Stents in Common Iliac Vein Obstruction with Acute Ipsilateral Deep Venous Thrombosis: Early and Late Results

Technical Feasibility and Clinical Efficacy of Iliac Vein Stent Placement in Adolescents and Young Adults with May-Thurner Syndrome

PURPOSE

To report technical feasibility and clinical efficacy of iliac vein stent placement in adolescent patients with May-Thurner Syndrome (MTS).

MATERIALS AND METHODS

Single-institution retrospective review of the medical record between 2014 and 2021 found 63 symptomatic patients (F = 40/63; mean age 16.1 years, 12-20 years) who underwent left common iliac vein (LCIV) stent placement for treatment of LCIV compression from an overriding right common iliac artery, or equivalent (n = 1, left IVC). 32/63 (50.7%) patients presented with non-thrombotic iliac vein lesions (NIVL). 31/63 (49.2%) patients presented with deep vein thrombosis of the lower extremity and required catheter-directed thrombolysis after stent placement (tMTS). Outcomes include technically successful stent placement with resolution of anatomic compression and symptom improvement. Stent patency was monitored with Kaplan-Meier analysis at 3, 6, 12, 24, and 36 months. Anticoagulation and antiplatelet (AC/AP) regimens were reported.

RESULTS

Technical success rate was 98.4%. 74 bare-metal self-expanding stents were placed in 63 patients. Primary patency at 12, and 24-months was 93.5%, and 88.9% for the NIVL group and 84.4% and 84.4% for the tMTS group for the same period. Overall patency for the same time intervals was 100%, and 95.4% for the NIVL group and 96.9%, and 96.9% for the tMTS group. Procedural complication rate was 3.2% (2/63) with no thrombolysis-related bleeding complications. Clinical success was achieved in 30/32 (93.8%) and 29/31 (93.5%) patients with tMTS and NIVL groups, respectively.

CONCLUSION

CIV stent placement in the setting of tMTS and NIVL is technically feasible and clinically efficacious in young patients with excellent patency rates and a favorable safety profile.

Effect of stent treatment on hemodynamics in iliac vein compression syndrome with collateral vein

BACKGROUND

Iliac vein compression syndrome (IVCS) leads to blood flow obstruction in the lower extremities and is usually treated with stents, but stenting may worsen the hemodynamics and increase the risk of thrombosis in the iliac vein. The present work evaluates the advantages and disadvantages of the stent on IVCS with a collateral vein.

METHODS

The computational fluid dynamics method is adopted to analyze the preoperative and postoperative flow fields in a typical IVCS. The geometric models of the iliac vein are constructed from medical imaging data. The porous model is used to simulate the flow obstruction in IVCS.

RESULTS

The preoperative and postoperative hemodynamic characteristics in the iliac vein are obtained, e.g., the pressure gradient at two ends of the compressive region and the wall shear stress. It is found that the stenting restores the blood flow in the left iliac vein.

CONCLUSION

Impacts of the stent are classified into short-term and long-term effects. The short-term effects are beneficial in relieving IVCS, i.e., shortening the blood stasis and reducing the pressure gradient. The long-term effects increase the risk of thrombosis in the stent, i.e., enlarging wall shear stress due to a large corner and a diameter constriction in the distal vessel, and suggests the need to develop a venous stent for IVCS.

Current Status and Prospect of Stent Placement for May-Thurner Syndrome

Stent implantation has been proven to be safe and has become the first-line intervention for May-Thurner syndrome (MTS), with satisfactory mid-term patency rates and clinical outcomes. Recent research has demonstrated that catheter-directed thrombolysis is the preferred strategy when MTS is combined with deep vein thrombosis after self-expanding stent placement. However, the stent used for the venous system was developed based on the experience obtained in the treatment of arterial disease. Consequently, relatively common corresponding complications may come along later, which include stent displacement, deformation, and obstruction. Different measures such as adopting a stent with a larger diameter, improving stent flexibility, and increasing stent strength have been employed in order to prevent these complications. The ideal venous stent is presently being evaluated and will be introduced in detail in this review.

A Systematic Review and Meta-Analysis of 12-Month Patency After Intervention for Iliofemoral Obstruction Using Dedicated or Non-Dedicated Venous Stents

BACKGROUND

Endovascular stenting of the deep venous system has been proposed as a method to treat patients with symptomatic iliofemoral outflow obstruction. The purpose of this systematic review and meta-analysis was to compare the effectiveness of this treatment at 1-year following the development of dedicated venous stents.

METHOD AND RESULTS

We searched MEDLINE and EMBASE for studies evaluating the effectiveness of venous stent placement. Data were extracted by disease pathogenesis: non-thrombotic iliac vein lesions (NIVL), acute thrombotic (DVT), or post-thrombotic syndrome (PTS). Main outcomes included technical success, stent patency at 1 year and symptom relief. A total of 49 studies reporting outcomes in 5154 patients (NIVL, 1431; DVT, 950; PTS, 2773) were included in the meta-analysis. Technical success rates were comparable among groups (97%-100%). There were no periprocedural deaths. Minor bleeding was reported in up to 5% of patients and major bleeding in 0.5% upon intervention. Transient back pain was noted in 55% of PTS patients following intervention. There was significant heterogeneity between studies reporting outcomes in PTS patients. Primary and cumulative patency at 1 year was: NIVL-96% and 100%; DVT-91% and 97%; PTS (stents above the ligament)-77% and 94%, and; PTS (stents across the ligament)-78% and 94%. There were insufficient data to compare patency outcomes of dedicated and nondedicated venous stents in patients with acute DVT. In NIVL and PTS patients, stent patency was comparable at 1 year. There was inconsistency in the use of validated tools for the measurement of symptoms before and after intervention. When reported, venous claudication, improved in 83% of PTS patients and 90% of NIVL patients, and ulcer healing occurred in 80% of PTS patients and 32% of NIVL patients.

