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

Anticoagulation plus antiplatelet therapy versus anticoagulation alone following iliac vein stent implantation in acute and subacute deep vein thrombosis: A multicenter study with propensity score matching

BACKGROUND

Iliac vein stenting is an effective treatment for iliac venous stenosis after percutaneous mechanical thrombectomy. Nevertheless, while some researchers have investigated medical therapy following iliac vein stenting, no consensus has been reached to date.

OBJECTIVES

To evaluate the effectiveness and safety of anticoagulation plus antiplatelet therapy following iliac vein stent implantation in patients with acute and subacute iliofemoral deep vein thrombosis (DVT).

MATERIALS AND METHODS

This retrospective study comprised 234 patients: 167 patients in Group 1 with a mean age of 64.3 ± 13.5 years received anticoagulants alone, and 67 patients in Group 2 with a mean age of 60.7 ± 15.4 years received anticoagulation plus antiplatelet therapy. All patients received technically successful percutaneous pharmacomechanical thrombectomy and iliac vein stent implantation, and 61 patients underwent additional catheter-directed thrombolysis. The two groups exhibited comparable demographics, comorbidities, DVT burdens, and procedural details. Through propensity score matching (PSM) analysis, 62 pairs of patients from Group 1 and Group 2 were matched.

RESULTS

During a follow-up period of 33.7 ± 16.5 months, the cumulative primary patency rates were 95.1 %, 89.7 % and 88.3 % at one, three and five years in Group 1 compared to 98.8 %, 98.5 % and 98.5 % in Group 2 for the entire cohort (p = 0.042); in the PSM analysis, the rates were 91.9 %, 87.3 % and 87.3 % at one, three and five years in Group 1 versus 98.4 % at one, three and five years in Group 2 (p = 0.039). The cumulative bleeding-free rate was 98.2 % at one, three and five years in Group 1 versus 95.5 %, 93.8 % and 93.8 % at one, three and five years in Group 2 for the entire cohort (p = 0.089), and it was 98.4 % at one, three and five years in Group 1 versus 95.2 %, 93.3 % and 93.3 % (p = 0.156) at one, three and five years in Group 2 in the PSM analysis.

CONCLUSION

Anticoagulation plus antiplatelet therapy significantly improved stent patency, with a non-significant increase in the bleeding rate.

Safety and efficacy assessment of the Inno-Xmart venous stent system in managing symptomatic iliofemoral venous obstruction: a 12-month outcome analysis

This study aims to evaluate the safety and efficacy of the dedicated Inno-Xmart braided venous stent system (Suzhou Innomed Medical Device Co., Ltd., Jiangsu, China) in treating symptomatic iliofemoral venous obstruction. This clinical study followed a prospective, multicentre, single-arm design with the application of an objective performance goal. Patients diagnosed with symptomatic iliofemoral venous obstruction who met the eligibility criteria of this study were enrolled and treated with the Inno-Xmart venous stent system. The safety endpoints included the assessment of stent fracture, satisfaction of delivery system and 12-month incidence rate of major adverse events (MAEs). The primary efficacy endpoint focused on evaluating the 12-month primary patency rate through venography as determined by core laboratory. Secondary efficacy endpoints included surgical success rate, 6-month primary patency rate and the changes in quality of life from baseline to 6- and 12-month follow-up intervals. Between September 18, 2019, and April 26, 2021, 193 patients were successfully enrolled across 18 research institutions. The surgical success rate was 95.3% (184/193), the 12-month MAE rate was 5.1% (9/178) with no stent fractures or migrations. The 12-month primary patency rate for the participants was 96.1%, significantly surpassing the literature-derived objective performance of 80% (95% confidence interval [CI], 92.1-98.4; P < 0.0001). In addition, the mean venous clinical severity score (VCSS) and Chronic Venous Disease Quality of Life Questionnaire (CIVIQ) scores at the 6- and 12-month follow-ups were significantly lower than the preoperative scores (P < 0.001). The innovative, dedicated braided venous stent designed to address symptomatic iliofemoral venous obstruction demonstrates a high technical success rate, low complication rates, and impressive mid-term (12-month) patency. It effectively enhanced the quality of life for patients and holds promising prospects for a wide range of applications. The clinical study was officially registered in the "Chinese Clinical Trial Registry" (Registration number: ChiCTR2000040216, date of registration: November 25th, 2020).

Fatigue Test Method to Evaluate the 50 Year Durability of Venous Stents

OBJECTIVE

Iliofemoral venous obstructive disease can result in significant, potentially debilitating symptoms that can negatively affect quality of life. Unlike arterial disease, patients with deep venous disease have a significantly lower median age, therefore the need for long term stent patency becomes a matter of decades rather than years. Furthermore, iliofemoral lesions frequently require stent placement across the inguinal ligament. Such stents are subject to dynamic stress from leg movement and associated concerns for device fatigue, resulting in stent fracture. The aim of this study was to describe an in vitro 50 year stent fatigue test method designed to assess durability against dynamic stress induced device fracture.

METHODS

Through literature review, cadaver studies, and computer modelling, the most challenging loading was confirmed to be hip flexion across the inguinal ligament. This occurs when the patient adjusts between a seated and standing position. Sit to stand hip flexion at the inguinal ligament was effectively simulated on the bench in this in vitro experimental study.

RESULTS

When tested under challenge parameters, hip flexion was reliably found to cause fractures in non-venous nitinol stents. However, a dedicated self expanding nitinol venous stent, engineered for improved durability, underwent up to 50 years of simulated loading on the bench with 15% (3/20) of stents experiencing fractures at 50 years, compared with fractures in 35% (14/40) of non-venous stents tested to 1.4 years; no statistical testing was performed as durations do not match and the objective was to demonstrate the test method.

CONCLUSION

The presented fatigue test method is a suitable approach for evaluating the durability of stents intended for venous use. Venous stents demonstrated superior fatigue resistance compared with non-venous stents via in vitro hip flexion testing.

Elevation of cardiac enzymes and B-type natriuretic peptides following venous recanalization and stenting in chronic venous obstruction

BACKGROUND

B-type natriuretic peptides (BNP) and cardiac enzymes are both recognized biomarkers of heart health. Many studies have reported that using these indicators can assess cardiac condition and predict prognosis of patients undergoing surgery. Currently little is known on the effect of increased cardiac input after venous recanalization on cardiac physiology in patients with chronic venous obstruction (CVO).

OBJECTIVES

The aim of this study was to explore the effect of iliocaval recanalization and stenting on cardiac biomarkers in patients with CVO.

METHODS

This was a prospective study involving 60 patients in a single unit. Blood tests were collected 1 day before and 1 day after venous intervention. Three groups as group 1: patients with iliofemoral post-thrombotic syndrome (PTS) but without involvement of inferior vena cava (IVC) (n = 33); group 2: patients with iliofemoral PTS and involvement of IVC (n = 19) and group 3: patients with non-thrombotic vein lesion (NIVL) (n = 8) were compared based on cardiac biomarker levels.

RESULTS

Median concentration of post-operative BNP (259.60 pg/mL) was greater than preoperative levels (49.80 pg/mL) [interquartile range (IQR), 147.15/414.68 versus 29.85/82.88; p < 0.001]. The levels of CK-MB [preop: 3 U/l (IQR, 1.40/11.00) versus postop: 14 U/l (IQR, 12/17), p < 0.001] and troponin T [preop: 3.00 pg/mL (IQR, 3.00/5.25) versus postop: level of 6 pg/mL (IQR, 3.00/9.50), p < 0.001]. Post-procedure increases in cardiac enzymes showed significant differences in BNP (p = 0.023) and troponin T (p = 0.007) across the three groups, while CK-MB levels were not significantly different (p > 0.05). Intergroup comparisons of postoperative BNP: group 1 versus group 2 (p = 0.013), group 2 versus group 3 (p = 0.029), group 1 versus group 3 (p = 0.834); and postoperative troponin T: group 1 versus group 2 (p = 0.018), group 2 versus group 3 (p = 0.002), group 1 versus group 3 (p = 0.282). According to multiple linear regression analysis, length of stenting and level of preoperative BNP were independent determinants of postoperative BNP levels (p < 0.05), and preoperative troponin T affected postoperative troponin T independently (p < 0.05).

