Chronic Venous Obstruction Research Articles

Prognostic Value of a Classification System for Iliofemoral Stenting in Patients with Chronic Venous Obstruction

This retrospective, multicentre study aimed to assess the prognostic value of a proposed classification system for chronic venous obstruction (CVO) patients undergoing successful interventional procedures. This study analysed data from 13 vascular centres, including 1 033 patients with CVO treated between 2015 - 2019. The patients were classified into five category types: 1 - non-thrombotic iliac vein lesion; 2 - CVO of iliac segment; 3 - CVO of iliofemoral segment above common femoral vein confluence; 4 - CVO of iliofemoral segment extending into the femoral vein (FV) or deep femoral vein (DFV); and 5 - CVO of iliofemoral segment involving both DFV and FV. Stent deployment, complications, and follow ups were evaluated. Univariate and multivariate analyses were performed to identify predictors of primary patency loss. Mean age of the patients was 44.0 ± 14.7 years, with 59.9% being women. A median of two stents were used for unilateral cases and five stents for bilateral cases. At 12 months of follow up, primary patency rates for types 1 - 5 were 94.9%, 90.3%, 80.8%, 60.6%, and 39.4%, respectively. These rates were strongly correlated with the extension of CVO and showed significant differences between each type. Univariate analysis identified predictors of primary patency loss as the type of CVO, history of deep vein thrombosis, and the total number of stents. In the multivariate analysis, the significant independent predictors of primary patency loss were the type of CVO and the total number of stents. The proposed anatomical classification of iliofemoral CVO will help to predict intervention outcomes and facilitate comparison of stent outcomes in future studies. However, further evaluation and validation in prospective studies are needed to confirm the utility of this classification.

Elevation of cardiac enzymes and B-type natriuretic peptides following venous recanalization and stenting in chronic venous obstruction.

B-type natriuretic peptides (BNP) and cardiac enzymes are both recognized biomarkers of heart health. Many studies have reported that using these indicators can assess cardiac condition and predict prognosis of patients undergoing surgery. Currently little is known on the effect of increased cardiac input after venous recanalization on cardiac physiology in patients with chronic venous obstruction (CVO). The aim of this study was to explore the effect of iliocaval recanalization and stenting on cardiac biomarkers in patients with CVO. This was a prospective study involving 60 patients in a single unit. Blood tests were collected 1day before and 1day after venous intervention. Three groups as group 1: patients with iliofemoral post-thrombotic syndrome (PTS) but without involvement of inferior vena cava (IVC) (n = 33); group 2: patients with iliofemoral PTS and involvement of IVC (n = 19) and group 3: patients with non-thrombotic vein lesion (NIVL) (n = 8) were compared based on cardiac biomarker levels. Median concentration of post-operative BNP (259.60pg/mL) was greater than preoperative levels (49.80pg/mL) [interquartile range (IQR), 147.15/414.68 versus 29.85/82.88; p < 0.001]. The levels of CK-MB [preop: 3U/l (IQR, 1.40/11.00) versus postop: 14U/l (IQR, 12/17), p < 0.001] and troponin T [preop: 3.00pg/mL (IQR, 3.00/5.25) versus postop: level of 6pg/mL (IQR, 3.00/9.50), p < 0.001]. Post-procedure increases in cardiac enzymes showed significant differences in BNP (p = 0.023) and troponin T (p = 0.007) across the three groups, while CK-MB levels were not significantly different (p > 0.05). Intergroup comparisons of postoperative BNP: group 1 versus group 2 (p = 0.013), group 2 versus group 3 (p = 0.029), group 1 versus group 3 (p = 0.834); and postoperative troponin T: group 1 versus group 2 (p = 0.018), group 2 versus group 3 (p = 0.002), group 1 versus group 3 (p = 0.282). According to multiple linear regression analysis, length of stenting and level of preoperative BNP were independent determinants of postoperative BNP levels (p < 0.05), and preoperative troponin T affected postoperative troponin T independently (p < 0.05). Troponin T, CK-MB and BNP seem to increase after venous recanalization and stent implantation, the elevation being more prominent for longer lesions.

