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.

Risk Factors for Venous Thromboembolism and Eventual Amputation in Traumatic Femoral and Iliac Vein Injuries: A Trauma Quality Improvement Program Analysis

BACKGROUND

Iliac and femoral venous injuries represent a challenging dilemma in trauma surgery with mixed results. Venous restoration of outflow (via repair or bypass) has been previously identified as having higher rates of VTE (venous thromboembolism) compared to ligation. We hypothesized that rates of VTE and eventual amputation were similar whether restoration of venous outflow vs ligation was performed at initial operation.

METHODS

Patients in the 2019-2021 National Trauma Data Bank with iliac and femoral vein injuries were abstracted and analyzed. The primary outcomes of interest were in-hospital lower extremity amputation and VTE.

RESULTS

A total of 2642 patients with operatively managed iliac and femoral vein injuries were identified VTE was found in 10.8% of patients. Multivariable logistic regression was performed and identified bowel injury, higher ISS, older age, open repair, and longer time to VTE prophylaxis initiation as independent predictors of VTE. Amputation was required in 4.2% of patients. Multivariable logistic regression identified arterial or nerve injury, femur or tibia fracture, venous ligation, percutaneous intervention, fasciotomy, bowel injury, and higher ISS as independent factors of amputation.

CONCLUSION

Venous restoration was not an independent predictor of VTE. Venous ligation on index operation was the only modifiable independent predictor of amputation identified on regression analysis.

Double Inferior Vena Cava with Major Predominance of the Left Inferior Vena Cava: A Cadaver Case Report

We encountered a case of a double inferior vena cava with major predominance of the left inferior vena cava during an anatomical dissection course for medical students in 2015. The right inferior vena cava (normal inferior vena cava) was 2.0 mm wide, and the left inferior vena cava was 23.2 mm wide. The fine right inferior vena cava began at the right common iliac vein, ascended along the right side of the abdominal aorta, and then joined the left inferior vena cava at the level of the lower margin of the first lumbar vertebra. The dominant left inferior vena cava started from the left common iliac vein and ascended along the left side of the abdominal aorta. Most patients with a double inferior vena cava are asymptomatic, and these variants are incidentally detected by computed tomography or magnetic resonance imaging. Their presence may have significant implications for surgery, particularly abdominal surgery in patients with paraaortic lymphadenopathy and in those undergoing laparoscopic radical nephrectomy or inferior vena cava filter placement. We herein discuss the embryology of a double inferior vena cava based on detailed anatomical data of the variations of a double inferior vena cava, including those that require clinical attention.

Preprocedural imaging modalities in patients undergoing iliocaval venous recanalization and stent placement

PURPOSE

To determine the diagnostic accuracy of preinterventional imaging modalities in patients being evaluated for iliocaval venous recanalization and stent placement.

METHODS

Consecutive patients with iliocaval postthrombotic obstructions or nonthrombotic iliac vein lesions (NIVL), who were scheduled for recanalization, underwent duplex ultrasound (DUS), magnetic resonance venography (MRV), multiplanar venography (MPV), and intravascular ultrasound (IVUS). The diagnostic accuracies of DUS, MRV, and MPV were analyzed using IVUS as reference.

RESULTS

A total of 216 limbs in 108 patients (80 patients with postthrombotic obstructions, 28 patients with NIVL) were examined. In patients with postthrombotic obstructions, the diagnostic sensitivities for the detection of lesions of the common femoral vein were 81% (95% CI 71-89%) for DUS, 76% (95% CI 65-85%) for MRV, and 86% (95% CI 76-93%) for MPV. The sensitivities for detecting lesions of the iliac veins were 96% (95% CI 89-99%) for DUS, 99% (95% CI 92-100%) for MRV, and 100% (95% CI 94-100%) for MPV. Regarding the inferior vena cava, the sensitivities were 44% (95% CI 24-65%) for DUS, 52% (95% CI 31-73%) for MRV, and 70% (95% CI 47-86%) for MPV. The sensitivities for detecting NIVL were 58% (95% CI 34-79%) for DUS, 90% (95% CI 68-97%) for MRV, and 95% (95% CI 73-99%) for MPV.

CONCLUSION

In patients scheduled for recanalization of iliocaval postthrombotic obstructions, the sensitivities of DUS, MRV, and MPV were similar. In patients with suspected inferior vena cava involvement and in patients with NIVL, additional imaging with MR or conventional venography is required.

Deep venous thrombosis of the contralateral iliac vein after stenting of the iliocaval confluence: a therapeutic challenge

The treatment of choice for patients with symptomatic venous compression syndrome is venous stenting. However, this treatment has well-documented complications and, although rare, contralateral deep venous thrombosis is one of these complications. Our objective is to present a case of deep venous thrombosis of the contralateral iliac vein resulting from placement of the stent beyond the recommended position and the therapeutic challenge is to recanalize the vein with reconstruction of the iliocaval confluence.

CFD Study of the Effect of the Angle Pattern on Iliac Vein Compression Syndrome

Iliac vein compression syndrome (IVCS, or May-Thurner syndrome) occurs due to the compression of the left common iliac vein between the lumbar spine and right common iliac artery. Because most patients with compression are asymptomatic, the syndrome is difficult to diagnose based on the degree of anatomical compression. In this study, we investigated how the tilt angle of the left common iliac vein affects the flow patterns in the compressed blood vessel using three-dimensional computational fluid dynamic (CFD) simulations to determine the flow fields generated after compression sites. A patient-specific iliac venous CFD model was created to verify the boundary conditions and hemodynamic parameter set in this study. Thirty-one patient-specific CFD models with various iliac venous angles were developed using computed tomography (CT) angiograms. The angles between the right or left common iliac vein and inferior vena cava at the confluence level of the common iliac vein were defined as α1 and α2. Flow fields and vortex locations after compression were calculated and compared according to the tilt angle of the veins. Our results showed that α2 affected the incidence of flow field disturbance. At α2 angles greater than 60 degrees, the incidence rate of blood flow disturbance was 90%. In addition, when α2 and α1 + α2 angles were used as indicators, significant differences in tilt angle were found between veins with laminar, transitional, and turbulent flow (p < 0.05). Using this mathematical simulation, we concluded that the tilt angle of the left common iliac vein can be used as an auxiliary indicator to determine IVCS and its severity, and as a reference for clinical decision making.

