Contemporary outcomes of elective iliocaval and infrainguinal venous intervention for post-thrombotic chronic venous occlusive disease

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Early thrombosis after iliac stenting for venous outflow occlusion is related to disease severity and type of anticoagulation

BACKGROUND

Stenting of the iliac venous system is often performed for symptomatic obstruction, with high patency rates reported. However, patients with post-thrombotic disease and those with more extensive obstruction have experienced poorer outcomes, including a higher rate of early post-stent thrombosis. In the present study, we examined the outcomes of patients with complete venous outflow occlusion. We focused on the variables associated with early post-stenting thrombosis to identify opportunities to reduce its incidence.

METHODS

From 2010 to 2020, the patients who had undergone stenting for chronic obstruction of the common femoral vein, iliac veins, and/or inferior vena cava were retrospectively reviewed. The pre- and intraoperative imaging studies were examined to identify those who had had total occlusion of one venous outflow segment (type III disease) or multiple venous outflow segments (type IV disease). The patient characteristics and procedural and post-stent variables were recorded. The post-procedure follow-up visits and imaging studies were reviewed to determine stent patency and thrombotic complications. Key variables were studied to determine their association with early stent reocclusion.

RESULTS

A total of 106 patients were identified, including 43 with type III (40.6%) and 63 with type IV (59.4%) disease. The mean patient age was 49.8 ± 13.7 years, and the mean stented length was 177.3 ± 63 mm. Stainless steel Wallstents were used solely in 44% of the cases, with a variety of nitinol stents used in the remainder. Femoral vein inflow was minimally diseased in 50% of the cases, moderately diseased in 26%, and severely diseased or occluded in 24%. Antiplatelet medications were prescribed after intervention for 52.8% and anticoagulation medication for 95.3% of the patients. Occlusion of the stented segment occurred within 3 months in 25.5%. Primary patency was 74.5% at 3 months, 63.9% at 12 months, and 58.5% at 3 years. Secondary patency was 93.4% at 3 months and 76.1% at 3 and 5 years. Univariate analysis of variables related to early stent thrombosis identified the presence of a hypercoagulable state, type IV obstruction, and the type of anticoagulation used after stenting were associated with early stent thrombosis. On multivariate analysis, each of these variables was independently associated with early stent thrombosis. The presence of type IV obstruction (odds ratio [OR], 4.596; 95% confidence interval [CI], 1.424-18.109) or a hypercoagulable state (OR, 3.835; 95% CI, 1.207-12.871) was associated with significantly greater odds of reocclusion than was class III obstruction and no hypercoagulable state. Treatment with low-molecular-weight heparin for >10 days was associated with significantly lower odds (OR, 0.012; 95% CI, 0.001-0.130) of reocclusion.

CONCLUSIONS

Patients who require recanalization of a completely occluded venous outflow tract before stenting have a high rate of early reocclusion. Patients with more extensive occlusion and a hypercoagulable state have greater odds of reocclusion. Treatment with low-molecular-weight heparin for >10 days reduced the odds of early reocclusion.

Medium-term outcomes after inferior vena cava reconstruction for acute and chronic deep vein thrombosis and retroperitoneal fibrosis

OBJECTIVE

In the present study, we evaluated the technical and clinical outcomes after endovascular inferior vena cava (IVC) reconstruction in patients with nonmalignant obstruction.

METHODS

The preoperative, procedural, and follow-up medical records and imaging studies were retrospectively reviewed for 59 consecutive patients who had undergone endovascular IVC reconstruction for nonmalignant obstruction from February 2014 to January 2019. The patients were classified into three groups according to the quality of their infrainguinal inflow vessels. The outcomes measured were the primary, primary-assisted, and secondary patency rates, reintervention rates, and symptomatic resolution.

