APG measures volume and AMVP measures pressure, each in its own domain, and the volume-pressure curve is nonlinear. AMVP may be omitted in routine clinical testing if APG is normal, as the yield (7%) will be very low. AMVP reflects venous hypertension, the end stage in CVD. AMVP should be used to identify such cases when APG is abnormal.

Treatment of superficial and perforator reflux and deep venous stenosis improves healing of chronic venous leg ulcers

OBJECTIVE

To evaluate the impact of three treatment modalities, superficial truncal vein ablation, perforator vein ablation, and deep venous stenting on venous leg ulcer (VLU) healing, as well as their cumulative effect on ulcer healing, in an attempt to establish the best algorithm for the treatment of chronic and recalcitrant VLUs.

METHODS

Multicenter retrospective cohort study using a standardized database to evaluate patients with chronic venous ulcers treated between January 2013 and December 2017.

RESULTS

Eight-hundred thirty-two consecutive patients with VLU were identified at 11 centers in the United States. All patients were initially managed with wound care and compression for at least 2 months. Compression and wound care management alone, used in 187 patients, led to ulcer healing in 75% of patients by 36 months. Ulcer recurrence in patients managed without surgery at 6, 12, and 24 months was 3%, 5% and 15%, respectively. Five hundred twenty-eight patients underwent ablation of incompetent superficial veins, and 344 of those also underwent incompetent perforator ablation. Patients who underwent truncal vein ablation alone had an ulcer healing rate of 51% at 36 months. Patients who received both superficial and perforator ablation were significantly younger, and had a 17% improvement in healing at 36 months (68% vs 51%, respectively), but there was no impact of combined superficial and perforator ablations on ulcer recurrence rates. One hundred thirty-four patients had stenosis of one of more lower extremity deep veins and 95 (71%) underwent endovenous stenting. Ulcer healing and recurrence rates for those who underwent stent placement alone was 77% and 27%, respectively, at 36 months. Patients who underwent deep venous stenting and ablation of both incompetent truncal and perforator veins had an ulcer healing rate of 87% at 36 months and ulcer recurrence of 26% at 24 months.

CONCLUSIONS

This study demonstrates that correction of superficial truncal vein reflux, as well as deep vein stenosis, both contribute to healing of VLU. Patients who fail to heal their VLU after superficial and perforator ablation should have the iliocaval system imaged to identify hemodynamically significant stenoses or occlusions amenable to stenting, which facilitates venous ulcer healing even in patients with large ulcers.

Iliac Vein Stenting for Chronic Proximal Venous Outflow Obstruction in a Predominantly Asian-American Cohort

BACKGROUND

We investigated the outcome of vein stenting placement for chronic proximal venous outflow obstruction (PVOO) in a predominantly Asian-American cohort to improve patient selection, enhance technical approach, and better define quality measurements of this emerging vascular intervention.

METHODS

A total of 462 consecutive patients, 73% Asian American (n = 336), who underwent iliac vein stenting for chronic PVOO from October 2013 to July 2016 were reviewed. Postoperative outcomes at five follow-up visits were assessed. Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were run for demographic and operative variables. Ordered logistic regressions were run for the outcome at each time point, and Chi-squared tests as well as Fisher's exact tests were used for categorical variables.

RESULTS

Follow-up was maintained in 90% of patients, with a mean follow-up time of 695 days. Asian-American patients were more likely to present with varicose veins (77.4% vs. 54.8%, P < 0.001), and non-Asian patients were more likely to present with active ulceration (26.2% vs. 5.1%, P < 0.001). Asian-American patients were more likely to have bilateral stents placed (61.6% vs. 50%, P = 0.026) and were less likely to have reinterventions (11.3% vs. 27.8%, P < 0.001), a history of deep vein thrombosis (8.3% vs. 29.4%, P < 0.001), or intraoperative findings of chronic postphlebitic changes (17.6% vs. 33.3%, P < 0.001). Kruskal-Wallis tests were significant for improvement in patients of all the Clinical, Etiology, Anatomy, Pathophysiology classes at 30 days (P = 0.041), 90 days (P = 0.045), 6 months (P = 0.041), and 1 year (P < 0.01). The Asian-American population had improved but comparatively lower follow-up scores at the 30-day mark (48% significantly improved or better vs. 63%, P = 0.008) but higher follow-up scores at the >1 year mark (80% significantly improved or better vs. 59%, P < 0.001).

CONCLUSIONS

Asian-American patients undergoing vein stent placement for chronic PVOO had comparatively worse outcomes than non-Asian patients at 30 days and better outcomes after one year. These patient groups had different outcomes postoperatively and outcomes which evolve differently over time.