Chronic Venous Obstruction Research Articles

Technique of stent sizing in patients with symptomatic chronic iliofemoral venous obstruction—the case for intravascular ultrasound-determined inflow channel luminal area-based stenting and associated long-term outcomes

ObjectiveFemoroiliocaval stenting has become the standard of care for patients with quality-of-life impairing chronic iliofemoral venous obstruction not responding to conservative measures. Although improvement after stenting has been noted in multiple large studies, sizing of stents has been subjective in nature with a general tendency to use smaller stents that would be required to relieve venous hypertension. This study evaluates the authors’ technique of using the intravascular ultrasound (IVUS) inflow channel luminal area to guide stent sizing. MethodsPatients who underwent femoroiliocaval stenting for quality-of-life impairing chronic iliofemoral venous obstruction and had failed conservative therapy from 2015 to 2021 were included in the study. Clinical outcomes including venous clinical severity score (VCSS), visual analog scale (VAS) pain score, and grade of swelling (GOS) were appraised before and after stenting. Also evaluated were quality of life (Chronic Venous Insufficiency Questionnaire-20 [CIVIQ-20] instrument) and stent outcomes including patencies and reinterventions. Comparisons were made between limbs that underwent placement of larger caliber stents (largest stent diameter >20 mm: >20 mm stent group) vs smaller caliber stents (largest stent diameter ≤20 mm: ≤20 mm stent group). t tests and analysis of variance were used to compare outcomes, whereas the Kaplan-Meier analysis was used to evaluate patencies with log rank used to compare the curves. ResultsA total of 300 patients (300 limbs) underwent stenting with a median age of 58 years. There was a preponderance of men (159 of 300), left laterality (176 of 300), and post-thrombotic syndrome (176 of 300). The median body mass index was 41. There were 120 limbs in the >20 mm stent group and 180 limbs in the ≤20 mm stent group. The median follow-up was 23 months. There was no significant difference in baseline VCSS, VAS pain score, or GOS between the two groups. However, there was a significant difference in IVUS-determined inflow channel luminal area between the two groups (228 mm2 >20 mm stent group vs 176 mm2 for ≤20 mm stent group [P < .0001]). After stenting there was a significant improvement in the VCSS, VAS pain score, and GOS at 6 weeks, 3, 6, 12, and 24 months (P < .0001) without any difference between the groups (P > .05). The CIVIQ-20 score also improved from 58 to 38 (P < .0001) for the entire cohort and for the two groups (P < .0001). Overall primary, primary-assisted, and secondary patencies at 60 months were 84%, 100%, and 100%, respectively. Reintervention rate was 10% without any difference between the groups. ConclusionsStent sizing using IVUS-determined inflow channel luminal area in patients undergoing stenting for quality-of-life impairing chronic iliofemoral venous obstruction resulted in a significant improvement in the VCSS, VAS pain score, GOS, and quality of life (CIVIQ-20) after stenting. Excellent stent patencies and low reintervention rates were also noted. IVUS-determined inflow channel luminal area represents an objective technique of stent sizing in comparison to the subjective techniques that currently exist.

Left common iliac vein diameter in patients referred for lower limb venous duplex ultrasound.

Evidence regarding ultrasound assessment of left common iliac vein diameter (LCIV) is limited. Extensive work is currently being undertaken worldwide on non-thrombotic iliac vein lesions to identify patients who may benefit from intervention to alleviate symptoms of chronic venous obstruction. Interventions include long-term stent implantation to improve vein diameter stenosis. This study aimed to assess a cohort of symptomatic venous patients and the diameter of the LCIV in these patients. : Retrospective medical records review of all patients attending a tertiary vascular surgery centre who underwent a venous duplex ultrasound assessment between April 2017 and February 2018 were analysed for assessment of LCIV. Medical records of those patients with documented LCIV diameter were assessed over 18 months of follow-up. : A total of 672 (271 males, 401 females) LCIV diameter measurements were collected. The age of the patients ranged from 21 to 95years (mean = 56.38). Median LCIV diameter overall was 7.64mm (IQR 5.80mm-9.00mm). 40 patients (6%) were reported to have a LCIV diameter measurement of < 4mm, 8 (20%) male and 32 female (80%). 17 of these 40 patients (47.5%) were treated conservatively. Median LCIV diameter was 3.4mm (IQR 2.5-3.7). 21 of these 40 patients (52.5%) underwent superficial venous intervention only, with a median LCIV diameter of 3.5mm (IQR 3.2-3.7) and 2 out of these 40 patients (5%) underwent deep venous stenting (2/2 female - 100%), with a median LCIV diameter of 2.9 (IQR 2.9-2.9). No patients underwent both superficial and deep venous treatment in this 40 patient cohort. In those undergoing superficial venous intervention, 4 (19%) underwent repeat treatment. The two deep venous stenting patients underwent magnetic resonance venogram and venogram with intravascular ultrasound to allow stent placement, which confirmed a narrowed left common iliac vein. Primary stent patency at 18 months was 100%. In this large study cohort of venous duplex assessments the median vein diameter was 7.64mm and 40 patients out of 672 had a vein diameter smaller than 4mm. 2 patients underwent deep venous stenting with primary patency of 100%.