CONCLUSIONS

Troponin T, CK-MB and BNP seem to increase after venous recanalization and stent implantation, the elevation being more prominent for longer lesions.

Review of the literature supporting international clinical practice guidelines on iliac venous stenting and their applicability to Australia and New Zealand practice

BACKGROUND

The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO).

METHODS

A group of vascular surgeons from Australia and New Zealand with specific interest, training, and experience in the management of VOO were surveyed to assess current local practices. The results were analyzed and areas of disagreement identified. After this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely, the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. A selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. The final recommendations were further reviewed and endorsed by another group of venous experts.

RESULTS

The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with clinically relevant VOO, a Clinical-Etiologic-Anatomic-Physiologic score of ≥3 or a Venous Clinical Severity Score for pain of ≥2, or both, including venous claudication, with evidence of >50% stenosis should be considered for venous stenting (Level of Recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should also be considered for venous stenting (Level of Recommendation Ic). Asymptomatic patients should not be offered venous stenting (Level of Recommendation IIIc). Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion of >50% has been uncovered, should be considered for venous stenting (Level of Recommendation Ib).

CONCLUSIONS

Patients with VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. International guidelines aimed at developing standards of care to avoid undertreating and overtreating patients are applicable to Australia and New Zealand practice and will serve as an educational platform for future developments.

Venous recanalisation in the setting of post-thrombotic syndrome: An expert consensus from the French Society of Vascular Medicine (SFMV) and the French Society of Cardiovascular Imaging and Interventional Radiology (SFICV)

Several aspects of the management of post-thrombotic syndrome (PTS) are still a matter of debate, or not yet addressed in international guidelines. The objective of this expert consensus from the French Society of Vascular Medicine (SFMV) and the French Society of Cardiovascular Imaging (SFICV) was to define the main elements of diagnosis and treatment of this syndrome, and to develop a proposal for its preoperative, procedural and follow-up management. In this consensus, the following issues were addressed: clinical and ultrasound diagnosis; pre-procedural workup; indications and contraindications to venous recanalisation; procedures; clinical and duplex ultrasound reports; follow-up; long-term treatment; management of great saphenous vein incompetency; anticoagulant and antiplatelet therapy after venous stenting.

Major Complications of Deep Venous Stenting

INTRODUCTION

Deep venous stent placement has developed into a primary treatment modality for venous obstruction in recent decades. Reported rates of complications are low in the literature and are based mainly on case reports and single-centre cohorts. Interventionalists performing these procedures must be aware of the occurrence of complications associated with stent placement to counsel patients adequately and promote avoidance through optimal procedural approach. This study aims to determine the incidence of serious complications associated with iliocaval and iliofemoral stent placement in a cohort of patients from 3 major tertiary deep venous referral centres.

METHODS

Data were collated from January 2014 to September 2023. The following major complications were included in the analysis: death, major bleeding requiring transfusion, massive pulmonary embolism, any complication which required endovascular or open surgical intervention, vessel rupture, acute kidney injury requiring dialysis, stent crushing, fracture, migration, involution or erosion.

RESULTS

One thousand eight hundred fourteen (1814) patients were treated for acute or chronic deep venous pathology during the 9-year study period. Sixty-one patients (3.3%) experienced a major stent-related complication. The most frequently reported complication was stent crushing (n = 18, 29.5%), followed by stent fracture (n = 10, 16.4%) and erosion of the stent through the vessel wall (n = 8, 13.1%). Death was a rare event (0.2%).

CONCLUSION

Deep venous stent placement is a safe procedure with low rates of major complications. It is incumbent upon operators to be aware of the risks associated with these procedures, however, rare, so that they may obtain fully informed consent from patients.

One-year outcomes of a novel venous stent for symptomatic iliofemoral venous obstruction: prospective cohort study

BACKGROUND

A stent with characteristics of a hybrid design may have advantages in improving the patency of symptomatic iliofemoral vein obstruction. This study assessed the safety and effectiveness of the V-Mixtent Venous Stent in treating symptomatic iliofemoral outflow obstruction.

METHODS

Eligible patients had a Clinical-Etiologic-Anatomic-Physiologic (CEAP) C classification of ≥ 3 or a Venous Clinical Severity Score (VCSS) pain score of ≥ 2. The primary safety endpoint was the rate of major adverse events within 30 days. The primary effectiveness endpoint was the 12-month primary patency rate. Secondary endpoints included changes in VCSS from baseline to 6 and 12 months, alterations in CEAP C classification, Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-14) scores at 12 months, and stent durability measures.

RESULTS

Between December 2020 and November 2021, 171 patients were enrolled across 15 institutions. A total of 185 endovenous stents were placed, with 91.81% of subjects receiving one stent and 8.19% receiving 2 stents. Within 30 days, only two major adverse events occurred (1.17%; 95% confidence interval [CI], 0.14-4.16%), below the literature-defined performance goal of 11% (P < .001). The 12-month primary patency rate (91.36%; 95% CI, 85.93-95.19%; P < .001) exceeded the literature-defined performance goal. VCSS changes from baseline demonstrated clinical improvement at 6 months (- 4.30 ± 3.66) and 12 months (- 4.98 ± 3.67) (P < .001). Significant reduction in symptoms, as measured by CEAP C classification and CIVIQ-14, was observed from pre-procedure to 12 months (P < .001).

CONCLUSIONS

The 12-month outcomes confirm the safety and effectiveness of the V-Mixtent Venous Stent in managing symptomatic iliofemoral venous outflow obstruction, including clinical symptom improvement compared to before treatment.

Percutaneous Transluminal Angioplasty Alleviate Pediatric Postthrombotic Syndrome: A Case Report and Literature Review

PURPOSE

Postthrombotic syndrome (PTS) is one of the long-term sequelae of deep vein thrombosis (DVT), and effective symptom management in pediatric PTS remains a challenge, with interventional therapy rarely explored in this population. We present a successful case of interventional treatment pediatric PTS, resulting in a remarkable amelioration of her symptoms.

CASE REPORT

This case features a 6-year-old girl diagnosed with hyperinsulinemia, leading to a hypoglycemic coma. Following a mini-pancreatic partial pancreatectomy, she required further intensive care in the pediatric intensive care unit. It was during this period that left lower extremity DVT was identified, prompting warfarin anticoagulation therapy. During the anticoagulation period, she had several bleeding events and was switched to anticoagulation with low molecular heparin. One month later, the left common iliac vein and external iliac vein was found to be completely occluded. Over time, she experienced a gradual onset of lower limb swelling and pain, which, after 6 months, was accompanied by perineal edema and venous claudication. As a result, she underwent successful percutaneous transluminal angioplasty. In addition, the anticoagulation regimen was adjusted to rivaroxaban. At the 8-month follow-up, we observed significantly improvement in her postoperative lower extremity swelling and symptoms related to venous occlusion had completely disappeared. Moreover, vascular imaging confirmed improvement in stenosis and uninterrupted blood flow.

CONCLUSIONS

In our review of pediatric PTS studies, we observed limited options to alleviate symptoms, and interventional treatments have not been reported. Our case study, demonstrating the safe and effective use of percutaneous transluminal angioplasty, helps to illuminate this area and alleviate pediatric PTS symptoms.

CLINICAL IMPACT

This case validates the efficacy and safety of using percutaneous transluminal angioplasty (PTA) for the treatment of postthrombotic syndrome (PTS) in pediatric patients. This interventional approach offers significant symptomatic relief and improves quality of life, especially in cases where traditional anticoagulation therapies fail or lead to complications. The successful case presented emphasizes the necessity of considering endovascular interventions for children with moderate to severe PTS, particularly when conservative management is ineffective. This research underscores the potential for PTA to be adopted in clinical practice, offering a promising new approach for managing pediatric PTS.

