Venous stents in chronic iliac vein occlusions

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.

Endovascular treatment for symptomatic iliac vein compression syndrome: a prospective consecutive series of 48 patients

BACKGROUND

We sought to assess the prevalence of iliac vein compression syndrome (IVCS) in patients with unilateral left lower limb chronic venous disease and evaluate the feasibility and effectiveness of endovascular treatment for IVCS.

METHODS

We conducted a prospective cohort study of 48 consecutive patients diagnosed with IVCS between December 2008 and May 2012. We divided the patients into 2 groups: thrombotic IVCS (n = 12) and nonthrombotic IVCS (n = 36). We evaluated the perioperative, 30-day, and 1-year outcomes of endovascular treatment. We estimated the stent patency rate using the Kaplan-Meier method.

RESULTS

The prevalence of IVCS within our cohort was 14.8% (48/324). The technical success rate of the endovascular treatment was 95.8%. There was no death, pulmonary embolism, or contrast-induced nephropathy among the patients. The 1-year primary patency rate was 93.0%. There was no significant difference between the thrombotic and nonthrombotic IVCS groups (P = 0.156). Perioperative complications were minor and improved quickly. The median pain level recorded on a visual analogue scale declined from 4.5 to 1.2 (P < 0.05) in the thrombotic ICVS group and from 3.3 to 0.3 (P < 0.05) in the nonthrombotic ICVS group. The edema relief rates in the thrombotic and nonthrombotic ICVS groups were 81.8% and 58.5%, respectively. The cumulative recurrence free ulcer healing rate was 71.4% 12 months after treatment.

CONCLUSIONS

IVCS is more common than previously thought among patients with unilateral left lower limb chronic venous disease. Endovascular therapy, a minimally invasive approach to treating venous lesions, is a feasible and effective treatment for left-sided IVCS and has a high technical success rate and an acceptable complication profile.

Intravascular ultrasound scan evaluation of the obstructed vein

PURPOSE

The purpose of this study was the comparison of intravascular ultrasound scanning (IVUS) with transfemoral venography in the assessment of chronic iliac vein obstruction.

METHODS

IVUS and standard, single-plane, transfemoral venography were performed in 304 consecutive limbs during balloon dilation and stenting of an obstructed iliac venous segment. The appearance of the obstruction was described, and the degree of stenosis (maximal diameter reduction) was estimated with venography and IVUS. The stenotic area was derived with diameter calculations (pir(2)) and also was measured with the built-in software of the IVUS apparatus before and after dilation and stenting in 173 limbs. Preoperative hand/foot differential pressure and preoperative dorsal foot venous and intraoperative transfemoral hyperemia-induced pressure elevations after intra-arterial injection of papaverine hydrochloride were measured.

RESULTS

With IVUS, fine intraluminal and mural details were detected (eg, trabeculation, frozen valves, mural thickness, and outside compression) that were not seen with venography. The median stenosis (with diameter reduction) on venographic results was 50% (range, 0 to 100%) and on IVUS results was 80% (range, 25% to 100%). In a comparison with IVUS as the standard, venography had poor sensitivity (45%) and negative predictive value (49%) in the detection of a venous area stenosis of >70%. The actual stenotic area was more severe when measured directly with IVUS (0.31 cm(2); range, 0 to 1.68 cm(2)) versus derived (0.36 cm(2); range, 0 to 3.08 cm(2); P <.001), probably as a result of the noncircular lumen geometry of the stenosis. No correlation was found between any of the preoperative or intraoperative pressure measurements and degree of stenosis with or without collaterals. When collaterals were present, a more severe stenosis (median, 85%; range, 25% to 100%) was observed (versus a 70% stenosis in the absence of collaterals; range, 30% to 99%; P <.001), along with actual stenotic area (with collaterals: median, 0.24 cm(2); range, 0 to 1.18 cm(2); without collaterals: median, 0.45 cm(2); range, 0.02 to 1.68 cm(2); P <.01) and a higher rate of hyperemia-induced pressure gradient (> or =2 mm Hg; with collaterals, 34%; without collaterals, 11%; P <.05).

CONCLUSION

Venous IVUS appears to be superior to single-plane venography for the morphologic diagnosis of iliac venous outflow obstruction and is an invaluable assistance in the accurate placement of venous stents after venoplasty. No preoperative or intraoperative pressure test appears to adequately measure the hemodynamic significance of the stenosis. In lieu of adequate hemodynamic tests, IVUS determination of morphologically significant stenosis appears to be presently the best available method for the diagnosis of clinically important chronic iliac vein obstruction. Collateral formation should perhaps be looked on as an indicator of a more severe stenosis, although significant obstruction may exist with no collateral formation.

Endovascular surgery in the treatment of chronic primary and post-thrombotic iliac vein obstruction

OBJECTIVES

To compare the results and complications of endovascular surgery in limbs with post-thrombotic and non-thrombotic disease and to detail some technical aspects of the procedure.

