Invited commentary

Abstract

Drs Raju, Darcey, and Neglen add more information about the important role of venous obstruction to the syndrome of chronic venous insufficiency (CVI) in patients with deep venous reflux disease. From my perspective, the most important findings of this study include: venous stenting improved the rates of healed ulcers, freedom of ulcer-recurrence rates in legs with healed ulcers (C5), and freedom from leg dermatitis; venous stenting improved pain and swelling at 5 years with no differences between nonthrombotic and post-thrombotic obstructions, limbs with severe vs moderate reflux, and limbs with axial and segmental reflux; venous stenting did not result in a deterioration of reflux parameters; and deep venous reflux can be initially ignored if it is combined with iliac vein obstruction. The authors of the current study have been leaders in the area of iliac venous obstruction treatment, and they have the largest world experience using venoplasty and stenting. They used large caliber stents (14-18 mm), covered all lesions without skip areas, extended stents into the inferior vena cava (IVC) 3 to 5 cm, and extended stents below the inguinal ligament as necessary. The patients exhibited advanced chronic venous disease with all having deep venous reflux, 59% demonstrating severe global reflux, 42% showing deep axial reflux, and 65% having superficial venous reflux in addition. By intravascular ultrasound (IVUS) scan, the percent stenosis was 74%, and despite this only 43% demonstrated collaterals on venography suggesting that this venographic sign leaves much to be desired. Only a small percentage of patients required open valve reconstructions by the authors, a group that has written extensively on these vein valve procedures in the past. It is surprising that the results were so good in which only the obstructive component of the disease was treated. The authors have suggested that nonthrombotic iliac vein lesions (NIVL) play a pivotal “permissive” role in the development of chronic venous insufficiency, and the current study supports this suggestion. How can this study be put into context? As the authors suggest, “a stepwise correction of pathology may be applied using initially minimally invasive techniques.” One cannot comment on saphenous vein ablation related to iliac vein stenting from the current study as limbs with concurrent saphenous ablation performed along with stenting were excluded, as were limbs with reflux confined only to the superficial venous system. However, the current study suggests that if iliac venous obstruction is part of the pathophysiology of CVI, iliac venous stenting should be performed as first-line therapy. Unexpected major role for venous stenting in deep reflux diseaseJournal of Vascular SurgeryVol. 51Issue 2PreviewTreatment of chronic venous insufficiency (CVI) has largely focused on reflux. Minimally-invasive techniques to address superficial and perforator reflux have evolved, but correction of deep reflux continues to be challenging. The advent of intravascular ultrasound (IVUS) scan and minimally invasive venous stent technology have renewed interest in the obstructive component in CVI pathophysiology. The aim of this study is to assess stent-related and clinical outcomes following treatment by iliac venous stenting alone in limbs with a combination of iliac vein obstruction and deep venous reflux. Full-Text PDF Open Archive