Diagnosis of chronic iliac venous obstruction

Diagnosis of chronic iliac venous obstruction

Impact of native iliac vein aspect ratio on initial clinical presentation and outcomes following stenting for symptomatic chronic iliofemoral venous obstruction

ObjectiveVenous stenting has become the first line of treatment for patients with symptomatic chronic iliofemoral venous obstruction (CIVO) in whom conservative therapy has failed. Intravascular ultrasound (IVUS) interrogation with the use of normal minimal luminal diameters or areas has become the standard to confirm the diagnosis and determine the adequacy of stenting. However, the aspect ratio (ratio between the maximal and minimal luminal diameters) has also been put forth as a possible metric for determining stent adequacy. This study explores the utility of the native iliac vein and stent aspect ratios in determining the initial presentation and outcomes after stenting. MethodsA retrospective analysis of contemporaneously entered data from patients who underwent stenting for quality of life (QoL)-impairing clinical manifestations of CIVO for whom conservative therapy had failed formed the study cohort. The limbs were grouped into three at the time of intervention using the IVUS-determined native vein aspect ratio: group I, those with a ratio of ≤1.4; group II, those with a ratio of 1.41 to 1.99; and group III, those with a ratio of ≥2. The characteristics appraised initially and after stenting included the venous clinical severity score, grade of swelling (GOS), visual analog scale (VAS) for pain score, and the CIVIQ-20 QoL score. Analysis of variance and paired and unpaired t tests were used for comparison of clinical and QoL variables, and Kaplan-Meier analysis was used to evaluate stent patency, with the log-rank test used to discriminate between different curves. ResultsThere were a total of 236 limbs (236 patients). The median age for the entire cohort was 62 years (range, 16-92 years). There were 161 women in the study, and left laterality was more common (137 limbs). Post-thrombotic obstruction was noted in 201 limbs (86%). The median body mass index was 36 kg/m2. There were 54 (23%), 64 (27%), and 118 (50%) limbs in groups I, II, and III, respectively. The median follow-up was 65 months. For the entire cohort, after stenting, the venous clinical severity score improved from 6 to 4 (P < .0001) at 3 months and remained at 4 at 6 months (P < .0001), 12 months (P < .0001), and 24 months (P < .0001). The GOS for the entire cohort improved from 3 to 1 (P < .0001) at 3 months and remained at 1 at 6 months (P < .0001), 12 months (P < .0001), and 24 months (P < .0001). The VAS for pain score for the entire cohort improved from 7 to 0 (P < .0001) at 3 months, increased to 2 (P < .0001) at 6 months, and remained at 2 (P < .0001) at 12 months. At 24 months, the VAS for pain score worsened to 3 (P < .0001). For the entire cohort, the CIVIQ-20 score improved from 62 to 40 (P < .0001). There was no difference in the GOS, VAS for pain score, or CIVIQ-20 score between the groups at baseline or at 6, 12, and 24 months after intervention. At 60 months, the primary stent patency was 89% for group I, 80% for group II, and 75% for group III (P = .85). The primary assisted stent patency was 100% for group I, 98% for group II, and 98% for group III (P = .5). Secondary patency was 100% for groups II and III (P > .5). Reintervention was pursued for QoL-impairing clinical manifestations in 53 limbs (22%) without a significant difference between the three groups (P = .13). ConclusionsThe native vein aspect ratio does not appear to determine the initial clinical presentation or QoL or impact the clinical or QoL outcomes after stenting for CIVO. Following stenting, no patient had an aspect ratio >2, with 97% of patients having an aspect ratio ≤1.4 and the remaining 3% having an aspect ratio of 1.41 to 1.99. IVUS-determined minimal cross-sectional luminal area and not the aspect ratios should be used for confirmation of the diagnosis of CIVO and to assess the adequacy of stenting.

Evaluation of iliocaval venous stenting in management of patients with chronic venous obstructions

Evaluation of iliocaval venous stenting in management of patients with chronic venous obstructions

Femoral vein stenting versus endovenectomy as adjuncts to iliofemoral venous stenting in extensive chronic iliofemoral venous obstruction.

To compare femoral endovenectomy with the creation of an arteriovenous fistula (FE + AVF), versus iliofemoral endovenous stenting with the concurrent extended femoral vein (FV-S) stenting in patients with chronic iliofemoral venous obstruction (IFVO). In a randomized prospective single-center study, 48 received (FV-S), while the other 54 had (FE + AVF). There were no statistically significant differences in the primary outcomes between the two groups (FV-S) and (FE + AVF) (59% vs 56.8%, 75% vs 79.1%, respectively). At a median of 13months after the treatment. However, the FV-S group's patients experienced fewer postoperative problems (p = .012), shorter procedures (p = .001), and shorter stays in the hospital (p = .025). There is no difference between the efficacy and symptomatic resolution of the FV-S group and the FE + AVF group at the same time, FV-S has lower postoperative complications and a shorter procedure duration and hospital stay.