Spontaneous Iliac Vein Ruptures: A Systematic Review

INTRODUCTION

Spontaneous iliac vein rupture is a rare, but frequently lethal condition. It is important to timely recognize its clinical features and immediately start adequate treatment. We aimed to increase awareness to clinical features, specific diagnostics, and treatment strategies of spontaneous iliac vein rupture by evaluating the current literature.

METHODS

A systematic search was conducted in EMBASE, Ovid MEDLINE, Cochrane, Web of Science, and Google Scholar from inception until January 23, 2023, without any restrictions. Two reviewers independently screened for eligibility and selected studies describing a spontaneous iliac vein rupture. Patient characteristics, clinical features, diagnostics, treatment strategies, and survival outcomes were collected from included studies.

RESULTS

We included 76 cases (64 studies) from the literature, mostly presenting with left-sided spontaneous iliac vein rupture (96.1%). Patients were predominantly female (84.2%), had a mean age of 61 years, and frequently presented with a concomitant deep vein thrombosis (DVT) (84.2%). After various follow-up times, 77.6% of the patients survived, either after conservative, endovascular, or open treatment. Endovenous or hybrid procedures were frequently performed if the diagnose was made before treatment, and almost all survived. Open treatment was common if the venous rupture was missed, for some cases leading to death.

CONCLUSION

Spontaneous iliac vein rupture is rare and easily missed. The diagnose should at least be considered for middle-aged and elderly females presenting with hemorrhagic shock and concomitant left-sided DVT. There are various treatment strategies for spontaneous iliac vein rupture. An early diagnose brings options for endovenous treatment, which seems to have good survival outcomes based on previously described cases.

Hematuria during the right heart catheterization procedure: Renal perforation as a very rare complication

The occurrence of hematuria during a right heart catheterization can be a sign of renal perforation, a rare but life-threatening complication that could be developed due to the misdirection of wire into the abdominopelvic venous plexus. We showed this complication could be managed with venoplasty of the common iliac vein.

Evaluation of 3-dimensional rotational venography for the diagnosis of non-thrombotic iliac venous lesion

Background

The purpose of this study was to determine the technical feasibility and safety of 3D rotational venography (3D-RV) in the diagnosis of non-thrombotic iliac vein lesions compared with traditional 2D-digital subtraction angiography (2-DSA).

Methods

The general epidemiological data (including age, gender), clinical manifestations (including major symptom, affected extremity, CEAP classification, comorbidity, stenosis rate), and intra-operative findings (iliac vein indentation position, collateral circulation, procedure time, X-rays dose, contrast agent dosage) of 61 NIVL patients who were assessed by 3D-RV and traditional 2-DSA between October 2018 to October 2022 were obtained and analyzed.

Results

A total of 61 consecutive patients with symptomatic NIVL from our institution were enrolled in this study. With the aggravation of iliac vein stenosis, the proportion of indicators such as contralateral formation and iliac vein compression indentation reflecting the severity of compression under 3D-RV reconstruction increased significantly. Also, significant differences were observed between the 3D-RV and 2-DSA groups concerning procedure time (10.56 ± 0.09 s vs. 12.59 ± 0.37 s; p < 0.01), X-ray dose (41.25 ± 0.21 mGy vs. 81.59 ± 1.69 mGy; p < 0.01) and contrast agent dosage (21.48 ± 0.24 mL vs. 33.69 ± 0.72 mL; p < 0.01). Contralateral iliac vein imaging (p = 0.002), pelvic collateral vein imaging (p = 0.03), and external iliac vein indentation (p = 0.001) were found to influence the severity of iliac vein compression.

Conclusion

3D-RV can display dynamic stereo image information of NIVL, augmenting the information obtained from traditional 2-DSA. Contralateral iliac vein imaging, pelvic collateral vein imaging, and external iliac vein indentation can be used to evaluate the severity of iliac vein compression to some extent.

Iliac vein compression syndrome caused by a large bladder diverticulum: Case report and literature review

Iliac vein compression syndrome is a rare disorder that causes oedema of one or both legs, with or without thrombosis. This current case report describes a 71-year-old male patient with left iliac vein compression caused by a bladder diverticulum that occurred secondary to chronic prostatic hyperplasia. The patient presented with left leg oedema without deep vein thrombosis. Contrast-enhanced computed tomography of the abdomen and pelvis, Doppler ultrasound imaging of the lower limb veins and magnetic resonance imaging helped confirm the diagnosis. The patient initially underwent urinary catheter placement, which relieved urinary retention and iliac vein compression. He subsequently underwent bladder diverticulectomy and transurethral prostatectomy. The postoperative clinical course was uneventful. During the 1.5-year follow-up, the patient did not have lower extremity oedema. Bladder diverticulum is an extremely rare cause of iliac vein compression syndrome, and only five such cases, including this one, have been reported to date. This article presents a literature review of these cases and a summary of the diagnosis and treatment experience.

Pivotal Study Evaluating the Safety and Effectiveness of the Abre Venous Self-Expanding Stent System in Patients With Symptomatic Iliofemoral Venous Outflow Obstruction

Supplemental Digital Content is available in the text.

Background:

Iliofemoral venous obstruction is recognized with increasing frequency as the underlying cause of lower extremity symptoms including edema, pain, skin changes, and, in advanced cases, ulceration. This study sought to evaluate the safety and effectiveness of the Abre venous self-expanding stent system for the treatment of symptomatic iliofemoral venous outflow obstruction.

Methods:

The ABRE Study (A Multi-Center, Non-Randomized Study to Evaluate the Safety and Effectiveness of the Abre Venous Self-Expanding Stent System in Patients With Symptomatic Iliofemoral Venous Outflow Obstruction) is a single-arm, multicenter, prospective study that included 200 subjects from 24 global sites. The primary end points were 12-month primary patency and major adverse events within 30 days. Secondary end points included lesion and procedure success, primary-assisted and secondary patency, major adverse events, stent migration, stent fracture, and quality of life changes. End point-related adverse events and imaging studies were adjudicated by independent clinical events committee and core laboratories, respectively.