Regulatory science promotes the translation of transcatheter tricuspid valve repair/replacement devices

For patients with symptomatic and severe tricuspid regurgitation but inoperable with open surgery, transcatheter tricuspid valve intervention (TTVI) is a procedure of great clinical value. TTVI products include repair and replacement devices. TTVI products are one of the hotspots of investigation now, with different innovative biomaterials and structural designs in trials to satisfy divergent indications and reduce complications. With the emerging biomaterials, the technical difficulty of structural design will be greatly reduced, spurring further product innovation and development. The innovativeness and complexity of TTVI products have brought challenges to academia, industry, and regulatory agencies. Regulatory science provides a bridge to address these difficulties and challenges. This perspective article introduces the latest development of the TTVI products. With traditional methods, regulatory agencies face challenges in evaluating the safety and efficacy of TTVr/TTVR devices given the uncertainty of clinical use and the diversity of innovative structural design. This perspective article analyzes the regulatory challenges and discusses regulatory science that can be developed to assess the safety, efficacy, quality and performance of such products: including new approaches for innovative devices, pre-review path, computer modeling and simulation, accelerated wear testing methods for transcatheter heart valves and evidence-based research. This article reveals for the first time how to apply regulatory science systematically to TTVI products, which is of great relevance to their development and translation.

Pharmacomechanical Thrombectomy and Catheter-Directed Thrombolysis, with or without Iliac Vein Stenting, in the Treatment of Acute Iliofemoral Deep Vein Thrombosis

BACKGROUND

This study aims to evaluate and compare the outcomes and clinical efficacy of pharmacomechanical thrombectomy (PMCT) plus catheter-directed thrombolysis (CDT) and PMCT combined with CDT and venous stenting in managing acute iliofemoral deep vein thrombosis (DVT), while also assessing the long-term safety and efficacy of these interventions.

METHODS

A retrospective case-control study spanning 3 years involved 112 patients presenting with acute symptomatic iliofemoral deep vein thrombosis (DVT), each with a symptom duration of less than 14 days. Patients were consecutively categorized into two groups based on individual clinical indications: PMCT + CDT vs. PMCT + CDT + venous stent. Statistical analyses were conducted to compare clinical features and outcomes between the two groups. Additionally, patients were followed up for 24 months post-treatment, during which quality of life (QoL) and severity of post-thrombotic syndrome (PTS) were analyzed.

RESULTS

In this retrospective study, we analyzed a total of 112 consecutive patients, with 63 patients undergoing PMCT + CDT and 49 patients undergoing PMCT + CDT + venous stent. Between the two groups, regarding primary outcomes at 6 months, there was no difference in the observed cumulative patency rates, standing at 82.5% for PMCT + CDT and 81.6% for PMCT + CDT + stent. Survival analyses for primary, primary-assisted, and secondary patency yielded comparable results for PMCT + CDT, with p-values of 0.74, 0.58, and 0.72, respectively. The two-year patency rate was high in both groups (85.7% for PMCT + CDT vs. 83.7% for PMCT + CDT + stent). Additionally, during the follow-up period, there were no statistically significant differences observed in the incidence of PTS or the average Villalta score between the two groups. At 24 months post-intervention, the incidence of post-thrombotic syndrome (PTS) was 11.1% in the PMCT + CDT group and 22% in the PMCT + CDT + stent group (p = 0.381). Both treatment arms of the study groups experienced bleeding complications during the thrombolysis therapy; in the PMCT + CDT group, there were three cases of gastrointestinal bleeding, compared to two cases in the PMCT + CDT + stent group (p = 0.900). Additionally, there was one intracranial hemorrhage in the PMCT + CDT group and two in the PMCT + CDT + stent group.

CONCLUSIONS

Pharmacomechanical thrombectomy (PMCT) combined with catheter-directed thrombolysis (CDT) therapy has shown significant efficacy in alleviating leg symptoms and reducing the occurrence of post-thrombotic syndrome (PTS), including the incidence of moderate-to-severe PTS. On the other hand, the utilization of PMCT + CDT + stent therapy, tailored to individual patients' clinical and venous conditions, may enhance long-term venous patency and lead to superior outcomes, including improved quality of life parameters.

A Systematic Review and Meta-analysis of 24 Month Patency After Endovenous Stenting of Superior Vena Cava, Subclavian, and Brachiocephalic Vein Stenosis

OBJECTIVE

This systematic review and meta-analysis aimed to appraise recent evidence assessing patency outcomes at various time points in patients with superior vena cava, subclavian, and brachiocephalic vein stenosis who had undergone stenting.

DATA SOURCES

PubMed, Scopus, and Cochrane Library databases were searched for studies up to December 2022.

REVIEW METHODS

Measured outcomes included technical success rate, primary, primary assisted, and secondary patency at various time points. A subgroup analysis was also conducted to compare malignant and benign obstruction. GRADE was used to assess the certainty of evidence.

RESULTS

Thirty nine studies reporting outcomes in 1 539 patients were included in the meta-analysis. Primary patency up to one year after the procedure was 81.5% (95% CI 74.5 - 86.9%). Primary patency declined after one year to 63.2% (95% CI 51.9 - 73.1%) at 12 - 24 months. Primary assisted patency and secondary patency at ≥ 24 months were 72.7% (95% CI 49.1 - 88.0%) and 76.6% (95% CI 51.1 - 91.1%). In the subgroup analysis, primary patency was significantly higher in patients with a malignant stenosis compared with a benign stenosis at 1 - 3 and 12 - 24 months. No significant difference was seen for pooled secondary patency rates when comparing the malignant and benign subgroups. GRADE analysis determined the certainty of evidence for all outcomes to be very low.

CONCLUSION

Stenting is an effective intervention for benign and malignant stenosis of the superior vena cava, subclavian, and brachiocephalic veins. Primary patency rates were good up to one year after the procedure, with 81.5% of stents retaining patency at 6 - 12 months. Patency rates declined after one year, to 63.2% primary and 89.3% secondary patency at 12 - 24 months, showing improved outcomes following re-intervention. High quality evidence is lacking. More research is needed to investigate patency outcomes and the need for surveillance or re-intervention programs.

Spontaneous Extraperitoneal Hematoma Related to May-Thurner Syndrome

In this report, we describe a rare case: deep vein thrombosis due to May-Thurner syndrome with a spontaneous pelvic extraperitoneal hematoma. This unique challenge highlights balancing thrombosis treatment and bleeding risk. Endovascular treatment with delayed anticoagulation may be an alternative to surgery for stable retroperitoneal hematoma in May-Thurner syndrome patients.

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.

Final 3-Year Study Outcomes from the Evaluation of the Zilver Vena Venous Stent for the Treatment of Symptomatic Iliofemoral Venous Outflow Obstruction (The VIVO Clinical Study)

PURPOSE

To report 3-year outcomes from a prospective, multicenter, nonrandomized, single-arm study designed to assess the safety and effectiveness of the Zilver Vena Venous Stent for the treatment of symptomatic iliofemoral venous outflow obstruction.

MATERIALS AND METHODS

The VIVO study included patients with symptomatic obstruction of 1 iliofemoral venous segment (ie, 1 limb), characterized by a Clinical, Etiological, Anatomic, Pathophysiology (CEAP) clinical classification of ≥3 or a Venous Clinical Severity Score (VCSS) for pain of ≥2. Patients were retrospectively grouped based on baseline clinical presentation as postthrombotic syndrome (PTS), nonthrombotic iliac vein (NIVL) obstruction, or acute deep vein thrombosis (aDVT). Clinical improvement was assessed by change in VCSS, Venous Disability Score, Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20) scores, and CEAP C classification. Stent performance was evaluated by rates of patency by ultrasound (US), freedom from clinically driven reintervention, and freedom from stent fracture.

