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

Indications, technical aspects, and outcomes of stent placement in chronic iliofemoral venous obstruction

BACKGROUND

Iliofemoral Venous Stent Placement (IVS) has evolved to a well-established endovascular treatment modality for chronic iliofemoral venous obstruction (CIVO). Dedicated venous stents gained FDA approval in 2019 and solidified IVS as a defined intervention with clear indications, contraindications, risks, benefits, and procedural management principles. This review focuses on the indications, technical aspects and outcomes of stenting for CIVO. Other aspects pertaining to IVS are covered in manuscripts that are part of this series.

METHODS

This study conducted a literature search limited to English articles. Three search strategies were employed, and references were managed in Covidence software. Four investigators independently screened and evaluated articles, excluding meta-analyses, clinical trial protocols, and non-relevant studies. Eligible studies, focused on clinical outcomes and stent patencies, underwent thorough review.

RESULTS

The literature search yielded 1,704 studies, with 147 meeting eligibility criteria after screening and evaluation. Exclusions were based on duplicates, irrelevant content, and non-iliac vein stent placement.

CONCLUSION

Successful IVS for CIVO relies on meticulous patient selection, consistent use of IVUS during procedures, and attention to the technical details of IVS.

The association between iliac vein compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis

Objective

This study aimed to investigate the association between the left common iliac vein (CIV) compression degree and characteristics of first diagnosed left lower extremity deep vein thrombosis (DVT).

Patients and methods

This was a single-center retrospective observational study. Between January 2015 and June 2022, first diagnosed left lower extremity DVT patients with enhanced computed tomography of lower extremities were included. Patient demographics, comorbidities, risk factors, DVT characteristics, and CIV compression degree were collected and analyzed. Logistic regressions were performed to evaluate the odds ratio (OR) with a 95% confidence interval (CI) of iliofemoral or mixed DVT vs. compression percentage. The association between compression percentage and iliofemoral or mixed DVT was evaluated on a continuous scale with restricted cubic splines (RCS). The association between compression percentage and thrombus burden was evaluated using the Spearman test.

Results

A total of 196 (mean age, 61.8 ± 16.1 years; 86 males) patients were included. The median CIV compression percentage in iliofemoral or mixed DVT patients was significantly greater than in non-iliofemoral or non-mixed DVT, respectively (64.4 vs. 46.6%, p < 0.001; 67.8 vs. 54.8%, p = 0.004). CIV compression >50% was associated with significantly increased morbidity of iliofemoral DVT (adjusted OR, 2.96; 95% CI, 1.58-5.52; p = 0.001) or mixed DVT (adjusted OR, 2.39; 95% CI, 1.19-4.81; p = 0.014). RCS showed that a greater compression percentage was associated with a continuously increased OR of iliofemoral DVT (overall p = 0.003, non-linear p = 0.577) or mixed DVT (overall p = 0.020, non-linear p = 0.771). CIV compression percentage had a positive correlation with thrombus burden (rs = 0.284, p < 0.001).

Conclusion

A greater left CIV compression percentage may be associated with increasing likelihood of more proximal location and severe clot extent in first diagnosed left lower extremity DVT.

Clinical outcomes of different endovenous procedures among patients with varicose veins and iliac vein compression: A retrospective cohort study

OBJECTIVE

This study aimed to investigate the short-term outcomes of three endovenous procedures in patients with varicose veins (VVs) and severe iliac vein compression syndrome (IVCS).

METHODS

A total of 158 consecutive patients were included in this multicenter retrospective study from May 2017 to December 2019; 54 patients underwent endovenous laser ablation (EVLA) alone, 47 patients underwent EVLA and balloon angioplasty (BA), and 57 patients underwent EVLA and stenting angioplasty (SA). Clinical outcomes and complications were assessed at one and twelve months post-surgery. The Quality of life (QoL) was assessed by the venous clinical severity score (VCSS) and Aberdeen Varicose Vein Questionnaire (AVVQ).