Results:

Venous obstruction cause was classified as acute deep vein thrombosis (16.5%, 33/200), post-thrombotic syndrome (47.5%, 95/200), or nonthrombotic iliac vein lesion (36.0%, 72/200). The common iliac and external iliac veins were stented in 96.0% (192/200), 80.5% (161/200) of subjects, respectively. Stent implant into the common femoral vein was required in 44.0% (88/200). Primary patency at 12 months was 88.0% (162/184). Four (2.0%) major adverse events occurred within 30 days. Twelve-month primary-assisted and secondary patency were 91.8% (169/184) and 92.9% (171/184), respectively. No stent fractures or migrations were reported. Mean target limb Villalta score decreased from 11.2±5.6 at baseline to 4.1±4.8 at 12 months, and the mean target limb revised Venous Clinical Severity Score decreased from 8.8±4.7 at baseline to 4.3±3.6 at 12 months. Clinically meaningful improvements in quality of life and venous functional assessment scores from baseline were demonstrated through 12 months in all measures.

Conclusions:

Symptomatic iliofemoral venous obstruction can be successfully treated with an Abre venous stent. Study outcomes demonstrated a high patency rate with a good safety profile. Patients demonstrated a significant reduction in clinical symptoms and improvement in quality of life that was maintained through 12-month follow-up.

Registration:

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03038438.

Cement-associated thrombotic embolism in the inferior vena cava and bilateral iliac veins after percutaneous vertebroplasty: a case report

Percutaneous vertebroplasty (PVP) was first reported in 1987 for treating vertebral hemangiomas. PVP is also an effective treatment for osteoporotic vertebral compression fracture that mainly involves a percutaneous injection of polymethylmethacrylate. Severe complications of PVP have been reported in recent years. However, to the best of our knowledge, cement-associated thrombotic embolism in the inferior vena cava and bilateral iliac veins after PVP has rarely been reported. We experienced a patient with cement-associated thrombotic embolism in the inferior vena cava and bilateral iliac veins after PVP. Fortunately, after conservative therapy, we achieved a satisfactory result. Unfortunately, we could not explain the cause of the cement leakage and formation of the thrombotic embolism. We believe that surgeons should have a better understanding of the fracture pattern and anatomy of the vertebral venous net system. They should also perform meticulous imaging monitoring with slower pushing of the cement to minimize the risks during the PVP. This case report highlights a rare, but potentially life-threatening, complication of PVP. Surgeons need to be aware of the possibility of cement leakage and the formation of cement-associated thrombotic embolism so that they are much more vigilant when performing PVP.

May-Thurner Syndrome: An Anatomic Predisposition to Deep Vein Thrombosis

May-Thurner syndrome (MTS) is a rare clinical condition caused by extrinsic compression of the left common iliac vein by the right common iliac artery, leading to venous stasis and predisposing to thrombus formation. Here, we present the case of a 39-year-old female with no obviously known other risk factors predisposing to thrombosis who presented with severe left leg pain and swelling for a week. The international normalized ratio was elevated and the venous Doppler study showed extensive thrombosis extending from the left common iliac vein to the common femoral vein and the popliteal vein. She was diagnosed with MTS and treated with catheter-directed mechanical thrombolysis and thrombectomy, along with angioplasty of the left common iliac vein and external iliac vein, with near-complete resolution post-treatment. MTS should be suspected in patients who present with unilateral limb thrombosis regardless of the presence of predisposing factors. Timely management with endovascular procedures is necessary to help prevent other potential life-threatening complications.

Left common iliac vein compression identified by vascular ultrasonography in asymptomatic women: does standing position influence diagnosis?

Background

Vascular ultrasonography is the imaging exam of choice for initial screening for left common iliac vein compression, which is an asymptomatic finding that can be detected in up to 25% of some patient samples.

Objective

To determine, using vascular ultrasonography, whether findings of left common iliac vein compression in asymptomatic women are different when assessed in the prone and standing positions.

Methods

This is a cross-sectional observational study of 50 adult female volunteers with no symptoms of pelvic venous compression. The parameters assessed with vascular ultrasonography in the prone and standing positions were diameters and maximum velocities of the left common iliac vein at the point at which it crosses behind the right common iliac artery and before this point, in addition to left common iliac vein velocity indices at the crossing.

Results

Eight cases of significant compression of the left common iliac vein were identified when assessed in prone position (16%) and just two cases (4%) were identified in the standing position. Left common iliac vein diameters were statistically larger (p = 0.002) at the point where it crosses behind the right common iliac artery in the standing position and velocities and velocity indices were statistically higher (p < 0.001) in the prone position. No significant compression of the left common iliac vein was identified in the standing position when velocity indices were normal in the prone position.

Conclusions

There was no difference in detection of significant compression of the left common iliac vein when assessed in the standing position in comparison with assessment in the prone position. However, the study showed that anatomic compression of the left common iliac vein may be reduced in the standing position.

Nightmare after iliac vein stenting: Spinal epidural hematoma

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

Common Iliac Vein Injury in Blunt Abdominal Trauma Without Pelvic Fractures

Iliac vein injury in the absence of pelvic fractures is rare. We present the case of a 27-year-old male involved in a motorcycle crash. Imaging demonstrated a lumbar hernia and pelvic hematoma in the absence of pelvic fractures. The patient became unstable and required emergency surgery demonstrating an iliac vein injury requiring ligation. Diagnosis and management of this rare injury is reviewed.

Case Report: Rare Iliac Vein Compression (May-Thurner) Syndrome in a Pediatric Patient

Iliac vein compression syndrome (IVCS) or May-Thurner syndrome occurs predominantly in young to middle-aged women. Here we reported a case of IVCS in a 5-year-old boy. The child was admitted to our vasculocardiology department with left lower extremity that had been swollen for 1 month. Blood tests revealed coagulation routine and platelets in the normal ranges. Computer tomography angiography (CTA) and magnetic resonance imaging (MRI) showed the left common iliac vein had become narrow before it entered the right common iliac vein. To further clarify, we performed angiography, which clearly showed the stenosis and the blood return of the left common iliac vein. So IVCS was diagnosed. What is more, we found the aorta descended to the right of the spine, and this may be the reason for the apparent compression of the left common iliac vein. Given the young age and mild symptoms of the child, the treatment was conservative mainly including elevation of the affected limb, wearing medical elastic socks, and short-term oral aspirin for anticoagulation. Meanwhile, the boy is being followed up closely. If the swelling of the left lower extremity significantly increases, stent placement may need to be considered in the future.

