Chronic Venous Obstruction Research Articles

Acute and chronic venous outflow obstructions – a global burden

Free AccessAcute and chronic venous outflow obstructions – a global burdenMichael Lichtenberg, Rick de Graaf, and Houman JalaieMichael Lichtenberg Vascular Center Arnsberg, Germany Search for more papers by this author, Rick de Graaf Radiology Department Klinikum Friedrichshafen, Germany Search for more papers by this author, and Houman Jalaie European Venous Center, Aachen-Maastricht, Germany/The Netherland Search for more papers by this authorPublished Online:January 04, 2021https://doi.org/10.1024/0301-1526/a000931PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreDeep vein thrombosis (DVT) is a potentially devastating condition and may cause permanent disability with significant morbidity and even mortality. Inadequate restoration of venous blood flow causes a persistent outflow obstruction with hemodynamic effects, inducing valve incompetence of the deep veins and subsequent valve failure of the saphenous veins of the affected lower extremity. Approximately 60% of patients with DVT recover without further symptoms. However, 40% will have some degree of post-thrombotic syndrome and 5–10% will develop severe post-thrombotic syndrome (PTS). PTS is the most common complication; it reduces quality of life and increases DVT-related costs.During the last years, evidence emerged for recanalization treatment of acute and chronic venous outflow obstruction to prevent PTS. Many questions still remain for new technologies, including modern dedicated venous stents and thrombectomy devices.Given the evolving evidence for deep venous recanalization in acute and chronic venous outflow obstruction, this VASA special issue, compiled by world-wide renowned and recognized authors, adds further dissemination of knowledge to this field. High-level studies, illuminating new recanalization technologies for acute and chronic venous outflow obstructions, including studies especially for novel dedicated venous stents, thrombectomy devices and recanalization techniques as well as systematic literature reviews on available epidemiologic data for PTS and literature reviews on available data for treatment of acute and chronic venous outflow obstructions are included in this special issue.On behalf of the editorial-team we would like to thank the authors for their contribution and support.FiguresReferencesRelatedDetails Special Issue: Venous interventionsVolume 50Issue 1January 2021ISSN: 0301-1526eISSN: 1664-2872 InformationVasa (2021), 50, pp. 1-1 https://doi.org/10.1024/0301-1526/a000931.© 2021Hogrefe AGPDF download

Comparative Analysis of Stenting and Hybrid Operations in Chronic Venous Obstruction of Iliofemoral Segments in Patients with Postthrombotic Syndrome

Comparative Analysis of Stenting and Hybrid Operations in Chronic Venous Obstruction of Iliofemoral Segments in Patients with Postthrombotic Syndrome

Long-term outcomes following use of a composite Wallstent-Z stent approach to iliofemoral venous stenting

ObjectiveAn endovascular approach has essentially replaced open surgery in the management of symptomatic chronic obstructive iliofemoral venous disease. In the last several years, such a minimally invasive approach has shifted from use of Wallstents alone to a combination of Wallstent-Z stent (composite stenting) to better deal with the iliocaval confluence. This study evaluates the clinical and stent related outcomes following use of composite stenting. MethodsA retrospective review of contemporaneously entered EMR data on 535 patients (545 limbs) with initial iliofemoral stents placed over a 4-year period from 2014 to 2017 for symptomatic chronic iliofemoral venous obstruction was performed. Patients who underwent stenting after intervention for acute deep venous thrombosis were excluded. The impact of stenting on clinical outcomes before and after the intervention were evaluated through use of the visual analog scale pain score (0-10), grade of swelling (0-4), and Venous Clinical Severity Score (0-27). Quality of life was appraised using the Chronic Venous Disease quality of life Questionnaire 20 instrument. Kaplan-Meier analysis was used to assess primary, primary assisted and secondary stent patencies, and paired and unpaired t-tests were used to examine clinical outcomes. ResultsOf the 545 limbs that underwent stenting, 183 were in men and 362 were in women. The median age was 60 years. Laterality was right in 205 limbs and left in 340 limbs. Post-thrombotic syndrome was seen in 441 limbs and nonthrombotic iliac vein lesions/May-Thurner syndrome in 104 limbs. At 24 months, visual analog scale pain score went from 5 to 2 (P < .0001), grade of swelling went from 3 to 1 (P < .0001), and Venous Clinical Severity Score went from 6 to 4 (P < .0001). Ulcers were present in 67 limbs and had healed in 49 limbs (73%) over a median follow-up of 26 months. Global Chronic Venous Disease quality of life Questionnaire scores improved from 60 to 36 (P < .0001) after stenting. Cumulative primary, primary-assisted, and secondary patencies at 60 months were 70%, 99% and 91%, respectively. Thirty limbs (5.5%) required contralateral stenting. There was only one instance (0.2%) of contralateral iliofemoral deep venous thrombosis. One hundred eleven limbs (20%) underwent reintervention, including for in-stent restenosis in 44 limbs, stent compression in 2 limbs, in-stent restenosis and stent compression in 48 limbs, and stent occlusion in 17 limbs. ConclusionsIn patients undergoing iliofemoral venous stenting for obstructive disease, clinical improvement, quality of life improvement, and stent patencies after use of a composite stent configuration are comparable with those seen after exclusive use of Wallstents. However, the use of a composite stent configuration not only decreases the need for contralateral stenting to relieve chronic obstruction, but also decreases the incidence of contralateral iliofemoral deep venous thrombosis.