Endovascular treatment of chronic ilio-femoral vein obstruction with extension below the inguinal ligament in patients with post-thrombotic syndrome

ObjectiveThis study aimed to evaluate postoperative outcomes of patients with chronic iliofemoral venous outflow obstruction and post-thrombotic syndrome (PTS) who underwent endovascular recanalization and stenting across the inguinal ligament. MethodsAll consecutive patients with chronic iliofemoral venous outflow obstruction and PTS were included in the analysis, from January 2018 and February 2022. Preoperative, intraoperative, and postoperative outcomes were assessed. Primary endpoints analyzed were major adverse events (MAEs) at 30 days and primary patency rate at 2 years of follow-up. Secondary endpoints assessed were secondary patency rate, target vessel revascularization, and clinical improvement evaluated with the Venous Clinical Severity Score (VCSS) classification, Villalta scale, and visual analog scale (VAS), respectively. ResultsA total of 63 patients (mean age, 48.1 ± 15.5 years; female, 61.9%) were evaluated. No intraoperative and 30-day postoperative complications were documented. The technical success rate was achieved at 100%. Overall, one in-stent occlusion and five in-stent restenosis were detected during follow-up. The primary patency rate was 93.7% (95% confidence interval [CI], 87.8%-99.9%) and 92.1% (95% CI, 85.6%-99%), at 1- and 2-year follow-up, respectively (Kaplan-Meier analysis). Target vessel revascularization was conducted in two cases, resulting in a secondary patency of 98.4% (95% CI, 95.4%-100%) at 2 years of follow-up. Stent fracture and/or migration were not observed during follow-up. A significant clinical improvement in the patient’s quality of life was documented. The median improvement of VCSS and Villalta scores were 4 (interquartile range, 2-7; P = .001), and 3 (interquartile range, 1.5-5; P = .001) vs baseline at the last follow-up. Overall, pain reduction of 17 mm on the VAS scale was documented at 2 years of follow-up. At multivariate analysis, presence of trabeculation into the femoral vein and deep femoral vein (odds ratio, 1.89; 95% CI, 0.15-6.11; P = .043), and Villalta scale >15 points at admission (odds ratio, 1.89; 95% CI, 0.15-6.11; P = .043) were predictive for in-stent occlusion during the follow-up. ConclusionsThe use of a dedicated venous stent across the inguinal ligament was safe and effective for the treatment of symptomatic iliofemoral venous disease with acceptable primary and secondary patency rates at 2 years of follow-up.

Diabetes, Hypertension, and Smoking Do Not Affect Outcomes of Iliofemoral Vein Stenting for Chronic Proximal Venous Outflow Obstruction

ObjectiveDiabetes, hypertension, and smoking are well-recognized risk factors for Peripheral Artery Disease (PAD), but little is known of their impact on chronic venous insufficiency (CVI). This study evaluates these factors in patients undergoing iliac vein stenting (IVS) for CVI. MethodsA registry of 708 patients who underwent IVS from August 2011 to June 2021 was retrospectively analyzed. Symptoms were quantified using venous clinical severity score (VCSS) and CEAP classification. Both major and minor reinterventions were recorded. Logistic regression models were used to determine the unadjusted and adjusted odds ratio (OR) of any reintervention. Log-rank test was used to assess differences in reintervention-free survival. ResultsThe prevalence of hypertension was 51.1% (N = 362), diabetes was 23.0% (N = 163), and smoking was 22.2% (N = 157). Patients with diabetes (3.6 vs 3.4; P = 0.062), hypertension (3.6 vs. 3.3; P < 0.001), and smoking (3.7 vs 3.4; P = 0.003) had higher CEAP scores than those without these comorbidities. Improvement in VCSS composite scores showed no differences postoperatively (Diabetes: P = 0.513; Hypertension: P = 0.053; Smoking: P = 0.608), at 1-year follow-up (Diabetes: P = 0.666; Hypertension: P = 0.681; Smoking: P = 0.745), or at 5-year follow-up (Diabetes: P = 0.525; Hypertension: P = 0.953; Smoking: P = 0.146). Diabetes (P = 0.454), smoking (P = 0.355), and hypertension (P = 0.727) were not associated with increased odds of major reintervention. Log-rank test similarly showed no differences in reintervention-free survival for major or minor reoperations between those with and without diabetes (P = 0.79), hypertension (P = 0.14), and smoking (P = 0.80). ConclusionsDiabetes, hypertension, and smoking were prevalent among CVI patients, but unlike in PAD patients, they had little to no impact on long-term outcomes or reinterventions after IVS.