Best practices in diagnosis and treatment of chronic iliac vein obstruction

Iliac vein obstruction occurs in 20-30% of the general population. In patients with severe chronic venous insufficiency, this prevalence can be even higher, reaching 50-90% when the obstruction is investigated using intravascular ultrasound. Less invasive methods, such as venous Duplex Scanning, and even invasive ones such as venography may fail to diagnose the condition. Endovascular treatment of these obstructions is effective, safe, and associated with excellent clinical outcomes and stent patency rates, provided that fundamental anatomical and technical principles are considered and applied.

In Well-Selected Patients With a Femoral Deep Vein Thrombosis Central Venous Imaging May Identify Additional Iliocaval Disease

OBJECTIVE

Patients who present acutely with a femoral deep vein thrombosis (DVT) diagnosed by ultrasound are often treated with anticoagulation and instructed to follow-up electively. This study sought to assess whether obtaining axial imaging of the central venous system results in the identification of additional iliocaval pathology warranting treatment.

METHODS

This study was a retrospective review of a prospectively maintained registry from November 2014 through April 2017 with follow-up through March 2020. Consecutive patients with a diagnosis of femoral DVT diagnosed by ultrasound were evaluated; those who underwent axial imaging of the iliocaval system (Group A) were compared to those who did not undergo imaging of the central veins (Group B). The primary outcome was the performance of any percutaneous central venous intervention. Secondary outcomes included the extent of DVT identified on duplex and after axial imaging, follow-up duplex patency and persistence of severe symptoms.

RESULTS

Eighty patients presented with an ultrasound diagnosis of a femoral vein DVT. Mean follow-up was 551 ± 502 days. Group A comprised 24 patients (30%) and Group B comprised 56 patients (70%). Baseline demographics did not differ significantly between the 2 groups. After duplex imaging, Group A exhibited an increased prevalence of DVT in the common femoral vein. After central imaging, Group A exhibited an increased prevalence of DVT in the iliocaval veins. The number of patients who underwent invasive treatment differed significantly between the 2 groups, Group A 16/24 (67%) vs. Group B 9/56 (16%), P < 0.0001. The number of patients that demonstrated duplex patency and had persistent symptoms on follow-up did not differ significantly.

CONCLUSIONS

Patients with an ultrasound diagnosis of femoral DVT may have additional iliocaval pathology warranting intervention. Well-selected imaging of the central veins may reveal a more complete picture, potentially altering management.

Evaluation of lumbar fusion using the anterior to psoas approach for the treatment of L5/S1 spondylolisthesis

To date, no studies have evaluated the outcomes of lumbar interbody fusion using the anterior to psoas (ATP) approach in patients with spondylolisthesis at L5/S1. We; therefore, aimed to evaluate short-term surgical outcomes of interbody fusion using the ATP approach combined with posterior fixation in these patients.We performed a retrospective analysis of 9 patients with grade I spondylolisthesis at L5/S1 who were treated with fusion and posterior fixation using the ATP approach at our hospital from April to July 2018. The recorded parameters included operation time, intraoperative blood loss, complications, intervertebral fusion rate, radiological intervertebral height, intervertebral foramen height, intervertebral foramen width, pain, visual analog scale, and Oswestry disability index.Four men and 5 women at an average age of 57.8 years (range: 46-71 years) were enrolled in the study. The average operation time was 152.8 ± 22.9 minutes, and the average blood loss during surgery was 165 ± 27.5 mL. All patients confirmed the relief of their low back pain, and there were no serious complications. The follow-up time was more than 6 months. The visual analog scale and Oswestry disability index scores 3 days postoperatively and at the last follow-up were significantly lower than those before surgery (P < .05). At the last follow-up, the intervertebral space of the surgical segment showed bony fusion in all patients, and the intervertebral height and intervertebral foramen height and width were significantly increased compared with those before surgery (P < .05).The ATP approach was safe and effective for the treatment of spondylolisthesis at L5/S1. It showed low vascular injury and cage shift rates and was technically easy to perform. We recommended that surgeons identify the vessels in the surgical field preoperatively so that they can be secured or safely ligated during surgery.

Covered Stent Implantation for Treatment of Iliac Vein Rupture During Percutaneous Left Atrial Appendage Occlusion

An 82-year-old woman who experienced an iatrogenic external iliac vein perforation during a left atrial appendage occlusion procedure was successfully treated by endovascular graft implantation. We report the short- and long-term outcomes of the procedure. (Level of Difficulty: Advanced.).

Compression of left renal vein and left common iliac vein on CT scans: how often are they detected?

Background

The nutcracker and May-Thurner syndromes are rare and, although often underdiagnosed, they can cause limiting symptoms. They are frequently considered only after exclusion of other diagnoses and there is no consensus in the literature on prevalence, incidence, or diagnostic criteria.

Objectives

To estimate the frequency of compression of the left common iliac vein and left renal vein in CT scans of the abdomen and pelvis.

Methods

Descriptive, quantitative, cross-sectional study. The criteria used to define compression of the left renal vein were a hilar/aortomesenteric diameter ratio > 4 and aortomesenteric angle < 39° and the criterion for compression of the left common iliac vein was a diameter < 4mm.

Results

CT scans of 95 patients were analyzed; 61% were women and 39% were men. Left renal vein compression was observed in 24.2% of the sample, with a mean age of 48.8 years, occurring in 27.6% of the women and 18.9% of the men (p = 0.3366). Compression of the left common iliac vein was detected in 15.7% of the sample, with a mean age of 45.9 years, occurring in 24.1% of the women and 2.7% of the men (p = 0.0024). Both veins were compressed in 7.4% of the patients.

