Common femoral endovenectomy in conjunction with iliac vein stenting to improve venous inflow in severe post-thrombotic obstruction

Review of the literature supporting international clinical practice guidelines on iliac venous stenting and their applicability to Australia and New Zealand practice

BACKGROUND

The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO).

METHODS

A group of vascular surgeons from Australia and New Zealand with specific interest, training, and experience in the management of VOO were surveyed to assess current local practices. The results were analyzed and areas of disagreement identified. After this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely, the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. A selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. The final recommendations were further reviewed and endorsed by another group of venous experts.

RESULTS

The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with clinically relevant VOO, a Clinical-Etiologic-Anatomic-Physiologic score of ≥3 or a Venous Clinical Severity Score for pain of ≥2, or both, including venous claudication, with evidence of >50% stenosis should be considered for venous stenting (Level of Recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should also be considered for venous stenting (Level of Recommendation Ic). Asymptomatic patients should not be offered venous stenting (Level of Recommendation IIIc). Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion of >50% has been uncovered, should be considered for venous stenting (Level of Recommendation Ib).

CONCLUSIONS

Patients with VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. International guidelines aimed at developing standards of care to avoid undertreating and overtreating patients are applicable to Australia and New Zealand practice and will serve as an educational platform for future developments.

Femoral vein stenting versus endovenectomy as adjuncts to iliofemoral venous stenting in extensive chronic iliofemoral venous obstruction

PURPOSE

To compare femoral endovenectomy with the creation of an arteriovenous fistula (FE + AVF), versus iliofemoral endovenous stenting with the concurrent extended femoral vein (FV-S) stenting in patients with chronic iliofemoral venous obstruction (IFVO).

MATERIALS AND METHODS

In a randomized prospective single-center study, 48 received (FV-S), while the other 54 had (FE + AVF).

RESULTS

There were no statistically significant differences in the primary outcomes between the two groups (FV-S) and (FE + AVF) (59% vs 56.8%, 75% vs 79.1%, respectively). At a median of 13 months after the treatment. However, the FV-S group's patients experienced fewer postoperative problems (p = .012), shorter procedures (p = .001), and shorter stays in the hospital (p = .025).

CONCLUSION

There is no difference between the efficacy and symptomatic resolution of the FV-S group and the FE + AVF group at the same time, FV-S has lower postoperative complications and a shorter procedure duration and hospital stay.

Criteria to predict midterm outcome after stenting of chronic iliac vein obstructions (PROMISE trial)

BACKGROUND

Endovenous stent placement has become a first-line approach to prevent post-thrombotic syndrome in patients with chronic post-thrombotic obstruction (PTO) or nonthrombotic iliac vein lesions if conservative management fails. This study aims to identify factors associated with loss of patency to facilitate patient selection for endovenous stenting.

METHODS

We retrospectively analyzed 108 consecutive patients after successful endovenous stenting for chronic vein obstruction performed at a single institution from January 2008 to July 2020. Using multivariable logistic regression, we explored potential predictive factors for loss of stent patency, including baseline demographics, post-thrombotic changes, and peak flow velocities measured in the common femoral vein (CFV), deep femoral vein, and femoral vein (FV) using duplex ultrasound examination.

RESULTS

The mean follow-up duration was 41 ± 26 months, and participants had a mean age of 47.4 ± 15.4 years with 46.3% women. Ninety (83.3%) patients had PTO and 18 (16.7%) had nonthrombotic iliac vein lesions, predominantly due to May-Thurner syndrome. Loss of patency occurred in 20 (18.5%) patients, all treated for PTO. Comorbidities, side of intervention, and sex did not differ between patients with occluded and patent stents. Stent occlusion was more common with increasing number of stents implanted (P < .001) and with distal stent extension into and beyond the CFV (P < .001). Preinterventional predictive factors for stent occlusion were lower duplex ultrasound peak velocity in the CFV (odds ratio [OR]: 7.52, 95% confidence interval [CI]: 2.54-22.28; P < .001) and FV (OR: 10.75, 95% CI: 2.07-55.82; P < .005), and post-thrombotic changes in the deep femoral vein (OR: 4.51, 95% CI: 1.53-13.25; P = .006) and FV (OR: 3.62: 95% CI: 1.11-11.84; P = .033). Peak velocities of ≤7 cm/s (interquartile range: 0-20 cm/s) in the CVF and ≤8 cm/s (interquartile range: 5-10 cm/s) in the FV were significantly associated with loss of patency.