Effectiveness of Venous Stenting for the Treatment of Lower Extremity Chronic Thrombotic Venous Obstruction

Patients with venous hypertension have significant morbidity and poor quality of life. Deep venous thrombosis (DVT) and congenital defects that led to chronic outflow blockage are frequent causes of venous hypertension. It is known that the venovenous bypass has been the standard method used in the treatment of chronic iliofemoral vein occlusions. Percutaneous recanalization has earlier been shown to be technically possible. With venoplasty and stenting, we used an aggressive endovascular strategy to treat the iliofemoral venous thrombotic occlusion. This study aims to assess the effectiveness and safety of percutaneous venous stenting performed in our hospital for cases with chronic thrombotic venous outflow blockage of the iliofemoral vein segment. From May 2019 to April 2021, the medical records were reviewed for sixty-three patients diagnosed with symptomatic iliofemoral thrombotic occlusive disease and treated with venous stenting. The procedures' results were analyzed at Al-Azhar University Hospitals. The medical records of 63 cases (44 women with a median age of 49.52 years) with chronic outflow block of iliofemoral vein segment who were treated with endovascular venous stenting were reviewed retrospectively. Optimal success was obtained in 56 cases (88.9%). Twelve months primary, assisted primary, and secondary patency rates were 76.8%, 80.4%, and 87.5%, respectively, while it was 73.2%, 80.4%, and 87.5%, respectively, after 2 years. The procedure-related complication rate was 6.3%. Puncture site hematoma was observed in 2 patients (3.2%). Early (30-days) stent thrombosis occurred in 2 patients (3.2%). Most importantly, there was no procedure-related mortality. Endovascular treatment with balloon angioplasty and stenting of chronic venous thrombotic occlusions is an effective and safe procedure associated with a high technical rate of success and excellent patency rates. Accordingly, it should be considered the first line in the treatment of symptomatic iliofemoral vein occlusion.

Venous Stenting for Postthrombotic Iliocaval Venous Obstructive Disease: Clinical Efficacy and Mid-term Outcomes.

Postthrombotic syndrome (PTS) can cause both venous outflow obstruction and deep venous reflux, and results in severe symptoms of chronic venous disease. Venous stenting in the chronic iliocaval venous obstruction has been shown to be a safe and efficacious procedure. The long-term studies have shown the high patency rate, the good symptom relief, and the low recurrence rate of healed venous ulcerations. Although venous stenting has become a widely accepted treatment option in PTS with chronic venous occlusion or severe stenosis, it is not yet covered by insurance in Japan, and is being performed at limited facilities using off-label arterial stents. In this study, we performed venous stenting in 30 patients with the moderate and severe PTS. All patients showed significant improvement in their venous scores postoperatively, the Villalta score changed from a median of 16 before treatment to a median of 7 after treatment. Likewise, the Venous Clinical Severity Score and the Venous Disability Score dropped from a median of 13, 2.4 before treatment to 6, 1.2 after treatment, respectively. The primary patency and the secondary patency at 40 months were 93% and 96%, respectively. We report the excellent results and discuss current issues and future perspective in Japan. (This is secondary publication from J Jpn Coll Angiol 2021; 61: 99-105.).

Nitinol stents placed in iliac veins are not associated with prolonged back pain.

Endovascular stenting is the standard of care for the management of symptomatic chronic venous obstruction. The increased radial resistive force and longer lengths of Nitinol stents have led to questions over persistent post-operative back pain. The purpose of this investigation was to assess the incidence and severity of post-operative back pain of Nitinol stents compared to Wallstents. A retrospective review of data at the Center for Vascular Medicine was performed. Patient demographics, pre-operative, oneweek, three-, six,- and 12month visual analog pain scores (VAS) for back pain, stent type, diameter, length, and vein locations were assessed. From April 2014 to November 2021, 627 (412 women/215 men) patients were assessed for the presence of post-operative back pain after an initial iliac vein stent placement. Stents utilized were Wallstents (n = 114), Venovo (n = 342), and Abre (n = 171). The most common Nitinol stent diameter and lengths were 14mm, 16mm, and 120mm, respectively (p ≤ .03). The incidence of back pain at oneweek was 66% (411/627). VAS scores at oneweek and one, three, and sixmonths post-operatively were the following: Wallstents-2.6 ± 3 (n = 66), 1.7 ± 2.6 (n = 43) 0.7 ± 2 (n = 51), and 0 ± 0 (n = 27); Abre-3.5 ± 3 (n = 130), 3.8 ± 3 (n = 19), 1.2 ± 2.5 (n = 12), and 1 ± 2 (n = 5); and Venovo- 2.5 ± 3 (n = 216), 2.4 ± 3 (n = 70), 0.9 ± 2 (n = 68), and 0.6 ± 1.7 (n = 49). There was no difference in the severity of back pain at any time point (p ≥ .99). The development of back pain was unrelated to stent type, diameter, length, or covered vein territory. Post-operative back pain was observed in 66% of patients at oneweek. The average pain score at oneweek for the entire cohort was three, which declined to less than one at onemonth. No difference in the severity of back pain between groups was observed at any time point, and the development of back pain is unrelated to stent type, diameter, length, or covered vein territory.