Conclusions

Left renal vein compression was detected in women and men at similar frequencies, whereas left common iliac vein compression was more frequent in women. Both venous compressions were most frequently found in patients aged 41 to 50 years.

External validation of the SOX-PTS score in a prospective multicenter trial of patients with proximal deep vein thrombosis

BACKGROUND

Using data from the SOX Trial, we recently developed a clinical prediction model for occurrence of the postthrombotic syndrome (PTS) after proximal deep vein thrombosis (DVT), termed the SOX-PTS score. The score includes anatomical extent of DVT; body mass index; and baseline Villalta score.

OBJECTIVE

To externally validate the SOX-PTS score.

METHODS

Logistic regression analysis of data from the ATTRACT Trial that evaluated pharmacomechanical catheter directed thrombolysis in patients with proximal DVT. The primary outcome was the occurrence of PTS (defined as Villalta score ≥ 5) from 6 to 24 months after DVT. Secondary outcomes included moderate-severe PTS (Villalta scale ≥ 10) and severe PTS (Villalta scale ≥ 14). Predictive performance was assessed by discrimination and calibration. An updated score was evaluated in an exploratory analysis.

RESULTS

Six hundred and ninety-one ATTRACT patients were included, of whom 328 (47%) developed PTS. The c-statistic was 0.63; 95% confidence interval (CI) 0.59-0.67 for PTS. The model's performance appeared to be better for the outcomes moderate to severe PTS and severe PTS (c-statistic 0.67; 95% CI 0.62-0.72 for moderate-severe PTS and 0.70; 0.64-0.77 for severe PTS). An updated model with age as an additional variable performed similarly to the original model.

CONCLUSION

We externally validated the SOX-PTS score for estimating the risk of developing PTS, moderate to severe PTS, and severe PTS, in patients with proximal DVT. The score may be useful to predict PTS at the time of DVT diagnosis. Further external validation in different patient cohorts is required.

Presentation and management of IVC and iliac vein encroachment by lumbar pedicle screws: a case-report

Pedicle screws are commonly used in spinal surgeries and are relatively safe, with venous complications occurring rarely. We report a patient with imaging following a L4-5 fusion that showed indentation of the inferior vena cava and right common iliac vein by the right L4 and L5 pedicle screws. She underwent revision surgery in which the hardware was removed and no bleeding was observed. Intraoperative venogram confirmed vascular integrity and absence of indentation on the venous structures following screw removal. The patient recovered without complications. Venous contact by pedicle screws should be treated on a case-by-case basis in a multidisciplinary approach with vascular surgery. We discuss a treatment algorithm for the operative management of this problem.

[Antithrombotic therapy after iliac vein stenting]

Stenting for iliac vein stenosis or compression has become a common therapeutic approach in recent years. The antithrombotic therapy after the stent deployment, however, reaches no consensus. Medications strategies and patients' prognoses differ in non-thrombotic, acute thrombotic and chronic thrombotic these three circumstances. Non-thrombotic patients usually possess satisfactory stent patency whatever antithrombotic therapy is used. Anticoagulant is the basic medication for acute thrombotic patients, benefits from additional antiplatelet drug remains to be clarified. In terms of chronic thrombotic patients, their prognoses are unsatisfactory under all antithrombotic therapies. In this review, we outlined the recent progress of antithrombotic therapy after iliac vein stenting, aiming to provide feasible medication plans for each circumstance.

Study on the Patency of the Contralateral Iliac Vein After Stenting Across the Iliocaval Confluence With an Experimental In Vivo Model

OBJECTIVE

Stenting is the preferred treatment for iliac vein lesions. For the treatment of occlusions in the junction of the iliac vein and the inferior vena cava (IVC), the stent needs to be positioned in the IVC to cover the lesion. However, the pathological changes in the contralateral iliac vein due to stent coverage on its ostium remain unclear. We observed the patency of the contralateral iliac vein via animal experiments.

METHODS

The stents were placed in the left iliac vein and extended into the IVC in 8 beagle dogs. Doppler ultrasonography, angiography, and histopathological examination were used to assess the patency and histopathological changes in the contralateral iliac vein.

RESULTS

Angiography showed patency of the contralateral iliac vein and no sign of thrombosis or stenosis. Twelve months after stenting, Doppler ultrasonography showed a stenotic change in the ostium of the contralateral iliac vein. The histopathological examination showed that the stent strut at the ostium of the contralateral iliac vein was mostly covered by the intima, and the cross-sectional stenosis rate was greater than 60%.

CONCLUSIONS

The coverage of the iliac vein stent on the ostium of the contralateral iliac vein does not cause complete occlusion of the contralateral vein but can cause significant stenosis at the ostium of the contralateral iliac vein, which is considered to be a potential risk factor for thrombosis.

Morphometric study of the anatomic relationship between large retroperitoneal blood vessels and intervertebral discs of the distal segment of the lumbar spine: a clinical significance

Aim To analyse potential clinical implications of the distance between large retroperitoneal vessels and lower segment of the lumbar spine in the supine and prone position. Methods Prospective, non-randomised study included 40 patients of different age and gender. For all patients magnetic resonance imaging of the lumbar spine was performed in supine and prone position. The level of aortal bifurcation, common iliac vein confluence, the distance from the anterior and posterior aspect of the annulus to the posterior wall of the large retroperitoneal vessels were analysed. Results The study included 40 patients, 22 (55%) males and 18 (45%) females. The level of aortal bifurcation was higher in prone compared to supine position (χ2 = 29.88571; p<0.05). In supine and prone positions, the common iliac veins confluence was most commonly at the level of the lower third of the L4 vertebra (p>0.05). There was a statistically significant difference between the distance from the left common iliac artery to the anterior contour of L4/L5 intervertebral disc (p<0.05). Conclusion Knowledge of the anatomic relationship between iliac vessels and structures of the lower segment of the lumbar spine is very important in the prevention of a potentially severe complication, such as artificial common iliac vessels rupture. Our study showed that the risk of lesions of the common left iliac artery was lesser in the prone position.