Iliac Vein Stenting for Chronic Proximal Venous Outflow Obstruction in a Predominantly Asian-American Cohort

Chronic proximal venous outflow obstruction (PVOO) presentation, treatment needs, and outcomes differ in Asian Americans compared with non-Asian patients. Study Summary: This was a large (N = 462) study of consecutive patients with PVOO that included 336 (73%) Asian Americans treated in a 3-year time span with a 90% follow-up during 695 days. Asian Americans were more likely to present with varicose veins rather than with ulceration and to have bilateral iliac venous stent placement and less likely to have had a deep venous thrombosis and any reinterventions. Follow-up outcome scores were worse at 30-days but improved at 1 year compared with non-Asians. This observational study of Asian Americans' presentation and response to treatment for PVOO is important, showing the effects of chronic venous insufficiency in a population. The literature has shown ethnic differences in the incidence and prevalence of venous thromboembolism in Asians, but this is the first study of which I am aware looking at iliac venous disease and interventions. More epidemiologic data are needed to understand interethnic disparities and possibly the relative roles of genetic and environmental factors.

Three-dimensional computed tomography venogram enables accurate diagnosis and treatment of patients presenting with symptomatic chronic iliofemoral venous obstruction

ObjectiveThe last several years has witnessed an increase in the diagnosis and treatment of chronic iliofemoral venous obstructive lesions. Although intravascular ultrasound (IVUS) examination has become the gold standard in the management of chronic iliofemoral venous obstruction (CIVO), it is an invasive technique. To ascertain the usefulness of noninvasive imaging technology in diagnosing and treating CIVO in symptomatic patients, we compared three-dimensional (3D) reconstructions from computed tomography venogram (CTV) with IVUS examination. MethodsTwenty-two continuous patients who underwent IVUS interrogation during intervention for CIVO formed the study cohort. Patients who had stenting performed in the setting of chronic total occlusion of the iliofemoral segment or acute iliofemoral deep venous thrombosis were excluded. All patients underwent CTV as part of their standard preoperative work up. Minimal (smallest) luminal areas of the common iliac vein (CIV), external iliac vein (EIV), common femoral vein (CFV) and the inflow channel (segment caudal to the CFV) were obtained from 3D CTV and IVUS. Centerline length measurements were obtained from 3D CTV to estimate the length of the venous stents necessary; the inflow channel luminal area was used to predict the required stent diameter. Pearson correlation was used to evaluate the association between the luminal areas obtained from the two techniques. Agreement was ascertained by use of Bland-Altman limits of agreement. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 3D CTV in predicting luminal areas was also determined. Predicted stent diameters and lengths were compared against actual stent diameters and lengths used. ResultsPearson correlation statistic for luminal areas between 3D CTV and IVUS for the CIV was 0.89 (P < .01), for EIV was 0.77 (P < .01), and for CFV was 0.69 (P < .01). The correlation statistic for the inflow channel luminal area was 0.90 (P < .01). The sensitivity of 3D CTV in diagnosing CIVO in the CIV, EIV, and CFV were 100%, 100% and 80%, respectively. The specificity was 67%, 57%, and 86%, respectively, in the CIV, EIV, and CFV segments. The positive predictive value of 3D CTV in determining CIVO in the CIV, EIV, and CFV segments was 89%, 83%, and 92%, and the negative predictive value was 100%, 100%, and 67%, respectively. The overall accuracy was 91%, 86%, and 82% in the CIV, EIV, and CFV segments. Thus, 3D CTV is able to predict stent length within 9.5 mm of the actual stent length used. With respect to stent diameter, 3D CTV was able to predict within 2 mm of the actual stent diameter used 91% (20/22) and within 4 mm of the actual stent diameter used 100% (22/22) of the time. ConclusionsFrom a diagnostic standpoint 3D CTV does well with an overall accuracy ranging from 82% in the CFV to 91% in the CIV in predicting CIVO. It is also able to accurately predict venous stent diameter and lengths required, rendering it a good tool in the diagnosis and treatment of symptomatic CIVO.