CONCLUSIONS

The first generation of dedicated venous stents perform comparably in terms of patency and clinical outcomes to non-dedicated technologies at 1 year for the treatment of patients with NIVL and PTS. However, significant heterogeneity exists between studies and standardized criteria are urgently needed to report outcomes in patients undergoing deep venous stenting.

Three-Year Results from the Venovo Venous Stent Study for the Treatment of Iliac and Femoral Vein Obstruction

Purpose

To assess safety and patency of the Venovo venous stent for the treatment of iliofemoral vein obstruction.

Materials and Methods

Twenty-two international centers enrolled 170 patients in the VERNACULAR study (93 post-thrombotic syndrome; 77 non-thrombotic iliac vein lesions). Primary outcome measures were major adverse events at 30 days and 12-month primary patency (freedom from target vessel revascularization, thrombotic occlusion, or stenosis > 50%). Secondary outcomes included the Venous Clinical Severity Score Pain Assessment and Chronic Venous Quality-of-Life Questionnaire assessments (hypothesis tested). Secondary observations included primary patency, target vessel and lesion revascularization (TVR/TLR), and assessment of stent integrity through 36 months.

Results

Freedom from major adverse events through 30 days was 93.5%, statistically higher than a pre-specified performance goal of 89% (p = 0.032) while primary patency at 12 months was 88.6%, also statistically higher than a performance goal of 74% (p < 0.0001). Mean quality-of-life measures were statistically improved compared to baseline values at 12 months (p < 0.0001). Primary patency at 36 months was 84% (Kaplan–Meier analysis) while freedom from TVR/TLR was 88.1%. There was no stent embolization/migration, and no core laboratory assessed stent fractures reported through 36 months. Six deaths were reported; none adjudicated as device or procedure related.

Conclusion

The Venovo venous stent was successfully deployed in obstructive iliofemoral vein lesions and met the pre-specified primary outcome measures through 12 months. At 3 years, primary patency was 84%, reintervention rates were low, standardized quality-of-life and pain measures improved from baseline, and there was no stent migration or fractures.

Level of Evidence

Level 2—prospective, multicenter, controlled clinical study without a concurrent control or randomization. Pre-specified endpoints were hypothesis-tested to performance goals derived from peer-reviewed clinical literature.

Registration clinicaltrials.gov

Unique Identifier NCT02655887.

Nightmare after iliac vein stenting: Spinal epidural hematoma

Spinal epidural hematoma is a rare but devastating complication of iliac vein stenting. Radicular back pain during and after procedure is an alarming sign for this complication.

Diagnosis and treatment of iliac vein stenosis

Stenosis of the iliac veins is common in patients with chronic venous insufficiency. The article describes the methods for the diagnosis and treatment of iliac vein stenosis. The causes of iliac vein stenosis include extravasal compression or the consequences of ileofemoral thrombosis. Stenosis of the iliac veins exists in 1/4 of the entire adult population, but clinical manifestations do not occur in all patients. Stenosis of the iliac veins should be considered in case of an unknown edema, more often in the left lower extremity, since venous duplex ultrasound of lower extremities is not sensitive and specific enough when examining the veins above the inguinal ligament. The most accurate diagnostic method is intravascular ultrasound (IVUS) but the appeared computed tomography angiography (CTA) and magnetic resonance angiography (MRA) with high-quality images have become a good replacement for IVUS. The main method of treatment of iliac vein stenosis, besides stenting, isindispensable drug therapy consisting of antithrombotic and phlebotonic drugs.

Association between deep vein thrombosis and stent patency in symptomatic iliac vein compression syndrome: Systematic review and meta-analysis

BACKGROUND

The study intended to evaluate stent primary patency rates for patients with iliac vein obstruction related with iliac vein compression syndrome according to clinic presentation.

METHODS

A systematic review and meta-analysis was conducted of studies that compared: unexposed patients with nonthrombotic iliac vein lesion (NIVL, group 1) vs exposed patients with iliac acute deep vein thrombosis (DVT, group 2); and NIVL (group 1) vs exposed patients with iliac vein obstruction and post-thrombotic syndrome (PTS, group 3). The following databases were searched: EMBASE, PubMed, Web of Science, Scopus, SciELO, and LILACS. Two reviewers independently selected the potential studies and extracted data. The pooled odds ratio (OR) and 95% confidence interval (95% CI) are shown for each outcome.

RESULTS

Five studies with a total of 1050 participants and 1169 lower limbs were included. Five hundred eighty-eight lower limbs presented NIVL (50.3%), 91 lower limbs presented acute DVT (7.7%), and 490 lower limbs presented PTS (42%). The endovascular technical success rate of stenting did not differ in any of the groups: 99.6% in NIVL, 94.5% in acute DVT, and 96.5% in PTS (P = .0632). The primary stent patency rates in the 6-month follow-up were 98.3% in NIVL vs 90.9% in PTS, with a statistical difference showing reduced stent patency rates in PTS (OR, 0.17; 95% CI, 0.06-0.48; P = .0008; I² = 0%), and 100% in the NIVL group vs 91.6% in acute DVT, with no statistical difference (OR, 0.30; 95% CI, 0.06-2.32; P = .30; I² = 0%). The primary stent patency rates in the 12-month follow-up were 94.6% in NIVL vs 84.1% in PTS, with a statistical difference showing decreases stent patency rates in the PTS group (OR, 0.29; 95% CI, 0.14-0.63; P = .0008; I² = 0%), and 91.1% in NIVL vs 90.9% in acute DVT, with no statistical difference (OR, 1.03; 95% CI, 0.26-4.07; P = .96; I² = 0%).

CONCLUSIONS

There is no statistical difference for the stent primary patency rates when the treatment is conducted in NIVL as compared with acute DVT lower limbs (at 6 and 12 months); therefore, other criteria must be considered for the indication of this treatment in NIVL patients. However, because there were better results of stent primary patency rates for NIVL vs PTS patients, this finding favors the treatment of acute DVT instead of PTS in lower limbs, once PTS renders smaller stent patency rates at 6 and 12 months.