RESULTS

The indications for treatment were post-thrombotic syndrome (n = 41), acute deep vein thrombosis (n = 12), and retroperitoneal fibrosis (n = 6). The median patient age was 37 years, 11 months, 71.2% were men, and 32.2% had a diagnosis of thrombophilia, with no significant difference in these demographics between the three inflow groups. The median follow-up duration was 2 years, 3 months (range, 6 months to 6 years, 5 months). The whole-cohort primary patency was 91.2%, 71.0%, and 24.1% at 1, 3, and 5 years, respectively. Secondary patency was 76.7% at 1 year and 66.4% at both 3 and 5 years. Inflow group A (no post-thrombotic disease in the femoral or deep femoral veins) demonstrated significantly higher primary patency compared with group B (stenotic disease in one or two infrainguinal inflow veins; P = .009) and significantly higher secondary patency than for both groups B (P = .008) and C (all three infrainguinal inflow veins had stenosed or femoral and/or deep femoral vein occlusion was present; P = .04). In post-thrombotic syndrome patients, the Villalta scores had decreased from a mean of 14.2 to 8.1 at 1 year and 6.8 at 2 years, and the Venous Insufficiency Epidemiological and Economic Study Quality of Life score had improved from a mean of 19.8 to 54.1 and 57.3 at 1 and 2 years, respectively. In the patients with acute deep vein thrombosis, the Villalta score was 2.8 at 1 year and 0 at 2 years. In the patients with retroperitoneal fibrosis, the Venous Insufficiency Epidemiological and Economic Study Quality of Life score had improved from a mean of 25.3 at baseline to 44 at 6 months.

CONCLUSIONS

Endovascular IVC reconstruction for nonmalignant obstruction can achieve good patency and clinical improvement, although the outcomes were poorer for patients with post-thrombotic disease of the femoral and deep femoral veins.

Iliac vein stenting is safe when performed in an office based laboratory setting

BACKGROUND

Venous stenting for iliac vein outflow obstruction is associated with excellent long-term stent patency and symptom resolution. However, the safety of iliac vein stenting performed in an office-based laboratory (OBL) setting is not well-defined. The purpose of our investigation was to determine the safety profile of iliac vein stenting in an OBL setting.

METHODS

Data were prospectively collected in the Center for Vascular Medicine electronic medical record system (NextGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. Standardized patient safety and sedation protocols were used in accordance with the accreditation standards of the Joint Commission for Accreditation of Hospital Organizations for office-based surgery centers. Patient consultations, interventions, and follow-up at 1 to 6 weeks were included in the present analysis. All the patients had received moderate sedation during their procedure. Complications requiring hospitalization were classified as major complications. Minor complications consisted of bleeding, hematoma, vasovagal response, in-stent thrombosis resulting in complete occlusion of the iliac vein stent, an allergic reaction, hematemesis, hypotension, pelvic discomfort, and pseudoaneurysm.

RESULTS

Between January 2015 and January 2019, 1223 iliac vein stents were placed in 1104 patients (23.7% male; 76.3% female). A total of 90 minor complications (7.36%) and 5 major complications (0.41%) were observed. The major complications included the following: one allergic reaction, one episode of atrial fibrillation, one episode of supraventricular tachycardia, one episode of chest pain, and one case of acute stent occlusion. The minor complications were primarily insertion site hematomas. No complications were related to sedation or acute renal failure. No patient died.

CONCLUSIONS

Major complications were rare after iliac vein stenting in an OBL setting. Minor complications were primarily insertion site hematomas, which did not require inpatient hospitalization. Our analysis has shown that iliac vein stenting in an OBL setting is a safe and well-tolerated procedure.

A case report of successful intravascular shockwave lithotripsy and ad hoc directional venous atherectomy of extensive chronic femoral deep venous thrombosis

Background

Conventional treatment for chronic deep venous thrombosis (DVT) is anticoagulation. However, limited interventional endovascular options exist for patients with non-healing venous ulcers secondary to chronic DVT.

Case summary

We present a case of 67-year-old man with severely symptomatic post-thrombotic syndrome (PTS) with persistent high-grade femoral DVT despite prior compressive therapy and chronic oral anticoagulation. It has been successfully treated with intravascular shockwave lithotripsy and ad hoc directional venous atherectomy facilitating subsequent mechanical thrombectomy and venoplasty. The procedure was without complication and resulted in significant clinical improvement.

Discussion

We believe our novel endovascular interventional approach represents a unique modality of intervention for patients with chronic DVT and PTS resistant to conventional venoplasty.

