1
|
Barbati ME, Avgerinos ED, Baccellieri D, Doganci S, Lichtenberg M, Jalaie H. Interventional treatment for post-thrombotic chronic venous obstruction: Progress and challenges. J Vasc Surg Venous Lymphat Disord 2024:101910. [PMID: 38777042 DOI: 10.1016/j.jvsv.2024.101910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/28/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
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.
Collapse
Affiliation(s)
- Mohammad E Barbati
- Clinic of Vascular and Endovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany.
| | | | | | - Suat Doganci
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara, Turkey
| | | | - Houman Jalaie
- Clinic of Vascular and Endovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany
| |
Collapse
|
2
|
Morris RI, Jackson N, Khan T, Karunanithy N, Thulasidasan N, Smith A, Black SA, Saha P. Performance of Open and Closed Cell Laser Cut Nitinol Stents for the Treatment of Chronic Iliofemoral Venous Outflow Obstruction in Patients Treated at a Single Centre. Eur J Vasc Endovasc Surg 2022; 63:613-621. [PMID: 35027274 DOI: 10.1016/j.ejvs.2021.10.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction. METHODS A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency. RESULTS A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 - 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 - 6.62, p < .001). CONCLUSION OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design.
Collapse
Affiliation(s)
- Rachael I Morris
- Academic Department of Vascular Surgery, St Thomas' Hospital, School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Nicholas Jackson
- Academic Department of Vascular Surgery, St Thomas' Hospital, School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Taha Khan
- Academic Department of Vascular Surgery, St Thomas' Hospital, School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | | | | | - Alberto Smith
- Academic Department of Vascular Surgery, St Thomas' Hospital, School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Stephen A Black
- Academic Department of Vascular Surgery, St Thomas' Hospital, School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Prakash Saha
- Academic Department of Vascular Surgery, St Thomas' Hospital, School of Cardiovascular Medicine and Sciences, King's College London, London, UK.
| |
Collapse
|
3
|
Saleem T, Raju S. An overview of in-stent restenosis in iliofemoral venous stents. J Vasc Surg Venous Lymphat Disord 2021; 10:492-503.e2. [PMID: 34774813 DOI: 10.1016/j.jvsv.2021.10.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/13/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although endovenous stents have been associated with overall low morbidity, they can require reinterventions to correct stent malfunction due to in-stent restenosis (ISR). ISR has often occurred iliofemoral venous stents but has not been well described. It has been reported to develop in >70% of patients who have undergone iliofemoral venous stenting. We sought to provide an overview of ISR in iliofemoral venous stents, including the pathologic, diagnostic, and management considerations and the identification of several areas of potential research in the future. METHODS A search of reported English-language studies was performed in PubMed and the Cochrane Library. "In-stent restenosis," "vein," "venous," "iliac," and "iliofemoral" were used as keywords. The pertinent reports included in the present review had addressed the pathology, diagnosis, and current management options for ISR. RESULTS ISR refers to the narrowing of the luminal caliber of the stent owing to the development of stenosis inside the stent itself. ISR should be differentiated from stent compression. Two main types of ISR have been described: soft and hard lesions. These lesions respond differently to angioplasty. Stent inflow and shear stress are important factors in the development of ISR. The treatment options available at present include balloon angioplasty (hyperdilation or isodilation), laser ablation, atherectomy, and Z-stent placement. CONCLUSIONS Reintervention for ISR should be determined by the presence of residual or recurrent symptoms and not simply by a numeric value obtained from an imaging study. Overall stent occlusion due to ISR is rare, and no role exists for prophylactic angioplasty to treat asymptomatic ISR. The current treatment options for ISR are mostly durable and effective. However, more research is needed on methods to prevent the development of ISR. The role of antiplatelet and anticoagulant agents in the prevention of ISR requires further investigation, with particular attention to unique subset of patients (after thrombosis vs nonthrombotic iliac vein lesions). For high-risk, post-thrombotic patients, anticoagulation can be considered to prevent ISR. The role of triple therapy (anticoagulation and dual antiplatelet therapy) in the prevention of ISR remains unclear.
Collapse
Affiliation(s)
- Taimur Saleem
- The RANE Center for Venous and Lymphatic Diseases, Jackson, Miss.
| | - Seshadri Raju
- The RANE Center for Venous and Lymphatic Diseases, Jackson, Miss
| |
Collapse
|
4
|
Taha MAH, Busuttil A, Bootun R, Thabet BAH, Badawy AEH, Hassan HA, Shalhoub J, Davies AH. A clinical guide to Deep venous stenting for chronic iliofemoral venous obstruction. J Vasc Surg Venous Lymphat Disord 2021; 10:258-266.e1. [PMID: 34020107 DOI: 10.1016/j.jvsv.2020.12.087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 12/20/2020] [Indexed: 11/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- Mohamed A H Taha
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom; Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Faculty of Medicine, Assiut University, Egypt
| | - Andrew Busuttil
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom
| | - Roshan Bootun
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom
| | - Bahgat A H Thabet
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Faculty of Medicine, Assiut University, Egypt
| | - Ayman E H Badawy
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Faculty of Medicine, Assiut University, Egypt
| | - Haitham A Hassan
- Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Faculty of Medicine, Assiut University, Egypt
| | - Joseph Shalhoub
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom; Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Alun H Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, United Kingdom; Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, United Kingdom.
