Choosing the Right Patient: Understanding the Presenting and Postoperative Complexities of Iliac Vein Stenting in Diabetic Patients With Lower Extremity Ulcers

Abstract

The incidence of lower extremity ulcers increases with venous disease and is strongly associated with diabetes. However, the effects of treating venous disease on preventing subsequent ulcer formation has not been widely explored. We undertook this study comparing patients with and without diabetes to examine differences in presentation and outcomes of iliac vein stenting (IVS) regarding their lower extremity ulcers. A clinical registry of 877 patients who underwent IVS for chronic proximal venous outflow obstruction (PVOO) from 2011 to 2021 at a single institution was retrospectively analyzed. Patients were stratified into groups based on the presence or absence of diabetes and were followed for an average of 743 days after IVS. Symptoms were quantified using venous clinical severity (VCSS) and Clinical-Etiological-Anatomical-Pathophysiological (CEAP) scores. Postoperative symptom resolution was assessed using Clinical Assessment Score (CAS), which grades symptoms from resolved, significant improvement, mild improvement, no change, or worsened. Major reoperations were defined as interventions requiring a venogram, whereas minor reoperations were defined as endovenous thermal ablation of a superficial vein. Of the 877 patients, 189 (21.5%) had diabetes, whereas 688 (78.5%) did not. Diabetes was associated with a statistically significant greater incidence of hypertension (82.8% vs 42.9%; P < .001), coronary artery disease (27.1% vs 7.4%; P < .001), smoking history (27.6% vs 19.2%; P = .015), and history of malignancy (17.4% vs 9.0%; P = .002). A greater incidence of CEAP 6 at presentation (11.6% vs 6.9%; P = .041) was also seen in the diabetic cohort as were intraoperative findings suggestive of a remote DVT (38.5% vs 23.3%; P < .001). At 1 year postoperatively, diabetic patients reported significantly less “complete resolution” and greater “worsening” symptoms (2.9% vs 12.2% and 3.5% vs 2.3%, respectively; P = .002) than those without diabetes. Diabetic patients with chronic PVOO were more likely to present with cardiovascular comorbidities as well as active ulcers. Intraoperatively, these patients were more likely to have a history of remote DVT. Postoperatively, these patients were less likely to report a resolution of lower extremity symptoms and more likely to experience worsening symptoms. IVS placement for chronic PVOO remains safe and durable and should be considered in patients with or without diabetes including those with active ulcers; however, diabetic patients should be counseled on the worsened prognosis for ulcer resolution.