Strategies and challenges in the treatment of chronic venous leg ulcers

Evaluating patients with chronic venous leg ulcers (CVLUs) is essential to find the underlying etiology. The basic tenets in managing CVLUs are to remove the etiological causes, to address systemic and metabolic conditions, to examine the ulcers and artery pulses, and to control wound infection with debridement and eliminating excessive pressure on the wound. The first-line treatments of CVLUs remain wound care, debridement, bed rest with leg elevation, and compression. Evidence to support the efficacy of silver-based dressings in healing CVLUs is unavailable. Hydrogen peroxide is harmful to the growth of granulation tissue in the wound. Surgery options include a high ligation with or without stripping or ablation of the GSVs depending on venous reflux or insufficiency. Yet, not all CVLUs are candidates for surgical treatment because of comorbidities. When standard care of wound for 4 wk failed to heal CVLUs effectively, use of advanced wound care should be considered based on the available evidence. Negative pressure wound therapy facilitates granulation tissue development, thereby helping closure of CVLUs. Autologous split-thickness skin grafting is still the gold standard approach to close huge CVLUs. Hair punch graft appears to have a better result than traditional hairless punch graft for CVLUs. Application of adipose tissue or placenta-derived mesenchymal stem cells is a promising therapy for wound healing. Autologous platelet-rich plasma provides an alternative strategy for surgery for safe and natural healing of the ulcer. The confirmative efficacy of current advanced ulcer therapies needs more robust evidence.

Strategies and challenges in the treatment of chronic venous leg ulcers

Evaluating patients with chronic venous leg ulcers (CVLUs) is essential to find the underlying etiology. The basic tenets in managing CVLUs are to remove the etiological causes, to address systemic and metabolic conditions, to examine the ulcers and artery pulses, and to control wound infection with debridement and eliminating excessive pressure on the wound. The first-line treatments of CVLUs remain wound care, debridement, bed rest with leg elevation, and compression. Evidence to support the efficacy of silver-based dressings in healing CVLUs is unavailable. Hydrogen peroxide is harmful to the growth of granulation tissue in the wound. Surgery options include a high ligation with or without stripping or ablation of the GSVs depending on venous reflux or insufficiency. Yet, not all CVLUs are candidates for surgical treatment because of comorbidities. When standard care of wound for 4 wk failed to heal CVLUs effectively, use of advanced wound care should be considered based on the available evidence. Negative pressure wound therapy facilitates granulation tissue development, thereby helping closure of CVLUs. Autologous split-thickness skin grafting is still the gold standard approach to close huge CVLUs. Hair punch graft appears to have a better result than traditional hairless punch graft for CVLUs. Application of adipose tissue or placenta-derived mesenchymal stem cells is a promising therapy for wound healing. Autologous platelet-rich plasma provides an alternative strategy for surgery for safe and natural healing of the ulcer. The confirmative efficacy of current advanced ulcer therapies needs more robust evidence.

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.

Venous stenting for patients with outflow obstruction and leg ulcers: cost–effectiveness and budget impact analyses

Aim: To perform cost–effectiveness analysis (CEA) and budget impact analysis (BIA) comparing stenting to standard medical treatment (SMT) for the management of deep venous outflow obstruction and leg ulcers from the Italian Healthcare Service perspective. Materials & methods: A Markov model was developed to project costs and quality-adjusted life-years (QALYs) over 3 years, based on data from literature combined with real-world data. Moreover, a BIA was performed comparing the current scenario (100% SMT) with increasing utilization rates of stenting over SMT from 0.5 to 5%, in the next 5 years. Results: Stenting is a cost-effective (incremental cost-utility ratio €12,388/QALY) or dominant option versus SMT, according to in-patient or day-hospital settings, respectively. Increasing use of stenting over SMT, in the next 5 years, is expected to yield additional costs of 39.5 million Euros (in-patient) or savings of 5.1 million Euros (day-hospital). Conclusion: Stenting is a cost-effective option compared with SMT for patients with deep vein occlusion and ulceration in Italy.

Evaluation of anticoagulant and antiplatelet therapy after iliocaval stenting: Factors associated with stent occlusion

OBJECTIVE

Iliocaval stenting has gained increased use over recent years for a variety of indications, including May-Thurner syndrome (MTS), post-thrombotic syndrome (PTS), and acute deep vein thrombosis (DVT).

METHODS

A retrospective review of 155 patients undergoing iliocaval venous stenting at a large teaching hospital was performed. Clinical and procedural data, mode and duration of anticoagulation or antiplatelet therapy, and outcomes were recorded.

