Indications for endophlebectomy and/or arteriovenous fistula after stenting

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

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

A clinical guide to Deep venous stenting for chronic iliofemoral venous obstruction

INTRODUCTION

An increase in endovenous interventions for deep venous pathologies has been observed. This article aims to provide an overview of the role of venous stenting in the management of chronic conditions affecting the deep venous system of the lower limbs, with a focus on intervention relating to the vena cava and iliofemoral venous segments.

METHOD

An overview of the literature on the minimally invasive venous stenting procedures that are being increasingly used in the management of chronic conditions affecting the deep venous system of the lower limbs.

RESULTS

We discuss key areas of interest to a venous specialist practicing in this area, including diagnostic imaging in chronic deep venous disease, with a focus on the use of intravascular ultrasound in this context; treatment of chronic venous outflow obstruction, including the rationale and structural indications for stenting, current guidance regarding stent placement, and fundamental points to consider during decision-making (endophlebectomy and stenting, stenting across the inguinal ligament, optimal sizing of venous stents, extension of venous stenting to beyond the common femoral vein confluence, the role of thrombolysis useful in chronic venous disease, and arteriovenous fistulae); outcomes and initial reports of stenting; and the future of venous stents.

CONCLUSION

Deep venous stenting has become a key treatment option for chronic (thrombotic or non-thrombotic) obstructive venous disease. Dedicated venous stents and intravascular ultrasound represent important technological advances in the minimally invasive treatment of symptomatic chronic deep venous obstruction, which previously required open surgical reconstruction.

Characteristics and outcomes of stent occlusion after iliocaval stenting

OBJECTIVE

With increasing use of iliocaval stenting, complications have become more noticeable. Stent occlusion is one such outcome that has not been studied in detail. Characteristics of stent occlusion in addition to outcomes after recanalization are presented.

METHODS

An analysis of 3468 initial iliocaval stents placed during an 18-year period from 1997 to 2015 was performed. A total of 102 stent occlusions were identified, amounting to a 3% stent occlusion rate. Characteristics evaluated included onset after stent placement, techniques used for restoring patency, and their outcome. Kaplan-Meier analysis was used to assess stent patency. Regression analysis was used to evaluate risk factors for stent occlusion.

RESULTS

Stent occlusions occurred at a median of 5.8 months after placement. The occluded stent could be reopened after a wide range of intervals, the longest being 14 years. The majority (69%) of occlusions were chronic (>30 days) and the remainder (31%) were acute; 77% of the occlusions occurred in post-thrombotic limbs. The most common technique used to recanalize the acutely occluded stent was pharmacomechanical thrombectomy, whereas wire recanalization with balloon angioplasty was the technique most used for chronic occlusions. Of the 102 occluded stents, patency was achieved in 75 of 88 (84%) attempts. After successful recanalization, the median primary patency was 7 ± 1.9 months, median primary assisted patency was 7.5 ± 3.5 months, and median secondary patency was 25 ± 8.3 months. Clinically, there was improvement in the visual analog scale pain scores from a median of 3.5 to 1 (P < .01), in the median grade of swelling from 2 to 1 (P < .01), and in the mean Venous Clinical Severity Score from 6.4 to 3.8 (P < .01) after recanalization. A 40% ulcer healing rate was noted after recanalization during a median follow-up period of 17 months. There were no significant adverse events or mortality. Regression analysis revealed stent placement for native vein occlusion as the only statistically significant predictor of stent occlusion.

CONCLUSIONS

Stent occlusion after iliocaval stenting is a rare occurrence. Recanalization of occluded stents can be performed with minimal morbidity even months to years after occlusion with good outcomes. Long-term patency of occluded stents that were recanalized is poor compared with patency of the initially placed stent.

Stent extension into a single inflow vessel is a valuable option after endophlebectomy

Background

Venous stenting with an endophlebectomy and arteriovenous fistula can be performed in patients with extensive post-thrombotic changes. However, these hybrid procedures can induce restenosis, sometimes requiring stent extension, into a single inflow vessel. This study investigates the effectiveness of stenting into a single inflow vessel.

Methods

All evaluated patients had temporary balloon occlusion of the arteriovenous fistula to evaluate venous flow into the stents. When stent inflow was deemed insufficient, AVF closure was postponed and additional stenting was performed. Patency rates and clinical outcomes were evaluated.

Results

Twenty-four (38%) of 64 patients had additional stenting. The primary, assisted primary and secondary patency were 60 %, 70% and 70% respectively. Villalta score reduced by 6.1 points (p < 0.001), and venous clinical severity score by 2.7 points (p = 0.034).

Conclusion

Stenting through the femoral confluence into a single inflow vessel is a feasible bailout option if primary hybrid intervention fails with relative high patency rates and clinical improvement.

First Experience of Performing Hybrid Operations in Chronic Venous Obstructions of Iliofemoral Segments in Patients With Postthrombotic Syndrome

OBJECTIVE

To assess the first results of hybrid operations in chronic venous obstructions of iliofemoral segments in patients with postthrombotic syndrome (PTS).