Iliac vein compression: epidemiology, diagnosis and treatment

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

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use:

https://youtu.be/InSwn2AebNY

Human Femoral Vein Diameter and Topography of Valves and Tributaries: A Post Mortem Analysis

The femoral vein (FV) is a clinically important vessel. Failure of its valves can lead to chronic venous insufficiency (CVI) with severe manifestations such as painful ulcers. Although they are crucial for identifying suitable implant sites for therapeutic valves, studies on the topography of FV tributaries and valves are rare. Moreover, the femoral vein diameter (FVD) must be known to assess the morphometric requirements for valve implants. To reassess the anatomical requirements for valve implants, 155 FVs from 82 human corpses were examined. FVDs and tributary and valve topographies were assessed using a laboratory straightedge. The FVD increased from 6 mm in the distal femoropopliteal vein to 11 mm in the iliofemoral vein proximal to the saphenofemoral junction (SFJ). Diameters were significantly bigger in males than females. Height correlated positively with FVD. Distal to the SFJ, within a distance of 38 cm, one to eight valves were present. Up to two valves were present within 10 cm proximal to the SFJ. Individual tributary and valve topography must be considered to ensure appropriate design and successful implantation of a venous valve for CVI therapy in the FV. A suitable implant site would be proximal to the SFJ via an infrainguinal transfemoral access. Clin. Anat. 31:1065-1076, 2018. © 2018 Wiley Periodicals, Inc.

The anatomy of the sacral promontory: How to avoid complications of the sacrocolpopexy procedure

Because of problems with vaginal meshes and the high rate of recurrences of native tissue repair, more and more surgeons treat pelvic organ prolapse with laparoscopic sacrocolpopexy. This surgery requires skilled surgeons. The first step of sacrocolpopexy is the dissection of tissues in front of the sacral promontory to reach the anterior longitudinal ligament. Some complications can occur during this dissection and the attachment of the mesh. This step is dangerous for surgeons because of the proximity of vessels, nerves, and ureters. The lack of knowledge of anatomy can lead to severe complications such as vascular, ureteral, or nerve injuries. These complications can be life-threatening. To show anatomic concerns when surgeons dissect and affix the mesh on the anterior longitudinal ligament, we have developed a video of the promontory anatomy. By reviewing anatomic articles about vessels, nerves, and ureters in this localization, we propose an educational tool to increase the anatomic knowledge to avoid severe complications. In this video, we show an alternative location for dissection and graft fixation when the surgeon believes that mesh cannot be fixed safely on the anterior surface of S1, as currently recommended.

Faecal impaction causing bilateral pelvic venous thrombosis

INTRODUCTION

We present a first description of faecal impaction (FI) causing occlusion of the pelvic venous system, resulting in a bilateral thrombosis of the external iliac vein.

PATIENTS AND METHODS

Our 76-year-old female patient was admitted with gradual swelling of both legs. Clinical evaluation revealed a painless abdominal distension and marked bilateral edema of the legs. A computed tomography (CT) scan showed gross dilatation of the colon and rectum, with FI. A short bilateral occlusion of the external iliac vein was seen, with thrombus in both pelvic veins. Doppler ultrasonography confirmed a thrombosis of the external iliac vein and common femoral vein on both sides.

RESULTS

A conservative treatment consisting of manual evacuation, enema, laxatives and systemic anticoagulation was successfully applied.

CONCLUSIONS

FI represents a common - yet preventable - health problem, mainly in the elderly. This case illustrates a rare complication of FI if left untreated.

Primary External Iliac Venous Aneurysm: A Case Report

Primary iliac venous aneurysm is an exceedingly rare abnormality that can be complicated by pulmonary embolism, thrombosis, and rupture. Here we report the case of an otherwise healthy 40-year-old man with a unilateral external iliac vein aneurysm without any evidence of an arteriovenous fistula, proximal stenosis, or obstruction, as reported on computed tomography. Pulmonary embolism was diagnosed using ^99mTc-macroaggregated albumin scintigraphy. To prevent life-threatening complications, we treated the patient with anticoagulant therapy and performed aneurysmectomy with reconstruction using a saphenous vein graft patch. Although postoperative venography showed obstruction of the external iliac vein, the patient remained asymptomatic.

Demographic and clinical features do not affect the outcome of combined endovenous therapy to treat leg swelling

Background There have been well-documented implications of race/ethnicity on the outcome of various vascular diseases, yet there are limited data on risk factors and outcome of lower limb swelling. While many patients improve with endovenous therapy (thermal ablation or iliac vein stenting), some patients' symptoms persist. The goal of this study was to identify clinical factors including race/ethnicity related to persistent leg swelling after treatment with both iliac vein stenting and thermal ablation. Methods From February 2012 to February 2014, this observational study analyzed data for 173 patients with chronic venous insufficiency who underwent both iliac vein stent placement as well as thermal ablation (radiofrequency ablation or endovenous laser ablation). All procedures of the thermal ablations and the iliac vein stenting were staged. Iliac vein stenosis was identified using intravascular ultrasound of the iliofemoral venous segment showing >50% cross-sectional area or diameter reduction. The patients were queried to the resolution of their leg swelling after both procedures were performed. The resolution of swelling was correlated with age, gender, presenting sign according to CEAP classification, race/ethnicity and degree of iliac vein stenosis. Patients were categorized by Caucasians ( n = 97), African Americans ( n = 27), or Hispanics ( n = 49). Statistical analysis performed using Chi-square and Student's t test. Results Of the total 173 patients who underwent both endovenous closure and iliac vein stent placements, 117 (67.6%) patients were women. The average age was 67 (±13 SD) years. The average pain score was 2.9(±3.1 SD). The average degree of iliac vein stenosis was 66.5(±13.3 SD). About 56.1% were Caucasians, 15.6% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 2. One hundred fifty-two (87.9%) patients stated that they had improvement in swelling after combined procedures, 100 (65.8%) patients were women. The average age was 67.3 (±13 SD) years. The average pain score was 2.9 (±3.1 SD). The average degree of iliac vein stenosis was 67.3% (±12.8 SD). About 56.6% were Caucasians, 15.1% were African Americans, and 28.3% were Hispanics. The number of patients with iliac vein stent thrombosis was 1. Twenty-one (12.1%) patients stated they had no improvement after both procedures. Correlating these group factors with the group of patients who improved their swelling after the combined procedures we found the following: 17 (81%) of these patients were females ( P=0.16). The average age was 68.4 (±17 SD) years ( P=0.72 SD). The average pain score was 3.2 (±3.7 SD) ( P=0.68). The average degree of iliac vein stenosis was 60.2% (±15.9 SD) ( P=0.02). Around 52.4% were Caucasians, 19% were African Americans, and 28.6% were Hispanics ( P=0.88). The number of patients with iliac vein stent thrombosis was 1 ( P = 0.1). Conclusion These data suggest that the clinical factors including race are not clinically significant factors in the response to swelling after combined iliac stent and endovenous ablation procedures. Interestingly, a higher degree of iliac vein stenosis was associated with improved resolution of swelling.