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

BackgroundCalf 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. MethodsRecords of 13,234 limbs in 8813 patients evaluated for suspected chronic venous disease over a 22-year period were analyzed. Prestent and poststent data in 406 CPF limbs (129 nonrefluxive; 277 refluxive) that underwent iliac vein stenting to correct associated stenosis are included. This is a single-center retrospective analysis of prospectively collected data. Duplex and APG data were available for included limbs. A RVF of more than 50% was defined as CPF. A reflux time of greater than 1 second elicited with automated cuffs in the erect position was defined as reflux. ResultsThere were 7780 (59%) limbs with reflux and 5454 (41%) that were nonrefluxive. Supine venous pressure, an index of venous obstruction, was elevated in both subsets. The incidence of CPF was 25% in refluxive limbs and 16% in nonrefluxive limbs totaling 2790 limbs. Venous volume and venous filling index were significantly elevated (P = .0001) in refluxive limbs compared to nonrefluxive limbs. The EF was diminished (<50%) in all CPF limbs except in a small fraction (n = 427 [3%]). Stent correction of iliac vein stenosis corrected CPF, normalizing the RVF in both subsets. ConclusionsCPF frequently occurs in nonrefluxive limbs with incidence only slightly less than in refluxive limbs. An RVF of more than 50% seems to be a practical definition of a CPF; an EF of less than 50% is associated with a RVF of greater than 50% in 97% of analyzed limbs. Prospective identification of CPF in limbs with chronic venous disease may allow more detailed investigation of its cause (preload, afterload, neuromuscular pathology or joint immobility, etc) and direct more targeted treatment than currently practiced.

S3210 Unraveling Extrapulmonary Sarcoidosis in a Patient With Unexplained Cholestatic Liver Injury

Introduction: Sarcoidosis is an autoimmune condition characterized by non-caseating granulomas most commonly in the lungs and hilar lymph nodes. We report a case of sarcoidosis presenting as hepatomegaly and cholestatic liver injury. Case Description/Methods: A 46-year-old female with end stage renal disease, latent tuberculosis (TB) and daily use of herbal teas, who had multiple hospitalizations over a 6-month period with similar presentation, presented with right upper quadrant pain and jaundice. Examination revealed pulsatile abdomen and jugular venous distention. During each admission, she had elevated alkaline phosphatase and total bilirubin to a peak of 2003 U/L and 37.4 mg/dL respectively, with otherwise normal liver enzymes. Infectious workup and tumor markers were negative. On her second admission, she had rapid improvement in her lab abnormalities and symptoms after initiating steroids for treatment of Bell’s palsy, otherwise, on other admissions she had slow improvement with ursodeoxycholic acid. Initial ultrasound abdomen, magnetic resonance cholangiopancreatography, and triphasic computed tomography (CT) liver showed hepatomegaly, otherwise unremarkable. She had two liver biopsies which revealed sinusoidal congestion and dilation, hepatocellular and sinusoidal fibrosis consistent with chronic venous outflow obstruction and few non-necrotizing granulomas. Repeated transthoracic echocardiogram eventually showed mild tricuspid and pulmonary insufficiency. Right heart catheterization showed mild pulmonary hypertension and hemodynamics not suggestive of a cardiac cause of liver disease. In a last attempt to locate tissue for biopsy, a CT chest, abdomen and pelvis was obtained and showed airspace opacities within the left lower lobe likely related to inflammatory process and an area of enhancement at the junction of segment 5 and 6 of the liver that could relate to hepatic sarcoid. She was started on Prednisone 40mg daily for presumed hepatic sarcoid and Rifampin 600mg daily for latent TB. She will undergo bronchoscopy with biopsy and renal biopsy to further establish a unifying diagnosis (Figure). Discussion: After an extensive workup was found to be negative, sarcoidosis became the top differential given non-caseating granulomas on liver biopsy, nerve palsy, renal disease, mild pulmonary hypertension and response to steroids. Lack of pulmonary involvement is an uncommon presentation in sarcoidosis, occurring in 5-9% of cases overall. Hepatic sarcoidosis occurs in 11-80% of cases and is mostly asymptomatic.Figure 1.: Hepatomegaly with heterogeneous enhancement. There is an area of increased enhancement at the junction of segment 5 and 6 (arrow) of the liver which is nonspecific, but could relate to hepatic sarcoidosis given clinical picture.

Role of lower extremity fasciectomy plus fasciotomy for patients with persistent leg pain after stenting for chronic iliofemoral venous obstruction.

Although clinical improvement after stenting for symptomatic iliofemoral venous obstruction has been demonstrated in multiple large studies, a small proportion of patients will experience persistent quality of life–impairing symptoms. Swelling in such a setting represents the concomitant presence of lymphedema and will respond to treatment directed at the lymphedema. In contrast, persistent pain likely arises from venous hypertension in the lower leg, leading to the development of chronic compartment syndrome. Evaluation of intracompartmental pressures in such patients can help confirm the diagnosis, and fasciectomy combined with fasciotomy will treat the issue. In the present series, we evaluated six patients (six limbs) who had undergone fasciectomy combined with fasciotomy and their outcomes.