RESULTS

The 3-year results for the 243 patients in the VIVO cohort included a 90.3% rate of patency by US and a 92.6% rate of freedom from clinically driven reintervention. The 3-year rates of patency by US for the NIVL, aDVT, and PTS groups were 100%, 84.0%, and 86.1%, respectively. Sustained clinical improvement through 3 years was demonstrated by changes in VCSS, Venous Disability Score, CIVIQ-20, and CEAP C classification. No stent fractures were observed.

CONCLUSIONS

The VIVO study demonstrated sustained high rates of patency and freedom from clinically driven reintervention and improvements in venous clinical symptoms through 3 years. Each patient group (NIVL, aDVT, and PTS) showed clinical improvement and sustained patency through 3 years; some variation existed among groups (eg, only the NIVL group had a 100% patency rate).

Percutaneous Image-Guided Treatment of Pediatric Deep-Vein Occlusions

Pediatric venous occlusions are a growing cause of morbidity and mortality, especially in hospitalized patients. Catheter-directed recanalization is a safe and effective treatment option in appropriately selected patients. Benefits of catheter directed therapies (CDTs) include the prevention of pulmonary embolism and end organ failure acutely as well as superior vena cava syndrome and post-thrombotic syndrome chronically. Timely diagnosis, recognition of underlying factors for thrombosis, and familiarity with the spectrum of tools and techniques for CDT are essential to optimizing outcomes in the acute setting. Recanalization of chronic venous occlusions can similarly provide symptomatic relief and achieve long term vessel patency. This review will detail the scope, techniques, and outcomes for CDT in the treatment of acquired systemic deep vein occlusions.

The Migrating Stent: A Case Report of a Patient With Circulation Issues Who Experienced Stent Migration to the Right Ventricle of the Heart

Over the past several decades, percutaneous venous stenting has surfaced as the forefront for addressing symptomatic venous outflow obstruction. Stent migration is a very rare, but serious life-threatening complication that can occur with the placement of iliofemoral stents. Life-threatening complications following stent migration include but are not limited to damaged valves, arrhythmias, endocarditis, tamponade, and acute heart failure. Stent failure is seldom understood, but one can attribute it to the incorrect stent and or vein sizing and or the inherent natural forces of the body during respiration. Intravascular ultrasound (IVUS) should be utilized for proper vein and stent sizing prior to placement and patients should be monitored more closely after the procedure. Stent retrieval can be very difficult, as the procedure must consider the location of the migrated stent and the comorbidities associated with the patient. This case report explains an 81-year-old Caucasian male who presented to the Emergency Department with dizziness and dyspnea on exertion. Upon further evaluation via transesophageal echocardiogram, he was found to have severe tricuspid regurgitation and an iliofemoral venous stent located in the right ventricle of the heart.

The TOPOS study

Background: We aimed to study the long-term safety and efficacy of oblique venous stents for post-thrombotic syndrome (PTS) with iliac vein compression. Patients and methods: In the multinational, prospective, single-arm TOPOS study, PTS patients scheduled for endovascular therapy with the sinus-Obliquus® stent and optional distal extension with the sinus-Venous® or sinus-XL Flex® stent were enrolled at eight European vascular centres between October 2016 and December 2020. The primary outcome was primary stent patency at 24 months, and secondary outcomes included the clinical course of PTS (Villalta score, revised Venous Clinical Severity Score [rVCSS], Visual Analog Scale [VAS] of pain), quality of life changes (Chronic Venous Insufficiency Quality of Life Questionnaire, CIVIQ-20), and device-related complications. Results: We enrolled 60 patients (mean age 46±15 years, 68% women, 13% active ulcers): 80% required stent extension (70% below the inguinal ligament). The primary patency rate at 24 months was 80.7% (95%CI 68.1-90.0%); it was higher in patients without vs. those with stent extension (90.9% vs. 78.3%, p=.01). Compared to baseline, the Villalta, rVCSS, pain VAS, and CIVIQ-20 decreased by a median of 8 (interquartile range (IQR): 4-11), 5 (IQR: 3-7), 3 (IQR: 2-5), and 17 (IQR: 6-22) points, respectively; p<.001 for all parameters. Overall, 9 events of acute stent occlusion, 4 symptomatic stent stenosis, and 1 pulmonary embolism occurred. We did not observe major bleeding events or contralateral thrombosis. Conclusions: Endovascular treatment with the oblique stent and optional stent extension was safe and resulted in high patency rates at 24 months. The reduction in PTS severity was substantial and persisted over 2-year follow-up.

A meta-analysis of the medium- to long-term outcomes in patients with chronic deep venous disease treated with dedicated venous stents

OBJECTIVE

This review summarizes the safety profile, stent patency, and clinical effectiveness of dedicated venous stents for the treatment of chronic deep venous disease. The approaches to stenting and post-procedural management of different vascular units are also explored.

METHODS

The MEDLINE and Embase databases were searched for pertinent literature published from January 2010 to January 2023. Outcomes related to post-stenting symptoms and health-related quality of life were described narratively. A meta analysis was conducted to evaluate stent patency, ulcer healing, bleeding, and 30-day stent thrombosis, and these outcomes were presented as proportion event rates.

RESULTS

Seventeen studies were identified comprising of 2218 patients. 62.7% of individuals had post-thrombotic stenosis or occlusion. The majority of patients (78.6%) were noted to have complete occlusions of their deep veins before stenting. Eleven different dedicated venous stents were deployed. At 12 months, the primary patency rate was 83% (95% confidence interval [CI]: 76%-90%), the primary-assisted patency rate was 90% (95% CI: 85%-96%), and the secondary patency rate was 95% (95% CI: 92%-98%). A significant improvement in health-related quality of life was demonstrated after intervention. In total, 68.8% (95% CI: 52.0%-83.7%) of ulcers healed at the last follow-up. The remaining symptomatic changes were described narratively; improvements in pain, venous claudication, and edema after stenting were observed. Seventeen deaths occurred, but none were linked to the stenting procedures. A total of 159 cases (7.2% of patients) of in-stent stenosis were observed, whereas 110 stents (5.0% of patients) were occluded. The incidence of major and minor bleeding was 1.7% (95% CI: 1.0%-2.5%) and 3.2% (95% CI: 1.3%-5.6%), respectively, more commonly seen in patients undergoing hybrid intervention.

CONCLUSIONS

Deep venous stenting using dedicated venous stents is a safe technique to treat chronic deep venous stenosis and/or occlusion. Within the limitations of this study, deep venous stenting is associated with good patency rates and symptomatic improvement.

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.

Endovascular treatment of chronic ilio-femoral vein obstruction with extension below the inguinal ligament in patients with post-thrombotic syndrome

OBJECTIVE

This study aimed to evaluate postoperative outcomes of patients with chronic iliofemoral venous outflow obstruction and post-thrombotic syndrome (PTS) who underwent endovascular recanalization and stenting across the inguinal ligament.

METHODS

All consecutive patients with chronic iliofemoral venous outflow obstruction and PTS were included in the analysis, from January 2018 and February 2022. Preoperative, intraoperative, and postoperative outcomes were assessed. Primary endpoints analyzed were major adverse events (MAEs) at 30 days and primary patency rate at 2 years of follow-up. Secondary endpoints assessed were secondary patency rate, target vessel revascularization, and clinical improvement evaluated with the Venous Clinical Severity Score (VCSS) classification, Villalta scale, and visual analog scale (VAS), respectively.