Venovo venous stent for treatment of non-thrombotic or post-thrombotic iliac vein lesions - long-term efficacy and safety results from the Arnsberg venous registry.

Background: Endovascular venous stenting with dedicated venous stents for the treatment of chronic venous outflow obstruction is developing as efficacious alternative to conservative therapy or open surgery. However, so far, mid- and long-term evidence on effectiveness and safety is poor. Patients and methods: The prospective, single-center, observational study enrolled consecutive patients with chronic non-thrombotic iliac vein lesions (NIVL) or post-thrombotic iliofemoral obstructions (PTO). From February 2016 to April 2017, patients underwent implantation of open cell, self-expandable dedicated venous stents. Short-term symptomatic improvement, patency, and complication rate were favorable. Evaluation at 2-years included improvement in the revised venous clinical severity score (rVCSS), patency, stent migration, major target limb events, clinically important pulmonary embolism, major bleeding, and all-cause mortality. Results: A total of 79 patients (57 ± 16 years, 44 female) were evaluated. At 2 years, rVCCS improved by 4.3 ± 2.7 (p < 0.001). Substantial clinical improvement of ≥ 2 score points was achieved in 86.4% (38 of 44) of patients. Improvement was not associated with thrombotic pathogenesis (regression coefficient [B] with PTO = 0.6 [95%CI: -1.1 to 2.3], p = 0.48). At 2 years, all ulcers (in 8 of 79 patients) were healed and none recurred. Two-year primary patency was 95.5% (95%CI: 86.5 to 98.5) with no difference between NIVL- and PTO-patients (log-rank p = 0.83). Target vessel revascularization was conducted in two PTO- and one NIVL-patients in the period of 34 days to 156 days from index procedure, resulting in a secondary patency of 100%. No stent migration, target limb deep vein thrombosis, major amputation, pulmonary embolism, or death occurred. Conclusions: Venovo venous open cell self-expanding stent implantation for chronic outflow obstruction was efficacious and provided a sufficient level of safety throughout 2 years.

Diagnosis and treatment of chronic venous obstruction: consensus statement of the Russian experts (part 2)

This consensus statement of Russian experts is based on a review of the relevant literature on the prevalence, diagnosis, and treatment of non-thrombotic and post-thrombotic venous obstruction, as well as management of patients after venous stenting. In the Part 1 we discussed the clinical manifestations of venous obstruction, the role of duplex ultrasound scan, CT venography, MR venography, direct venography, and intravascular ultrasound scan, as well as typical findings obtained by using these methods. The authors mentioned the functional assessment of venous outflow in healthy subjects and in those with obstruction and changes in them after the intervention. In conclusion, the authors formulated the suggestions for clinical recommendations on the diagnosis of chronic venous obstruction.

Diagnosis and treatment of chronic venous obstruction: consensus statement of the Russian experts (part 1)

This consensus statement of Russian experts is based on a review of the relevant literature on the prevalence, diagnosis, and treatment of non-thrombotic and post-thrombotic venous obstruction, as well as management of patients after venous stenting. In the Part 1 we discussed the clinical manifestations of venous obstruction, the role of duplex ultrasound scan, CT venography, MR venography, direct venography, and intravascular ultrasound scan, as well as typical findings obtained by using these methods. The authors mentioned the functional assessment of venous outflow in healthy subjects and in those with obstruction and changes in them after the intervention. In conclusion, the authors formulated the suggestions for clinical recommendations on the diagnosis of chronic venous obstruction.

