The effect of stent placement for May-Thurner syndrome combined with symptomatic superficial venous reflux disease

Efficacy Analysis of Endovascular Therapy for Nonthrombotic Iliac Vein Compression Syndrome Combined with Chronic Venous Insufficiency

Purpose

This research is aimed at elucidating the clinical efficacy of balloon dilatation (BD) plus stent implantation for nonthrombotic iliac vein compression syndrome (NIVCS) combined with chronic venous insufficiency (CVI) in different compression positions.

Methods

Sixty-five NIVCS patients comorbid with CVI admitted between December 2015 and April 2020 were selected and assigned to two groups according to different iliac vein compression positions. Both groups of patients received iliac vein BD + stent implantation, with the difference lying in that the tip of the stent was inserted 0.5-1 cm into the inferior vena cava (IVC) in the experimental group versus 2-3 cm in the control group. The technical success rate, the postoperative venous clinical severity score (VCSS), and the incidence of complications were compared.

Results

The technical success rate of both groups was 100%. Patients were followed up for 12-36 months (average: 25.5 ± 6.2). Decreases in VCSS were observed in both cohorts at 3, 6, 12, 24, and 36 months postoperatively compared with the preoperative scores, but with no statistical difference. There was no death, nor related complications such as restenosis and lower limb deep vein thrombosis during the follow-up period, with no statistical difference in the incidence of complications between groups.

Conclusions

BD + stent implantation is a safe and effective treatment for NIVCS with few complications and remarkable short-term and medium-term effects.

Clinical outcomes of different endovenous procedures among patients with varicose veins and iliac vein compression: A retrospective cohort study

OBJECTIVE

This study aimed to investigate the short-term outcomes of three endovenous procedures in patients with varicose veins (VVs) and severe iliac vein compression syndrome (IVCS).

METHODS

A total of 158 consecutive patients were included in this multicenter retrospective study from May 2017 to December 2019; 54 patients underwent endovenous laser ablation (EVLA) alone, 47 patients underwent EVLA and balloon angioplasty (BA), and 57 patients underwent EVLA and stenting angioplasty (SA). Clinical outcomes and complications were assessed at one and twelve months post-surgery. The Quality of life (QoL) was assessed by the venous clinical severity score (VCSS) and Aberdeen Varicose Vein Questionnaire (AVVQ).

RESULTS

Patients who underwent the SA procedure were older (P < 0.05). Incidence of laser ablation complications was similar among the three procedures; closure rates of the great saphenous vein were 96.8%, 98.0%, and 98.4%, respectively, at 12 months. Reflux times in the SA procedure were lower than those in the EVLA and BA procedures at 12 months, while ulcer healing time was faster with the SA procedure (P < 0.05) than with the other procedures. The VCSS and AVVQ values were significantly improved post-procedure (P < 0.05), with lower AVVQ scores in the SA procedure than in the EVLA and BA procedures at 12 months post-surgery. The EVLA and BA procedures (stenosis >70%) caused a significantly higher symptom recurrence than the SA procedure, with an odds ratios of 14.04 (95% confidence interval (CI), 1.99-99.18) and 10.50 (95% CI, 1.26-87.15), respectively.

CONCLUSIONS

Our results demonstrate that EVLA and SA procedures relieve symptoms, improve the QoL, and decrease symptom recurrence in patients with VVs and severe IVCS (stenosis >70%).

A systematic review of management of superficial reflux in the setting of deep venous obstruction

BACKGROUND

Due to fear of obliterating collateral outflow path and thus worsening venous hypertension, many physicians believe that deep venous obstruction is a contraindication for treatment of superficial venous reflux. This review will present the available clinical data in this important group of patients.

METHODS

A literature search was performed on PubMed, Web of Science and Google scholar to identify clinical research studies between 1991 and 2021 evaluating the concomitant management of superficial reflux and deep venous obstruction. Studies were excluded if they reported on less than 5 patients, did not specify interventions to treat superficial reflux or had no follow-up data available. All studies included were observational, and their quality assessed using the Newcastle-Ottawa scale.

