Quality of life outcomes for patients undergoing venous stenting for chronic deep venous disease

Interventional treatment for post-thrombotic chronic venous obstruction: Progress and challenges

Chronic venous obstruction, including nonthrombotic iliac vein lesions and post-thrombotic syndrome, presents a significant burden on patients' quality of life and health care systems. Venous recanalization and stenting have emerged as promising minimally invasive approaches, yet challenges in patient selection, procedural techniques, and long-term outcomes persist. This review synthesizes current knowledge on the interventional treatment of post-thrombotic syndrome, focusing on the evolution of endovascular techniques and stenting. Patient selection criteria, procedural details, and the characteristics of dedicated venous stents are discussed. Particular emphasis is given to the role of inflow and other anatomical considerations, along with postoperative management protocols for an optimal long-term outcome.

Lower extremity woven and nonwoven venous stent morphology and luminal changes

OBJECTIVE

Venous stents are a common treatment modality for obstructive venous disease. Venous stents differentiate themselves by either a woven or braided structure, open or closed cell arrangement or based on material composition (elgiloy vs nitinol). Changes in the morphology of venous stents over time may contribute to restenosis or thrombosis. Woven elgiloy stents are prone to proximal and distal edge deformation compared with dedicated venous stents, which offer increased radial force at stent edges. The objective of this study is to describe luminal morphological changes among various venous stents and between woven to nonwoven venous stent configuration, over time.

METHODS

A retrospective review at a single institution between January 2014 and June 2021 identified patients treated with venous stents. Patients with iliac and/or femoral venous stents with intraoperative intravascular ultrasound and a postoperative computed tomography scan were included in the study. Cross-sectional diameters measurements were taken at proximal, middle, and distal portions of each stent from intravascular ultrasound examination at the time of initial stenting and compared with the cross-sectional diameter measurements taken from computed tomography imaging at follow-up. A paired t test was used to compare the luminal change with a D'Agostino-Pearson test used for normality.

RESULTS

Fifty-four stents distributed among 38 patients were identified. The mean time to follow-up was 17.5 months. Stents were placed in the common iliac vein (n = 37, 68.5%), external iliac vein (n = 14, 25.9%), and common femoral vein (n = 3, 5.6%). Implanted stents included the Boston Scientific Wallstent (n = 23, 42.6%), Bard Venovo (n = 3, 5.6%), Boston Scientific Vici (n = 23, 42.6%), and Medtronic Abre (n = 5, 9.3%). The mean luminal loss was measured at 2.12 mm proximally (95% confidence interval [CI], 1.64-2.60; P<.001), 1.29 mm at the mid-stent (95% CI, 0.83-1.74, P<.001), and 1.56 mm distally (95% CI, 0.99-2.12; P<.001). There was no significant difference in luminal changes between woven and nonwoven stents at proximal (P = .374), middle (P = .179), and distal (P = .609) stent measurements.

CONCLUSIONS

This study reports morphological changes within venous stents and between woven and nonwoven venous stents. Our findings demonstrate that the edge-stent luminal decrease traditionally attributed to woven configurations also occurs with the newer nonwoven stents. Additional factors such as anatomical location, pelvic curvature, and other external forces may be accountable for this change rather than geometrical configuration of the stent.

Three-Year Outcomes of the Abre Venous Self-Expanding Stent System in Patients with Symptomatic Iliofemoral Venous Outflow Obstruction

PURPOSE

To report 36-month outcomes and subgroup analysis of the ABRE study evaluating the safety and effectiveness of the Abre venous self-expanding stent system for the treatment of symptomatic iliofemoral venous outflow obstruction disease.

METHODS

The ABRE study was a prospective, multicenter, nonrandomized study that enrolled and implanted Abre venous stents in 200 participants (mean age 51.5 years [SD ± 15.9], 66.5% women) with symptomatic iliofemoral venous outflow obstruction at 24 global sites. Outcomes assessed through 36 months included patency, major adverse events, stent migration, stent fracture, and quality-of-life changes. Adverse events and imaging studies were adjudicated by independent clinical events committee and core laboratories, respectively.

RESULTS

Primary, primary-assisted, and secondary patency through 36 months by Kaplan-Meier estimates were 81.6%, 84.8%, and 86.3%, respectively. The cumulative incidence of major adverse events through 36 months was 10.2%, mainly driven by 12 thrombosis events. Subgroup analyses demonstrated a primary patency of 76.5% in the acute deep vein thrombosis group, 70.4% in the postthrombotic syndrome group, and 97.1% in the nonthrombotic iliac vein lesion group through 36 months. The overall mean lesion length was 112.4 mm (SD ± 66.1). There were no stent fractures or migrations in this study. Quality of life and venous functional assessments demonstrated significant improvements from baseline to 36 months across all patient subsets.

CONCLUSIONS

Results from the ABRE study demonstrated sustained patency with a good safety profile after implantation of a dedicated venous stent in patients with symptomatic iliofemoral venous outflow obstruction disease.

Patient-Reported Outcomes in Venous Thromboembolism: A Systematic Review of the Literature, Current Challenges, and Ways Forward

BACKGROUND

Venous thromboembolism (VTE) affects >1.2 million Americans annually. Although the clinical outcomes and economic burdens of VTE have been well described, the impact of VTE on patients' health status has yet to be summarized. This systematic review summarizes how patient-reported outcome measures (PROMs) have been used in VTE to date.