Device profile of the Vici venous stent for chronic iliofemoral venous obstruction recanalization: overview of its safety and efficacy

ABSTRACT Introduction: Endovenous stenting is being increasingly used for the management of iliofemoral venous outflow obstruction due to thrombotic or non-thrombotic iliac vein lesions (NIVL). Dedicated venous stents have replaced re-purposed arterial stents but there are limited data on their relative safety and efficacy. Areas covered: This review looks at the available literature on the safety and efficacy of the Veniti Vici Venous stent (Boston Scientific), a specific venous stent, and compares its outcomes with the other venous stents that are currently available. Reported outcomes include patency, clinical efficacy, and the number of adverse events. Expert opinion: The initial clinical trials of the Vici venous stent have shown both good clinical and safety outcomes at 12–24 months follow-up. Longer follow-up data are pending and further trials comparing available stents are required. Current evidence supports its use in the management of deep venous reconstruction, especially in occlusive post-thrombotic disease. Patients should, however, be made aware of the paucity of long-term data and the need for monitoring within a dedicated surveillance program following stent placement.

Comparative study between Surgical and Endovascular Management of Chronic Iliofemoral Venous Obstruction

Background: Most of the chronic iliofemoral venous obstructions were managed with low morbidity and no mortality through endovascular intervention which was appropriate for patients with chronic venous obstruction. Endovascular treatment for iliofemoral venous obstruction had progressed rapidly,venous stenting was the primary choice as the stent placement was safe, effective and minimally invasive. However, surgical treatment remains an excellent option in cases in which endovascular techniques had failed or weren’t possible. Objective: The purpose of this study was to review and discuss comparative study between surgical and endovascular procedures in the management of chronic iliofemoral venous obstruction. Patients and Methods: This study included 30 patients (18 females and 12 males) with a ratio of 1.5:1 suffering from chronic ilio-femoral venous obstruction, randomly divided into two equal groups: group (1) for surgical treatment,group (2) for endovascular treatment. Their mean age was 40 years “ranging from 19-83 years” . All patients were belonging to CEAP classifications, C(clinical), E(etiological), A(anatomical) and P(pathological) which included C3 to C6 = clinically state of venous disease in which there was edema up to active venous ulcer. Results: There was no difference between the groups regarding the length of follow up. Iliofemoral venous stenting was safe and effective procedure which could be performed with low morbidity, no mortality, and long-term high patency rate patients for open venous surgery had complication with low patency rate. Conclusion: Endovascular treatmentis the primary treatment for patients with chronic iliofemoral venous obstruction, open surgical treatment should be considered only in cases of unsuccessful or failed endovenous treatment.

Comparative study between Surgical and Endovascular Management of Chronic Iliofemoral Venous Obstruction

Background: Most of the chronic iliofemoral venous obstructions were managed with low morbidity and no mortality through endovascular intervention which was appropriate for patients with chronic venous obstruction. Endovascular treatment for iliofemoral venous obstruction had progressed rapidly,venous stenting was the primary choice as the stent placement was safe, effective and minimally invasive. However, surgical treatment remains an excellent option in cases in which endovascular techniques had failed or weren’t possible. Objective: The purpose of this study was to review and discuss comparative study between surgical and endovascular procedures in the management of chronic iliofemoral venous obstruction. Patients and Methods: This study included 30 patients (18 females and 12 males) with a ratio of 1.5:1 suffering from chronic ilio-femoral venous obstruction, randomly divided into two equal groups: group (1) for surgical treatment,group (2) for endovascular treatment. Their mean age was 40 years “ranging from 19-83 years” . All patients were belonging to CEAP classifications, C(clinical), E(etiological), A(anatomical) and P(pathological) which included C3 to C6 = clinically state of venous disease in which there was edema up to active venous ulcer. Results: There was no difference between the groups regarding the length of follow up. Iliofemoral venous stenting was safe and effective procedure which could be performed with low morbidity, no mortality, and long-term high patency rate patients for open venous surgery had complication with low patency rate. Conclusion: Endovascular treatmentis the primary treatment for patients with chronic iliofemoral venous obstruction, open surgical treatment should be considered only in cases of unsuccessful or failed endovenous treatment.