RESULTS

A total of 63 patients (mean age, 48.1 ± 15.5 years; female, 61.9%) were evaluated. No intraoperative and 30-day postoperative complications were documented. The technical success rate was achieved at 100%. Overall, one in-stent occlusion and five in-stent restenosis were detected during follow-up. The primary patency rate was 93.7% (95% confidence interval [CI], 87.8%-99.9%) and 92.1% (95% CI, 85.6%-99%), at 1- and 2-year follow-up, respectively (Kaplan-Meier analysis). Target vessel revascularization was conducted in two cases, resulting in a secondary patency of 98.4% (95% CI, 95.4%-100%) at 2 years of follow-up. Stent fracture and/or migration were not observed during follow-up. A significant clinical improvement in the patient's quality of life was documented. The median improvement of VCSS and Villalta scores were 4 (interquartile range, 2-7; P = .001), and 3 (interquartile range, 1.5-5; P = .001) vs baseline at the last follow-up. Overall, pain reduction of 17 mm on the VAS scale was documented at 2 years of follow-up. At multivariate analysis, presence of trabeculation into the femoral vein and deep femoral vein (odds ratio, 1.89; 95% CI, 0.15-6.11; P = .043), and Villalta scale >15 points at admission (odds ratio, 1.89; 95% CI, 0.15-6.11; P = .043) were predictive for in-stent occlusion during the follow-up.

CONCLUSIONS

The use of a dedicated venous stent across the inguinal ligament was safe and effective for the treatment of symptomatic iliofemoral venous disease with acceptable primary and secondary patency rates at 2 years of follow-up.

An Evaluation of the Duration of Oral Anticoagulant Use Among Patients Undergoing Endovascular Treatment of Nonthrombotic Iliac Vein Lesions

BACKGROUND

This study aimed to compare clinical outcomes associated with the duration of postoperative direct oral anticoagulant (DOACs) therapy in patients with nonthrombotic iliac vein lesions.

METHODS

We retrospectively analyzed 176 consecutive patients who underwent stenting for nonthrombotic iliac vein lesions between March 2018 and December 2021. In total, 99 and 77 patients were discharged on a 3-month and >3-month regimen of DOAC therapy, respectively. The primary cumulative endpoint was a composite of thrombotic complications, bleeding complications, primary patency, primary-assisted patency, and secondary patency within 1 year.

RESULTS

Patients undergoing 3-month and >3-month DOAC therapy were similar in age, sex, lesion site, symptoms, and average stent diameter and length. Upon multivariate analysis, the primary cumulative endpoint did not differ between the 2 groups (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 0.42-3.30; P = 0.76). Moreover, the primary patency at 1 year did not differ between the groups (HR: 1.50; 95% CI: 0.14-16.54; P = 0.74). Furthermore, there were no discernible differences in the secondary endpoints of bleeding complications (HR: 0.66; 95% CI: 0.22-1.96; P = 0.45) or thrombotic complications (HR: 1.79; 95% CI: 0.55-5.80; P = 0.34) between the groups.

CONCLUSIONS

The 3-month regimen of DOAC therapy showed a similar risk of postoperative thrombosis and bleeding when compared to longer DOAC therapy durations over the course of 1 year following endovascular intervention. This could be a preferred option for patients with a higher estimated bleeding risk after venous stenting.

The role of iliac vein stent placement in pelvic venous disorder management

Pelvic venous disease (PeVD) has historically been challenging to diagnose and treat. This paper describes a comprehensive approach to the diagnosis of PeVD and reviews the role of iliac vein stent placement in treatment. Patient selection is vital for non-thrombotic iliac vein lesions (NIVLs) as only a small subset of patients with an NIVL will benefit from stent placement. There is limited, inconclusive data on optimal treatment for patients with both primary ovarian vein reflux and an NIVL. Patients with chronic post-thrombotic outflow obstruction typically have a more favorable risk/benefit ratio for intervention but require anticoagulation and close follow-up due to poorer long-term stent patency. Intravascular ultrasound is a useful tool for identifying obstructive lesions, sizing stents, and planning landing zones. More research is needed to characterize underlying pathophysiology, validate thresholds for intervention, develop reliable methods for outcomes assessment, and determine treatment response. Until this data is produced, an individualized treatment approach is warranted.

Intravascular Ultrasound Use in Peripheral Arterial and Deep Venous Interventions: Multidisciplinary Expert Opinion From SCAI/AVF/AVLS/SIR/SVM/SVS

Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable's aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.

Intravascular Ultrasound Use in Peripheral Arterial and Deep Venous Interventions: Multidisciplinary Expert Opinion From SCAI/AVF/AVLS/SIR/SVM/SVS

Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable's aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.

Three-Year Outcomes, Risk Factors for Restenosis After Stenting for DVT Combined with Iliac Vein Compression Syndrome

This study aimed to evaluate the safety and efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) and stenting for treating acute iliofemoral deep venous thrombosis (DVT) combined with iliac vein compression syndrome (IVCS), and to identify the predictors of stent restenosis. Patients with acute proximal DVT combined with IVCS underwent PCDT and stenting from January 2017 to December 2022 were enrolled. Primary and secondary patency were assessed by duplex ultrasound (DUS). The morbidity of postthrombotic syndrome (PTS) was assessed by the Villalta score. Risk factors for stent restenosis were assessed using univariate and multivariate Cox regression models. Total of 254 patients were included. The mean follow-up time was 36.06 ± 17.66 months. The primary patency rates at 1 year, 3 years, and 5 years were 92.5%±1.7%, 85.4%±2.4%, and 82.4%±2.9%, respectively. The incidence of stent restenosis was 14.2%. Discontinuation of anticoagulants within one year [hazard ratio (HR) = 5.03; P = .048] was the factor associated with acute in-stent thrombosis. Previous DVT history (HR =2.29; P = .037) and stent placement across the inguinal ligament (HR =6.70; P < .001) were identified as independent risk factors significantly associated with stent restenosis. The overall PTS rate was 19.3%. PCDT with stenting is safe and effective for patients with iliofemoral DVT secondary to IVCS, leading to low rates of PTS. Previous DVT history and stents placed across the inguinal ligament may be predictors of stent restenosis. Furthermore, stent restenosis typically occurs within one year and is mainly caused by acute thrombosis due to discontinuation of anticoagulants.

Azygos vein stenting as an alternate route for inferior vena cava obstruction

Chronic venous insufficiency, caused by inferior vena cava occlusion, can lead to thromboembolic complications and tissue loss. We present two cases of azygos vein stenting (AVS) in which vena cava recanalization techniques were exhausted. In the first case, the left iliac vein and vena cava were recanalized and stented; however, the right iliac vein had been previously resected and required AVS. Conventional recanalization attempts from the right and left iliac systems failed in the second patient with congenital inferior vena cava occlusion; therefore, AVS was chosen to establish in-line drainage.

Objective Performance Goals Based on a Systematic Review and Meta-Analysis of Clinical Outcomes for Bare-Metal Stents and Percutaneous Transluminal Angioplasty for Hemodialysis-Related Central Venous Obstruction

PURPOSE

To use safety and efficacy outcomes following treatment with percutaneous transluminal angioplasty (PTA) and/or stent placement for thoracic central venous obstruction in hemodialysis-dependent patients to establish objective performance goals (OPGs).

METHODS

A systematic literature review and meta-analysis were conducted for articles published between January 1, 2000, and August 31, 2021. Efficacy outcomes included primary patency rates at 6 and 12 months, and safety outcomes included adverse events (AEs) categorized as access loss, procedure-related AEs, and serious AEs (SAEs). OPGs were derived from the upper and lower bounds of the 95% confidence intervals for primary patency and SAE rates.

RESULTS

Of 66 articles reviewed, 17 met the inclusion criteria (PTA, n = 4; stent placement, n = 5; PTA/stent, n = 8). The 6- and 12-month primary patency rates for PTA were 50.9% and 36.7%, respectively. Based on these findings, the proposed 6- and 12-month primary patency OPGs identifying superiority against PTA were 66.5% and 52.6%, respectively, and those for noninferiority were 39.0% and 25.7%, respectively. For stent placement, the 6- and 12-month primary patency rates were 69.7% and 47.9%, respectively. The proposed 6- and 12-month primary patency OPGs identifying superiority were 82.1% and 64.1%, respectively, and those for noninferiority were 59.3% and 35.8%, respectively. SAE rates for PTA and stent placement were 3.8% and 8.1%, respectively. Proposed safety OPGs for noninferiority versus superiority for PTA and stent placement were 10.1% versus 1.4% and 13.6% versus 4.8%, respectively.