RESULTS

Forty-five patients were treated for MTS, 49 for PTS. and 61 for acute DVT. The median follow-up was 19 months (interquartile range, 9-30 months). Primary patency rates were 97.8% in the MTS group, 85.7% in PTS, and 85.2% for the acute DVT group. Stent restenosis or occlusion occurred in one patient with MTS (2.2%), seven patients with PTS (14%), and nine patients with acute DVT (15%). An ipsilateral DVT recurred in 7 patients with PTS (14%) and 15 patients with acute DVT (25%). The stents that occluded had a tendency toward longer length (162.2 vs 125.2 mm; P = NS) and extension into the common femoral vein (18.8 vs 5.3%; P = NS). The patent stent group had statistically larger nominal diameter stents (P = .013). The duration of anticoagulation did not seem to be a significant factor in stent patency.

CONCLUSIONS

Stent diameter has a significant influence on iliocaval stent patency rates.

Total endovenous recanalization and stent reconstruction for naïve non-inferior vena cava filter-associated chronic iliocaval occlusive disease: Placement of 352 venous stents in 69 debilitated patients

The aim of this study was to report the technical success, adverse events, clinical outcomes, and long-term stent patency of iliocaval stent reconstruction for naïve, non-inferior vena cava (IVC) filter-related, chronic iliocaval thrombosis. A total of 69 patients, including 47 (68%) men, with a mean age of 36 years (range: 8-71 years), underwent first-time iliocaval stent reconstruction for non-IVC filter-associated iliocaval thrombosis. The mean number of prothrombotic risk factors was 2.2 (range: 0-5), including 30 (43%) patients with IVC atresia. Upon initial presentation, the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification was C3 in 55 (80%) patients, C4 in four (5.8%) patients, C5 in one (1.4%) patient, and C6 in seven (10%) patients. Technical aspects of stent reconstruction, technical success, adverse events, 2-week and 6, 12, and 24-month clinical response, and 6, 12, and 24-month primary, primary-assisted, and secondary stent patency rates were recorded. Technical success was defined as recanalization and stent deployment. Adverse events were reported according to the Society of Interventional Radiology classification system. Clinical success was defined as a 1-point decrease in CEAP classification and stent patency was defined by the Cardiovascular and Interventional Radiological Society guidelines. The technical success rate was 100%. There were 352 venous stents deployed during stent reconstructions. One (1.4%) severe, four (5.8%) moderate, and four (5.8%) minor adverse events occurred and median post-procedure hospitalization was 1 day (range: 1-45 days). Clinical success at 2 weeks and 6, 12, and 24 months was 76%, 85%, 87%, and 100%, respectively. The estimated 6, 12, and 24-month primary patency rates were 91%, 88%, and 62%, respectively. The estimated 6, 12, and 24-month primary-assisted patency rates were 98%, 95%, and 81%, respectively. The estimated 6, 12, and 24-month secondary-assisted patency rates were all 100%. In conclusion, iliocaval stent reconstruction is an effective treatment for non-IVC filter-associated chronic iliocaval thrombosis with high rates of technical success, clinical responses, and stent patency.

Outcomes and predictors of failure of iliac vein stenting after catheter-directed thrombolysis for acute iliofemoral thrombosis

OBJECTIVE

Iliac vein stenting is recommended to treat venous outflow obstruction after catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis (DVT). Data on the outcome of proximal and distal stent extension are limited. Proximal stent extension to the vena cava may obstruct the contralateral iliac vein, whereas distal extension below the inguinal ligament contradicts common practice for arterial stents. The aim of this retrospective study was to assess outcomes and predictors of failure of iliac vein stents and contralateral iliac vein thrombosis, taking into consideration stent positioning.

METHODS

Consecutive patients who underwent thrombolysis and stenting for DVT between May 2007 and September 2017 were identified from a prospectively maintained database. The intraoperative venograms were reviewed for proximal stent placement (covering >50% contralateral iliac vein orifice) and distal placement across the inguinal ligament. End points were ipsilateral DVT recurrence, post-thrombotic syndrome (PTS; Villalta score ≥5), and contralateral DVT. Patients with chronic contralateral DVT or contralateral iliac vein stenting at baseline were excluded from the contralateral DVT outcome evaluation. Survival analysis and Cox regression models were used to determine outcomes.