Inferior Vena Cava Reconstruction in Symptomatic Patients Using Palmaz Stents: A Retrospective Single-Center Experience

The use of stents for treating central venous occlusion is well described. Limited evidence exists related to Palmaz balloon-expandable stent use in inferior vena cava (IVC) reconstruction. We analyzed patency and complication rates after IVC reconstruction using Palmaz stents. From 2002 to 2019, 37 patients (mean age: 51year) underwent IVC reconstruction with 68 Palmaz stents. Indications were symptomatic chronic venous obstruction in the infrarenal (n=25) and intrahepatic (n=12) IVC. Demographic, operative, and imaging data were evaluated. Clinical data, abdominal CT, and/or duplex ultrasound were used to determine patency at follow-up. Restoration of caval patency was achieved in all patients, with complications in 2/37 (5.4%) patients (thrombus formation within the stent; stent embolization eight days after placement). Follow-up data were available for 27 patients. Primary patency was maintained through last follow-up in 19/27 (70%) patients (mean: 1.1year), with successful stent redilation performed in 6 patients. Mean duration of primary-assisted patency (n=5) was 1.2year. Late lumen loss was (n=13) was 40% during a mean time to follow-up of 2.0years. Primary patency in patients with occlusion secondary to malignancy was 109day (range: 1 day-1.0year), whereas primary patency in patients with occlusion from other etiologies was 1.1year (range: 2day-5.9year). The Kaplan-Meier analysis demonstrated primary and primary-assisted patency of 66% and 84%, respectively, at 24 and 48 months. Palmaz balloon-expandable stents for IVC reconstruction is feasible and effective for symptomatic IVC occlusion. Risk of stent migration was low.

Iliac Vein Stenting for Chronic Proximal Venous Outflow Obstruction in a Predominantly Asian-American Cohort

We investigated the outcome of vein stenting placement for chronic proximal venous outflow obstruction (PVOO) in a predominantly Asian-American cohort to improve patient selection, enhance technical approach, and better define quality measurements of this emerging vascular intervention. A total of 462 consecutive patients, 73% Asian American (n=336), who underwent iliac vein stenting for chronic PVOO from October 2013 to July 2016 were reviewed. Postoperative outcomes at five follow-up visits were assessed. Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were run for demographic and operative variables. Ordered logistic regressions were run for the outcome at each time point, and Chi-squared tests as well as Fisher's exact tests were used for categorical variables. Follow-up was maintained in 90% of patients, with a mean follow-up time of 695days. Asian-American patients were more likely to present with varicose veins (77.4% vs. 54.8%, P<0.001), and non-Asian patients were more likely to present with active ulceration (26.2% vs. 5.1%, P<0.001). Asian-American patients were more likely to have bilateral stents placed (61.6% vs. 50%, P=0.026) and were less likely to have reinterventions (11.3% vs. 27.8%, P<0.001), a history of deep vein thrombosis (8.3% vs. 29.4%, P<0.001), or intraoperative findings of chronic postphlebitic changes (17.6% vs. 33.3%, P<0.001). Kruskal-Wallis tests were significant for improvement in patients of all the Clinical, Etiology, Anatomy, Pathophysiology classes at 30days (P=0.041), 90days (P=0.045), 6months (P=0.041), and 1year (P<0.01). The Asian-American population had improved but comparatively lower follow-up scores at the 30-day mark (48% significantly improved or better vs. 63%, P=0.008) but higher follow-up scores at the >1year mark (80% significantly improved or better vs. 59%, P<0.001). Asian-American patients undergoing vein stent placement for chronic PVOO had comparatively worse outcomes than non-Asian patients at 30 days and better outcomes after one year. These patient groups had different outcomes postoperatively and outcomes which evolve differently over time.

Management of acute and chronic iliofemoral venous outflow obstruction: a multidisciplinary team consensus.