CONCLUSIONS

Insufficient venous inflow as assessed by low peak velocities in the CFV and FV as well as post-thrombotic findings represent reliable risk predictors for stent occlusions, warranting their inclusion into the decision-making process for invasive treatment of PTO.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of endovascular strategy versus hybrid procedure in treatment of chronic venous obstructions involving the confluence of common femoral vein

OBJECTIVE

Treatment of extensive chronic venous obstruction (CVO) with post-thrombotic trabeculation involving the common femoral vein with extension into the femoral vein or deep femoral vein remains a challenge and the best treatment technique for such cases is not clear. In the present study, we compared the results of endovascular alone vs endovascular with additional endophlebectomy (hybrid) procedures for such patients.

METHODS

The medical records of 102 consecutive patients (108 limbs) treated between 2015 and 2020 for iliofemoral CVO extending to the femoral confluence were retrospectively reviewed. The patients were divided into two groups: the hybrid procedure (HP) and endovascular treatment (EN) groups. The HP group consisted of those treated with stent implantation and endophlebectomy of the common femoral vein with creation of an arteriovenous fistula. The EN group included those who had undergone stent implantation alone. The patency rates, complications, and clinical outcomes were analyzed.

RESULTS

Of the 102 patients, 47 (49 limbs) were in the EN group and 55 (59 limbs) were in the HP group. The demographics of the two groups were similar with no statistically significant differences in cumulative primary, assisted primary, or secondary patency rates at 36 months (33.7% vs 36.3%, P = .839; 59.8% vs 64%, P = .941; 69% vs 72.7%, P = .851; respectively). The patients in the EN group, however, had better clinical improvement with a lower postoperative complication rate (P = .012), shorter procedure duration (P < .001), and shorter hospital stay (P = .025).

CONCLUSIONS

The EN and HP both provided similar patency rates for patients with CVO extending into the femoral confluence. The endovascular strategy has the benefit of fewer postoperative complications and a shorter procedure duration and hospital stay compared with the HP.

Endovascular treatment of iliofemoral vein obstruction below the inguinal ligament using a new-dedicated stent: early experience from a single center

BACKGROUND

The aim of this study was to assess our experience with a new commercially available venous stent as an extension below the inguinal ligament in patients with iliofemoral venous outflow obstruction involving the common femoral vein.

METHODS

We treated 16 patients with iliofemoral venous outflow occlusion and post-thrombotic syndrome (PTS) (mean age: 52.5±20.2; female: 87.5%) with the Blueflow Venous Stent (plusmedica GmbH & Co. KG, Düsseldorf, Germany) between 2019 and 2020. All patients had unilateral venous disease with >50% stenosis in the iliofemoral veins. The primary endpoints assessed were technical success, primary and secondary patency rate at 1 year of follow-up, respectively. Clinical improvement was assessed with the Villalta Scale, revised venous clinical severity score (rVCSS) classification and visual analog-scale (VAS) respectively.

RESULTS

The technical success rate was 100%. No intraoperative and 30-days postoperative complications were documented. The primary and secondary patency rates were 80.2% and 100% respectively, at 1 year of follow-up. One in-stent occlusion and two in-stent restenosis were detected during follow-up. Stent fracture and/or migration were not observed during follow-up. A significant improvement in the Villalta Scale and rVCSS score was documented with a median score of 3 (IQR: 2-6) and 2.5 (IQR: 1-5) versus baseline at the last follow-up. A pain reduction of 18 mm on the VAS scale was documented at 1-year follow-up.