RESULTS

Of 142 patients lysed, 73 patients (12 bilateral DVTs; mean age, 45.8 ± 17.2 years; 46 female patients) were treated with various combinations of thrombolytic techniques and at least one self-expanding iliac stent (77 stented limbs). Thirty-day recurrence developed in nine (12.3%) patients. The 3-year primary patency and secondary patency rates were 75.2% and 82.2%, respectively. The single predictor for loss of primary patency was incomplete thrombolysis (≤50%; hazard ratio [HR], 7.41; P = .002). Overall, 3 of 12 (25%) stents extending below the inguinal ligament occluded at 1 month, 2 months, and 9 months, respectively. The overall rate of PTS (Villalta score ≥5) in the stented cohort was 14.4% at 5 years. This was predicted by incomplete lysis (<50%; HR, 7.09; P = .040), stent extension below the inguinal ligament (HR, 6.68; P = .026), and male sex (HR, 6.02; P = .041). Of the 17 stents that extended into the contralateral common iliac vein and 58 stents that did not, there were 1 (5.9%) and 5 (8.6%) contralateral DVTs (P = .588) at an average follow-up of 27.4 ± 33.7 and 22.2 ± 22.3 months (P = .552), respectively.

CONCLUSIONS

Iliac stenting after thrombolysis for acute DVT guarantees high patency and low PTS rates, provided adequate thrombus resolution has been achieved before stent placement. Stent placement below the inguinal ligament does not affect the patency but may be associated with a higher PTS rate. Stenting proximal to the iliocaval confluence, although a precipitating factor, may not independently increase the likelihood of contralateral DVT.

Two Year Outcome After Chronic Iliac Vein Occlusion Recanalisation Using the Vici Venous Stent®

OBJECTIVE/BACKGROUND

The aim was to assess two year outcomes with placement of the Vici Venous Stent^® in patients with chronic iliofemoral venous occlusions (complete blockage).

METHODS

This was a retrospective single centre study comprising patients treated with the Vici Venous Stent for venographically verified iliofemoral venous occlusion and post-thrombotic syndrome (Villalta score ≥ 5 points) at least 12 months after acute deep vein thrombosis. Venography and intravascular ultrasound were used peri-operatively; duplex ultrasound was used to assess stent patency during follow up.

RESULTS

Eighty-eight patients (101 limbs) had stent placement between March 2014 and October 2016. Median pre-treatment Villalta score was 14 (range 5-33). Stenting extended across the inguinal ligament in 63 limbs (62%) in order to land in a healthy venous segment. Six patients (7%) required endophlebectomy and fistula creation. Median imaging follow up was 21 months (range 0-41 months). Primary, assisted primary and secondary patency rates at one year were 59%, 78%, and 87%, respectively, and two years 51%, 73%, and 82%, respectively. Forty-three limbs (43%) had re-intervention (lysis, venoplasty, and/or placement of stent) during follow up; median time to re-intervention was 32 days (range 0-520 days). At 24 months, 37 of 53 limbs (70%) with available Villalta assessment showed clinically significant improvement (>30% reduction of baseline score). Villalta scores at the 6, 12, and 24 month clinical follow up were significantly lower than before stenting (p < .001, all time points). In a subset analyses of limbs with stenting terminating above and below the inguinal ligament, secondary cumulative patency rates at 24 months were 90% and 79%, respectively; clinical outcome showed 58% vs. 73% of limbs with clinically significant improvement, respectively. There was no statistically significant difference in patency or clinical outcomes.

CONCLUSION

The Vici Venous Stent is associated with a good secondary patency rate and durable and substantial symptomatic resolution in patients with chronic post-thrombotic occlusions, regardless of whether stents extended beneath the inguinal ligament.

Endovascular iliocaval reconstruction for the treatment of iliocaval thrombosis: From imaging to intervention

Thrombosis of the inferior vena cava and iliac veins, known as iliocaval thrombosis, is a common cause of significant morbidity. Patients with chronic iliocaval obstruction often present with life-limiting occlusive symptoms secondary to recurrent lower extremity deep venous thrombosis, swelling, pain, venous stasis ulcers, or phlegmasia. Endovascular iliocaval reconstruction is a technically successful procedure that results in favorable clinical outcomes and stent patency rates with few complications and is often able to relieve debilitating symptoms in affected patients. This review presents an approach to endovascular iliocaval stent reconstruction in patients suffering from chronic iliocaval thrombosis, including background, patient selection, timing of intervention, procedural steps, technical considerations, patient follow-up, and a brief review of outcomes. Schematic illustrations and clinical cases outlining iliocaval stent reconstruction and crossing chronic venous occlusions have been provided.