May-Thurner Syndrome: A Consideration for Deep Vein Thrombosis in Males

May–Thurner syndrome (MTS) is an underdiagnosed cause of lower limb deep vein thrombosis (DVT). The clinical prevalence of MTS-related DVT is likely underestimated, particularly in patients with other more recognisable risk factors. MTS is classically described in females between the age group of 20–50 years. In patients with acute iliofemoral thrombosis, medical treatment with anticoagulation alone has been associated with higher risk of postthrombotic syndrome (PTS) and lower iliofemoral patency rates, as compared to endovascular correction. We describe a case of MTS-related extensive iliofemoral DVT occurring in a middle age male who presented with acute onset of left lower limb swelling and pain, complicated by pulmonary embolism. Doppler compression ultrasonography of the left lower limb showed partial DVT extending from the left external iliac to the popliteal veins, and contrasted computed tomography (CT) of the thorax abdomen and pelvis established features of MTS, together with right pulmonary embolism. He was started on low molecular weight heparin (LMWH) and then underwent left lower limb AngioJet pharmacomechanical thrombolysis/thrombectomy, iliac vein stenting, and temporary inferior vena cava (IVC) filter insertion. After the procedure, the patient recovered and improved symptomatically with rapid resolution of this left lower limb swelling and pain. He was switched to an oral Factor Xa inhibitor and was subsequently discharged. After 1-month follow-up, he remained well with stent patency visualised on repeat ultrasound and underwent an uneventful elective IVC filter retrieval with subsequent plans for a 1-year follow-up.

Contemporary nationwide trends and in-hospital outcomes of adjunctive stenting in patients undergoing catheter-directed thrombolysis for proximal deep venous thrombosis

OBJECTIVE

Outflow venous stenting as an adjunct to catheter-directed thrombolysis (CDT) is performed to prevent recurrent thrombosis and to reduce the risk of post-thrombotic syndrome. Historical data show that stenting improves outcomes of surgical thrombectomy in patients with iliofemoral deep venous thrombosis (DVT), and recent observational data suggest that stenting improves long-term outcomes of CDT. However, the impact of stenting during CDT on acute safety outcomes is unknown. We sought to investigate the contemporary trends, safety outcomes, and resource utilization of adjunctive stent placement in patients undergoing CDT.

METHODS

Patients with proximal lower extremity and caval DVT were identified within the National Inpatient Sample from January 2005 to December 2013. From this data set, we stratified our patients into three groups: patients who received CDT alone, patients who received CDT plus angioplasty, and patients who received CDT plus angioplasty with stenting. We used an inverse probability treatment weighting algorithm to create three weighted cohorts. Cochran-Armitage test was used to evaluate the trends of stent placement among patients treated with CDT. The primary outcome was a composite end point of all-cause mortality, gastrointestinal bleed, or intracranial hemorrhage.

RESULTS

A total of 138,049 patients were discharged with a principal diagnosis of proximal and caval DVT; 7097 of these patients received CDT (5.1%). From this group, 2854 (40.2%) were treated with CDT alone, 2311 (32.6%) received adjunctive angioplasty alone, and 1932 (27.2%) received adjunctive angioplasty and stent. Adjunctive stenting had a significantly lower rate of primary composite outcome compared with CDT alone (2.7% vs 3.8%; P = .04). Stent placement was associated with a similar length of stay compared with angioplasty and CDT alone groups (6.8 vs 6.9 vs 7.1 days, respectively; P = .94) and higher in-hospital charges ($115,164.01 ± $76,985.31 vs $98,089.82 ± $72,921.94 vs $80,441.63 ± $74,024.98; P < .001).

CONCLUSIONS

This nationwide study suggests that one in four patients undergoing CDT is treated with adjunctive stent placement in the United States. This observational study showed that adjunctive stenting does not adversely affect the acute safety outcomes of CDT; however, it was associated with increased hospital charges.

May-Thurner syndrome: History of understanding and need for defining population prevalence

Patients with May-Thurner syndrome (MTS) are at elevated risk of developing an extensive left iliofemoral deep vein thrombosis (DVT; localized blood clot) due to an anatomical variant where the right common iliac artery compresses the left common iliac vein against the lumbar spine. While MTS was initially presumed to be rare when it was first anatomically defined in 1957, case reports of this syndrome have recently become more frequent, perhaps due to improved imaging techniques allowing for enhanced visualization of the iliac veins. Still, the population burden of this condition is unknown, and there is speculation it may be higher than generally perceived. In the present review, we (a) review history of how MTS became recognized, (b) describe practical challenges of studying MTS in population-based settings due to the specialized imaging required for diagnosis, (c) discuss why the contribution of MTS to DVT may be underestimated, (d) describe uncertainty regarding the degree of venous compression which leads to DVT, and (e) outline future research needs. Our goal is to raise awareness of MTS and spark additional research into the epidemiology of this condition, which may be an underappreciated causative venous thromboembolism risk factor.

Modified one-session endovascular treatment for deep venous thrombosis with high risk of pulmonary embolism: Short-term outcomes

OBJECTIVES

To evaluate the safety and short-term outcomes of the modified one-session endovascular treatment with inferior vena cava filter placement and retrieval in one stage for the treatment of acute lower extremity deep vein thrombosis.

METHOD

Twenty-three patients with unilateral acute lower extremity deep vein thrombosis underwent modified one-session endovascular treatments, which were performed in one stage. Inferior vena cava filter placement without detachment, thrombectomy, and inferior vena cava filter retrieval were performed in one stage. Angioplasty and stent implantation were performed for patients with iliac vein stenosis. Venography was performed to identify the clearance of the thrombus. Color Doppler ultrasound and/or venography were conducted during the follow-up.