CONCLUSION

The OPGs derived from real-world studies of PTA and stent placement may serve as a benchmark for future interventions indicated for this patient population.

Society of Interventional Radiology Position Statement on the Management of Chronic Iliofemoral Venous Obstruction with Endovascular Placement of Metallic Stents

PURPOSE

To state the position of the Society of Interventional Radiology (SIR) on the endovascular management of chronic iliofemoral venous obstruction with metallic stents.

MATERIALS AND METHODS

A multidisciplinary writing group with expertise in treating venous disease was convened by SIR. A comprehensive literature search was conducted to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements.

RESULTS

A total of 41 studies, including randomized trials, systematic reviews and meta-analyses, prospective single-arm studies, and retrospective studies were identified. The expert writing group developed 15 recommendations on the use of endovascular stent placement.

CONCLUSIONS

SIR considers the use of endovascular stent placement for chronic iliofemoral venous obstruction to be likely to help selected patients, but the risks and benefits have not been fully quantified in well-designed randomized studies. SIR recommends urgent completion of such studies. In the meantime, careful patient selection and optimization of conservative therapy are recommended prior to stent placement, with attention to appropriate stent sizing and quality procedural technique. The use of multiplanar venography with intravascular ultrasound is suggested in diagnosing and characterizing obstructive iliac vein lesions and in guiding stent therapy. After stent placement, SIR recommends close patient follow-up to ensure optimal antithrombotic therapy, durable symptom response, and early identification of adverse events.

No More Venous Ulcers-What More Can We Do?

Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70-90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.

Stent deformations in the common iliac and iliofemoral veins as a result of hip flexion and extension

OBJECTIVE

In the present study, we characterized deformations of venous stents implanted into common iliac veins for nonthrombotic iliac vein lesions and iliofemoral veins for deep vein thrombosis due to hip movements commensurate with everyday activities such as walking, sitting, and stair climbing.

METHODS

Patients treated with iliofemoral venous stents were recruited from three centers and underwent imaging with two orthogonal two-dimensional projection radiographs. Stents in the common iliac veins and iliofemoral veins crossing the hip joint were imaged with the hip in 0°, 30°, 90° and -15°, 0°, and 30° positions, respectively. Using the radiographs, the three-dimensional geometries of the stents were constructed for each hip position, and the diametric and bending deformations between those positions were quantified.

RESULTS

Twelve patients were included, and the findings showed that the common iliac vein stents experienced approximately twofold more local diametric compression with 90° hip flexion compared with 30° flexion. Also, iliofemoral vein stents crossing the hip joint experienced significant bending with hip hyperextension (-15°) but not with hip flexion. In both anatomic locations, maximum local diametric and bending deformations were in proximity with each other.

CONCLUSIONS

Stents implanted in the common iliac and iliofemoral veins exhibit greater deformation during high hip flexion and hyperextension, respectively, and iliofemoral venous stents interact with the superior ramus of the pubis during hyperextension. These findings suggest that device fatigue could be influenced by the type and level of patient physical activity, in addition to anatomic positioning, opening up the potential benefit of activity modification and the use of a careful implantation strategy. The proximity of maximum diametric and bending deformations means that simultaneous multimodal deformations should be considered for device design and evaluation.

Long Term Follow Up, Causes for Re-intervention, and Consequences for Surveillance After Stenting for Proximal Deep Vein Obstruction

OBJECTIVE

Venous stenting is performed increasingly for acute deep vein thrombosis (DVT) and post-thrombotic syndrome (PTS) with good short term patency results, but long term data are scarce. The purpose of this study was to evaluate long term outcome of stenting for acute DVT and PTS and to study causes of re-intervention.

METHODS

All patients stented for acute DVT and PTS between May 2006 and November 2021 were included retrospectively in this single centre cohort study. Patency was studied by duplex ultrasound (DUS) or computed tomography. The primary endpoint was stent patency. Re-intervention free survival was calculated using Kaplan-Meier methods. Secondary endpoints were causes of re-intervention, using the Pouncey classification system (2022). Binary logistic regression was used to calculate odds ratios for predictors of re-intervention.

RESULTS

A total of 114 patients were included, with 129 limbs involved (acute DVT n = 53; 41%), PTS n = 76; 59%). Median follow up was 2.3 years (interquartile range [IQR] 2.3) for acute DVT and 5.2 years (IQR 7.1) for PTS. Primary patency, secondary patency, and permanent occlusion were 73.5%, 98.1%, and 1.9% for acute DVT, and 63.2%, 92.1%, and 7.9% for PTS limbs. Overall, 41 limbs underwent at least one re-intervention: 14 in the acute DVT group and 27 for PTS. Most re-interventions (82.9%) were performed within the first year after stenting. Missed inflow, insufficient flow, and thrombosis despite anticoagulation were the most common causes of re-intervention. The strongest predictor for re-intervention for PTS was inflow disease (odds ratio 3.57, 95% confidence interval 1.26 - 10.13, p= .017).

CONCLUSION

Long term patency of deep venous stenting is good. Re-interventions are typically performed in the first year and are potentially preventable by improving the procedure and patient selection. Since secondary patency rates are excellent, selected patients may be considered for discharge from long term surveillance.

RETRACTED: Australian and New Zealand Society for Vascular Surgery clinical practice guidelines on venous outflow Obstruction of the femoral-iliocaval veins

BACKGROUND

The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO) in Australia and New Zealand.

METHODS

A group of vascular surgeons from the Australian and New Zealand Society for Vascular Surgery with specific interest, training, and experience in the management of VOO were surveyed to assess current local practice. The results were analyzed and areas of disagreement identified. Following this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. Finally, a selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified.

RESULTS

The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with a CEAP (Clinical-Etiologic-Anatomic-Physiologic) score of ≥3 or a venous clinical severity score for pain of ≥2, or both, and evidence of >50% stenosis on venography, computed tomography venography, magnetic resonance venography, and/or intravascular ultrasound should be considered for venous stenting (level of recommendation Ib) Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion has been uncovered, should be considered for venous stenting (level of recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should be considered for venous stenting (level of recommendation Ic). Asymptomatic patients should not be offered venous stenting (level of recommendation IIIc).

CONCLUSIONS

Patients with deep VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. The advent of simpler and safer treatment options has revolutionized its management, but, unfortunately, formal training for venous disease has not grown at the same rate. Simplifying the technology and training required can result in inconsistent outcomes. These guidelines are aimed at developing standards of care and will serve as an educational platform for future developments.

Delphi Consensus on Reporting Standards in Clinical Studies for Endovascular Treatment of Acute Iliofemoral Venous Thrombosis and Chronic Iliofemoral Venous Obstruction

Acute iliofemoral deep vein thrombosis and chronic iliofemoral venous obstruction cause substantial patient harm and are increasingly managed with endovascular venous interventions, including percutaneous mechanical thrombectomy and stent placement. However, studies of these treatment elements have not been designed and reported with sufficient rigor to support confident conclusions about their clinical utility. In this project, the Trustworthy consensus-based statement approach was utilized to develop, via a structured process, consensus-based statements to guide future investigators of venous interventions. Thirty statements were drafted to encompass major topics relevant to venous study description and design, safety outcome assessment, efficacy outcome assessment, and topics specific to evaluating percutaneous venous thrombectomy and stent placement. Using modified Delphi techniques for consensus achievement, a panel of physician experts in vascular disease voted on the statements and succeeded in reaching the predefined threshold of >80% consensus (agreement or strong agreement) on all 30 statements. It is hoped that the guidance from these statements will improve standardization, objectivity, and patient-centered relevance in the reporting of clinical outcomes of endovascular interventions for acute iliofemoral deep venous thrombosis and chronic iliofemoral venous obstruction in clinical studies and thereby enhance venous patient care.