Iliac vein stenting outcomes for patients with superficial venous insufficiency concurrent with deep venous disease

ObjectiveMany patients will present with chronic proximal venous outflow obstruction (PVOO) and superficial venous insufficiency (SVI) at the time of iliac vein stenting. In the present study, we aimed to determine whether differences in outcomes were present for patients receiving an iliac vein stent according to whether concurrent SVI was present. MethodsA registry of 553 patients who had undergone iliac vein stent placement for chronic PVOO from 2011 to 2021 was retrospectively analyzed. Two groups of patients were followed for ≤6 years after initial vein stent placement: group 1 (n = 178; 32.2%) had not had SVI before or after stent placement and group 2 (n = 375; 67.8%) had had SVI at initial iliac vein stent procedure. The patients’ symptoms were evaluated using the venous clinical severity score (VCSS). Postoperative procedures after initial stent placement were recorded. Postoperative procedures included any operation performed after the index iliac vein stent procedure. Endovenous thermal ablation was classified as a minor postoperative procedure, and any intervention with venography was classified as a major postoperative reintervention. Multivariate regression models were used to determine the odds of a major reintervention or minor procedure postoperatively. ResultsAcross the two groups, the mean age (group 1, 65.3 years; group 2, 59.9 years; P < .001), body mass index (27.6 vs 26.1 kg/m2; P = .004), diabetes (32.6% vs 17.6%; P < .001), arterial hypertension (68.5% vs 42.1%; P < .001), and coronary artery disease (16.9% vs 9.6%; P = .048) differed significantly. The time to follow-up was similar between the two groups (P = .915). Longitudinally, both groups had had similar improvements in the composite VCSSs. After multivariable adjustment, group 2 was more likely than group 1 (odds ratio, 5.26; 95% confidence interval, 3.33-8.59; P < .001) to have required a postoperative minor procedure, but not a major reintervention. Group 2 had also averaged a shorter interval from the index procedure to a postoperative procedure than group 1 (525.7 days vs 258.1 days; P < .001). ConclusionsCompared with patients without SVI, those with SVI and chronic PVOO were younger, had had fewer comorbidities, and fared similarly in the change in the composite VCSSs but were more likely to have required a minor procedure and less likely to have required a major reintervention after the index iliac vein stent procedure.

Three Lumens Full of Blood—An Unusual Case of Gastrointestinal Bleeding

Question: A 58-year-old man was initially referred to our gastroenterology outpatient clinic for investigation of iron-deficiency anemia and positive fecal occult blood test (FOBT). His medical history was significant for simultaneous pancreas-kidney transplants 9 years earlier in the context of type 1 diabetes, for which he remained on triple immunosuppressive therapy with prednisolone, mycophenolate, and tacrolimus. His transplants were complicated by biopsy-proven chronic antibody-mediated rejection 4 years earlier, for which he received 6 months of intravenous immunoglobulin. There was no history of chronic liver disease or nonsteroidal medication use. Investigations demonstrated iron-deficiency anemia with a hemoglobin of 88 g/L, ferritin 14 μg/L, transferring saturation 5%, and a positive FOBT (1 of 3 samples). The patient underwent further evaluation with gastroscopy and colonoscopy, which were both unremarkable and did not identify a cause for iron-deficiency anemia. One month later, the patient re-presented to the emergency department with several days of melena and symptomatic anemia with a hemoglobin of 78 g/L. The patient underwent repeated gastroscopy, which did not reveal a cause for his symptoms. He received a blood transfusion and was referred for outpatient capsule endoscopy. Several weeks later, the patient represented with 3 days of melena and symptomatic anemia with a hemoglobin level of 45 g/L. The patient underwent an urgent push enteroscopy. What are the differential diagnoses of gastrointestinal bleeding in this patient? Look on page 335 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. A pediatric colonoscope was inserted 60 cm beyond the pylorus. There was no evidence of esophageal varices, esophagitis, or gastric varices. There was no ulceration or stigmata of recent hemorrhage found in the stomach or duodenum. At 55 cm distal to the pylorus, the anastomosis of the pancreatic transplant was encountered. It demonstrated a side-to-side duodenojejunostomy with 2 short blind duodenal limbs and the native efferent jejunal limb (Figure A). At the anastomosis, multiple varices were noted, of which one vessel was actively bleeding (Figure B). Hemostasis was achieved with the injection of adrenaline (2 mL, 1:10,000) and 2 through-the-scope hemostatic clips (Figure C). The patient then underwent a computed tomographic scan with pancreas protocol to characterize the anatomy and vasculature at the duodenojejunal anastomosis. Multiple venous varices were identified that communicated with a distended transplant pancreatic vein (Figure D). The transplant pancreatic vein anastomoses with the proximal right common iliac vein, and therefore the varices were not due to portal venous hypertension. There was no anastomotic stenosis, no venous thrombosis, and no arteriovenous fistulae. The hemoglobin remained stable after endoscopy and the patient was discharged home 3 days later. At outpatient follow-up 2 months after discharge, there was no evidence of further gastrointestinal bleeding and the hemoglobin level was stable. The patient will continue to be closely observed in the outpatient setting, with a view to endovascular intervention if further gastrointestinal bleeding occurs. Ectopic variceal bleeding from anastomotic varices between the donor duodenum and recipient small bowel are rare, with only 3 cases reported in the literature.1Gopal J.P. Jackson J.E. Palmer A. Taube D. Rathnasamy Muthusamy A.S. Gastrointestinal bleeding in a pancreas transplant recipient: a case to remember.Am J Case Rep. 2020; 21e923197Crossref PubMed Scopus (3) Google Scholar, 2Rostambeigi N. Shrestha P. Dunn T.B. et al.Recurrent ectopic variceal bleed after pancreas transplantation with no portal hypertension: case report and outcomes of endovascular onyx embolization.Vasc Endovasc Surg. 2019; 53: 415-419Crossref PubMed Scopus (5) Google Scholar, 3Fontana I. Bertocchi M. Di Domenico S. et al.Percutaneous embolization of periduodenal varix due to portal hypertension in a patient with kidney-pancreas transplantation: a case report.Transplant Proc. 2010; 42: 2162-2163Crossref PubMed Scopus (5) Google Scholar The mechanism by which ectopic varices develop after pancreas transplantation are not clear. Potential explanations include portal hypertension secondary to cirrhosis, increased vascular resistance, rejection of pancreatic transplant, and chronic venous obstruction. In our case, the mechanism was not elucidated.