RESULTS

A total of 20/23 (87%) patients with thrombus removal rate >90% successfully underwent modified one-session endovascular treatment. inferior vena cava filters were detached in 3/23 (13%) patients achieving 50%-90% thrombus removal rate. Twenty-one iliac vein stents were implanted in 21/23 (91%) patients with iliac vein stenosis. After treatment, the differences in the circumferences of the affected limb and the healthy limb both significantly decreased. No procedure-related death, symptomatic pulmonary embolism, or major bleeding occurred. During the 12-25 months of follow-up, iliac vein stents and lower extremity veins maintained patent.

CONCLUSIONS

The modified one-session endovascular treatment with one-stage inferior vena cava filter placement and retrieval might be safe for the treatment of acute lower extremity deep vein thrombosis, and the early clinical outcomes are satisfactory. Placing and retrieving an inferior vena cava filter in one session could safeguard the endovascular interventions as well as reduce the filter-related complications associated with long dwelling times.

Iliac vein compression: epidemiology, diagnosis and treatment

Iliac vein compression (LIVC) is a prevalent finding in the general population, but a smaller number of patients are symptomatic. ILVC should be considered in symptomatic patients with unexplained unilateral lower leg swelling. Patients typically complain of one or more of the following symptoms: lower leg pain, heaviness, venous claudication, swelling, hyperpigmentation and ulceration. ILVC can be thrombotic, combined with acute or chronic DVT, or non-thrombotic. ILVC is best diagnosed with intravascular ultrasound (IVUS), but computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have emerged as valid screening tests. Venography underestimates the severity of ILVC but may provide insights into the anatomy and the presence of collaterals. Based on current available evidence, endovascular therapy with stenting remains the main treatment strategy for ILVC. Dedicated nitinol venous stents are currently under review by the Food and Drug Administration for potential approval in the United States. These stents have been released outside the US. There is no consensus to the optimal anticoagulation regimen post-ILVC stenting. Oral anticoagulants, however, remain a preferred therapy in patients with history of thrombotic ILVC.

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Long-term outcome and quality of life in patients with iliac vein compression syndrome after endovascular treatment

Purpose

Deep venous thrombosis induced by iliac vein compression syndrome often interferes with patients’ work or daily living. This study aims to investigate the long-term outcome and quality of life in patients with iliac vein compression syndrome after endovascular treatment.

Methods

From October 2011 until June 2016, 28 patients with acute deep venous thrombosis diagnosed as iliac vein compression syndrome by ultrasonography were enrolled in this perspective study. Fifteen patients underwent balloon dilation and stent insertion (group A); 13 patients received anticoagulation treatment, thrombolysis, or balloon dilation without stenting (group B). The Medical Outcomes Study-Short Form-36 was used to assess the quality of life preoperatively and after endovascular treatment. The follow-up of Short Form-36 questionnaire was obtained within 12.13 ± 12.04 months after repair.

Results

There was no operative mortality in two groups, and technical success was achieved in 14 (93.3%) patients in group A. Thirteen (86.7%) patients were cured in group A, which was significantly higher than that of group B (46.2%, p = 0.042). Only one patient showed occlusion of stent in group A, with a secondary patency rate of 93.3%. Except for ‘Role emotion’, all remaining domains were significantly improved in group A when compared with preoperative score ( p < 0.01). The scores of ‘Physical functioning’, ‘Role physical’, and ‘General health’ in group A were significantly higher than those of group B ( p < 0.05).

Conclusions

Endovascular stenting to treat iliac vein compression syndrome shows beneficial clinical outcome, cumulative patency rate, and quality of life, with high technical success and low complications.

Symptomatic Iliofemoral and Iliocaval Venous Thrombosis in Patients With Cancer: Endovascular Treatment

INTRODUCTION:

Proximal (iliocaval and iliofemoral) deep vein thrombosis (DVT) and pulmonary thromboembolism are the second cause of death in patients with cancer.

MATERIAL AND METHODS:

A retrospective analysis was performed in 35 patients with cancer treated with endovascular therapy for proximal DVT. The primary objective was to evaluate the technical success of the procedure and the 30-day and long-term symptom improvement.

RESULTS:

Thirty-five patients with a mean age of 57.7 years were treated. In 27 patients, DVT was due to tumor compression and/or invasion of the iliocaval venous axis, and in the remaining 8, it was secondary to their hypercoagulability state. The revascularization techniques used were manual catheter-directed aspiration of the thrombus plus angioplasty and stenting. Technical success was achieved in 33 patients. No complications occurred. Twenty-seven patients were followed up at 30 days posttreatment: 21 were free of postthrombotic syndrome, 4 (14.8%) had mild symptoms, and 2 (7.4%) had moderate symptoms. The mean long-term follow-up was 27.3 months, with a primary patency of 68.8% and assisted and secondary patency rates of 100%.

CONCLUSION:

Endovascular revascularization in patients with cancer with extensive and symptomatic proximal DVT is safe and efficient, with a low rate of complications. We consider that this therapy should be offered to patients with cancer with an average or long life expectancy.

A systematic review on the use of deep venous stenting for acute venous thrombosis of the lower limb

OBJECTIVES

The aim is to evaluate venous stent patency, the development of post-thrombotic syndrome, recurrence, quality of life and the optimal post-procedural anticoagulation regimen in the treatment of iliofemoral deep venous thrombosis.

METHOD AND RESULTS

EMBASE and Medline databases were interrogated to identify studies in which acute deep venous thrombosis patients were stented. Twenty-seven studies and 542 patients were identified. Primary, assisted primary and secondary patency rates 12 months after stent placement ranged from 74 to 95, 90 to 95 and 84 to 100%, respectively. The observed post-thrombotic syndrome rate was 14.6%. The incidence of stent re-thrombosis was 8%. In 26% of studies, patients received additional antiplatelet therapy. Quality of life questionnaires employed in 11% of studies, demonstrating an improvement in the chronic venous insufficiency questionnaire (22.67 ± 3.01 versus 39.34 ± 6.66).

CONCLUSION

Venous stenting appears to be an effective adjunct to early thrombus removal; however, further studies are needed to identify optimal anticoagulant regimen and effect on quality of life.

