Patency Rates After Stenting Across the Inguinal Ligament for Treatment of Post-Thrombotic Syndrome Using Nitinol Venous Stents

Abstract

Endovenous stents can be used for deep venous reconstruction to treat patients with post-thrombotic syndrome. Guidelines on iliocaval stenting suggest that stenting across the inguinal ligament should be avoided. However, stenting from a normal peripheral inflow segment is more important; therefore, stenting across the ligament may be necessary. There are limited data on the outcomes of nitinol venous stents placed across the inguinal ligament for patients with occlusive post-thrombotic disease, but it is thought that this procedure is associated with early stent thrombosis because of the extensive nature of the disease. The aim of this study was to examine patency rates in patients having deep venous reconstruction using nitinol venous stents that were placed across the inguinal ligament. Consecutive patients in whom a venous stent was inserted for symptomatic post-thrombotic disease between 2012 and 2015 were included for analysis. All patients had a minimum of 1-year follow-up, with preoperative Villalta scores taken before intervention and at 1 year. Patients were therapeutically anticoagulated after surgery, and patency was assessed perioperatively using intravascular ultrasound and postoperatively using duplex ultrasound. Computed tomography and venography were also used in selected cases. Primary patency was defined as a patent stent with <50% diameter reduction; primary assisted patency included those requiring reintervention to maintain patency; and secondary patency was defined as stents that were blocked and successfully reopened. Of 168 patients treated in our venous program during the study period, 102 (61%) were treated for post-thrombotic obstruction. From this group, 94 of 102 (92%) patients had a nitinol venous stent, of which 71 (76%) crossed the inguinal ligament. In six patients, an endophlebectomy with fistula was also created to ensure adequate inflow. The respective patency rates are shown in the Table. Primary, primary assisted, and secondary patency rates were significantly better in stents placed above the inguinal ligament (P < .05). There was a significant improvement in Villalta scores of patients with patent stents in those placed above the inguinal ligament (median improvement of 9 points; range, 0-18) and those with stents placed across it (median improvement of 11 points; range, 0-25). Patients with post-thrombotic syndrome frequently have lesions that involve the common femoral vein and often require stenting across the inguinal ligament. Maintaining stent patency when the stents cross the ligament can be challenging, and close surveillance is required as reintervention may be required. However, nitinol venous stent patency is good at 1 year in both groups, and significant clinical improvement can be achieved.TablePatency rates after nitinol venous stenting above and below the inguinal ligamentPrimary patencyPrimary assisted patencySecondary patencyAbove the ligament (n = 23), %72100100Across the ligament (n = 71), %528082 Open table in a new tab