Development of a clinical prediction model for the postthrombotic syndrome in a prospective cohort of patients with proximal deep vein thrombosis

Essentials We developed a prediction model for postthrombotic syndrome (PTS) after deep vein thrombosis (DVT). High risk predictors were iliac vein DVT, BMI>35 and moderate-severe Villalta category. Patients with a score ≥4 had an odds ratio of 5.9 (95% CI 2.1-16.6) for PTS. SOX-PTS score may select DVT patients for close monitoring or aggressive strategies to treat DVT.

SUMMARY

Background Postthrombotic syndrome (PTS) is a chronic complication that develops in 20-50% of patients after deep vein thrombosis (DVT). Although individual risk factors for PTS have been characterized, the ability to predict which DVT patients are likely to develop PTS remains limited. Objective To develop a clinical prediction score for PTS in patients with DVT. Methods The derivation cohort consisted of participants in the SOX Trial, a randomized double-blind placebo-controlled trial of elastic compression stockings versus placebo stockings worn for 2 years after DVT to prevent PTS in patients with a first proximal DVT, enrolled in 24 community and tertiary-care hospitals from 2004 to 2010. Multivariable logistic regression analysis of baseline characteristics was performed. The outcome was the occurrence of PTS, diagnosed starting from 6 months or later according to Ginsberg's criteria. Results Seven hundred and sixty-two patients were included in the analysis. The median follow-up was 728 days. The model includes three independent predictors, and has a range of possible scores from 0 to 5. High-risk predictors were: index DVT in the iliac vein; body mass index of ≥ 35 kg m-2 ; and moderate-severe Villalta severity category at DVT diagnosis. As compared with patients with a score of 0, those with a score of ≥ 4 had an odds ratio of 5.9 (95% confidence interval 2.1-16.6) for developing PTS. Conclusions To our knowledge, this is the first clinical prediction score for PTS. We identified three independent predictors that, when combined, predicted PTS risk after a first proximal DVT. The SOX-PTS score requires external validation before it can be considered for clinical use.

Biventricular ICD Placement Percutaneously Via the Iliac Vein: Case Reports and a Review

Cardiac resynchronization therapy (CRT) has been demonstrated to improve symptoms of heart failure. As a result, it has become the standard of care in selected patients, and is commonly completed with three leads placed via an upper-extremity vein. However, in rare situations, such as in the case of superior vena cava occlusion, venous access is not possible via the upper extremity. It is in such instances that alternative means must be sought. Here, two patients who received a CRT defibrillator via an iliac vein approach with a mid-abdominal generator are introduced, and a review of the techniques used is presented. Technical aspects to this approach are discussed, including iliac venous access, defibrillation electrode positioning, coronary sinus access, and lead tunneling to an abdominal generator for patient comfort. This approach should be considered when vascular access is compromised, at least until combined leadless CRT pacing and subcutaneous implantable cardioverter-defibrillator devices become available and feasible for use.

Knowns and Unknowns in Managing Postthrombotic Syndrome

The postthrombotic syndrome (PTS) is a frequent cause of long-term disability in patients with lower extremity deep vein thrombosis. A broad variety of interventions have been applied to patients with established PTS, including lifestyle, medical, compressive, endovascular, and open surgical therapies. However, the volume of evidence to support many individual elements of care is sparse, and important questions remain that must be answered to enable judicious individualization of PTS care. The purpose of this article is to describe what is known about PTS care elements and to identify important evidence gaps that merit future studies.

Segmental portal/superior mesenteric vein resection and reconstruction with the iliac vein after pancreatoduodenectomy

Objective

The results of segmental venous resection (VR) combined with pancreatoduodenectomy (PD) are controversial but may be promising. Few studies have described reconstruction of the portal/superior mesenteric vein (PV/SMV) with the iliac vein harvested from donation after cardiac death (DCD).

Methods

From January 2014 to April 2016, PD combined with segmental excision of the PV/SMV (VR group) was performed in 21 patients with adenocarcinoma of the head of the pancreas (ADHP). The authors established a new technique of venous reconstruction using the iliac vein from DCD and analysed patients’ long-term survival.

Results

The tumour dimensions and tumour staging were greater and the operation time was longer in the VR than PD group; however, no differences in the resection degree, blood loss, complications, reoperation rate, or mortality rate were found. The median survival was similar between the VR and PD groups. The long-term patency of the donor iliac vein was 90%. The degree of resection was a strong predictor of long-term survival.

Conclusion

Segmental PV/SMV resection combined with PD is applicable to selective patients with venous invasion by ADHP if R0 resection has probably been achieved. An iliac vein obtained by DCD provides an effective graft for venous reconstruction.

Influence of Iliac Vein Stent Implantation on the Contralateral Iliac Vein

OBJECTIVES

Stent implantation is frequently used to treat iliac vein occlusion. However, the recommended extension of the stent mesh into the inferior vena cava (IVC) may affect blood flow through the contralateral iliac vein. We analyzed the influence of iliac vein stent extension on contralateral iliac vein patency and neointima formation in a dog surgery model.

METHODS

Bare stents were implanted into the left iliac veins of 12 beagles with the proximal end covering the opening of the contralateral iliac vein. Blood flow was measured by color Doppler 4, 8, and 12 weeks postoperation. At each measurement point, a subgroup was killed, and the stents and veins were removed for pathological examination.

