Prevalence, risk factors, and evaluation of iliocaval obstruction in advanced chronic venous insufficiency

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.

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.

Prevalence and predictors of combined >50% iliocaval venous obstruction and superficial venous reflux in chronic venous insufficiency patients with healed or active venous leg ulcer

OBJECTIVE

The aim of the present study was to investigate the prevalence and predictors of combined >50% iliocaval venous obstruction (ICVO) and superficial venous reflux (SVR) in patients with chronic venous insufficiency (CVI) with a healed (C5) or an active (C6) venous leg ulcer (VLU).

METHODS

We conducted a retrospective review of prospectively collected data from patients with CVI with CEAP (Clinical, Etiology, Anatomy, Pathophysiology) class C5 (healed ulcer) or C6 (active ulcer) with SVR who had been treated at our institution from February 2017 to January 2018. The demographic, clinical, and surgical data and duplex ultrasound and computed tomography venography findings were collected. We used OsiriX MD, version 2.9, software (Pixmeo SARL, Bernex, Switzerland) to measure the vein diameter via multiplanar reconstruction. The prevalence of combined >50% ICVO and SVR was evaluated, and univariate and multivariate analyses were performed to identify the independent predictors of >50% ICVO in patients with CVI and SVR.

RESULTS

A total of 79 limbs from 67 patients were enrolled. The mean age was 59.82 ± 12.86 years, the mean body mass index was 28.68 ± 6.41 kg/m², and 41.8% were men. The prevalence of >50% ICVO in the patients with SVR was 31.6%. Univariate analysis showed a history of deep vein thrombosis (DVT) in the affected leg (P = .001), a VLU in the left leg (P = .033), a history of a recurrent VLU (P = .038), and reversed flow in the superficial epigastric vein (P = .004) were significantly associated with >50% ICVO in patients with CVI and SVR. Multivariate analysis revealed a history of DVT in the affected leg (adjusted odds ratio [aOR], 8.31; 95% confidence interval [CI], 2.29-30.19; P = .001), a VLU in the left leg (aOR, 3.95; 95% CI, 1.18-13.19; P = .026), and a history of a recurrent VLU (aOR, 3.08; 95% CI, 1.02-9.32; P = .047) to be independently associated with combined >50% ICVO and SVR in patients with CVI.

CONCLUSIONS

The prevalence of combined >50% ICVO and SVR in patients with CVI and CEAP C5 or C6 was 31.6%. The independent predictors of combined >50% ICVO and SVR in those with CVI were a history of DVT in the affected leg, a VLU in the left leg, and recurrent VLUs.

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.

Prevalence of left iliac vein compression in an asymptomatic population and patients with left iliofemoral deep vein thrombosis: A multicenter cross-sectional study in southern China

OBJECTIVE

Population-based epidemiological data on left common iliac vein (LCIV) compression is scarce. This study aimed to investigate the prevalence of LCIV compression in an asymptomatic population and patients with left iliofemoral deep vein thrombosis (IF-DVT).

MATERIALS AND METHODS

Nonprobability sampling method was used in this multicenter cross-sectional study. The minimum diameter of LCIV and right common iliac vein minimum were measured. The percentage of LCIV compression (LCIV-CP) was calculated. Compression severity (CS) was classified as mild (CP ≤ 50%), moderate (50% < CP ≤ 70%), and severe (CP > 70%).

RESULTS

In all, 896 subjects constituted the asymptomatic population and 93 patients constituted the IF-DVT population. In the asymptomatic population, LCIV-CP ranged from 1.1% to 89.9% (mean 44.0%), and people with mild, moderate, and severe CS accounted for 62.3%, 28.2%, and 9.5%, respectively. In the IF-DVT population, the mean LCIV-CP was 71.1% (range 42.2%-95.2%), and patients with severe CS accounted for 75.3%. Gender and age differences in LCIV-CP and CS distribution were observed in the asymptomatic population. Females, the young- and middle-aged group had higher LCIV-CPs. In the population with moderate-severe CS, the middle-aged group accounted for a larger proportion. Middle-aged females comprised the highest percentage of patients with moderate or severe CS. Sex and age affected the LCIV-CP and CS distribution. No gender and age differences were observed in the IF-DVT population.