Comparison between a dedicated venous stent and standard composite Wallstent–Z stent approach to iliofemoral venous stenting: Intermediate-term outcomes

ObjectiveDedicated venous stents have not been used in the management of symptomatic chronic iliofemoral venous obstruction (CIVO) until recently. The Bard Venovo stent (Becton, Dickinson, and Co, Franklin Lakes, NJ) is one such stent noted to have an increased chronic outward force and radial resistive force compared with the Wallstent (Boston Scientific, Marlborough, MA). In the present study, we evaluated the outcomes following the use of the Bard Venovo stent vs a matched cohort of limbs that had undergone stenting with the Wallstent–Zenith (Z) stent (Cook Medical Inc, Bloomington, IN) composite configuration. MethodsA review of contemporaneously entered electronic medical record data for 167 patients (167 limbs) with initial iliofemoral stents placed from 2019 to 2020 for quality of life (QOL)-impairing CIVO that had failed conservative therapy was performed. The visual analog scale for pain score (score, 0-10), grade of swelling (score, 0-4), venous clinical severity score (score, 0-27), and the 20-item chronic venous insufficiency quality of life questionnaire instrument for QOL were evaluated before and after intervention to assess the effects of stenting. A Kaplan-Meier analysis was used to examine primary, primary-assisted and secondary stent patency, and analysis of variance with repeated measures was used to compare clinical outcomes. ResultsA total of 167 limbs had undergone Bard Venovo stenting (56 men and 111 women). Their median age was 61 years. The laterality was right and left in 70 and 97 limbs, respectively. Post-thrombotic syndrome was seen in 84 limbs and nonthrombotic iliac vein lesions/May-Thurner syndrome in 83 limbs. At 6 months, the venous clinical severity score had improved from 7 to 4 in the limbs with a unilateral Venovo (UV) stent and from 5 to 4 in the composite Wallstent–Z stent group (P = .9). The grade of swelling had improved from 3 to 1 in the UV group and from 3 to 1 in the composite group (P = .6), and the visual analog scale for pain score had improved from 7 to 2 in the UV group and from 5 to 0 in the composite group (P = .007). At 12 months, ulcers had healed in 53% (8 of 15) of the UV group and 56% (5 of 9) of the composite group (P = .7). The global 20-item chronic venous insufficiency quality of life questionnaire scores had improved from 58 to 28 in the UV group and from 59 to 40 in the composite group (P = .6). The cumulative primary, primary-assisted, and secondary patency at 18 months was 81%, 97%, and 98% in the UV group and 87%, 98%, and 100% in the composite group, respectively (P > .4). No difference in the reintervention rates was noted between the two groups (P = .5). ConclusionsFor patients who had undergone stenting for QOL-impairing CIVO, the results with the Bard Venovo venous stent were comparable to those with the composite Wallstent–Z stent configuration for clinical outcomes, QOL improvement, and stent patency. Further study is, however, required to confirm this improvement in the long term.