Endovascular Treatment for Iliofemoral Vein Thrombosis with Composite Stents

BACKGROUND

To evaluate the applicability of endovascular treatment for iliofemoral vein thrombosis with composite stents.

METHODS

Between September 2013 and August 2016, 29 consecutive patients underwent endovascular therapy with composite stents for iliofemoral vein thrombosis and were followed up at our institution. All the patients with acute or chronic iliofemoral vein thrombosis enrolled in this study were evaluated by color Doppler ultrasonography and diagnosed by venography. Treatment measures and related complications were recorded, and cumulative stent patency was assessed with Kaplan-Meier curves.

RESULTS

Patients with acute iliofemoral vein thrombosis (n = 7) were successfully treated with catheter-directed thrombolysis treatment, balloon angioplasty, and stents, whereas patients (n =  = 22) with chronic deep vein thrombosis were treated successfully by balloon angioplasty and stent only. Among all patients, 2 stents were inserted in 25 patients, whereas 3 stents were deployed in 4 patients. Endovascular treatment for iliofemoral vein thrombosis with laser-cut stents combined with Wallstents showed primary patency of treated limbs at 6, 12, and 24 months was 96.6%, 93.1% and 93.1%, respectively. Mean duration of follow-up was 23 months, and there was no occurrence of contralateral vein thrombosis during follow-up by ultrasound.

CONCLUSIONS

Iliofemoral vein thrombosis was successfully recanalized by endovascular therapy with composite stents, and there was no occurrence of contralateral vein thrombosis by ultrasound during follow-up.

Variant May-Thurner syndrome: Compression of the left common iliac vein by the ipsilateral internal iliac artery

May Thurner syndrome (MTS) is an anatomic variant that can present as acute or chronic deep vein thrombosis. Although it is classically reported in young and middle-aged women, it is also seen in both young and older men. Multiple cases of anatomic variations of MTS have been described. We present an uncommon case of variant MTS, including diagnostic imaging and approach to treatment.

Midterm Results of Endovascular Treatment for Iliac Vein Compression Syndrome from a Single Center

BACKGROUND

The efficacy of endovascular interventional treatment for iliac vein compression syndrome (IVCS) is not well studied. The purpose of our study was to investigate the clinical outcome of endovascular interventional treatment for IVCS.

METHODS

Data of 68 patients with IVCS, who underwent interventional treatment in our hospital, were analyzed retrospectively. Among these patients, 46 had lower extremity varicose veins. Sixty-five patients underwent stent implantation, and 3 patients underwent simple balloon angioplasty. Fourteen patients had post-thrombotic syndrome (PTS) and 11 patients had acute deep venous thrombosis (DVT). Among these 14 patients with PTS, 12 underwent stent implantation and 2 underwent iliac venous simple balloon angioplasty. On the other hand, 9 of the 11 patients with DVT underwent catheter-directed thrombolysis (CDT) and then stent implantation. Of the remaining 2 patients, one underwent Angiojet Rheolytic thrombectomy (ART) before CDT and the other underwent CDT with simple balloon angioplasty. The stenosis rate of iliac vein and the circumference differences between the affected limb and healthy one were measured before and after operation. These patients were followed up with duplex ultrasound postoperatively.

RESULTS

A total of 75 stents were placed in 65 patients. The diameter and the length of stent were 6 to 14 mm (mean 12.5 ± 2.0 mm) and 40 to 260 mm (mean 82.5 ± 36.9 mm), respectively. CDT with/without ART was performed, using urokinase and/or alteplase, after inferior vena cava filtration in all of 11 patients with DVT, without the recurrence of pulmonary embolism. The difference in iliac venous stenosis was statistically significant ([91.2% ± 8.4%] [70.0% ∼ 100.0%] vs. 3.9% ± 13.0% [0 ∼ 70.0%], P < 0.01). The patency rates at 1-, 3-, 6- months, 1 year, and 2 years were 98.5%, 95.6%, 94.1%, 92.4%, and 90.7%, respectively. Four patients (5.9%) suffered from minor bleeding at puncture point and were successfully treated with compression. However, 1 (1.5%) patient underwent stent implantation of right iliac vein that became complicated due to migration of stent to the right ventricle which was successfully arrested by Amplatz Goose Neck Snare Kit. The incidence of PTS was 10.3% (7/68) during the follow-up at 1 to 24 (mean 18.2 ± 7.7) months.

CONCLUSIONS

Interventional therapy for patients of IVCS is safe and effective. Satisfactory outcomes were obtained for stent placement for IVCS.

Investigation of adverse events associated with an off-label use of arterial stents and CE-marked iliac vein stents in the iliac vein: insights into developing a better iliac vein stent

We analyzed the adverse events associated with an off-label use of arterial stents and CE-marked iliac vein stents for the treatment of iliac venous thromboembolism and investigated their relationships with the anatomical features of the iliac vein, to gain insights into the development of a better iliac vein stent. Reports of adverse events following the use of stents in the iliac vein were retrieved from the Manufacturer and User Facility Device Experience (MAUDE) database that contain suspected device-associated complications reported to the Food and Drug Administration. Data from 2006 to 2016 were investigated. The literature analysis was also conducted using PubMed, Cochrane Library, EMBASE, and Web of Science focusing on English articles published up to 4 October 2016. The analysis of 88 adverse events from the MAUDE database and 182 articles from the literature revealed that a higher number of adverse events had been reported following the use of arterial stents in the iliac vein compared to CE-marked iliac vein stents. While stent migration and shortening were reported only for the arterial stents, stent fracture and compression occurred regardless of the stent type, even though a vein does not pulsate. A study of the anatomical features of the iliac vein implies that bending, compression, and kink loads are applied to the iliac vein stents in vivo. For designing, developing, and pre-clinical testing of stents intended for use in the iliac vein, the above mechanical load environments induced by the anatomical features should be considered.