| |
Collapse
|
5
|
Dumantepe M, Aydin S, Ökten M, Karabulut H. Endophlebectomy of the common femoral vein and endovascular iliac vein recanalization for chronic iliofemoral venous occlusion. J Vasc Surg Venous Lymphat Disord 2020; 8:572-582. [DOI: 10.1016/j.jvsv.2019.11.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 11/25/2019] [Indexed: 11/26/2022]
|
6
|
Coelho A, O'Sullivan G. Usefulness of Direct Computed Tomography Venography in Predicting Inflow for Venous Reconstruction in Chronic Post-thrombotic Syndrome. Cardiovasc Intervent Radiol 2019; 42:677-684. [PMID: 30627773 DOI: 10.1007/s00270-019-02161-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this paper is to assess the applicability of direct computed tomography venography (DCTV) in assessing dominant inflow vein in the femoral confluence in extensive chronic iliofemoral venous obstruction, using venography as the gold standard. METHODS All DCTVs performed in symptomatic patients with previous iliofemoral deep vein thrombosis subsequently submitted to venography in the period from January 2014 to August 2018 were retrospectively reviewed. Two groups were defined depending on whether the femoral vein (FV) or the deep femoral vein (DFV) was the dominant inflow on venography in order to identify predictors of DFV as dominant inflow in DCTV. Statistical analysis was performed with SPSS V25. RESULTS A total of 30 DCTVs and subsequent venographies were reviewed. Venography identified the FV as the dominant inflow in 18 (60%) and the DFV in 12 (40%) patients. Predictors for DFV as dominant inflow were identified as follows: larger DFV diameter 50 mm and 250 mm below lesser trochanter (8.73 ± 4.34 mm vs. 11.9 ± 3.52 mm; p = 0.043 and 5.4 ± 3.90 mm vs. 8.90 ± 2.70 mm; p = 0.011); lower FV/DFV ratio 150 mm below lesser trochanter (11.39 ± 20.01 mm vs. 1.05 ± 0.47 mm; p = 0.043); and presence of FV scarring/synechiae, collaterals and abnormal wall thickness (p = 0.003, p = 0.003 and p < 0.0001). CONCLUSION In cases of extensive chronic iliofemoral venous obstruction, especially when stent deployment into the DFV is entertained, the key to success is thorough pre-procedure planning focusing on choosing the access site. This study suggests DCTV is valuable in defining the dominant iliac vein inflow, but additional findings are necessary to validate these preliminary data.
Collapse
Affiliation(s)
- Andreia Coelho
- Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia e Espinho, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Gerard O'Sullivan
- Interventional Radiology, Galway University Hospital, Galway, Ireland.
| |
Collapse
|
7
|
Grøtta O, Enden T, Sandbæk G, Gjerdalen GF, Slagsvold CE, Bay D, Kløw NE, Rosales A. Infrainguinal inflow assessment and endovenous stent placement in iliofemoral post-thrombotic obstructions. CVIR Endovasc 2018; 1:29. [PMID: 30652160 PMCID: PMC6319667 DOI: 10.1186/s42155-018-0038-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 10/31/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose To assess the technical success, patency, and clinical outcome, following assessment of inflow and infrainguinal endovenous stent placement in patients with iliofemoral post-thrombotic obstruction with infrainguinal involvement. Methods A retrospective analysis of 39 patients with iliofemoral post-thrombotic venous obstruction accepted for infrainguinal stent placement in the period November 2009–December 2016. The clinical status was categorized according to the Clinical Etiological Anatomical Pathophysiological (CEAP) classification and symptom severity was assessed using Venous Clinical Severity Score (VCSS). The inflow was categorized as “good”, “fair”, or “poor” depending on vein caliber and extent of post-thrombotic changes in the inflow vessel(s). Stent patency was assessed by duplex ultrasound. Median follow-up was 44 months (range 2–90 months). Results Stent placement was successful in all 39 patients. Primary patency after 24 months was 78%. Thirty of 39 patients (77%) had open stents at final follow-up. Re-interventions were performed in four patients and included catheter-directed thrombolysis (CDT) in all and adjunctive stenting in two. Twenty-eight of 39 patients (72%) reported a sustained clinical improvement. Patients with “good” inflow had better patency compared to those with “fair”/“poor” (p = 0.01). One patient experienced acute contralateral iliofemoral thrombosis; this segment was successfully treated with CDT and stenting. No other complications required intervention. Conclusion Infrainguinal endovenous stent placement was a feasible and safe treatment with good patency and clinical results, and should be considered in patients with substantial symptoms from post-thrombotic obstructions with infrainguinal involvement. Stents with good inflow have better patency and inflow assessment is essential in deciding the optimal stent landing zone.