Inguinal intranodal lymphangiography reveals a high incidence of suprainguinal lymphatic disease in patients with leg edema undergoing stenting for symptomatic chronic iliofemoral venous obstruction

Inguinal intranodal lymphangiography reveals a high incidence of suprainguinal lymphatic disease in patients with leg edema undergoing stenting for symptomatic chronic iliofemoral venous obstruction

The beneficial role of complex decongestive therapy in patients with symptomatic chronic iliofemoral venous obstruction with phlebolymphedema

ObjectivePhlebolymphedema has been noted to be one of the most common causes of lymphedema in the lower extremity in western societies. Although complex decongestive therapy (CDT) represents the mainstay of lymphedema treatment, its role for phlebolymphedema arising from chronic iliofemoral venous obstruction (CIVO) merits further exploration. We evaluated this through the use of a protocol of CDT first for limbs with CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical C3 disease and stent correction of obstruction before CDT for those with more advanced disease (CEAP C4-C6). In the present study, we analyzed the outcomes after the use of such a protocol. MethodsWe analyzed prospectively collected data for 192 limbs (166 patients) that underwent treatment of quality-of-life (QoL) impairing symptoms from CIVO due to lymphoscintigraphically determined phlebolymphedema between 2017 and 2022. The characteristics evaluated included CEAP clinical class, venous clinical severity score (VCSS), grade of swelling (GOS), visual analog scale (VAS) pain score, QoL (CIVIQ-20 [20-item chronic venous disease quality of life questionnaire]), stenting for CIVO, and outcomes related to CDT and stenting. For the limbs undergoing CDT or stenting followed by CDT, the outcomes were evaluated at 6 weeks and 3, 6, and 12 months after completion of CDT. Paired and unpaired t tests, χ2 tests, and analysis of variance were used for comparisons of clinical variables. Kaplan-Meier analysis was used to evaluate stent patency, with the log-rank test used to discriminate between different curves. ResultsOf the 192 limbs (166 patients) in the entire cohort, 74 were in the C3 group and 118 were in the C4-C6 group. The median patient age was 63 years; 57 were men and 109 were women. In the C3 group, after CDT, improvement had occurred in the VCSS and VAS pain score at 6 weeks (P < .0001) and at 3 (P < .0001), 6 (P < .0001), and 12 (P < .0001) months. Improvement in the GOS was noted at 6 (P < .0001) and 12 (P = .0005) months. The CIVIQ-20 score improved from 63 to 38 (P = .009). Nine limbs (12%) in the C3 group required stenting after CDT. In the C4-C6 group, of the 118 limbs, 75 (64%) underwent stenting only and 43 (36%) underwent stenting followed by CDT for persistent QoL impairing symptoms. For this latter group, after CDT, improvement occurred in the VCSS, GOS, and VAS pain score at 6 weeks (P < .0001) and 3 (P < .0001), 6 (P < .0001), and 12 (P < .0001) months. The CIVIQ-20 score improved from 61 to 34 (P < .0001). The primary, primary assisted, and secondary patency in the C4-C6 group at 36 months was 92%, 100%, and 100%, respectively. ConclusionsFor CEAP C3 patients with phlebolymphedema due to CIVO, CDT should be a part of the first line of treatment. Stenting should be reserved for those with QoL impairing symptoms despite the use of CDT. Additionally, CDT helps provide symptom relief for patients with more advanced CEAP C4-C6 disease with persistent or residual edema after stenting. Further study is warranted.

Identifying venous clinical severity score thresholds for Clinical-Etiology-Anatomy-Pathophysiology classifications of venous edema and higher.