Venous Compression Syndromes: a Review

OPINION STATEMENT

Venous compression syndromes present a diagnostic and therapeutic challenge as the clinical presentation can be vague, diagnostic criteria are often not present, and high quality standardization of when and how to treat is not available in part due to the limited number of cases reported and also due to the limited literature available. Significant venous compression should be considered when clinical symptoms correlate to location of compression and there is evidence of hemodynamic changes including venous hypertension, collateral/variceal formation, and/or thrombus formation. In general, treatment of venous compression should address the etiology of the compression as opposed to just treating symptoms associated with it such as significant varices or anticoagulation for thrombus to avoid recurrence of symptoms.

Feasibility of continuous, catheter-directed thrombolysis using low-dose urokinase in combination with low molecular-weight heparin for acute iliofemoral venous thrombosis in patients at risk of bleeding

The present study aimed to examine the feasibility of catheter-directed thrombolysis (CDT) using continuous infusion of low-dose urokinase in combination with low molecular weight heparin (LMWH) for acute iliofemoral venous thrombosis. This retrospective analysis included patients with symptomatic acute iliofemoral venous thrombosis who received CDT using continuous infusion of low-dose urokinase in combination with LMWH within the past four years. Urokinase was administered at 1×10⁴ U/h and 2×10⁴ U/h in patients at high-risk and low-risk of bleeding, respectively. Measurements included urokinase dosage, duration, clinical outcomes and CDT-related complications. A total of 46 patients were included (high-risk, n=17; low-risk, n=29). In the high-risk patients, 64.7% experienced dissolution of ≥50% thrombi after a median CDT duration of 8 days (range, 6-10 days) and median total urokinase dose of 1.92×10⁶ units (range, 1.44-2.4×10⁶ units). In the low-risk patients, 82.8% achieved dissolution of ≥50% thrombi after a median CDT duration of 7 days (range, 4-10 days) and a median total urokinase dose of 3.36×10⁶ units (range, 1.92-4.80×10⁶ units). Remission of clinical symptoms after CDT was achieved in 15 (88.2%) and 28 (96.6%) cases in high-risk and low-risk patients, respectively. No treatment-associated pulmonary embolism or major bleeding was observed. Three (6.5%) subjects (high-risk, n=1; low-risk, n=2) experienced minor bleeding. In conclusion, continuous infusion of low-dose urokinase via CDT in combination with LMWH is effective and safe for acute iliofemoral venous thrombosis in patients with one or more risk factor for bleeding.

Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines

Lower extremity deep vein thrombosis is a serious medical condition that can result in death or major disability due to pulmonary embolism or post-thrombotic syndrome. Appropriate diagnosis and treatment are required to improve symptoms and salvage the affected limb. Early thrombus clearance rapidly resolves symptoms related to venous obstruction, restores valve function and reduces the incidence of post-thrombotic syndrome. Recently, endovascular treatment has been established as a standard method for early thrombus removal. However, there are a variety of views regarding the indications and procedures among medical institutions and operators. Therefore, we intend to provide evidence-based guidelines for diagnosis and treatment of lower extremity deep vein thrombosis by multidisciplinary consensus. These guidelines are the result of a close collaboration between interventional radiologists and vascular surgeons. The goals of these guidelines are to improve treatment, to serve as a guide to the clinician, and consequently to contribute to public health care.

Safety and Effectiveness of Stent Placement for Iliofemoral Venous Outflow Obstruction: Systematic Review and Meta-Analysis

BACKGROUND

Endovenous recanalization of iliofemoral stenosis or occlusion with angioplasty and stent placement has been increasingly used to maintain long-term venous patency in patients with iliofemoral venous outflow obstruction. The purpose of this systematic review and meta-analysis was to determine safety and effectiveness of venous stent placement in patients with iliofemoral venous outflow obstruction.

METHODS AND RESULTS

We searched MEDLINE and EMBASE for studies evaluating safety or effectiveness of stent placement in patients with iliofemoral venous outflow obstruction. Data were extracted by disease pathogenesis: nonthrombotic, acute thrombotic, or chronic post-thrombotic. Main outcomes included technical success, periprocedural complications, symptom relief at final follow-up, and primary/secondary patency through 5 years. A total of 37 studies reporting 45 treatment effects (nonthrombotic, 8; acute thrombotic, 19; and chronic post-thrombotic, 18) from 2869 patients (nonthrombotic, 1122; acute thrombotic, 629; and chronic post-thrombotic, 1118) were included. Technical success rates were comparable among groups, ranging from 94% to 96%. Complication rates ranged from 0.3% to 1.1% among groups for major bleeding, from 0.2% to 0.9% for pulmonary embolism, from 0.1% to 0.7% for periprocedural mortality, and from 1.0% to 6.8% for early thrombosis. Patient symptom relief data were reported inconsistently. At 1 year, primary and secondary patency were 96% and 99% for nonthrombotic, 87% and 89% for acute thrombotic, and 79% and 94% for chronic post-thrombotic.

CONCLUSIONS

Stent placement for iliofemoral venous outflow obstruction results in high technical success and acceptable complication rates regardless of cause of obstruction.

Catheter-directed thrombolysis for extensive iliofemoral deep vein thrombosis: review of literature and ongoing trials

In patients with extensive lower limb deep vein thrombosis (DVT) that, typically, extends into the iliofemoral veins, catheter-directed thrombolysis (CDT) can achieve faster and more complete thrombus lysis as compared with systemic thrombolysis, while providing an acceptable safety profile through administration of lower doses of thrombolytic agents. Through a reduction in thrombus burden, CDT has the potential to mitigate the risk for post-thrombotic syndrome by restoring venous patency and preserving venous valve function. The efficacy of CDT may be improved by adjunctive approaches that include percutaneous mechanical thrombectomy, angioplasty with or without stenting, and ultrasound-assisted CDT. CDT may also have a specific therapeutic role in the management of iliofemoral DVT involving patients who are pregnant or with May-Thurner syndrome. This article summarizes the literature in this area and discusses recently completed and ongoing randomized trials on the use of CDT in patients with extensive lower limb DVT.