RESULTS

Stents were successfully implanted, and there was no immediate stent occlusion or iliac vein thrombus by color Doppler examinations. Contralateral blood flow was maintained with no obvious abnormalities for 12 weeks. Neointima formed and advanced toward the center of the stent, but small coverage of the contralateral iliac vein opening did not change significantly with time postoperation (9.33% ± 1.54% at 4 weeks, 10.65% ± 1.01% at 8 weeks, and 10.92% ± 1.30% at 12 weeks; P > .05). Scanning electron microscopy showed neointima covering the surface of stent wires at the opening of the contralateral iliac vein, which did increase with time: 63.58% ± 12.39% at 4 weeks, 97.13% ± 2.71% at 8 weeks (P < .001 vs 4 weeks), and 99.63% ± 0.60% after 12 weeks (P > .05 vs 8 weeks; P < .001 vs 4 weeks). The neointimal coverage rate of the meshes increased obviously with time. However, no neointima was found forming a mesh between stent wires.

CONCLUSION

Although there was intimal hyperplasia on the rim of the bare stent in the IVC, expansion was limited and did not block the opening of the contralateral iliac vein. The stent had no obvious influence on blood backflow in the contralateral iliac vein.

Long-standing hemospermia in a patient with megacava associated to a circumaortic renal vein

Hemospermia may have a broad range of functional and organic causes. It is defined as the presence of blood in seminal fluid and usually tends to resolve spontaneously within a few weeks. We present the case of a patient with a 10-year history of hemospermia associated with megacava and circumaortic renal vein. The diagnosis, treatment, and evolution of the condition are reported. Vascular anomalies are rare causes of chronic hemospermia, and the one described in our patient may constitute the first case reported in the literature.

May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery

Acute and chronic venous disorders of the lower extremities affect millions of people and cause substantial disability. Long ago, surgeons and pathologists identified the presence of 'spur-like' abnormalities of the left common iliac vein; these abnormalities were hypothesized to result from compression and/or irritation from the adjacent crossing right common iliac artery. In the 1990s, physicians, starting to perform catheter-directed thrombolysis to treat extensive deep vein thrombosis (DVT), observed that about 50% of patients had an iliac vein stenosis. Vascular physicians have become aware of the occasional patient with otherwise-unexplained extremity swelling and/or pain but without a DVT history who is subsequently found to have an iliac vein abnormality. These 'lesions' have been hypothesized to elevate ambulatory venous pressures and thereby produce lower-extremity symptoms, increase the risk of initial and recurrent DVT episodes, and increase the risk of treatment failure with medical and endovascular therapies for thrombotic and non-thrombotic venous conditions. As a result, many practitioners now actively seek iliac venous obstructive 'lesions' when evaluating patients with known or suspected venous disease. However, for many patients, it continues to be unclear what degree of obstruction to venous blood flow is being caused by such lesions, how clinically significant they are, how much emphasis should be placed on identifying them, and when they should be treated. This article seeks to improve the knowledge base of vascular practitioners who make clinical decisions about the diagnosis and treatment of obstructive iliac vein lesions.

External iliac vein - transplant ureteral fistula combined with renal cell carcinoma: an unusual case of hematuria

Iliac vein-ureteral fistula is a rare cause of hematuria. The diagnosis of an iliac vein-ureteral fistula can be elusive even with the use of multiple methods. With regards to the treatment, there appears to be a shift in management from primarily open surgical to primarily angiographic management. We present a unique case of an external iliac vein – transplant ureteral fistula. A 48 year-old female complained of recurrent gross hematuria. She underwent transplant nephrectomy and radical left nephrectomy because of rejection of transplanted kidney and cystic renal cell carcinoma when the hematuria arose for the first time. Ten months later, the hematuria recurred again, and cystoscopy showed bleeding from the right transplant ureteral orifice. Open exploration confirmed the diagnosis of external iliac vein – transplant ureteral fistula. Diagnostic difficulties and treatment dilemma of such a rare cause of hematuria are also discussed.

Iliac arterial injury following anterior lumbar surgery: a case report

A 31-year-old woman presented with persistent left leg pain 3 weeks after revision lumbar surgery. She had numbness of the leg immediately after surgery, followed by intense, spasmodic pain 4 days later, which was managed with analgesia. Subsequent computed tomographic angiography demonstrated occlusion of the left common iliac artery. This had been missed by her spinal surgeon and by physicians in our emergency department in 2 separate visits. Vascular complications of anterior spinal surgery can be limb- or life-threatening. A high index of suspicion is necessary.

Effect of long-term LMWH on post-thrombotic syndrome in patients with iliac/noniliac venous thrombosis: a subanalysis from the home-LITE study

Patients with iliac deep vein thrombosis (DVT) have a poor prognosis and high incidence of postthrombotic syndrome (PTS). We evaluated the effect of low-molecular-weight heparin (LMWH; tinzaparin) versus usual care (tinzaparin plus warfarin for ≥12 weeks at home) in the development of PTS according to DVT location (iliac/noniliac) by retrospective analysis of the Home-LITE cohort (480 patients with proximal DVT). Patients with iliac DVT had an overall odds ratio of 0.53 (95% confidence interval [CI] 0.33, 0.83; P = .0079) for PTS (including ulcer data) in favor of tinzaparin. Patients with noniliac DVT had a similar odds ratio (0.79 [95% CI 0.67, 0.93], P = .0046) to that reported in the overall Home-LITE population (0.76 [95% CI 0.66, 0.89], P = .0004; including ulcer data), both in favor of tinzaparin. Long-term LMWH may be a suitable alternative for the prevention of PTS in patients with iliac DVT who are unlikely to undergo invasive thrombolysis.

Multifaceted management of the postthrombotic syndrome

The postthrombotic syndrome (PTS) is a frequent cause of chronic pain, swelling, ulceration, and disability in patients with lower extremity deep vein thrombosis (DVT). As interventional radiologists are consulted on more patients with chronic DVT and PTS, their management strategies must be informed by a balanced understanding of the different facets of chronic DVT care and the available treatment options. This article provides an overview of the important elements of a multifaceted approach to the management of patients with PTS that includes pharmacological, physiological, and endovascular aspects of care.