Iliofemoral venous configurations from three-dimensional computed tomography venogram and their relevance to stent design

ObjectiveIliofemoral venous stenting has become the standard of care for patients presenting with quality-of-life impairing symptoms of chronic iliofemoral venous obstruction not responding to conservative measures. This has led to an increased use of venous stenting over the last several years. However, iliofemoral venous anatomy in patients requiring such intervention remains poorly elucidated. This study attempts to fill that gap. MethodsTwenty-two consecutive patients with intravascular ultrasound examination-confirmed chronic iliofemoral venous obstruction underwent three-dimensional reconstruction of their computed tomography venogram images. Relevant angles, tortuosity (tort index-ratio between centerline length, and straight line length), lengths, and diameters were computed and analyzed. We used t tests for comparisons between the right and left sides. A P value of .05 or less was considered significant. ResultsOf the angles calculated, the median of the angles between the horizontal and common iliac vein (CIV) was 66° on the right and 60° on the left (P < .01). The median inferior vena cava-CIV angle was 172° on the right and 165° on the left (P < .0001). The CIV-EIV angle was 159° on the right and 151° on the L (P = .01). Overall, the median tortuosity was 1.07 on the right and 1.12 on the left (P = .007). The median centerline length of the CIV was 42mm on the right and 60mm on the left (P < .0001). The median external iliac vein length was 73 mm on the right and 88 mm on the left (P < .0001). The overall median iliac vein length was 220 mm on the right and 237 mm on the left (P < .01). The median diameters of the inferior vena cava at the iliocaval confluence, 20, 40, and 60 mm cranial to the confluence, were 23, 20, 22, and 23 mm, respectively. ConclusionsOverall, the left side has steeper angles, greater tortuosity, and longer lengths than the right side. These disparities should be considered during femoroiliocaval stent construction.

Patients with active venous leg ulcers at the time of iliac vein stenting require more reoperations

ObjectiveAn active venous leg ulcer (VLU) caused by lower extremity venous insufficiency is challenging to treat and will often recur after initially healing. In the present study, we compared the symptomatic outcomes and need for reoperation after iliac vein stenting (IVS) in patients with an active VLU (VLU+) and those without an active VLU (VLU−). MethodsA single-institution database of patients with chronic venous outflow obstruction who underwent IVS from August 2011 to June 2021 was analyzed. Symptoms were quantified using the venous clinical severity score. The patients were divided into two cohorts: those with (VLU+) and without (VLU−) VLUs. ResultsA total of 872 patients (71 VLU+ and 801 VLU−) were identified. Many of the demographics and comorbidities differed between the two cohorts, and these variables were included in the multivariable analysis. On univariate analysis, the VLU+ cohort was more likely to need a major reoperation (odds ratio, 1.94; 95% confidence interval, 1.01-3.52; P = .036). However, on multivariable analysis, the difference was not statistically significant (odds ratio, 1.17; 95% confidence interval, 0.55-2.40; P = .667). Additionally, the VLU+ cohort required a significantly greater mean total of reoperations (1.4 vs 1.0; P = .006) than the VLU− cohort. Comparatively, for patients who underwent at least one reoperation, the difference in the mean total number of reoperations was even greater for the VLU+ cohort (2.6 vs 1.8; P = .001). The results from the Kaplan-Meier log-rank test revealed no differences in the reintervention-free survival time (P = .980). Both cohorts experienced a durable mean reduction in the venous clinical severity score. The ulcer healing rates for the VLU+ cohort at 6, 12, 24, and 36 months were 38%, 47%, 52%, and 59%, respectively. The ulcer recurrence rates for the VLU+ cohort were 4%, 10%, 19%, and 30% at 6, 12, 24, and 36 months, respectively, with a median time to recurrence of 1.2 years. ConclusionsPatients with active VLUs who underwent a first reintervention after initial IVS, on average, required an additional reintervention.

Symptom Relief and Reintervention after Iliac Vein Stenting Stratified by CEAP Clinical Classification

This study sought to evaluate long-term symptom relief and reintervention rates after iliac vein stenting (IVS) in patients with chronic venous outflow obstruction. A single-institution database of patients undergoing IVS from August 2011 to June 2021 was analyzed. Patients were stratified into three cohorts based on the clinical component of the clinical, etiology, anatomical, and pathophysiology (CEAP) classification: C3, C4, and C5/6. Symptoms were quantified using the venous clinical severity score (VCSS). Reintervention was defined as any procedure using venography. Edema, pigmentation, and ulceration progression-free survival as well as reintervention-free survival were assessed with Kaplan Meier analysis. Among 737 total patients, there were 435 C3, 206 C4, and 96 C5/6 patients. The C5/6 cohort had the highest percentage of patients undergo reoperation (36.4%). C5/6 patients yielded the poorest ulceration progression-free survival (P<0.001) while C3 patients had the poorest skin pigmentation progression-free survival (P=0.009). On adjusted analysis there was no significant difference in odds of reintervention between study cohorts. Mean composite VCSS scores were significantly different at each yearly post-operative follow-up visit up to 6 years. The present study is one of the largest investigations of long-term outcomes in IVS patients. Most patients with long-term follow-up experienced an improvement in their composite VCSS. CEAP clinical classification at the time of IVS had a significant influence on the likelihood and quantity of reintervention.

Endovascular Therapy of Chronic Iliofemoral Venous Outflow Obstructions

Deep vein thrombosis (DVT) is associated with a high cost burden for health care systems because of secondary cost intensive complications like pulmonary embolism and especially the post thrombotic syndrome (PTS). Current standard therapy of anticoagulation for DVT therapy has not changed through the years leaving patients especially with iliofemoral vein thrombus on a high-risk situation for developing PTS. For patients with chronic venous outflow obstruction of the iliac vein system dedicated venous stents and recanalization techniques are today available.