The aim of this manuscript was to establish a consensus for the management of acute and chronic venous obstruction among specialists in the UK. Specialist physicians representing vascular surgery, interventional radiology and hematology were invited to 3 meetings to discuss management of acute and chronic iliofemoral obstruction. The meetings outlined controversial areas, included a topic-by-topic review; and on completion reached a consensus when greater than 80% agreement was reached on each topic. Physicians from 19 UK hospitals agreed on treatment protocols and highlighted areas that need development. Potential standard treatment algorithms were created. It was decided to establish a national registry of venous patients led by representatives from the treating multidisciplinary teams. Technical improvements have facilitated invasive treatment of patients with acute and chronic venous obstruction; however, the evidence guiding treatment is weak. Treatment should be conducted in centers with multi-disciplinary input; robust, coordinated data collection; and regular outcome analysis to ensure safe and effective treatment and a basis for future evolvement.

Obturator Hook Sign as a Marker of Chronic Iliofemoral Venous Outflow Obstruction in Computed Tomography Venography – Multicentric Evaluation of Incidence and Clinical Significance

Introduction: Chronic iliac venous outflow obstruction is a common condition that has been increasingly recognized as a causal factor in patients with both post-thrombotic syndrome (PTS) and nonthrombotic iliac vein lesions (NIVL). Diagnosis is challenging, and there is no gold standard diagnostic method. The aim of this paper is to describe the “Obturator Hook Sign” (OHS), a distinctive dilated angled vein, similar to a hook. It is identified mainly in Direct Computed Tomography Venography (DCTV), evidencing obturator vein engorgement as a marker of hemodynamically significant collateralization and representing an indirect sign for chronic iliac vein outflow obstruction. Methods: All CTVs of lower limbs performed from January 2014-August 2018 in Galway University Hospitals and the Galway Clinic were retrospectively reviewed. Data was analysed using SPSSv25.0. Results: In total, 531 CTV's were reviewed, of which 122 (23%) were performed for acute DVT, 183 (34.5%) for post-iliac stenting follow-up and 109 (20.5%) for etiologic study of CVD. OHS was identified in 73 CTV's: 29 Direct CTV's (40.3%) and 44 Indirect CTV's (10.6%). Two groups were defined depending on whether OHS was present, and significant predictors were identified: female sex (p=0.003), younger age (p=0.0004), DCTV (p< 0.0001), NIVL (p< 0.001), past history of iliofemoral DVT (p=0.002) and dilated pelvic veins (p< 0.0001). Obturator hook sign was significantly more common in chronic occlusions, when compared to chronic stenosis or acute occlusion (p< 0.0001). Findings from CTV were compared with results from ascending venography used as gold standard, and the sign proved to have high specificity (99.58% 95%c.i. 97.69-99.99%) and high positive predictive value (98.63% 95%c.i. 90.97-99.81%), while sensitivity and negative predictive value were relatively low (24.66% 95%c.i. 19.82-30.02% and 51.97% 95%c.i. 50.31-53.61%). Conclusion: The identification of haemodynamically significant lesions in patients with clinically significant chronic venous disease is the aim of any form of imaging. In this study, we have depicted a previously undescribed sign which is straightforward to identify, particularly in DCTV, immediately pointing us towards hemodynamically significant chronic iliac venous outflow obstruction diagnosis. It presents an exceedingly high specificity and positive predictive value, and although it is too early to call it pathognomonic, perhaps comparative analysis involving data from additional centres could lead to this conclusion. Disclosure: Nothing to disclose

Venous Stenting in Proximal Venous Outflow Obstruction – Lessons Learned from 500 Cases

