Incidence of and Risk Factors for Iliocaval Venous Obstruction in Patients with Chronic Venous Leg Ulcers

Abstract

Iliocaval venous obstruction (ICVO) can be a significant contributor to venous hypertension in patients with advanced disease. Percutaneous stenting has been reported to correct ICVO, resulting in improvement in pain, swelling, and other venous symptoms. The incidence of ICVO in patients with CEAP clinical class 5 and 6 disease has not been reported. In this study, we reviewed a series of patients with healed or active venous leg ulcers to determine the incidence of ICVO and the risk factors related to its occurrence. Patients with CEAP clinical class 5 and 6 venous insufficiency underwent routine evaluation with duplex ultrasound imaging to identify the presence of venous reflux in the deep and superficial systems. Computed tomography (CT) or magnetic resonance (MR) venography was performed in all patients. Each study was evaluated by two separate examiners to determine the percentage of obstruction in the iliocaval outflow tract. Demographics and risk factors related to venous disease were collected and examined for their association with the presence of ICVO. We retrospectively reviewed 78 CEAP clinical class 5 and 6 patients (53.4% men; average age, 59.3 years) evaluated with a CT or MR venogram. The ulcer affected the left lower extremity in 46%, and 50% reported a history of deep vein thrombosis (DVT). Duplex ultrasound imaging identified deep venous reflux (DVR) only in 13% of ulcerated limbs, superficial venous reflux (SVR) only in 38%, and combined DVR and SVR in 49%. The incidence of iliac and IVC obstruction is listed in the Table. Overall, 37% of imaging studies demonstrated ICVO of at least 50%. Risk factors that were associated with a significantly higher incidence of >80% narrowing of the iliocaval outflow tract included a history of DVT (P = .005) and reflux in the deep venous system (P = .002). No limb with SVR alone was found to have ICVO > 80%. Although high-grade ICVO occurred more frequently in women and in patients with left leg ulcers, the frequency was not statistically significance.TableIncidence of iliocaval stenosis in all cases and in limbs with prior deep vein thrombosis (DVT) or deep venous reflux (DVR)Iliocaval stenosisTotal cases, %DVT history, %DVR, %100%8.817.218.380% to 99%1420.721.550% to 79%1413.812.330% to 49%5.33.45.110% to 29%17.513.811.8<10%42.13130.8 Open table in a new tab ICVO is a frequent and under-appreciated contributor to venous hypertension in patients with venous leg ulcers. Patients with a history of DVT or duplex-diagnosed DVR have a higher incidence of outflow obstruction and should be routinely studied with CT or MR venography to allow correction in this high-risk group of patients.