Acute venous problems: Integrating medical, surgical, and interventional treatments

"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.

How to Evaluate and Choose the Proper Treatments for Patients with Lower Extremity Venous Disease

With an increasing number of interventional and noninterventional treatment options available for venous disorders, it is important that patients undergo a thorough and systematic evaluation. Clinical evaluation should include a personal and family history of venous thromboembolism (VTE), varicose veins, and thrombophilia as these factors affect response and recurrence of disease. Patient should undergo diagnostic and quality of life assessment using validated tools to monitor response to treatment. Duplex ultrasound, both deep and superficial veins, documenting both obstruction and reflux is initial imaging with CT and MRI indicated to document pelvic, iliac vein, and IVC patency and pathology. Conservative therapy including compression, healthy lifestyle with diet, and exercise. New and novel interventional therapies are available for patients with venous disease with recent randomized controlled trials and multisocietal guidelines providing evidence-based recommendations for patients with superficial and deep venous disease. Since the use of anticoagulant and antiplatelet therapies post venous intervention is not well studied nor standardized, patients should routinely undergo evaluation for ongoing risk of recurrent thrombosis and stent occlusion. Finally, patients should be counseled that superficial and deep venous disease is a chronic and often progressive disease, and follow-up at least annually is recommended.

Twelve-month end point results from the evaluation of the Zilver Vena venous stent in the treatment of symptomatic iliofemoral venous outflow obstruction (VIVO clinical study)

BACKGROUND

In the present study, we evaluated the safety and effectiveness of the Zilver Vena venous stent in the treatment of patients with symptomatic iliofemoral outflow obstruction.

METHODS

The VIVO clinical study was a prospective, nonrandomized, multicenter study that enrolled patients with symptomatic obstruction of one iliofemoral venous segment. Included were patients with Clinical, Etiological, Anatomical, Pathophysiological (CEAP) clinical classification of ≥3 or a Venous Clinical Severity Score (VCSS) pain score of ≥2. All patients received a self-expanding venous stent (Zilver Vena venous stent; Cook Ireland Ltd, Limerick, Ireland). The primary safety end point was 30-day freedom from major adverse events. The primary effectiveness end point was the 12-month rate of primary quantitative patency by venography as determined by the core laboratory. The secondary end point was the change in the VCSS from baseline to 1 and 12 months. Additional measures included freedom from clinically driven reintervention; change in the CEAP C classification, Venous Disability Score (VDS), and Chronic Venous Disease Quality of Life Questionnaire (CIVIQ) scores from baseline to 12 months; and stent durability measures.

RESULTS

Between December 2013 and October 2016, 243 patients (70% female; mean age, 53 ± 15 years; 67.5% with current or previous deep vein thrombosis) were enrolled at 30 institutions. Iliac vein compression by the iliac artery (n = 191; 78.6%) was the primary indication for stent placement. The mean lesion length was 98.6 ± 69.8 mm. The 30-day freedom from major adverse events rate was 96.7%, greater than the literature-defined performance goal of 87% (95% confidence interval [CI], 93.5%-98.6%; P < .0001). The 12-month primary quantitative patency rate was 89.9%, greater than the literature-defined performance goal of 76% (95% CI, 85.1%-93.4%; P < .0001). The change in the VCSS from baseline was -3.0 (95% CI, -3.5 to -2.6; P < .0001) at 1 month and -4.2 (95% CI, -4.7 to -3.7; P < .0001) at 12 months, demonstrating clinical improvement. Similarly, significantly (P < .0001) fewer symptoms over time (from preprocedure through 12 months) were measured using the clinical measures of VDS, CEAP C classification, and CIVIQ. The 12-month rate of freedom from clinically driven reintervention was 95.8% ± 1.3%. Through 12 months, no stent fractures and one clinical migration (Clinical Events Committee adjudicated the latter as technique-related due to device undersizing at placement) had occurred.

CONCLUSIONS

The 12-month results of the VIVO study have demonstrated the safety and effectiveness of the Zilver Vena venous stent for the treatment of symptomatic iliofemoral venous outflow obstruction, including clinical symptom improvement compared with baseline.

Deep venous stenting in females

Deep venous stenting has gained increasing prominence in recent years. This issue focuses on special considerations in female patients. The specific challenge relates to the fact that these patients are often much younger than those in whom arterial stents are placed. The stents have to perform adequately over potentially 60 years- and there is no data of that length available.

Characterization and treatment of thoracic duct obstruction in patients with lymphatic flow disorders

PURPOSE

The contribution of thoracic duct obstruction to lymphatic flow disorders has not been well-characterized. We describe imaging findings, interventions, and outcomes in patients with suspected duct obstruction by imaging or a lympho-venous pressure gradient (LVPG).

MATERIALS AND METHODS

Clinical, imaging, and interventional data, including the LVPG, of patients with flow disorders and imaging features of duct obstruction who underwent lymphatic intervention were retrospectively reviewed, collated, and analyzed with descriptive statistics.

RESULTS

Eleven patients were found to have obstruction, median age 10.4 years (interquartile range: 8-14.9 years). Pleural effusions were seen in 8/11 (72%), ascites in 8/11 (72%), both in 5/11 (45%), and protein-losing enteropathy in 5 (45%). Eight patients (72%) had congenital heart disease. The most common site of obstruction was at the duct outlet in 7/11 patients (64%). Obstruction was secondary to extrinsic compression or ligation 4 patients (36%). Nine patients (82%) underwent interventions, with balloon dilation in 7/9 (78%), massive lymphatic malformation drainage and sclerotherapy in 1, and lympho-venous anastomosis in 1. There was resolution of symptoms in 7/9 (78% who underwent intervention, with worsening in 1 patient and no change in 1. In these patients, preprocedure mean LVPG was 7.9 ± 5.7 mmHg and postprocedure gradient was 1.6 ± 1.9 mmHg (p = 0.014). Five patients in this series underwent intervention solely to alleviate duct obstruction and in 4/5 (80%) this led to resolution of symptoms (p = 0.05).

CONCLUSION

Duct obstruction may be seen in lymphatic flow disorders and can occur from intrinsic and extrinsic causes. Stenosis at the outlet was most common. Obstruction can be demonstrated by an elevated LVPG, and interventions to alleviate the obstruction can be beneficial.

Interventional Radiology in Obstetrics and Gynecology: Updates in Women's Health

Interventional radiology has had an expanding role in women's health over the past few decades, with recent accelerated growth and development. Interventional radiology is fundamental in the treatment of multiple conditions that affect women, including pelvic venous disease, uterine fibroids, and adenomyosis, and in postpartum management. Patient workup, classification, and treatment techniques have continued to evolve as interventional radiology has become more prevalent in the treatment of patients affected by these conditions. The authors provide a review of the pathophysiology of, patient workup for, and treatment of pelvic venous disease and uterine artery embolization for various disease processes. The authors also highlight updates from the past 5-10 years in diagnosis, classification, and treatment strategies. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

A systematic review of reported outcomes in people with lower limb chronic venous insufficiency of the deep veins

OBJECTIVE

The prevalence of lower limb chronic venous insufficiency (CVI) of the deep veins is increasing and presents a significant burden to patients and health care services. To improve the evaluation of interventions it is necessary to standardise their reporting. The aim of this study was to perform a systematic review of the outcomes of interventions delivered to people with CVI of the deep veins as part of the development of a novel core outcome set (COS).