Introduction - Venous stenting is emerging as an important treatment strategy in venous disease. What is the real world experience with this procedure? This study reviews our experience with venous stenting in chronic venous insufficiency, highlighting patient selection, procedural considerations, outcomes, and re-interventions. Methods - This is a retrospective study of 500 patients who underwent venous stenting for chronic proximal venous outflow obstruction (PVOO) in the iliac veins from October 2013 to August 2016 at one centre. Preoperatively, we utilized venous duplex scan and magnetic resonance venogram to assist in patient selection. Intraoperative evaluation comprised of bilateral venogram and intravascular ultrasound. Wallstents were used in all cases (Boston Scientific, MA). Patients were discharged on day of procedure with rivaroxaban 10 mg initially followed by long-term Aspirin 81 mg. Wilcoxon-Mann-Whitney, Kruskal-Wallis, and logistic regressions were used in statistical analysis of variables and outcomes. Results - Of these 500 patients, follow-up was maintained in 90% of patients with a mean follow-up 320 days. Mean age of patients was 60 years old (SD 13.4 years) and 57% were female. Preoperatively, edema was present in 90.5%, and active ulceration 10.7%. 85 patients (17%) presented with persistent symptoms after a prior endovenous thermal ablation or surgery for superficial venous disease, and 69 patients (13.8) presenting with post-thrombotic syndrome. Among patients without any known DVT history, 21.5% had findings of chronic phlebitic changes (long segment diffuse disease, occlusion of vessel, intraluminal filling defects) on venogram or IVUS. Bilateral vein stents were performed in 59%. Kruskal-Wallis tests were significant for improvement (symptoms, CEAP class, and physical exam) in patients at thirty days (p=0.027), ninety days (p=0.045), six months (p=0.037), and one year (p=0.012). Ordered logistic regressions found the presence of edema (coefficient 1.59, 95% CI [0.52, 2.65], p=0.004), active ulceration (95% CI [0.022, 3.40], p=0.047), and decreased number of stents placed (coefficient -0.56, 95% CI [-1.08, -0.036], p=0.036) to predict increased improvement at thirty days, and a history of DVT (coefficient: -0.94, 95% CI [-1.79, -0.096], p=0. 029) to predict decreased improvement at one year post-operatively. Wilcoxon-Mann-Whitney tests were significant for more improvement in patients who had unilateral versus bilateral stents placed at thirty days (p=0.013) and six months (p=0.039). Major re-interventions (61.7% for recurrent symptoms, 17.6% for persistent symptoms, 6% for DVT) were performed in 7.6% of patients. Mean time to re-intervention was 191 days, and re-interventions were more prevalent (29. 4%) among patients with a known history of DVT. Conclusion - Our experience with venous stenting in chronic PVOO on an expanded scale suggested a satisfactory outcome at one year. Those patients with a prior history of DVT have poorer outcomes after venous stenting. Unilateral stents have better outcomes than bilateral stents, but the difference may reflect complexity of disease. Approximately 8% of patients will require a secondary re-intervention. Patient selection, procedural indications, and optimal pharmacologic therapy after venous stenting need further studies and clarification.

Evaluation of incidence and clinical significance of obturator hook sign as a marker of chronic iliofemoral venous outflow obstruction in computed tomography venography

ObjectiveThe aim of this paper was to describe the obturator hook sign (OHS), a distinctive dilated angled vein similar to a hook, by computed tomography venography (CTV). It is identified mainly on direct CTV (DCTV) as opposed to indirect CTV (ICTV), evidencing obturator vein engorgement as a marker of hemodynamically significant collateralization and representing an indirect sign for chronic iliac vein outflow obstruction. MethodsAll CTV studies of lower limbs performed from January 2014 to August 2018 in Galway University Hospital and the Galway Clinic were retrospectively reviewed. Data were analyzed using SPSS software (version 25.0; IBM Corp, Armonk, NY). ResultsIn total, 531 CTV studies were reviewed, of which 122 (23%) were performed for acute deep venous thrombosis, 183 (35%) for follow-up after iliac stenting, and 109 (21%) for etiologic study of chronic venous disease. For the purpose of analysis for the presence of OHS, only first-time CTV studies were included in patients who were never submitted to venous intervention (n = 296), of which 40 were DCTV (14%) and 256 were ICTV (86%). Two groups were defined according to whether OHS was present, and significant predictors were identified: female sex (P = .038), younger age (P < .0001), DCTV (P < .0001), nonthrombotic iliac vein lesion (P < .001), past history of iliofemoral deep venous thrombosis (P < .0001), and dilated pelvic veins (P < .0001). OHS was significantly more common in chronic occlusions compared with chronic stenosis or acute occlusion (P < .0001). Findings from DCTV and ICTV were compared with results from ascending venography as the “gold standard,” and the sign proved to have high specificity and positive predictive value (100% for both tests), whereas sensitivity and negative predictive value were low for both DCTV (65% [95% confidence interval (CI), 43%-84%] and 11% [95% CI, 7%-18%], respectively) and ICTV (8% [95% CI, 4%-14%] and 6% [95% CI, 9%-20%], respectively). From analysis of the remaining CTVs, particularly follow-up after iliac stenting, an interesting fact was recognized: successful venous stenting was associated with OHS disappearance, and stent occlusion was also sometimes associated with OHS reappearance or appearance de novo. ConclusionsThe identification of hemodynamically significant lesions in patients with clinically significant chronic venous disease is the aim of any form of imaging. In this study, we have depicted a previously undescribed sign that is straightforward to identify, particularly in DCTV, immediately pointing us toward hemodynamically significant chronic iliac venous outflow obstruction diagnosis. It is too early to call it pathognomonic, but perhaps comparative analysis involving data from additional centers could lead to this conclusion.