RESULTS

Patients who underwent the SA procedure were older (P < 0.05). Incidence of laser ablation complications was similar among the three procedures; closure rates of the great saphenous vein were 96.8%, 98.0%, and 98.4%, respectively, at 12 months. Reflux times in the SA procedure were lower than those in the EVLA and BA procedures at 12 months, while ulcer healing time was faster with the SA procedure (P < 0.05) than with the other procedures. The VCSS and AVVQ values were significantly improved post-procedure (P < 0.05), with lower AVVQ scores in the SA procedure than in the EVLA and BA procedures at 12 months post-surgery. The EVLA and BA procedures (stenosis >70%) caused a significantly higher symptom recurrence than the SA procedure, with an odds ratios of 14.04 (95% confidence interval (CI), 1.99-99.18) and 10.50 (95% CI, 1.26-87.15), respectively.

CONCLUSIONS

Our results demonstrate that EVLA and SA procedures relieve symptoms, improve the QoL, and decrease symptom recurrence in patients with VVs and severe IVCS (stenosis >70%).

A systematic review of current trends in pharmacologic management after stent placement in nonthrombotic iliac vein lesions

Objective

Stenting of the iliac vein is increasingly recognized as a treatment for chronic venous insufficiency (CVI). However, the pharmacologic management after stent placement is unclear. This review was conducted to illustrate recent trends in anticoagulation and antiplatelet regimens following stent placement for nonthrombotic iliac vein lesions (NIVL).

Methods

The MEDLINE database was searched using the term “iliac vein stent.” Retrieval of articles was limited to studies conducted on humans and published in English between 2010 and 2020. Studies were included that described iliac vein stent placement. Studies were excluded that contained fewer than 25 patients, performed procedures other than stent placement, did not specify the postoperative anticoagulant used, or treated lesions of thrombotic origin.

Results

12 articles were included in this review, yielding a total of 2782 patients with a male-to-female ratio of 0.77. The predominant CEAP classification encountered was C3. The most common stent used in the included studies was the Wallstent (9/12), and the most common pharmacologic regimen was 3 months of clopidogrel (6/12). Warfarin, aspirin, cilostazol, and rivaroxaban were among other agents used. Primary stent patency ranged from 63.1 to 98.3%. There was no apparent correlation between pharmacologic agent used and stent patency or subjective patient outcomes.

Conclusion

Multiple different approaches are being taken to pharmacologically manage patients following stent placement for NIVL. There is no consensus on which agent is best, nor is there a formal algorithmic approach for making this decision. Additionally, the findings in this study call into question whether anticoagulation following stenting for NIVL is necessary at all, given the similar outcomes among the different agents utilized. This review underscores the potential value of undertaking a multi-institutional prospective study to determine what is the best pharmacologic therapy following venous stent placement for NIVL.

Timing of Endovascular Interventions for Iliac Vein Compression Syndrome With Thrombus

The aim of this study is to explore the timing and method of endovascular intervention for iliac vein compression syndrome (IVCS) with thrombus. Data from 111 patients with IVCS, complicated acute deep vein thrombosis (DVT), or post-thrombotic syndrome (PTS) who underwent endovascular interventions were analyzed retrospectively. Patients were divided into Group A (DVT group), including 56 patients with IVCS and iliofemoral DVT, with or without femoropopliteal DVT, with sudden lower limb swelling, and Group B (PTS group) included 55 patients with IVCS and PTS, including 18 with lower extremity wet ulcers and 32 with lower limb infections. Interventional therapies were used to treat the thrombus and eliminate stenosis and occlusion of the iliac vein. In both groups, clinical symptoms in the lower limbs after surgery were reduced significantly, and PTS incidence was low during long-term follow-up. The cumulative patency rate was 75.2% in the DVT group and 88.6% in the PTS group. Comprehensive interventional therapies are safe and effective in patients with IVCS and thrombi. Long-term efficacy in the PTS group tended to be better than that in the DVT group.