METHODS

Following the Core Outcome Measures in Effectiveness Trials (COMET) framework for COS development, a systematic review was conducted to PRISMA guidance. The protocol was preregistered on PROSPERO (CRD42021236795). MEDLINE, Embase, Emcare, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Database of Systematic Reviews and Clinicaltrials.gov were searched from January 2018 to January 2021. Clinical trials and observational studies involving more than 20 participants, reporting outcomes for patients with CVI of the deep veins were eligible. Outcomes were extracted verbatim, condensed into agreed outcome terms and coded into domains using standard COMET taxonomy. Outcome reporting consistency, where outcomes were fully reported throughout the methods and results of their respective articles was also assessed.

RESULTS

Some 103 studies were eligible. There were 1183 verbatim outcomes extracted, spanning 22 domains. No outcome was reported unanimously, with the most widely reported outcome of primary patency featuring in 51 articles (<50%). There was a predominant focus on reporting clinical outcomes (n = 963 [81%]), with treatment durability (n = 278 [23%]) and clinical severity (n = 108 [9%]) reported frequently. Life impact outcomes were relatively under-reported (n = 60 [5%]). Outcome reporting consistency was poor, with just 50% of outcomes reported fully.

CONCLUSIONS

Outcome reporting in studies of people with CVI of the deep veins is currently heterogeneous. Life impact outcomes, which likely reflect patients' priorities are under-reported. This study provides the first step in the development of a COS for people with lower limb CVI of the deep veins.

The Efficacy of Stenting in the Iliofemoral Vein of Patients with Venous Obstruction and Secondary Lymphedema from Malignancy

OBJECTIVE

To investigate the safety and effectiveness of venous stenting in patients with chronic iliofemoral venous obstruction and secondary lymphedema from malignancy.

METHODS

From July 2012 to December 2020, patients with iliofemoral venous obstruction and secondary lymphedema who underwent venous stenting in our institution were retrospectively reviewed. Clinical characteristics, surgical complications, and symptom relief were assessed. Stent patency was evaluated with duplex ultrasound or computed tomographic venography. Twelve-month outcomes were reported.

RESULTS

Fifty-three patients with concurrent secondary lymphedema who had stents placed for iliofemoral venous obstruction were included. There were 42 females, and the mean age was 56.9 years. Nonthrombotic iliac vein lesions were identified in 16 (30.1%) patients. Immediate technical success was 100%, with an average of two stents implanted. The median Villalta score, and Chronic venous disease quality of life questionnaire scores decreased from 12 (IQR, 10-15) and 58 (IQR, 50-66) at baseline, respectively, to 5 (IQR, 4-6) and 28 (IQR, 22-45) at 12 months after the procedure (p <.05), showing significant improvement in the quality of life. At the end of a median follow-up of 12 months (range 3-25 months), the cumulative primary, assisted primary, and secondary patency rates were 70.8%, 76.9%, and 90.1%, respectively.

CONCLUSION

In patients with secondary lymphedema from malignancy, venous stent placement is safe and effective for iliofemoral venous obstruction.

Society of Interventional Radiology Position Statement on the Endovascular Management of Acute Iliofemoral Deep Vein Thrombosis

PURPOSE

To establish the updated position of the Society of Interventional Radiology (SIR) on the endovascular management of acute iliofemoral deep vein thrombosis (DVT).

MATERIALS AND METHODS

A multidisciplinary writing group with expertise in treating venous diseases was convened by SIR. A comprehensive literature search was conducted to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements.

RESULTS

A total of 84 studies, including randomized trials, systematic reviews and meta-analyses, prospective single-arm studies, and retrospective studies were identified and included in the review. The expert writing group developed 17 recommendations that pertain to the care of patients with acute iliofemoral DVT with the use of endovascular venous interventions.

CONCLUSIONS

SIR considers endovascular thrombus removal to be an acceptable treatment option in selected patients with acute iliofemoral DVT. Careful individualized risk assessment, high-quality general DVT care, and close monitoring during and after procedures should be provided.

Criteria to predict midterm outcome after stenting of chronic iliac vein obstructions (PROMISE trial)

BACKGROUND

Endovenous stent placement has become a first-line approach to prevent post-thrombotic syndrome in patients with chronic post-thrombotic obstruction (PTO) or nonthrombotic iliac vein lesions if conservative management fails. This study aims to identify factors associated with loss of patency to facilitate patient selection for endovenous stenting.

METHODS

We retrospectively analyzed 108 consecutive patients after successful endovenous stenting for chronic vein obstruction performed at a single institution from January 2008 to July 2020. Using multivariable logistic regression, we explored potential predictive factors for loss of stent patency, including baseline demographics, post-thrombotic changes, and peak flow velocities measured in the common femoral vein (CFV), deep femoral vein, and femoral vein (FV) using duplex ultrasound examination.

RESULTS

The mean follow-up duration was 41 ± 26 months, and participants had a mean age of 47.4 ± 15.4 years with 46.3% women. Ninety (83.3%) patients had PTO and 18 (16.7%) had nonthrombotic iliac vein lesions, predominantly due to May-Thurner syndrome. Loss of patency occurred in 20 (18.5%) patients, all treated for PTO. Comorbidities, side of intervention, and sex did not differ between patients with occluded and patent stents. Stent occlusion was more common with increasing number of stents implanted (P < .001) and with distal stent extension into and beyond the CFV (P < .001). Preinterventional predictive factors for stent occlusion were lower duplex ultrasound peak velocity in the CFV (odds ratio [OR]: 7.52, 95% confidence interval [CI]: 2.54-22.28; P < .001) and FV (OR: 10.75, 95% CI: 2.07-55.82; P < .005), and post-thrombotic changes in the deep femoral vein (OR: 4.51, 95% CI: 1.53-13.25; P = .006) and FV (OR: 3.62: 95% CI: 1.11-11.84; P = .033). Peak velocities of ≤7 cm/s (interquartile range: 0-20 cm/s) in the CVF and ≤8 cm/s (interquartile range: 5-10 cm/s) in the FV were significantly associated with loss of patency.

CONCLUSIONS

Insufficient venous inflow as assessed by low peak velocities in the CFV and FV as well as post-thrombotic findings represent reliable risk predictors for stent occlusions, warranting their inclusion into the decision-making process for invasive treatment of PTO.

Chronic Venous Disease of the Lower Extremities: A State-of-the Art Review

Chronic venous disease is a common disease, the prevalence of which increases with age, and can cause debilitating symptoms that adversely affect the quality of life. The risk factors include family history, female sex, obesity, pregnancy, parity, and history of deep vein thrombosis. Moreover, it is associated with venous obstruction, reflux, or both, which, in turn, leads to ambulatory venous hypertension. Chronic venous disease is the leading cause of leg ulcers, which place a significant cost burden on the health care system. Compression therapy remains the cornerstone of treatment, particularly for more advanced disease. Superficial saphenous vein reflux can be associated with significant symptoms. Catheter techniques, both thermal and nonthermal, have demonstrated efficacy and safety in successful closure and symptom improvement. Deep vein obstruction can be broadly divided into thrombotic and nonthrombotic and can lead to symptomatic chronic venous disease. Recanalization using balloons and stents has been increasingly used and studied in such patients. It is critical to develop training opportunities and guidelines to improve evidence-based and appropriate care for cardiologists treating chronic venous disease.

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.

Nutcracker syndrome: A case report and review of the literature

Background

Nutcracker syndrome (NS) is an uncommon condition resulting from the compression of the left renal vein (LRV) between the aorta and superior mesenteric artery (SMA), resulting in symptoms such as flank pain and hematuria.

Case presentation

We present the case of a 30-year-old woman complaining of abdominal pain who was found to have nutcracker syndrome and treated with endovascular stenting of the left renal vein.

Discussion

We review the literature related to endovascular treatment of NS with focus on the distribution of the sizes of stents and rates of stent migration.

Conclusion

NC is a rare condition requiring a high index of suspicion for diagnosis. Endovascular treatment is a reasonable option, but its limitations must be considered.