Venous Clinical Severity Score (VCSS) is a widely used standard for assessing and grading the severity of chronic venous disease (CVD). Prior research highlighted its high validity in detecting and quantifying venous disease. However, there is little, if any, known about the precise thresholds at which VCSS discriminates important stages of deep venous disease. This study sought to elucidate the diagnostic accuracy, thresholds, and correlation at which VCSS detects salient CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classes in deep venous disease progression. A registry of 840 patients who presented with chronic proximal venous outflow obstruction (PVOO) secondary to non-thrombotic iliac vein lesions from August 2011 to June 2021 was retrospectively analyzed. VCSS and CEAP classifications were used to evaluate preoperative symptoms. VCSS was compared to CEAP classes to determine the precise VCSS composite values at which the instrument was able to detect CEAP C3 and higher, C4 and higher, and C5 and higher. Receiver operative characteristic (ROC) curve and area under the curve (AUC) were used to evaluate VCSS for its ability to discriminate disease at these stages of CEAP classification. Spearman's rank coefficient was used to determine the correlation between CEAP VCSS composite as well as individual VCSS components (pain, varicose vein, edema, pigmentation, inflammation, induration, ulcer number, ulcer size, ulcer duration, compression). VCSS composite was able to detect venous edema (C3) and higher at a sensitivity of 68.9% and a specificity of 54.8% at an optimized threshold of 8.5 (AUC = 0.648; 95% C.I. = 0.575-0.721). To detect changes in skin and subcutaneous tissue from CVD (C4) and higher, an optimal threshold of 11.5 was found with a sensitivity of 51.7% and specificity of 76.5% (AUC = 0.694; 95% C.I. = 0.656-0.731). Healed venous ulcer (C4) and higher was detectable at an optimized threshold of 13.5 at a sensitivity of 67.7% and a specificity of 88.9% (AUC = 0.819; 95% C.I. = 0.766-0.873). The correlation between VCSS composites and CEAP was weak (ρ = 0.372; p < .001). Attributes of VCSS that reflect more severe venous disease correlated more closely with CEAP classes, namely pigmentation (ρ = 0.444; p < .001), inflammation (ρ = 0.348; p < .001), induration (ρ = 0.352; p < .001), number of active ulcers (ρ = 0.497; p < .001), active ulcer size (ρ = 0.485; p < .001), and ulcer duration (ρ = 0.497; p < .001). The correlation between CEAP class and the other four components of VCSS were not statistically significant. VCSS composite thresholds of 8.5, 11.5, and 13.5 are threshold values for detecting CEAP classification C3 and higher, C4 and higher, and C5 and higher, respectively. Consistent with prior work, VCSS appears to have a better ability to discriminate CVD at more severe CEAP classifications. In this registry, the correlation between VCSS and CEAP was found to be weak while components of VCSS that suggest more advanced disease exhibited the strongest correlation with CEAP.

Inguinal intranodal lymphangiography reveals a high incidence of suprainguinal lymphatic disease in patients with leg edema undergoing stenting for symptomatic chronic iliofemoral venous obstruction

ObjectiveRecent studies have emphasized the important role lymphatics play in the drainage of interstitial fluid and edema prevention. Although the infrainguinal lymphatics have been studied in some depth, with patterns of pathology identified, such data above the groin are sparse, especially for patients with phlebolymphedema. The present study attempts to evaluate the status of lymphatic flow above the inguinal ligament in patients presenting with edema and undergoing stenting for symptomatic chronic iliofemoral venous obstruction (CIVO). MethodsA total of 31 lower limbs that underwent pedal lymphoscintigraphy for leg edema and subsequent stenting for symptomatic CIVO formed the study cohort. Each limb underwent intranodal lymphangiography of an ipsilateral inferior inguinal lymph node (10 mL of lipiodol) at the time of stenting. Fluoroscopic visualization of lipiodol transit was performed at 20, 40, and 60 minutes and 3 hours after injection. Enumeration of the lymph nodes and lymphatic collector vessels from above the inguinal ligament to L1, visualization of the thoracic duct, the time delay to visualization of the thoracic duct, and pathologic changes to the thoracic duct when present were all evaluated. These anomalies were independently scored, with the scores combined to generate a total suprainguinal score (range, 0-3). This score was then compared to the limb's lymphoscintigraphically derived infrainguinal score (total infrainguinal score range, 0-3) using the t test and Spearman correlation. The clinical outcomes (grade of swelling, venous clinical severity score) after stenting were appraised. ResultsOf the 30 patients (31 limbs), 18 were women, with left laterality noted in 23 limbs. A nonthrombotic iliac vein lesion occurred in 9 limbs and post-thrombotic syndrome in 22 limbs. Of the 31 limbs, 24 (77%) had suprainguinal lymphatic disease (SLD), with 22 of the 24 limbs having severe SLD and 2, mild SLD. When SLD was compared with infrainguinal lymphatic disease, 6 limbs (19%) had the same degree of involvement above and below the groin (1 with normal and 5 with severe disease), 17 limbs (55%) had more severe SLD, and 8 limbs (26%) had more severe infrainguinal lymphatic disease. Three limbs with normal pedal lymphoscintigraphic findings had severe SLD. The Spearman correlation coefficient for the comparison of SLD and infrainguinal disease in the same limb was 0.1 (P = .69). At baseline, the limbs with severe SLD had the same degree of leg swelling and venous clinical severity score as the limbs with absent to mild SLD (P > .1) with similar improvements after stenting (P > .4). Seven limbs underwent complex decongestive therapy (all with severe SLD and concomitant severe infrainguinal disease in one) to treat significant residual leg edema, with improvement. ConclusionsSLD appears to be common in patients with leg edema undergoing stenting for symptomatic CIVO. Such disease appears to affect the thoracic duct more commonly. Although patients with persistent or residual leg edema after stenting can benefit from complex decongestive therapy, further workup in the form of inguinal intranodal lymphangiography and targeted intervention might need to be considered for those who do not benefit from such therapy. Further study is warranted.