Increasing role of interventional cardiologists for peripheral vascular disease

Improvements in the design of endovascular devices and technical skills of interventionalists have opened new possibilities for patients with a wide range of peripheral vascular diseases. In lower extremity peripheral artery disease, percutaneous treatments have become the predominant revascularization strategy for simple and complex lesions. Newer generations of stents and drug-coated balloons have demonstrated strong potential in the treatment of femoropopliteal and infrainguinal diseases. One of the most dramatic advances in the recent past has been endovascular repair of thoracic and abdominal aortic aneurysms, which has become the preferred approach in lieu of open surgical repair. Contemporary trials have established the safety and effectiveness of carotid stenting in selected patients with severe stenosis. Endovascular treatments for venous occlusive disease have long been underutilized, but their effectiveness is being increasingly recognized. This review covers new endovascular procedures performed by interventional cardiologists for peripheral vascular diseases.

Functional outcomes following catheter-based iliac vein stent placement

OBJECTIVES

Although previous reports have demonstrated the efficacy of catheter-directed thrombolytic therapy and iliac vein stent placement for the management of iliofemoral deep vein thrombosis (DVT), functional outcomes remain undefined. The purpose of this study was to determine midterm outcomes and functional quality of life among patients treated with iliac vein stenting.

METHODS

Records of all the patients treated with iliac vein stent placement between March 2004 and March 2011 were examined for primary patency, assisted primary patency, and secondary patency. Midterm functional outcomes were measured quantitatively, including ongoing symptoms and return to work status.

RESULTS

Over the study interval, 32 patients (33 limbs) underwent iliac vein stent placement. In all, 72% (n = 23) of these patients were female, with an average age of 43 years. In all, 78% (n = 25) of the patients were diagnosed with acute DVT, 89% of which occurred in the left leg. Catheter-directed thrombolysis was utilized in 92% (23 of 25) of the patients with acute DVT. All patients treated with thrombolysis and stent placement presented with pain and edema in the affected limb. One-year primary, assisted primary, and secondary patencies were 75%, 96%, and 96%, respectively. Freedom from reintervention at 1 year was 83%. Treatment was associated with a sustained significant reduction in pain (91% vs 6%, P < .001) and edema (97% vs 12%, P < .001) at a mean follow-up of 29 months (range 5-83 months), at which time 89% of the patients reported to be at their pre-DVT functional status.

CONCLUSIONS

Aggressive therapy of symptomatic iliac vein stenosis or occlusion with venography, catheter-directed thrombolysis, and iliac vein stent placement provides durable patency and freedom from reintervention. Most patients can anticipate good functional recovery with decreased pain, decreased edema, and high likelihood of returning to work.

Symptomatic ileofemoral deep vein thrombosis due to May-Thurner syndrome

A 33-year-old woman with no medical history reported an acute onset of left leg and thigh swelling. A review of her medications revealed that she had started oral contraceptives 2 months previously. Ultrasonography and subsequent venography demonstrated extensive ileofemoral clot burden. Thrombolysis and thrombectomy successfully restored venous return with subsequent improvement in the leg swelling and oedema. In this case, we describe a patient presenting with extensive ileofemoral deep vein thrombosis, otherwise known as the May-Thurner syndrome.

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.

Iliac vein stenting as a durable option for residual stenosis after catheter-directed thrombolysis and angioplasty of iliofemoral deep vein thrombosis secondary to May–Thurner syndrome

Introduction

This study aims to evaluate the primary patency and clinical outcomes after stenting for residual iliac venous stenosis during catheter-directed thrombolysis treatment of acute iliofemoral deep vein thrombosis arising from May–Thurner syndome.

Methods

A retrospective study was done for the all patients who underwent iliac vein stenting after catheter-directed thrombolysis treatment of acute iliofemoral deep vein thrombosis due to May–Thurner syndrome from January 2005 to April 2011 in Inha University Hospital. Patient information was assembled from the electronic medical records, imaging and interview. The patency of iliac vein stent was evaluated with serial computed tomography.

Results

Fifty-one patients were enrolled. The median age was 70 years (range 44–86). There were 37 females (72.5%). The duration of symptoms of acute deep vein thrombosis before catheter-directed thrombolysis treatment was 6 days (median, range 1–33). Self-expanding stent was used for iliac vein stenting. Initial technical success rate was 94.1%. There were two complications (3.9%): an arteriovenous fistula formation in left popliteal area and a right inguinal hematoma. Mean follow-up was 15.6 months (range 6 days–80.8 months). Primary patency rate after iliac vein stenting was 95.8% at 6 months, 87.5% at 12 months and 84.3% at 24 months. Four patients had recurrent thrombotic occlusion (7.8%) during the follow-up.

Conclusion

Iliac vein stenting showed good primary patency rate with few complications. Iliac vein stenting is a durable option for residual stenosis after catheter-directed thrombolysis treatment of acute deep vein thrombosis in May–Thurner syndrome.

Postintervention duration of anticoagulation in venous surgery

For a substantial proportion of patients with deep venous thrombosis (DVT), current treatment strategies are suboptimal and new treatment options are needed. Especially for the group of patients who are at the highest risk for post-thrombotic syndrome, new treatment modalities such as catheter-directed thrombolysis and additional stenting are being investigated. With current clinical studies addressing new technical options, the medical management of patients following these interventions deserves attention. The duration of anticoagulant treatment following surgical or radiological interventions for DVT seems not to be influenced by the presence of a venous stent. According to recent ACCP 2012 guidelines the anticoagulant management in patients who have had any method of thrombus removal performed, the same intensity and duration of anticoagulant therapy as in comparable patients who do not undergo thrombosis removal is recommended (Grade 1B). In the acute phase of thrombosis, irrespective of the technique and whether or not stenting is applied, immediate anticoagulation following the procedure is pertinent to reduce the risk of recurrent thrombosis and thrombus propagation. The long-term treatment duration after venous interventions therefore may be tailored based on common risk factors for recurrent thrombosis and the individual risk for bleeding. Selected thrombophilia factors, d-dimer assessment and residual venous thrombosis provide markers for recurrent DVT. Currently, vitamin K antagonists) provide the main anticoagulants for (prolonged) anticoagulation, while the new oral anticoagulants emerge as promising alternatives. In case prolonged anticoagulation after unprovoked DVT is not indicated, cardiovascular risk management is warranted because of an increased rate of arterial thrombotic events after DVT; aspirin may be indicated as secondary prevention against recurrent thrombosis (while providing primary prevention against arterial thrombosis).