Collapse
Affiliation(s)
- Ole Grøtta
- 1Division of Radiology and Nuclear Medicine, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway.,4Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, PO Box 1171, Blindern, 0318 Oslo, Norway
| | - Tone Enden
- 1Division of Radiology and Nuclear Medicine, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway
| | - Gunnar Sandbæk
- 1Division of Radiology and Nuclear Medicine, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway.,4Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, PO Box 1171, Blindern, 0318 Oslo, Norway
| | - Gard Filip Gjerdalen
- 3Section of Vascular Investigations, Department of Vascular Surgery, Oslo University Hospital Aker, PO Box 4950, Nydalen, N-0424 Oslo, Norway
| | - Carl-Erik Slagsvold
- 3Section of Vascular Investigations, Department of Vascular Surgery, Oslo University Hospital Aker, PO Box 4950, Nydalen, N-0424 Oslo, Norway
| | - Dag Bay
- 1Division of Radiology and Nuclear Medicine, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway
| | - Nils-Einar Kløw
- 1Division of Radiology and Nuclear Medicine, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway.,4Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, PO Box 1171, Blindern, 0318 Oslo, Norway
| | - Antonio Rosales
- 2Department of Vascular Surgery, Oslo University Hospital, PO Box 4950, Nydalen, N-0424 Oslo, Norway
| |
Collapse
|
8
|
Wadhwa V, Srinivasa RN, Cooper KJ, Hage AN, Bundy JJ, Spencer B, Vadlamudi V, Chick JFB. Endovascular Therapy for Lower Extremity Chronic Deep Venous Occlusive Disease: State of Practice. Semin Intervent Radiol 2018; 35:333-341. [PMID: 30402016 DOI: 10.1055/s-0038-1669963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Vibhor Wadhwa
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Ravi N Srinivasa
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Kyle J Cooper
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan.,Department of Radiology, Loma Linda University, Loma Linda, California
| | - Anthony N Hage
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Jacob J Bundy
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Brooke Spencer
- Minimally Invasive Procedure Specialists, Interventional Institute of Colorado, Parker, Colorado
| | - Venu Vadlamudi
- Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, Alexandria, Virginia
| | - Jeffrey Forris Beecham Chick
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan.,Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, Alexandria, Virginia
| |
Collapse
|
9
|
Chick JFB, Srinivasa RN, Cooper KJ, Jairath N, Hage AN, Spencer B, Abramowitz SD. Endovascular Iliocaval Reconstruction for Chronic Iliocaval Thrombosis: The Data, Where We Are, and How It is Done. Tech Vasc Interv Radiol 2018; 21:92-104. [DOI: 10.1053/j.tvir.2018.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
10
|
van Vuuren T, Wittens C, de Graaf R. Stent Extension below the Common Femoral Vein in Extensive Chronic Iliofemoral Venous Obstructions. J Vasc Interv Radiol 2018; 29:1142-1147. [PMID: 29803717 DOI: 10.1016/j.jvir.2018.02.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 02/21/2018] [Accepted: 02/28/2018] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To analyze whether primary venous stent placement into 1 dominant inflow vein peripheral to the common femoral vein (CFV) confluence is feasible. MATERIALS AND METHODS Retrospective review was performed of 14 consecutive patients who underwent primary venous stent placement into veins peripheral to the CFV between 2013 and 2016. Mean patient age was 49 years; 6 (43%) patients were women. All patients had successful deep venous stent placement with brisk contrast flow through the stent. Patients had primary percutaneous stent placement when postthrombotic changes extended peripherally to the femoral confluence but a trabeculation-free area in the deep femoral vein (DFV) could be identified. Based on imaging findings, the DFV had to be considered the prominent inflow vein with normal anatomy. Femoral vein, DFV, and collateral inflow were minimally impaired owing to postthrombotic scarring or trabeculations. RESULTS Primary, assisted primary, and secondary patency rates were 92% at a median follow-up of 481 d (range, 411-792 d). Venous Clinical Severity Score decreased from a mean of 8.9 to 6.4 (P = .03). The Villalta scale decreased from a mean of 11.7 to 4.3 (P = .003). Before intervention, venous claudication was present in 92% and remained in 38% after intervention (P = .016). CONCLUSIONS Stent placement through the femoral confluence into a dominant inflow vein is a promising option in a carefully selected group of patients.
Collapse
Affiliation(s)
- Timme van Vuuren
- Department of Surgery, Maastricht University Medical Centre, P. Debyelaan 25, Maastricht 6202 AZ, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands.
| | - Cee Wittens
- Department of Surgery, Maastricht University Medical Centre, P. Debyelaan 25, Maastricht 6202 AZ, Netherlands; Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands; Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Rick de Graaf
- Department of Radiology, Maastricht University Medical Centre, P. Debyelaan 25, Maastricht 6202 AZ, Netherlands
| |
Collapse
|