Delphi Consensus on Reporting Standards in Clinical Studies for Endovascular Treatment of Acute Iliofemoral Venous Thrombosis and Chronic Iliofemoral Venous Obstruction.

Acute iliofemoral deep vein thrombosis and chronic iliofemoral venous obstruction cause substantial patient harm and are increasingly managed with endovascular venous interventions, including percutaneous mechanical thrombectomy and stent placement. However, studies of these treatment elements have not been designed and reported with sufficient rigor to support confident conclusions about their clinical utility. In this project, the Trustworthy consensus-based statement approach was utilized to develop, via a structured process, consensus-based statements to guide future investigators of venous interventions. Thirty statements were drafted to encompass major topics relevant to venous study description and design, safety outcome assessment, efficacy outcome assessment, and topics specific to evaluating percutaneous venous thrombectomy and stent placement. Using modified Delphi techniques for consensus achievement, a panel of physician experts in vascular disease voted on the statements and succeeded in reaching the predefined threshold of >80% consensus (agreement or strong agreement) on all 30 statements. It is hoped that the guidance from these statements will improve standardization, objectivity, and patient-centered relevance in the reporting of clinical outcomes of endovascular interventions for acute iliofemoral deep venous thrombosis and chronic iliofemoral venous obstruction in clinical studies and thereby enhance venous patient care.

Choosing the Right Patient: Understanding the Presenting and Postoperative Complexities of Iliac Vein Stenting in Diabetic Patients With Lower Extremity Ulcers

The incidence of lower extremity ulcers increases with venous disease and is strongly associated with diabetes. However, the effects of treating venous disease on preventing subsequent ulcer formation has not been widely explored. We undertook this study comparing patients with and without diabetes to examine differences in presentation and outcomes of iliac vein stenting (IVS) regarding their lower extremity ulcers. A clinical registry of 877 patients who underwent IVS for chronic proximal venous outflow obstruction (PVOO) from 2011 to 2021 at a single institution was retrospectively analyzed. Patients were stratified into groups based on the presence or absence of diabetes and were followed for an average of 743 days after IVS. Symptoms were quantified using venous clinical severity (VCSS) and Clinical-Etiological-Anatomical-Pathophysiological (CEAP) scores. Postoperative symptom resolution was assessed using Clinical Assessment Score (CAS), which grades symptoms from resolved, significant improvement, mild improvement, no change, or worsened. Major reoperations were defined as interventions requiring a venogram, whereas minor reoperations were defined as endovenous thermal ablation of a superficial vein. Of the 877 patients, 189 (21.5%) had diabetes, whereas 688 (78.5%) did not. Diabetes was associated with a statistically significant greater incidence of hypertension (82.8% vs 42.9%; P < .001), coronary artery disease (27.1% vs 7.4%; P < .001), smoking history (27.6% vs 19.2%; P = .015), and history of malignancy (17.4% vs 9.0%; P = .002). A greater incidence of CEAP 6 at presentation (11.6% vs 6.9%; P = .041) was also seen in the diabetic cohort as were intraoperative findings suggestive of a remote DVT (38.5% vs 23.3%; P < .001). At 1 year postoperatively, diabetic patients reported significantly less “complete resolution” and greater “worsening” symptoms (2.9% vs 12.2% and 3.5% vs 2.3%, respectively; P = .002) than those without diabetes. Diabetic patients with chronic PVOO were more likely to present with cardiovascular comorbidities as well as active ulcers. Intraoperatively, these patients were more likely to have a history of remote DVT. Postoperatively, these patients were less likely to report a resolution of lower extremity symptoms and more likely to experience worsening symptoms. IVS placement for chronic PVOO remains safe and durable and should be considered in patients with or without diabetes including those with active ulcers; however, diabetic patients should be counseled on the worsened prognosis for ulcer resolution.