CONCLUSIONS

In this cohort of patients, the Blueflow Venous Stent across the inguinal ligament was safe and effective for the treatment of symptomatic iliofemoral venous disease, with a high primary patency rate at 1-year of follow-up. However, longer follow-up and larger cohorts are still needed.

Postthrombotisches Syndrom auf dem Boden einer chronischen iliofemoralen Thrombose: Therapieoptionen und -limitationen

Ein 49-jähriger Patient stellte sich mit einer langsam progredienten, ca. 7 cm großen Schwellung in der linken Kniekehle vor. Sonografisch und MR-tomografisch zeigte sich das Bild eines postthrombotischen Syndroms am linken Bein mit einem langstreckigen chronischen venösen iliofemoralen Verschluss und ausgeprägten Kollateralen sowie Varixkonvoluten in der linken Kniekehle, die der beklagten Schwellung entsprachen. Es erfolgte die Endophlebektomie der Vena femoralis und Vena femoralis profunda mit einer ventralen Rekonstruktion durch eine bovine Perikard-Patch-Plastik mit Rekanalisation der chronisch okkludierten venösen Iliakalachse mit langstreckiger Stentangioplastie als Hybridoperation. Abschließend wurde eine inguinale AV-Fistel angelegt. Postoperativ entwickelte der Patient einen Frühverschluss der venösen iliofemoralen Strombahn und eine inguinale Lymphfistel. Aufgrund dieser erfolgte zunächst kein operativer, sondern ein perkutaner transjugulärer, letztlich frustraner Rekanalisationsversuch. Die inguinale Heilung benötigte bis zum Sistieren der Lymphexsudation 8 Wochen. Nach diesem Zeitintervall entschieden wir uns aufgrund der zu erwartenden schlechten sekundären Offenheitsrate gegen eine operative Revision, sodass therapeutisch nur die Antikoagulation und Kompression blieb. Die Ursache des dargestellten Frühverschlusses bleibt unklar, mögliche Ursachen und sich daraus ergebende Konsequenzen werden diskutiert.

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

OBJECTIVE

Stent placements are considered as a treatment for post-thrombotic syndrome (PTS) with iliofemoral obstruction, but the application of these iliofemoral venous stents has also caused a lot of controversy. The purpose of this systematic review and meta-analysis was to summarise the efficacy and safety of venous stents in PTS with obstruction in iliofemoral venous segments.

METHODS

MEDLINE, EMBASE, and the Cochrane Central Register for Controlled Trials databases and key references were searched up to 15 January 2018. The main relevant outcomes included technical success, peri-operative complications, symptom resolution, a change of symptom scores, and long-term patency of the stents.

RESULTS

Overall, 504 limbs of 489 patients from seven studies were included in this study. A GRADE assessment showed the quality of the evidence was "very low" for 11 relevant outcomes. The technical success rate was 95%. The pooled rate of complications including 30 day thrombotic event, per-operative venous injury, and back pain was 3.4%, 18.14%, and 52%, respectively. The rates of ulcer healing, pain and oedema relief were 75.66%, 52%, and 42%, respectively. The primary, assisted primary and secondary patency rates were 83.36%, 90.59%, and 94.32%, respectively, at 12 months and 67.98%, 82.26%, and 86.10%, respectively, at 36 months.

CONCLUSIONS

Endovenous stenting has the potential to be effective and has a low risk of peri-operative complications. The quality of evidence to support this treatment is very low. Endovenous iliofemoral stenting should be considered a treatment option for PTS with iliofemoral obstruction.

The contemporary hybrid operative procedure for incapacitating post-thrombotic iliofemoral and vena caval obstruction improves procedural outcomes

OBJECTIVE

Chronic, post-thrombotic iliofemoral and inferior vena caval obstruction is associated with debilitating morbidity. Venoplasty and stenting are often successful; however, in the presence of a diseased or occluded common femoral vein (CFV), failure is common. A hybrid operative procedure of open surgical CFV endovenectomy and endoluminal recanalization or bypass of the obstructed iliofemoral and vena caval segments has been developed and modified. The purpose of this report was to assess the technical evolution of this procedure on operative complications.