Iliac Vein Stenting Outcomes for Patients with Superficial Venous Insufficiency Concurrent with Deep Venous Disease

Superficial venous insufficiency (SVI) and chronic proximal venous outflow obstruction (PVOO) can occur in the same patient before, during, or after iliac vein stenting, whereas some patients with PVOO never develop SVI. The clinical course of these different patients remains unclear. We undertook this study to determine how SVI would influence the outcomes after vein stenting for chronic PVOO.

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

Diabetes, hypertension, and smoking are well-recognized risk factors for peripheral artery disease, but little is known of their impact on chronic venous insufficiency (CVI). The aim of this study was to evaluate these factors in CVI patients undergoing iliac vein stent placement for chronic iliofemoral venous outflow obstruction. A clinical registry of 708 patients who underwent iliac vein stenting from August 2011 to June 2021 at a single institution was analyzed. Symptoms were quantified using Venous Clinical Severity Score and CEAP class. Both major (any intervention that included venography) and minor (superficial vein ablation) reinterventions after the initial iliac vein stenting were recorded. Univariate differences were analyzed using χ2 or Fisher exact tests for categorical variables and one-way analysis of variance for continuous variables. Logistic regression models were used to determine the unadjusted and adjusted odds ratio (OR) of any minor and major reintervention. A Log-rank test was used to assess differences in reintervention-free survival. Among patients with CVI undergoing vein stent placement, the prevalence of diabetes was 23.0% (n = 163), hypertension was 51.1% (n = 362), and smoking was 22.2% (n = 157). Patients with diabetes (3.6 vs 3.4; P = .062), hypertension (3.6 vs 3.3; P < .001), and smoking (3.7 vs 3.4; P = .003) had higher CEAP scores than those without diabetes, hypertension, and smoking, respectively. Improvement in venous clinical severity score composite scores after vein stenting showed no differences postoperatively (diabetes: P = .513; hypertension: P = .053; smoking: P = .608), at 1-year follow-up (diabetes: P = .666; hypertension: P = .681; smoking: P = .745), or at 5-year follow-up (diabetes: P = .525; hypertension: P = .953; smoking: P = .146) (Table I). Diabetes (OR, 0.80; 95% CI, 0.45-1.43), smoking (OR, 1.34; 95% CI, –0.73 to 2.51), and hypertension (OR, 1.11; 95% CI, 0.63-1.95) were not associated with increased risk of major reintervention after iliac vein stent placement in the multivariate regression models (Table II). Log-rank test similarly showed no differences in reintervention-free survival for major or minor reoperations between those with and without diabetes (P = .79), hypertension (P = .14), and smoking (P = .80). Unlike in peripheral artery disease, diabetes, hypertension, and smoking have little to no impact on long-term outcomes or reinterventions after iliac vein stent placement for CVI.Table IComparison of patients with and without smoking history, diabetes, and hypertension preoperatively and postoperatively.VariablesSmoking historyP valueNo (n = 551)Yes (n = 157)PreoperativeVCSS composite10.5 (4.0)10.5 (4.3).894CEAP class3.4 (1.0)3.7 (1.1).003PostoperativeVCSS composite6.4 (3.6)6.7 (3.7).586Change in VCSS composite postoperative to preoperative3.5 (3.3)3.7 (3.3).608Reintervention1.8 (1.2)2.0 (1.6).091DiabetesP valueNo (n = 545)Yes (n = 163)PreoperativeVCSS composite10.6 (3.9)10.3 (4.5).478CEAP class3.4 (1.0)3.6 (1.2).062PostoperativeVCSS composite6.5 (3.5)6.4 (4.0).827Change in VCSS composite postoperative to preoperative3.6 (3.3)3.4 (3.2).513Reintervention1.8 (1.3)1.9 (1.2).709HypertensionP valueNo (n = 346)Yes (n = 362)PreoperativeVCSS composite10.4 (3.6)10.6 (4.5).594CEAP class3.3 (0.9)3.6 (1.2)<.001PostoperativeVCSS composite6.6 (3.5)6.4 (3.7).727Change in VCSS composite postoperative to preoperative3.9 (5.3)4.6 (5.3).053Reintervention1.8 (1.2)1.9 (1.3).174VCSS, Venous Clinical Severity Score. Open table in a new tab Table IIAdjusted and unadjusted odds of any minor and major reinterventionComparisonModelORP value95% CISmoking historyUnadjusted1.120.595(0.75-1.70)Adjusted1.340.355(0.73-2.51)DiabetesUnadjusted0.640.022(0.43-0.94)Adjusted0.80.454(0.45-1.43)HypertensionUnadjusted0.730.071(0.52-1.03)Adjusted1.110.727(0.63-1.95)CI, Confidence interval; OR, odds ratio. Open table in a new tab

Patients With Post-thrombotic Syndrome Are More Likely to Undergo Venographic Reintervention and Experience Slower Symptom Resolution After Iliac Vein Stenting

Patients undergoing iliac vein stent placement (IVS) for chronic proximal venous outflow obstruction are observed to have two types of stenosis: a more focal stenosis from external compression, also known as nonthrombotic iliac vein lesions (NIVL), or more diffuse stenosis suggestive of post-thrombotic syndrome (PTS) from a remote deep venous thrombosis (DVT). We assessed the influence of PTS on the outcomes of IVS.