CONCLUSIONS

LCIV compression is common in population. Middle-aged females are the predominant population with moderate-severe compression. Overlapping of LCIV-CP in the asymptomatic and IF-DVT population is significant and other risk factors should be integrated into the consideration when assessing the risk of IF-DVT secondary to LCIV compression.

The presence of a pathologic perforator may be predictive of central venous pathology and multilevel disease in severe chronic venous insufficiency

OBJECTIVES

The treatment of a refluxing perforator is indicated in the setting of severe chronic venous insufficiency, but there are limited data on the presence of multilevel disease in these patients. This study sought to evaluate whether the presence of a pathologic perforator is predictive of the presence of central venous pathology.

METHODS

This study was a retrospective review of the institutional Vascular Quality Initiative database. Consecutive patient limbs were identified that underwent intervention of refluxing perforators. The patients who underwent imaging, including magnetic resonance imaging or computed tomography (group A), were compared with those who did not undergo imaging (group B). The treated limbs in group A were also compared with the contralateral limbs as an internal control. Anatomical findings on imaging were analyzed by two independent investigators. The primary outcome was the presence and degree of central venous stenosis as measured by an orthogonal diameter reduction of >50% by axial imaging. Secondary outcomes included demographic and clinical differences between the two groups, frequency of central venous intervention, and duration of ulcer healing. Standard statistical analysis was performed.

RESULTS

Ninety-three patient limbs underwent treatment of a pathologic perforator, with 30 in group A and 63 in group B. The following demographic and clinical variables were higher in group A compared with group B: male sex, body mass index, deep venous thrombosis history, recent or active anticoagulation use, perforator diameter, Clinical Etiology Anatomy Pathophysiology class 4, 5, or 6, and Venous Clinical Severity Score. Radiographic analysis of group A revealed concordance of a treated pathologic perforator with an ipsilateral central venous stenosis in 53.3% of patients, and a higher frequency of common iliac vein stenosis (50% vs 21.4%, P = .024) and external iliac vein stenosis (20% vs 0%, P = .012) compared with the contralateral limbs. When separated by the left or right limb, the left limbs exhibited a greater degree of common iliac vein stenosis as compared with the contralateral limbs (50.7% ± 20.9% vs 16.3% ± 16.5%, P < .001) as well as a greater frequency of >50% common iliac vein stenosis (46.7% vs 13.3%, P = .046). The right limbs exhibited a greater frequency of >50% external iliac vein stenosis as compared with the contralateral limbs (33.3% vs 0%, P = .022).

CONCLUSIONS

This study suggests that patients with severe chronic venous insufficiency who undergo treatment for a pathologic perforator may have additional ipsilateral central venous pathology, supporting the presence of multilevel disease. Additional axial imaging might unmask central venous pathology and provide another option for treatment.

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.

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.

Computed tomography venography versus intravascular ultrasound in the diagnosis of iliofemoral vein stenosis

Summary: Background: Iliofemoral vein stenosis can cause debilitating chronic venous disease. Diagnostic tools include both computed tomography venography (CTV) and intravascular ultrasonography (IVUS). We aim to compare the diagnostic performance of CTV and IVUS. Patients and methods: We performed a retrospective study of patients with chronic venous disease presenting with iliac vein compression or post-thrombotic limb symptoms, excluding those with acute deep vein thrombosis, high anaesthesia risk, or who had contrast allergy. All patients received CTV before IVUS, as part of the diagnostic work-up and intervention. The cross-sectional area (CSA) of iliofemoral vein segments obtained from both studies were compared against reference CSAs to derive percentage stenosis. A 50% reduction in CSA was considered significant. Results: We studied 50 patients between May 2018 and April 2019. 58% of patients had severe disease CEAP C5-6. 48% of patients had at least one vein segment with significant stenosis. The left proximal common iliac vein was the most commonly stenosed vein segment (n = 12, 24% on IVUS). CSA measurements from CTV were greater than those of IVUS, with a correlation coefficient of 0.57 (p < 0.005). Conversely, percentage stenosis measured on CTV was lower than on IVUS, with approximately one-third of significant stenosis missed on CTV (58 veins from CTV vs. 78 from IVUS, p < 0.005). With IVUS as the gold standard, CTV has low sensitivity (37.2%, 95% CI 26.5–48.9) and high specificity (92.5%, 95% CI 89.3–94.9) in detecting significant stenosis. Conclusions: CTV has limited diagnostic performance in identifying iliofemoral vein stenosis. Patients with normal CTV findings should proceed with IVUS imaging if the clinical features are supportive of iliofemoral vein stenosis.