RESULTS

Ten retrospective cohort studies were included, encompassing a total of 2476 limbs in 2428 patients out of which concurrent superficial venous reflux (SVR) and deep venous obstruction (DVO) or a known history of DVT were managed in 944 limbs. Eight of the studies were comparative. The level of deep venous obstruction was supra-inguinal when specified in most cases. The mean age ranged between 42 and 65 years, and 1432 patients (59%) were female and advanced CVD (i.e. CEAP C4-6) was present in 614 limbs (70%) with two studies reporting uniquely on C6 patients. Out of the 944 limbs treated for concomitant SVR and DVO, a combination of saphenous vein ablative procedures and deep venous stenting (DVS) was carried out in 483 limbs (51.2%), saphenous vein ablative procedures alone in 293 limbs (31%) and DVS alone in 168 (17.8%). Out of the five studies comparing different treatment strategies of concurrent SVR and DVO, four reported better outcomes after a combined deep venous stenting and saphenous vein ablation compared to ablation alone. Studies comparing the outcomes of saphenous ablation in patients with reflux alone versus patients with concurrent reflux and DVO did not find any significant difference in clinical improvement and postoperative complication rates.

CONCLUSION

Current evidence is weak owing to limited number of studies and small sample size but suggests that ablation of superficial venous reflux is safe in patients with concurrent deep venous obstruction. Patients with advanced venous disease and iliac vein obstruction have better results when superficial reflux ablation is combined with treatment of iliac vein obstruction. Additional contemporary studies are needed to confirm the safety and specifically investigate the efficacy of superficial reflux ablation in relieving symptoms in patients with concurrent infrainguinal obstruction.

May-Thurner syndrome

May-Thurner syndrome (MTS) is a venous compression syndrome in which the left common iliac vein (LCIV) is compressed between the lower lumbar spine and the right common iliac artery (RCIA). Variations are known where in the right lower limb can be affected. While most of the cases are asymptomatic, it can cause severe morbidity in symptomatic individuals, most commonly deep vein thrombosis and post thrombotic sequelae. In this article, we review the key clinical features, multimodality imaging findings and treatment options of this disorder. Our goal is to raise awareness of this under-diagnosed condition among clinicians in order to promote early detection and recognition to enhance positive and expedited outcomes.

May Thurner syndrome: Sixty years later

May-Thurner syndrome (MTS) was described sixty years ago. Once ignored for several years, it is currently a recognized pathology in the vascular surgery community; but not long ago due to several factors, it was underdiagnosed and sub-optimally treated. In the last 20 years, with renewed interest in venous pathology, technical imaging advances and the recent interventional procedures, it has become a better known disease. On the other hand, nowadays the easiness in diagnosis and treatment of the syndrome has lead to overtreatment of such patients. In this article, we do a historical review and describe the significant advances and current management of May-Thurner syndrome.

Single-stage treatment with iliac vein stenting and stripping of great saphenous veins for patients with left iliac vein compression syndrome

BACKGROUND

We sought to evaluate the safety and feasibility of single-stage treatment with left iliac vein stenting and saphenous stripping in patients with left iliac vein compression (LIVC) and left great saphenous vein (GSV) incompetence.

METHOD

s: We conducted a prospective cohort study of 72 patients diagnosed with LIVC and left GSV incompetence between June 2012 to Oct 2018. We evaluated the periprocedural, 30-day, and 1-year outcomes of venous clinical severity score (VCSS), Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), the success rate of stent placement, duration of intervention, length of hospital stay, duplex recurrence, and clinically visible recurrence.

RESULTS

There were 43 patients in the two-staged group and 29 patients in the single-staged group. The clinical characteristics of the two groups were similar. There were no differences between the two groups in the technical success rate, perioperative mortality, and surgical morbidity. There was no significant difference in the duplex and clinically visible recurrence. The length of hospital stay was significantly lower in the single-staged group. The single-staged group was associated with a higher complication rate of ecchymosis. There was no death, pulmonary embolism, or contrast-induced nephropathy among the patients. The 1-year primary patency rate was similar.

CONCLUSIONS

Both treatment approaches were equally effective and had a high technical success rate. The single-staged group had a higher complication rate of ecchymosis due to heparin applying during the procedure.

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.

Outcomes of endovenous laser ablation with additional iliac vein stenting of nonthrombotic lesions in patients presenting with active venous ulcers

OBJECTIVE

We evaluated the clinical outcomes of superficial and perforator ablation and the effects on wound healing by adding iliac vein stenting of nonthrombotic iliac vein lesions (NIVLs) in patients presenting with active venous ulcers.