METHODS AND RESULTS

PubMed/MEDLINE was queried for literature published through March 2023 using PROMs in a population of patients with VTE. Studies were excluded if the reference was an editorial, review, or case report, or if the study included patients with conditions other than VTE. Qualitative analyses were performed. After screening and exclusion, 136 references were identified; 5 described PROM development, 20 focused on PROM validation, and 111 used PROMs in outcomes research. The most used generic PROMs were the 36-item Short-Form Health Survey and EuroQol 5-dimensional questionnaire, and the most common disease-specific PROMs were the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms and the Pulmonary Embolism Quality of Life Questionnaire. PROMs were used to quantify the changes in health status after diagnosis, characterize the trajectory of subsequent improvement, and identify drivers of continued impairments in health status like postthrombotic syndrome and postpulmonary embolism syndrome. PROMs were also used to investigate the impact of novel treatment modalities on quality of life.

CONCLUSIONS

This review demonstrates the many benefits of PROM use, including quantifying changes in health status with treatment, capturing patients' experiences with the treatment itself, and identifying complications of VTE. Incorporating PROMs into VTE care will be an essential component of evaluating the effectiveness of novel therapies and should lead to improved shared decision-making for patients with VTE.

Editor's Choice - Quality of Life after Stenting for Iliofemoral Venous Obstruction: A Randomised Controlled Trial with One Year Follow Up

OBJECTIVE

Deep venous obstruction (DVO) is a great burden on the healthcare system and patients' quality of life (QoL). Case series show stenting is safe and effective, however most studies lack control groups and QoL changes have not been compared with conventional treatment. The aim was to assess the difference in QoL changes from baseline to 12 months between stent and conventionally treated patients with DVO.

METHODS

Subjects > 18 years old with DVO due to post-thrombotic (PTS) or non-thrombotic iliac vein lesions (NIVLs) in a tertiary hospital were prospectively randomised to best medical therapy (BMT) or stent placement with BMT in a ratio 2:1, stratified for PTS or NIVL. The primary outcome was the between group difference in VEINES-QoL scores change from baseline to 12 months after treatment. Secondary outcomes included the difference in score changes for EuroQoL 5-Dimension 5 Level (EQ-5D-5L), Pain Disability Index (PDI), Venous Clinical Severity Score (VCSS), and the Villalta score.

RESULTS

After three years, the inclusion rate dropped to almost zero, therefore the study had to be stopped. Sixty-three patients were randomised to either the stent (n = 42) or control group (n = 21). Overall, 50 patients had available data for primary outcome analysis. The adjusted mean difference between 12 month scores for VEINES-QoL and VEINES-Sym was 8.07 (95% CI 3.04 - 13.09) and 5.99 (95% CI 0.75 - 11.24) (p = .026), respectively, in favour of the stent group. The differences were significant, but a pre-defined meaningful 14 point improvement in QoL was not reached. The mean difference between 12 month scores for VCSS was -2.93 (95% CI -5.71 - 0.16, p = .040), -11.83 (95% CI -20.81 - 2.86, p = .011) for PDI, 0.015 (95% CI -0.12 - 0.15, p = .82) for the EQ-5D index, and -2.99 (95% CI -7.28 - 1.30, p = .17) for the Villalta score.

CONCLUSION

Symptomatic patients with DVO who received dedicated venous stents had significantly higher VEINES-QoL/Sym scores at 12 months compared with the control group, but the between group difference was lower than the pre-specified clinically relevant QoL difference of at least 14 points.

STUDY REGISTRATION NUMBER

NCT03026049.

Effectiveness of Venous Stenting for the Treatment of Lower Extremity Chronic Thrombotic Venous Obstruction

BACKGROUND

Patients with venous hypertension (HTN) have significant morbidity and poor quality of life. Deep venous thrombosis (DVT) and congenital defects that led to chronic outflow blockage are frequent causes of venous HTN. It is known that the venovenous bypass has been the standard method used in the treatment of chronic iliofemoral vein occlusions. Percutaneous recanalization has earlier been shown to be technically possible. With venoplasty and stenting, we used an aggressive endovascular strategy to treat the iliofemoral venous thrombotic occlusion.

METHODS

From May 2019 to April 2021, the medical records were reviewed for 63 patients diagnosed with symptomatic iliofemoral thrombotic occlusive disease and treated with venous stenting. The procedures' results were analyzed at Al-Azhar University Hospitals.

RESULTS

The medical records of 63 cases (44 women with a median age of 49.52 years), with chronic outflow block of iliofemoral vein segment that were treated with endovascular venous stenting, were reviewed retrospectively. Optimal success was obtained in 56 cases (88.9%). The twelve-month primary, assisted primary, and secondary patency rates were 76.8%, 80.4%, and 87.5%, respectively, while it was 73.2%, 80.4%, and 87.5%, respectively, after 2 years. The procedure-related complication rate was 6.3%. Puncture site hematoma was observed in 2 patients (3.2%). Early (30 days) stent thrombosis occurred in 2 patients (3.2%). Most importantly, there was no procedure-related mortality.

CONCLUSIONS

Endovascular treatment with balloon angioplasty and stenting of chronic venous thrombotic occlusions is an effective and safe procedure associated with a high technical rate of success and excellent patency rates. Accordingly, it should be considered the first line in the treatment of symptomatic iliofemoral vein occlusion.

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.

Performance of Open and Closed Cell Laser Cut Nitinol Stents for the Treatment of Chronic Iliofemoral Venous Outflow Obstruction in Patients Treated at a Single Centre

OBJECTIVE

A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction.

METHODS

A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency.

RESULTS

A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 - 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 - 6.62, p < .001).

CONCLUSION

OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design.