May-thurner syndrome: a case report and review of the literature

May-Thurner syndrome (MTS) has been recognized as a clinical entity for almost six decades. The true incidence rate of MTS is unknown and perhaps ranges from 22 to 32% according to the autopsy studies in the early twentieth century. However, MTS related deep venous thrombosis (DVT) accounts for only 2%-3% of all lower limb DVTS. In MTS, the left common iliac vein is compressed against the fifth lumbar vertebrae by the right common iliac artery, as it crosses in front of the vein. Chronic pulsation of the artery is thought to cause elastin, collagen deposition, and intimal fibrosis leading to formation of venous spur and venous thrombosis. MTS can present as acute or chronic DVT leading to pulmonary embolism (PE), chronic leg pain, chronic ulcers, or skin pigmentation changes. In this case report we have described an interesting case of a 28-year-old Caucasian female who presented for evaluation of shortness of breath (SOB) associated with cough for one week. SOB was found to be secondary to massive bilateral pulmonary embolism resulting from extensive MTS related DVT of the left lower extremity. Patient underwent pharmacomechanical treatment with local thrombolysis, thrombectomy, and venoplasty along with stent placement that extended to inferior vena caval junction. Subsequently patient was discharged on coumadin. MTS should be considered in differentials when faced with a case of unilateral DVT particularly in younger age group.

Management of proximal deep vein thrombosis

Iliofemoral DVT constitutes approximately 20-25% of lower limb DVT and represents a specific subgroup of patients at highest risk for post-thrombotic syndrome (PTS). Anticoagulation alone has no significant thrombolytic activity and has not impact on PTS prevention. Early thrombus removal has reduced PTS in uncontrolled reports and reviews but major trials are awaited. The optimal timing for treatment appear to be thrombus <2 weeks old and, methods for thrombus removal include direct open or suction thrombectomy, catheter directed thrombolysis (CDT), with or without percutaneous mechanical thrombectomy (PMT) devices. Three principle types of PMT device are in use (rotational, rheolytic and ultrasound enhanced devices) and are combined with CDT in pharmocomechanical thrombolysis (PhMT) to enhance early thrombus removal. These devices have individual device specific attributes and side effects that are additional to the bleeding complications of thrombolysis. A number of additional interventions may be utilised to the improve results of CDT and PhMT. IVC filter deployment to reduce periprocedural PE, is supported by little evidence unless an indication for its use already exists. However, balloon venoplasty and vein stents undoubtedly vein patency after treatment. Early thrombus removal comes with additional upfront costs derived from devices, imaging and critical care bed usage. However, significant potential savings from reduction in PTS and rethrombosis rates may reduce overall societal costs. This review focuses on iliofemoral thrombosis, however, the less commonly encountered but clinically important subclavian vein thrombosis is also discussed.

Iliac vein compression syndrome in an active and healthy young female

Iliac vein compression syndrome is a condition involving external compression of the left common iliac vein by the right iliac artery, which was first described in the 1850s. It predominates in females typically between the third and fourth decade of life and has been associated with thrombophilias. Importantly, the syndrome is amenable to endovascular treatment. Here, we describe a case of a young athletic female with an incidental finding of a left iliac vein thrombosis while taking oral contraceptives, who was identified as having iliac vein compression syndrome on follow-up MR venography with positive testing for Factor V Leiden mutation.

Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial

BACKGROUND

Conventional anticoagulant treatment for acute deep vein thrombosis (DVT) effectively prevents thrombus extension and recurrence, but does not dissolve the clot, and many patients develop post-thrombotic syndrome (PTS). We aimed to examine whether additional treatment with catheter-directed thrombolysis (CDT) using alteplase reduced development of PTS.

METHODS

Participants in this open-label, randomised controlled trial were recruited from 20 hospitals in the Norwegian southeastern health region. Patients aged 18-75 years with a first-time iliofemoral DVT were included within 21 days from symptom onset. Patients were randomly assigned (1:1) by picking lowest number of sealed envelopes to conventional treatment alone or additional CDT. Randomisation was stratified for involvement of the pelvic veins with blocks of six. We assessed two co-primary outcomes: frequency of PTS as assessed by Villalta score at 24 months, and iliofemoral patency after 6 months. Analyses were by intention to treat. This trial is registered at ClinicalTrials.gov, NCT00251771.

FINDINGS

209 patients were randomly assigned to treatment groups (108 control, 101 CDT). At completion of 24 months' follow-up, data for clinical status were available for 189 patients (90%; 99 control, 90 CDT). At 24 months, 37 (41·1%, 95% CI 31·5-51·4) patients allocated additional CDT presented with PTS compared with 55 (55·6%, 95% CI 45·7-65·0) in the control group (p=0·047). The difference in PTS corresponds to an absolute risk reduction of 14·4% (95% CI 0·2-27·9), and the number needed to treat was 7 (95% CI 4-502). Iliofemoral patency after 6 months was reported in 58 patients (65·9%, 95% CI 55·5-75·0) on CDT versus 45 (47·4%, 37·6-57·3) on control (p=0·012). 20 bleeding complications related to CDT included three major and five clinically relevant bleeds.

INTERPRETATION

Additional CDT should be considered in patients with a high proximal DVT and low risk of bleeding.

FUNDING

South-Eastern Norway Regional Health Authority; Research Council of Norway; University of Oslo; Oslo University Hospital.