DESIGN

A single centre, prospective study.

MATERIALS AND METHODS

Between March 1997 and August 1999, 139 consecutive lower extremities with chronic iliac venous obstruction (61 limbs with primary disease [MTS] and 78 with post-thrombotic disease [PTS]) were treated by balloon dilation and stenting. History, clinical examination, procedure and follow-up data were recorded.

RESULTS

Mortality was zero. Non-thrombotic complication rate was only 3%. Postoperative (8%, 6/78) and late occlusion (3%, 2/69) occurred only in post-thrombotic limbs. Primary, primary-assisted and secondary cumulative patency rates of the stented area at 2 years were 52%, 88% and 90%, respectively, in the PTS group as compared to 60%, 100% and 100% in the MTS group. Clinical improvement in pain and swelling was significant in both groups. Half of active venous ulcers healed after the procedure.

CONCLUSIONS

Chronic iliac vein obstruction appears to be a symptomatic lesion that can be treated safely and effectively by endovascular surgery regardless of aetiology. Generous use of IVUS is suggested in both diagnosis and treatment since phlebography is unreliable. The clinical improvement was significant in both groups; however, more excessive neointimal hyperplasia and a higher early and late occlusion rate were observed in post-thrombotic disease. Stenting after balloon dilation is advised in all venoplasties; stents should be inserted well into the IVC when treating iliocaval junction stenosis. A wide-diameter (16 mm) stent is recommended. The stent should cover the entire lesion as outlined by the IVUS.

Endovascular management of iliac vein compression (May-Thurner) syndrome

PURPOSE

To evaluate the feasibility of endovascular techniques in treating venous outflow obstruction resulting from compression of the iliac vein by the iliac artery of the left lower extremity (May-Thurner syndrome).

MATERIALS AND METHODS

A retrospective analysis of 39 patients (29 women, 10 men; median age, 46 years) with iliac vein compression syndrome (IVCS) was performed. Nineteen patients presented with acute deep vein thrombosis (DVT) and 20 patients presented with chronic symptoms. All patients presented with leg edema or pain. In the acute group, patients were treated with catheter-directed thrombolysis (120,000-180,000 IU urokinase/h) and angioplasty followed by stent placement. In the chronic group, patients were treated with use of angioplasty and stent placement alone (n = 8), or in combination with thrombolysis (n = 12). Patients were then followed-up with duplex ultrasound and a quality-of-life assessment.

RESULTS

Initial technical success was achieved in 34 of 39 patients (87%). The overall patency rate at 1 year was 79%. Symptomatically, 85% of patients were completely or partially improved compared with findings before treatment. Thirty-five of 39 patients received stents. The 1-year patency rate for patients with acute symptoms who received stents was 91.6%; for patients with chronic symptoms who received stents, the 1-year patency rate was 93.9%. Five technical failures occurred. Major complications included acute iliac vein rethrombosis (< 24 hours) requiring reintervention (n = 2). Minor complications included perisheath hematomas (n = 4) and minor bleeding (n = 1). There were no deaths, pulmonary embolus, cerebral hemorrhage, or major bleeding complications.

CONCLUSION

Endovascular reconstruction of occluded iliac veins secondary to IVCS (May-Thurner) appears to be safe and effective.

Left iliac venous thrombosis caused by venous spur: treatment with thrombectomy and stent implantation

PURPOSE

To determine the frequency of iliac venous spurs in left iliofemoral venous thrombosis and to report the results of interventional management of venous spurs after transfemoral venous thrombectomy.

METHODS

From 1990 through 1996, 77 patients with acute iliac venous thrombosis (61 left and 16 right) underwent surgical treatment. Patients with malignant disease were excluded from this series. All patients had transfemoral venous thrombectomy with construction of an inguinal arteriovenous fistula and perioperative anticoagulation with heparin with a switch to warfarin sodium for at least 12 postoperative months. Immediate results of thrombectomy were documented by means of intraoperative completion venography. Arteriovenous fistulas were ligated 3 months after control arteriovenography. Since 1995 venous spurs eventually detected during thrombectomy were treated immediately by means of stent implantation.

RESULTS

Among 61 patients with left-sided thrombosis, intraoperative phlebography revealed common iliac venous obstruction suggestive of venous spurs in 30 patients (49%). In 16 of 22 patients (73%) with untreated spurs, postoperative rethrombosis of the iliac vein was documented despite adequate anticoagulation. Only one of eight patients (13%) with stented spurs had reocclusion (chi2 test P < .01).

CONCLUSION

Venous spurs are found among about half of patients with left-sided iliac venous thrombosis. As long as the underlying venous pathologic process is left untreated, thrombectomy will not restore patency. Stent implantation is a simple and safe means to correct central venous strictures and provides excellent long-term results.