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.

Iliocaval outflow obstruction in patients with venous ulcers in a small comparison study between patients with primary varicose veins and chronic deep vein disease

OBJECTIVE

Iliocaval outflow obstruction was investigated in patients with venous ulcers caused by primary superficial disease and chronic deep vein disease METHODS: After clinical assessment, patients with healed or active venous leg ulcers underwent lower extremity duplex ultrasound examination to identify the presence of venous disease in the superficial, deep and perforating systems. Bilateral contrast venography and intravascular ultrasound examination were then performed to determine the presence and degree of iliocaval obstructive lesions.

RESULTS

This retrospective study included a total of 59 patients with 71 legs presenting active or healed ulcer. There were 16 limbs (22.5%) with superficial venous reflux associated with normal infrainguinal deep veins (group I) and 55 limbs (77.5%) with infrainguinal post-thrombotic deep venous disease (group II). Using venography and intravascular ultrasound examination, the incidence of >50% of venous obstruction in the iliocaval system in groups I and II were 75% and 83.6%, respectively. All obstructive lesions in group I were nonthrombotic. However, group II included thrombotic, nonthrombotic and combinations of the two types of obstructions. Group II had more ulcers (1.73 ± 1.3 vs 1.17 ± 0.5; P = .03), larger ulcers (>6 cm in 34.1% vs 8.3%), longer duration of ulcers (71.3 ± 110.5 months vs 37.9 ± 40.4 months; P = .03), smaller diameter of refluxing superficial veins (7.7 ± 2.6 mm vs 15.1 ± 6.6 mm; P = .001), and higher incidence of occluded iliocaval systems (18 [32.7%] vs 0; P = .003) than group I. After the exclusion of bilateral cases and thrombotic obstructions, the incidence of >50% nonthrombotic obstruction in ipsilateral and contralateral sides was 76.5% and 24.4%, respectively (P = .003).

CONCLUSIONS

The results of this study revealed that the majority of patients with venous ulcers with either infrainguinal primary superficial or post-thrombotic deep venous disease had an element of iliocaval venous obstruction.

Review of imaging and endovascular intervention of iliocaval venous compression syndrome

Iliocaval venous compression syndrome (ICS) is the extrinsic compression of the common iliac vein by the overlying iliac artery against the vertebra. Chronic compression can lead to venous stenosis and stasis, which manifests as chronic venous disease and treatment resistance. Therefore, early recognition of ICS and prompt treatment are essential. Clinical presentations of ICS can be ambiguous and diagnosis requires a high index of suspicion with the relevant imaging studies. The initial imaging test is typically a Duplex ultrasound for vessel assessment and pelvic ultrasound to exclude a compressive mass, which is followed by computed tomography (CT) or magnetic resonance (MR) venography. CT and MRI can identify the anatomical causes for venous compression. In patients with high clinical suspicion for ICS, negative findings on CT and MR venography would still warrant further investigations. Definitive diagnosis can be established using catheter-based venography complemented with intravascular ultrasonography but the nature of their invasiveness limits its utility as a routine imaging modality. In this review paper, we will discuss the evidence, utility and limitations of the existing imaging modalities and endovascular intervention used in the management of ICS.