Procedural and Clinical Outcomes of Dedicated Venous Stents in Acute and Chronic Venous Obstruction: A Retrospective Single Center Study

Background Endovenous angioplasty with stenting is an accepted treatment for patient with venous obstruction. Dedicated venous stents have been developed to improve the efficacy and safety of the venoplasty procedure. We report the procedural as well as clinical outcomes of these new generation stents in the treatment of acute and chronic venous obstruction. Method This is a single centre retrospective cohort study of patients who received venous stenting for either acute or chronic venous obstruction. Baseline demographics, procedural details, clinical outcomes including 30 day all-cause mortality, 90 day primary patency rate, and change in Villalta score were reported. Result 41 patients with venous obstruction were included in this study. The mean Villalta score before the procedure was 13.8 (±3.8). Extrinsic compression of the affected vein was found in 95.1% of cases. Procedural success was achieved in 97.6% of cases, with 2±1 stents of mean diameter of 15.3mm +/- 1.9mm and total stented length of 179.3mm±85.3mm used per case. There were no procedural complications. 90 days primary patency rate was 90.2%. The Villalta score decreased by 9.2±0.7 to 4.6±2.4 at 90 days. Conclusion Endovenous angioplasty with new generation of dedicated venous stents is a safe and effective treatment option for patients with acute and chronic venous obstruction.

Factors associated with difficulty in stenting the chronic iliofemoral venous obstruction.

The main aim of this article is to investigate the causes of technical failure during endovascular recanalization in patients with post-thrombotic syndrome with occluded iliofemoral veins and to suggest alternative techniques to improve outcomes in such challenging cases. Between November 2015 and August 2020, 230 patients (274 limbs) treated in our institution with symptomatic chronic iliofemoral venous obstruction underwent endovascular recanalization with angioplasty and stent placement. Overall, the initial attempt was unsuccessful in 15 limbs. We retrospectively analyzed the basic demographic and health characteristics of the involved patients and evaluated the endovascular procedures and techniques that resulted in a successful second intervention. The first attempts at endovascular intervention were unsuccessful in 15 of the 274 limbs (5.4%). Failures were attributed to hostile groin areas in intravenous drug abusers caused by multiple punctures in six cases. In addition, five interventions failed due to prior surgery at the site of venous occlusion and in retroperitoneal space, three patients due to severe stent deformity, and one patient due to congenital venous aplasia. Of the 15 patients, 11 underwent a subsequent attempt that included six successful recanalizations. The mean follow-up time of the six patients with successful recanalization was 27 months (5-62 months). The primary, assisted primary and secondary patency rates were 83.3%, 100%, and 100%, respectively. The remaining five patients, in whom the second recanalization attempt failed, received conservative treatment. Recanalization failure is rare in chronic venous obstruction patients. Severe stent deformities have the lowest chance of successful second intervention. Patients with a hostile groin or prior open surgeries at the occlusion site may be considered for reintervention with a success rate of nearly 50%.

Chronic Venous Occlusive Disease: Stenting Below the Inguinal Ligament

Objective: The treatment of Iliofemoral venous outflow with dedicated nitinol venous stents has changed treatment options for patients with chronic venous obstruction. In post thrombotic syndrome, the disease often extends from the caval confluence to common femoral vein (CFV) confluence. Paucity of data on the prevalence and long term sequelae of venous stent compromise exists when stents are placed below the inguinal ligament. This study aimed to determine the re-intervention rate for stent compromise in stents placed below the inguinal ligament in a tertiary centre.

