PC184 Delayed Conversion to Kissing Stent Configuration in the Setting of Unilateral Iliac Vein Stenting

Abstract

Iliac vein stents are being increasingly used to treat chronic proximal venous outflow obstruction. Among patients with unilateral stenting in the proximal common iliac vein with extension into the inferior vena cava (IVC), a small number of patients presented with venous symptoms related to outflow obstruction of the contralateral common iliac vein. While the incidence of this complication of iliac vein stenting is unknown, this abstract presents one technical approach to this complication. We present 11 patients with outflow obstructive symptoms in the contralateral iliac vein after a prior IVC common iliac vein stent placement. Postanesthesia, ultrasound guidance is used to obtain access to the common femoral vein bilaterally. Inferior vena cavograms and venograms of the iliac veins are undertaken using contrast in digital subtraction mode. Intravascular ultrasound (IVUS) using a Volcano Visions PV .035 Digital IVUS catheter (Volcano Corporation, San Diego, Calif) is then used to evaluate the iliac veins and assess the degree of stenosis in each vein segment. The use of IVUS is critical to locate the narrow channel present between the contralateral stent and wall of the IVC, assist passage of the guidewire through this narrow channel, and ensure that the guidewire does not pass through the interstices of the stent (Fig 1). Balloon angioplasty is seldom necessary. The initial guidewire is then exchanged for a stiff 0.35-inch × 180-cm guidewire. Next, a 16-mm or 18-mm stent is positioned alongside the existing stent in a kissing iliac stents configuration. After the newly placed stent is deployed, both stents are simultaneously dilated with either 16-mm or 18-mm balloons (Fig 2). Finally, a completion venogram and IVUS confirm fully expanded stents. This procedure was performed in 11 patients (6 males, 5 females), with three performed on the right iliac vein and eight on the left iliac vein. The mean time to development of contralateral occlusive symptoms was 626 days from the initial stenting. Average follow-up time from the second stenting was 167 days, with no postoperative complications. Eight patients reported significant symptomatic improvement in their newly treated limb at 30 days postoperatively, while 10 patients did at 90 days postoperatively. No patients reported any worsening symptoms in either limb. Delayed conversion to a kissing stent configuration can be considered for treatment of contralateral iliac vein outflow obstruction in the setting of previous unilateral iliac vein stenting.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)