METHODS

Hybrid operations (open endovenectomy from the common femoral vein with arteriovenous fistula creation and iliac vein stenting) were performed in 12 patients diagnosed with PTS. All of the patients were diagnosed with severe chronic venous insufficiency. The degree of manifestations of PTS was assessed by means of the Villalta score 7 months before and after the surgical intervention. Diagnostic methods of study included ultrasound duplex scanning, magnetic resonance and/or multispiral computed venography, and contrast venography.

RESULTS

Technical success of the procedure was 92%. The outcomes of hybrid operations after 7 months were followed up in 6 patients and in 4 patients in 3 months. Secondary patency rates of the stented iliac veins amounted to 100%. No recurrences of venous ulcers were observed. Median Villalta scores improved from 15 to 7 ( P = .012).

CONCLUSION

The first experience of hybrid operations for obstructive lesions of veins of the iliofemoral segments demonstrated their high efficacy and safety.

Wound complications after common femoral vein endophlebectomy: Influence on outcome

Introduction Venous recanalization of obstructed femoral and iliac veins is associated with good results regarding the feasibility and patency rate. If the common femoral vein with its inflow vessels is involved, open surgical desobliteration or endophlebectomy has been described as a crucial part of the intervention. However, when performing the hybrid procedure, a number of specific complications have been described. We present our results after venous recanalization including an endophlebectomy, focussing on wound complications and its impact on outcome. Material and methods A retrospective analysis of prospective recorded data of all patients who underwent a hybrid procedure for chronic obstruction of iliofemoral veins between 2010 and 2015 was performed. The patients were treated by recanalization of the affected veins combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation. Data assessment focussed on complications and patency rates. Results This study includes 96 patients, thereof 58 females with a mean age of 44.1 years. The mean procedure time was 344 ± 140 min (range 124-663). Median follow-up time was 12.5 months (2-33 months). Primary patency was 62.5% and secondary patency was 90%. Re-intervention due to early occlusion within the first 30 post-intervention days was necessary in 37.5% of all cases. Besides bleeding complications, wound complications, mainly classified as Szilagyi I, occurred in 33% of all patients. A multivariate analysis showed a significant impact of wound complications on primary as well as secondary patency rate ( p = 0.032, respectively 0.015). Conclusion Recanalization of obstructed iliac veins and/or the inferior vena cava combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation is a safe and feasible treatment option in the post-thrombotic syndrome. As wound complications are a common and associated with a significant impact on patency rate, further attempts to improve the procedure are crucial.

Endophlebectomy of the common femoral vein and arteriovenous fistula creation as adjuncts to venous stenting for post-thrombotic syndrome

Background

Good results have been reported for angioplasty and stenting of post-thrombotic lesions of the iliac and proximal femoral veins. If lesions at the origin of the superficial femoral and profunda veins are stented, the intraluminal synechiae can be pushed against the orifices of inflow vessels, potentially decreasing stent inflow. Surgical disobliteration of the common femoral vein (endophlebectomy) has been suggested to mitigate this problem. Because of a temporary increase in thrombogenicity, this procedure may be accompanied by arteriovenous fistula creation.

Methods

Data on consecutive patients treated by hybrid venous reconstruction, between December 2010 and May 2015, were analysed. Standard recording consisted of clinical scoring systems (including Villalta scale) and imaging. Patency was assessed with duplex ultrasonography.

Results

Seventy-six legs (70 patients) were included. Median follow-up was 379 (range 73–1508) days. Primary, assisted primary and secondary patency rates at 12 months were 51, 70 and 83 per cent respectively. Sixty per cent of loss of primary patency (24 of 40 legs) was related to common femoral vein stenosis, and the rest to rethrombosis. Other complications included wound infection (29 per cent) and lymphatic leak (39 per cent). The Villalta score had decreased by a median of 7 points at 1-year follow-up.

Conclusion

The combination of venous stenting, endophlebectomy and arteriovenous fistula creation for patients with extensive post-thrombotic vein damage and severe post-thrombotic syndrome is feasible.

Interventional treatment of postthrombotic syndrome

BACKGROUND

Postthrombotic syndrome (PTS) is the development of symptoms and signs of chronic venous insufficiency following deep vein thrombosis (DVT) and has a significant negative effect on the quality of life. The current understanding is that the clinical manifestation of PTS is related more to venous obstruction than it is to venous reflux. The use of interventional techniques for the treatment of venous obstruction and/or venous occlusion has rapidly increased in recent years.

OBJECTIVE

This article summarizes the current concept of endovenous and hybrid interventions and presents the optimized treatment of choice in patients with chronic symptomatic venous obstruction.

METHODS

We performed a systematic literature search in the Medline database to identify relevant studies on the treatment of patients with PTS.

RESULTS

A meta-analysis of the relevant studies showed that this minimally invasive procedure is an effective treatment option with low morbidity and no mortality. Use of the newly developed dedicated venous stents showed promising results with good mid-term patency rates and a significant decrease in related symptoms.