Venous Clinical Severity Score has a suboptimal ability to detect improvement after iliac vein stenting across three years of follow-up

ObjectiveVenous Clinical Severity Score (VCSS) is currently the gold standard for measuring the severity of chronic venous disease, especially in patients with chronic proximal venous outflow obstruction (PVOO) secondary to non-thrombotic iliac vein lesions. Change in VCSS composite scores is often used to quantitatively measure the degree of clinical improvement after venous interventions. This study sought to assess the discriminative ability, sensitivity, and specificity of change in VCSS composites for detecting clinical improvement after iliac venous stenting. MethodsA registry of 433 patients who underwent iliofemoral vein stenting for chronic PVOO from August 2011 to June 2021 was retrospectively analyzed. These 433 patients had follow-up exceeding 1 year after the index procedure. Change in VCSS composite and clinical assessment scores (CAS) were used to quantify improvement after venous interventions. CAS is an assessment by the operating surgeon based on patient self-reporting to assess the degree of improvement at each clinic visit compared with before the index procedure longitudinally across the treatment course of a patient. Patients are rated as worse (−1), no change (0), mildly improved (+1), significantly improved (+2), and asymptomatic/complete resolution (+3) at every follow-up visit as compared with their disease severity prior to the procedure based on patient self-report. This study defined improvement as CAS >0 and no improvement as CAS ≤0. VCSS was then compared with CAS. Receiver operative characteristic curve and area under the curve (AUC) were used to evaluate change in VCSS composite for its ability to discriminate between improvement and no improvement after intervention at each year of follow-up. ResultsChange in VCSS was a suboptimal measure for discriminating clinical improvement (1-year AUC, 0.764; 2-year AUC, 0.753; 3-year AUC, 0.715). Across all three time points, a change in VCSS threshold of +2.5 maximized the sensitivity and specificity of the instrument to detect clinical improvement. At 1 year, change in VCSS at this threshold was able to detect clinical improvement at a sensitivity of 74.9% and specificity of 70.0%. At 2 years, VCSS change had a sensitivity of 70.7% and specificity of 66.7%. At 3 years of follow-up, VCSS change had a sensitivity of 76.2% and specificity of 58.1%. ConclusionsAcross 3 years, change in VCSS exhibited a suboptimal ability to detect clinical improvement in patients undergoing iliac vein stenting for chronic PVOO with considerable sensitivity but variable specificity at a threshold of 2.5.

Plethysmographic features of calf pump failure in chronic venous obstruction and reflux

Background Calf pump failure (CPF) is a common concept in chronic venous disease. Dorsal vein pressures were originally used to define the pathophysiology. More recently, an abnormal ejection fraction (EF) and residual volume fraction (RVF) with air plethysmography (APG) have been substituted for its diagnosis. The relationship between reflux and calf pump function has been studied extensively. Reflux is thought to be the main cause of CPF, although other mechanisms may play a secondary role. Data mining in our dataset revealed that CPF is frequently found in nonrefluxive limbs—an unexpected finding. We analyzed the APG features of CPF in nonrefluxive limbs of a large cohort of patients investigated for chronic venous disease in our clinic. Data from refluxive limbs (control) seen over the same period was included for comparison. Venous obstructive pathology was variably present in both subsets. Iliac vein stent outcome in CPF limbs from both subsets is included. The role of obstruction in CPF is currently unknown.

The efficacy of stenting in the iliofemoral vein of patients with venous obstruction and secondary lymphedema from malignancy

ObjectiveTo investigate the safety and effectiveness of venous stenting in patients with chronic iliofemoral venous obstruction and secondary lymphedema from malignancy. MethodsFrom July 2012 to December 2020, patients with iliofemoral venous obstruction and secondary lymphedema who underwent venous stenting in our institution were reviewed retrospectively. Clinical characteristics, surgical complications, and symptom relief were assessed. Stent patency was evaluated with duplex ultrasound or computed tomographic venography. Twelve-month outcomes were reported. ResultsFifty-three patients with concurrent secondary lymphedema who had stents placed for iliofemoral venous obstruction were included. There were 42 females, and the mean age was 56.9 years. Nonthrombotic iliac vein lesions were identified in 16 patients (30.1%). Immediate technical success was 100%, with an average of two stents implanted. The median Villalta score, and Chronic Venous Disease Quality of Life quality of life questionnaire scores decreased from 12 (IQR, 10-15) and 58 (IQR, 50-66) at baseline, respectively, to 5 (interquartile range [IQR], 4-6) and 28 (IQR, 22-45) at 12 months after the procedure (P < .05), showing significant improvement in the quality of life. At the end of a median follow-up of 12 months (range, 3-25 months), the cumulative primary, assisted primary, and secondary patency rates were 70.8%, 76.9%, and 90.1%, respectively. ConclusionsIn patients with secondary lymphedema from malignancy, venous stent placement is safe and effective for iliofemoral venous obstruction.