METHODS

Thirty-one patients undergoing CFV endovenectomy and proximal ipsilateral endoluminal reconstruction (iliac, inferior vena caval) or contralateral outflow were analyzed. The initial techniques of patient management were compared with the present contemporary techniques, evaluating procedural complications and failures. The contemporary procedure evolved to include routine axial imaging, preoperative venography through the popliteal vein, preoperative passage of a guidewire or catheter into the patent vena cava, placement of an ipsilateral popliteal vein sheath for intraoperative and postoperative anticoagulation, routine patch closure, routine arteriovenous fistulas, routine completion intravascular ultrasound, and long-term anticoagulation with warfarin to a target international normalized ratio of 3.0 to 4.0. Procedure-related complications were compared between the initial and contemporary techniques.

RESULTS

Of 17 patients treated with the early techniques, 15 (88%) had major complications: 5 iliofemoral thromboses, 4 major wound bleeds, 4 wound infections, and 2 CFV stenoses requiring reintervention. One iliac vein rupture treated with a stent graft thrombosed. Of 14 patients treated with the contemporary techniques, 2 (14%; P = .006) had major complications: 1 bleed and 1 infected seroma. One intraoperative iliac vein rupture, treated with a second stent relining the first, remains patent.

CONCLUSIONS

Contemporary hybrid operative techniques for incapacitating post-thrombotic iliofemoral and vena caval obstruction increase procedural success and reduce complications compared with the initial approach. The contemporary techniques are recommended for patients undergoing hybrid operative management of post-thrombotic iliofemoral and vena caval occlusion involving the CFV.

Treatment of Femoral Vein Obstruction Concomitant with Iliofemoral Stenting in Patients with Severe Post-thrombotic Syndrome

BACKGROUND

The aim was to assess the clinical and anatomical outcomes of iliofemoral stenting, with concomitant femoral stenting or balloon angioplasty alone, in patients with severe post-thrombotic syndrome (PTS) and compromised inflow.

METHODS

A database of patients with severe PTS who successfully underwent endovascular iliofemoral stenting was reviewed retrospectively. Patients with impaired inflow with chronic post-thrombotic obstructive lesions in the femoral vein (FV), but patent profunda vein, were selected and divided into two groups: the FV stenting (FV-S) group and the FV angioplasty (FV-A) group. Patients in the FV-S group were treated with concomitant iliofemoral and FV stenting, and patients in the FV-A group were treated with iliofemoral stenting and balloon angioplasty alone of the obstructed femoral vein. The clinical and stent outcomes were recorded and compared in the two groups.

RESULTS

There were 45 patients in the FV-S group and 69 patients in the FV-A group. The groups were well matched for age, gender, and diseased limbs. The pre-procedural symptoms, CEAP classifications, VCSS scores, Villalta scores, and prevalence of active ulcers were also similar between the two groups. Immediate failure (<30 days post-procedure) in the femoral segment occurred more frequently in the FV-A group (70% in FV-A group vs. 24% in FV-S group, p < .001); however, all treated femoral vein segments had occluded at 12 months. There was no significant difference between the FV-S and FV-A groups in cumulative primary and secondary patency rates of the iliofemoral stent at 3 years (55% vs. 52%, p = .71, and 77% vs. 85%, p = .32, respectively). Complete pain relief, swelling relief, VCSS score, Villalta score, and freedom from ulcers at a median of 22 months (1-48 months) following the procedure were similar in the two groups.

CONCLUSIONS

Stent placement to treat post-thrombotic iliofemoral obstruction with concomitant obstructed femoral vein but patent profunda vein shows cumulative patency rates and clinical outcomes similar to previous reports. Adjunctive femoral stenting or angioplasty of the obstructed femoral vein does not appear to improve clinical or stent outcomes in patients with severe PTS.