Iliocaval Confluence Stenting for Chronic Venous Obstructions.

Rick De Graaf,Mark De Wolf,Houman Jalaie,Anna M Sailer,Jorinde Van Laanen,Cees Wittens

doi:10.1007/s00270-015-1068-5

Abstract

PurposeDifferent techniques have been described for stenting of venous obstructions. We report our experience with two different confluence stenting techniques to treat chronic bi-iliocaval obstructions.Materials and MethodsBetween 11/2009 and 08/2014 we treated 40 patients for chronic total bi-iliocaval obstructions. Pre-operative magnetic resonance venography showed bilateral extensive post-thrombotic scarring in common and external iliac veins as well as obstruction of the inferior vena cava (IVC). Stenting of the IVC was performed with large self-expandable stents down to the level of the iliocaval confluence. To bridge the confluence, either self-expandable stents were placed inside the IVC stent (24 patients, SECS group) or high radial force balloon-expandable stents were placed at the same level (16 patients, BECS group). In both cases, bilateral iliac extensions were performed using nitinol stents.ResultsRecanalization was achieved for all patients. In 15 (38 %) patients, a hybrid procedure with endophlebectomy and arteriovenous fistula creation needed to be performed because of significant involvement of inflow vessels below the inguinal ligament. Mean follow-up was 443 ± 438 days (range 7–1683 days). For all patients, primary, assisted-primary, and secondary patency rate at 36 months were 70, 73, and 78 %, respectively. Twelve-month patency rates in the SECS group were 85, 85, and 95 % for primary, assisted-primary, and secondary patency. In the BECS group, primary patency was 100 % during a mean follow-up period of 134 ± 118 (range 29–337) days.ConclusionStenting of chronic bi-iliocaval obstruction shows relatively high patency rates at medium follow-up. Short-term patency seems to favor confluence stenting with balloon-expandable stents.

Highlights

Recanalization and stenting of chronic deep venous obstructions is a minimally invasive intervention that has proven effective and safe over the last decades [1]
Chronic iliocaval obstruction was defined as 50 % or more venous lumen obstruction [10] of the inferior vena cava (IVC) involving the confluence on Duplex ultrasound (DUS) or magnetic resonance venography (MRV) with presence of postthrombotic trabecular changes in both common iliac and external arteries
In 6 (15 %) patients, no clinically obvious deep venous thrombosis (DVT) was noted in their medical history, but the combination of DUS and MRV showed postthrombotic changes in the venous system in all of these patients

Summary

Introduction

Recanalization and stenting of chronic deep venous obstructions is a minimally invasive intervention that has proven effective and safe over the last decades [1]. With low complication rates and substantial clinical improvement, this procedure has been increasingly performed over the last years. Long-term stent patency rates vary substantially between clinical reports. Encouraging 92 % stent patency after 10 years has been reported. R. de Graaf et al.: Iliocaval Confluence Stenting by dedicated high-volume centers [2, 3], lower results were published by clinics with lesser numbers of patients [4, 5]. This variation might be explained by lack in dedicated venous interventional tools, e.g., stents. It is of great importance to report on experience with new developments in stent design and stenting technology to help establish an optimal protocol, both for defining the right indication and choosing the optimal treatment

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Conclusion