METHODS

A retrospective analysis was performed of patients who had presented with venous ulcers and had a diagnosis of NIVLs from January 2017 to December 2019. Patients with a >50% diameter reduction in the iliac vein as determined by computed tomography venography had undergone transfemoral venography for further confirmation. Patients were divided into the endovenous laser ablation (EVLA) group and EVLA with stenting (EVLAS) group. The EVLA group had undergone endovascular laser treatment of superficial venous reflux, and the EVLAS group had undergone EVLA and stenting for NIVLs. The clinical outcomes were compared between the two groups. The primary endpoint was cumulative ulcer healing at 12 months. The secondary endpoints included complications, venous clinical severity score improvements, and pain scores during the follow-up period. Univariable and multivariable regression models were used to determine the refractory ulcer predictors.

RESULTS

A total of 157 patients were included, 93 in the EVLAS group and 64 in the EVLA group. Of the 93 patients in the EVLAS group and patients in the EVLA group, 30 (32.26%) and 17 (26.56%) had presented with iliac venous occlusion, respectively (P = .48). The mean percentage of stenosis was 78.0% ± 13.6% in EVLAS group and 77.0% ± 14.0% in the EVLA group (P = .36). No significant differences in the general preoperative data were observed between the two groups. Cumulative ulcer healing at 1 year was 86.8% and 65.6% in the EVLAS and EVLA groups, respectively (P = .001). After a mean follow-up of 22 months (median, 24 months), the EVLAS group had a significantly improved venous clinical severity score compared with the EVLA group (EVLAS group, 8.3; EVLA group, 11.7; P = .01). Multivariable analysis of the entire cohort showed that obesity and employment that requires standing were predictive of refractory ulcers and that iliac venous stent placement was a protective factor for ulcer healing.

CONCLUSIONS

The results of the present study have suggested an association between improvement in the overall success of venous leg ulcer healing when including treatment of NIVLs with stents into a treatment plan that already includes saphenous and perforator vein ablation.

Three-dimensional computed tomography venography reconstruction facilitates identification of atypical radiologic features of May-Thurner syndrome

OBJECTIVE

May-Thurner syndrome (MTS) is typically characterized by compression of the left common iliac vein by the overlying right common iliac artery. The present study evaluated the occurrence of atypical imaging features of MTS using three-dimensional computed tomography venography reconstruction (3D-CTV) and analyzed their correlation with clinical features.

METHODS

We analyzed the data from 268 patients with left lower extremity chronic venous disease (CVD) using 3D-CTV at a single institution from January to June 2019. An area stenosis percentage >50% was defined as significant venous compression. Of the 268 patients, 92 had at least one significant iliac and/or vena cava compression confirmed by 3D-CTV. Of the 92 patients, 89 underwent digital subtraction venography via the left common femoral vein, and the outcomes were compared with their 3D-CTV findings. Different types of venous compression were evaluated using 3D-CTV. The relationship among compression type, sex, age, and CVD symptoms was evaluated.

RESULTS

A total of 106 venous compression sites were found in 92 patients. Atypical compression included inferior vena cava (IVC) compression and partial IVC compression (8.5% and 55.7%, respectively). Multiple compression sites were present in 13 patients (14.1%). The compression sites correlated significantly with clinical symptoms (P = .017) and were related to sex (P = .001). The number of patients with IVC and partial IVC compression but false-negative venography findings was four (33.3%) and six (50%), respectively.

CONCLUSIONS

3D-CTV facilitates the detection of atypical venous compression in patients with MTS with notable chronic symptoms. Patients with multiple compression sites had more severe clinical symptoms and greater false-negative rates with venography. IVC compression was more likely to occur in female patients with MTS.

Iliac vein stenting is a safe and effective treatment for iliac vein compression syndrome: A systematic review of Chinese data

OBJECTIVES

This study was a systematic review of available data from China, and our aim was to evaluate the safety and efficacy of stenting in iliac vein compression syndrome.

METHODS

We searched the PubMed, National Knowledge Infrastructure, Chongqing Weipu Information Company, and Cochrane Central Register for Controlled Trials databases, and key references.

RESULTS

Twelve studies were included (nine retrospective analyses, two retrospective case series studies, and one prospective cohort study) involving 2292 patients and 1897 stented limbs. The overall primary patency rates ranged from 81.8% to 100%. Studies showed significant improvements in patients' symptoms, and ulcer healing rates ranged from 71.4% to 100% in stented limbs. The incidence of severe complications ranged from 0 to 16.8%.

CONCLUSIONS

For Chinese patients with iliac vein compression syndrome, stenting provided significant efficacy regarding favorable patency rates, symptom relief, and complications. However, the quality of evidence to support the use of iliac vein stenting to treat iliac vein compression syndrome is currently weak, especially for Chinese patients.