CONCLUSION

Interventional therapy for the treatment of symptomatic chronic venous obstruction has become the method of choice in recent years. More studies are needed to evaluate the long-term success rate of dedicated venous stents.

Effect of a new incision management system (PREVENA®) on wound healing after endophlebectomy of the common femoral vein: a case series

Background

New endovascular techniques facilitate treatment of complex deep vein obstructions in cases of post-thrombotic syndrome. In a relevant number of these patients, endophlebectomy including the implantation of an arteriovenous fistula between the common femoral artery and the femoral vein is indispensable in order to establish a good inflow. These procedures display a high risk of wound complications. Despite conservative efforts to prevent these postoperative complications, wound healing problems occur in more than 20 % of cases. The present case report is the first description of wound dressing using a PREVENA® incision management system in cases of endophlebectomy.

Case presentation

A single center’s experience with the incision management system PREVENA®, which was used after endophlebectomy and venous stenting in complex hybrid procedures in three white men aged 46 years, 53 years, and 61 years is the subject of this case report. Although the surgical procedures were performed under therapeutical anticoagulation and took a couple of hours, no wound complications occurred.

Conclusions

These encouraging results underline a potential benefit of the incision management system PREVENA® in cases of complex venous recanalization including endophlebectomy of the femoral vein as well as the implantation of an arteriovenous fistula.

Short-Term Clinical Experience with a Dedicated Venous Nitinol Stent: Initial Results with the Sinus-Venous Stent

OBJECTIVE

Deep venous stenting has become the primary treatment option for chronic venous obstructive disease, both for iliac vein compression and post-thrombotic venous lesions. Until recently, only stents aimed at arterial pathology were used, because no dedicated venous stents were available. However, three such stents have now become available. These venous stents are characterized by increased length, diameter, flexibility, and radial force. This study reports an early experience with one of these devices; the sinus Venous stent (OptiMed GmbH, Ettlingen, Germany).

METHODS

Between March 2012 and July 2014, 75 patients were treated with the sinus Venous stent: 35 cases of iliac vein compression syndrome and 40 cases of unilateral chronic obstruction in post-thrombotic syndrome (PTS). Diagnosis of relevant obstruction was made using clinical evaluation, duplex ultrasound, and magnetic resonance venography. Patency during follow up was assessed with duplex ultrasound. Clinical improvement was assessed by VCSS, Villalta score, rate of ulcer healing, and improvement of venous claudication.

RESULTS

The cumulative patency rates at 3, 6, and 12 months were 99%, 96%, and 92%, respectively. The cumulative assisted primary patency rates were 99% at 3, 6, and 12 months. The cumulative secondary patency rate at 12 months was 100%. Differences exist in patency rate between the subgroups of non-thrombotic and post-thrombotic, with the first showing no re-occlusions. All re-thromboses in the PTS group were treated by ancillary treatment modalities. VCSS and Villalta score decreased significantly after stenting, as did venous claudication. Morbidity was low without clinically relevant pulmonary embolism, and mortality was nil. Although two out of seven ulcers healed temporarily, no ulcer remained healed at 12 months follow up.

CONCLUSION

Short-term clinical results using the sinus Venous stent are excellent, with significant symptom reduction, low morbidity rates, and no mortality. Loss of stent patency is seen less often compared with arterial stents described in the literature.

Arteriovenous fistula geometry in hybrid recanalisation of post-thrombotic venous obstruction

Introduction

Post-thrombotic obstruction can be adequately treated by percutaneous transluminal angioplasty and stenting. When post-thrombotic trabeculations extend below the femoral confluence, proper inflow can be facilitated by endophlebectomy and creation of an arteriovenous fistula. The aim of this study was to investigate whether it is more favourable to place the arteriovenous fistula at the cranial or caudal end of the endophlebectomy to prevent stenosis or occlusion.

Methodology

We retrospectively analysed the clinical data of all patients who underwent a hybrid procedure in our two centres. Demographics, interventional details and post-operative imaging were collected.

Results

Data on 42 limbs with cranially and 23 limbs with caudally placed arteriovenous fistulas were collected. Post-thrombotic disease of the profunda femoral vein alone or in combination with the femoral vein was observed more often in the cranial group. The caudal group more often received a smaller sized and straight polytetrafluoroethylene fistula, while the cranial group comprised a significantly higher amount of stented segments. Logistic regression showed that only reduced femoral inflow (hazard ratio 2.934 (95%CI, 1.148–7.494)) was a significant predictor of stent stenosis and/or occlusion. Logistic regression for risk of occlusion showed a significant influence of stent-related complications (hazard ratio 4.691 (95%CI, 1.205–18.260)) and a tendency towards influence of arteriovenous fistula geometry in favour of the cranially placed fistula.

Conclusion

Placement of the arteriovenous fistula in the cranial part of the endophlebectomy during hybrid recanalisation may result in a more favourable outcome, yet this tendency was not statistically significant. Moreover, femoral inflow is pivotal in maintaining patency and should thus be adequately assessed pre-operatively.