Assessment of the lymphatic system by indirect lymphography in patients with post-thrombotic syndrome

ObjectiveAlterations in lower extremity lymph drainage caused by chronic venous obstruction (CVO) have not been well studied, partially because of a lack of standardized imaging modalities to assess the quality of lymphatic drainage in the lower extremities of patients with post-thrombotic syndrome (PTS). However, these changes are likely to have an impact on the severity of the disease and clinical outcomes of interventions. In the present study, we investigated the feasibility and diagnostic value of preintervention indirect lymphography in patients with CVO and their pre- and postintervention Villalta scores. MethodsA total of 17 patients (21 limbs) with iliofemoral and caval CVO were included in the study between 2017 and 2018. The deep and superficial lymphatic vessels in both legs were assessed before venous recanalization and stenting. The quality of lymphatic flow was compared between the legs with CVO and healthy legs. Moreover, the correlation between the lymphatic changes and clinical severity of PTS was evaluated using the Villalta score and CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) classification. ResultsThe mean patient age was 44 ± 12 years, and 10 patients (59%) were women. The patients had undergone treatment at a mean of 25 ± 6 months after their first episode of deep vein thrombosis. Five patients (29%) had had recurrent deep vein thrombosis. The mean pre- and postinterventional Villalta score was 10.5 ± 1.46 and 9.27 ± 1.12, respectively (P = .0096). Using the CEAP classification, four legs were class 5, seven were class 4, and three each were class 3 and 2. The primary and secondary patency rate was 70.5% and 82.5% after a mean follow-up of 18 months, respectively. Indirect lymphography of the superficial and deep lymphatic systems was completed before intervention in both legs for all 17 patients (21 legs). According to the qualitative criteria, abnormal lymphatic vessel function was found in 35.2% of the superficial and 58.8% of the deep lymphatic vessels of the affected legs. Further analysis revealed abnormal function of the deep lymphatic vessels in all patients with moderate to severe PTS according to the Villalta score. ConclusionsIndirect lymphography is a feasible diagnostic tool to use for the evaluation of the function of lymphatic vessels. Impaired drainage of the deep lymphatic system was found in all our patients with moderate to severe PTS. The clinical significance of these lymphatic changes is not clear; however, an association between clinical severity and outcomes is possible.

Comparison of intravascular ultrasound and magnetic resonance venography in the diagnosis of chronic iliac venous disease

BackgroundThe diagnosis of chronic iliofemoral venous obstruction (CIVO) can be made with several different modalities. Intravascular ultrasound (IVUS) examination is the gold standard in the diagnosis of CIVO. However, being invasive, it should not be the initial examination to screen patients with CIVO. The aim of this report is to compare the performance of magnetic resonance venography (MRV) with IVUS examination in the diagnosis of CIVO. MethodsFrom January 2016 to December 2020, the records of all patients who underwent preoperative MRV and then IVUS in the evaluation of CIVO were analyzed retrospectively. ResultsThere were 505 patients who were evaluated by any modality for CIVO. Of these patients, 15% (78) were evaluated by MRV. Patients who had failed a trial of conservative therapy for at least 3 to 6 months and who had disabling and lifestyle-limiting symptoms of CIVO were selected to undergo further evaluation with MRV at the treating physician’s discretion. For inclusion in analysis, technically satisfactory IVUS examination and MRV data were mandatory. Data was available for 60 common iliac vein (CIV) segments and 61 external iliac vein (EIV) segments for comparative analysis after appropriate exclusions. The mean age of the patients was 56 ± 15 years. The male to female ratio was 1:2. The distribution of patients across different CEAP classes was as follows: CEAP 3, 28%; CEAP 4, 62%; CEAP 5, 2%; and CEAP 6, 8%. Bland-Altman plots of the mean difference in area between IVUS examination and MRI were 74.1% for CIV and 56.9% for EIV. The sensitivity of MRV was 93% and 100%, and the specificity was 0% and 50% for CIV and EIV, respectively. The positive predictive value was 93% and 86%; the negative predictive value was 0 and 50% for CIV and EIV, respectively. Improvement was noted in clinical parameters (Venous Clinical Severity Score, visual analog pain scale, and grade of swelling) after IVUS examination and stenting after MRV. For the Venous Clinical Severity Score, the score improved from 6.0 ± 2.7 (before the procedure) to 4 ± 2.7 (after the procedure) (P = .0001). ConclusionsThere is dimensional disparity between MRV and IVUS examination in the diagnosis of symptomatic CIVO. MRV has a high sensitivity but low specificity when compared with IVUS examination and overestimates the severity of the stenosis in both the EIV and CIV. MRV is not a reliable diagnostic tool for iliac vein stenosis and should not be used for the definitive disposition of patients with CIVO.