LEV 1. Endovenectomy of the Common Femoral Vein as Last Option in Severe Post-thrombotic Syndrome

The common femoral vein (CFV) and iliac veins compose the common channel for venous drainage of the lower extremity. Occlusive venous thrombosis of the CFV and iliac veins is associated with severe post-thrombotic syndrome and in some cases with nonhealing vein ulcers. After percutaneous intervention, relative obstruction of the CFV can persist, leading to incomplete drainage of the femoral and profunda femoris venous systems, thereby mitigating the benefit of iliac vein recanalization and risking rethrombosis; associated restenosis intrastent could occur, resulting in a great challenge for endovascular management. We describe a patient with incapacitating post-thrombotic syndrome and nonhealing ulcer who underwent angioplasty and stenting in the left common and external iliac veins, presenting with an occlusion intrastent that was impossible to cross with endovascular techniques. For this reason, a common femoral endovenectomy was performed, which allowed the ulcer to heal in 1 month after surgery. A 50-year-old man presented with left lower extremity pain, swelling, discoloration, and a venous ulcer above the lateral and medial malleolus. His medical history includes a left lower extremity deep venous thrombosis in 2012 (iliofemoral segment). He underwent angioplasty and stenting in the left common and external iliac veins in 2015, present ulcer healing. In 2018, he returned to our consultation with a residual ulcer. At that time, he had left leg pain and edema, which limited his daily activities, as well as a 3-cm-diameter venous ulcer above the lateral malleolus and 2 cm above the medial malleolus. The patient was offered a hybrid procedure to treat the chronic proximal venous obstruction, consisting of an open endovenectomy of the CFV and angioplasty. A 10-cm longitudinal incision was made at the left inguinal region. The CFV was identified and referenced with vessel loops. Five profunda femoris veins were controlled (Fig 1), and a venotomy was performed on the CFV. Dense synechiae and endoluminal fibrous tissue were excised. A bovine patch was placed in the venotomy. After that, a 5F introducer was placed over the path; phlebography was performed, observing intrastent occlusion in the common and external iliac veins with important collaterality. After several attempts, it was determined to be impossible to cross the occlusion of the stent. The procedure was finished with the potential to perform a femoral-femoral vein bypass as a second procedure 1 month after the endovenectomy (Fig 2). In this case, the patient’s symptoms improved and the vein ulcers healed 1 month after endovenectomy despite occlusion in the common and external iliac veins. Endovenectomy is a well-known but uncommonly reported procedure that could improve the symptoms of patients with post-thrombotic syndrome and help to heal vein ulcers even when the common and external iliac veins are occluded.Fig 2Healed ulcer 1 month after surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

1642 Pelvic Congestion Syndrome: An Unusual Manifestation of Sigmoid Pneumatosis Cystoides Intestinalis

INTRODUCTION: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts in the intestinal subserosa and submucosa. We present a rare case of primary PCI affecting sigmoid colon complicated by pelvic congestion syndrome (PCS). CASE DESCRIPTION/METHODS: A 34-year-old morbidly obese female presented with diffuse lower abdominal pain and intermittent foamy diarrhea without blood or mucus for the past 5 months. CT abdomen showed small bubbles of gas in the peritoneum in the left upper quadrant and large amount of cystic pneumatosis in a loop of sigmoid colon. Lab work was unremarkable. She was given one week course of antibiotics. A repeat CT scan 5 months later showed interval resolution of free intraperitoneal air but pneumatosis bubbles had enlarged in size. A colonoscopy was performed which showed large cystic-appearing air-filled bullae in sigmoid colon causing some luminal narrowing and the scope could not be safely advanced beyond mid-transverse colon. Patient underwent laparoscopic sigmoid colectomy and intraoperatively noted to have dilated and tortuous bilateral gonadal veins. Surgical pathology showed multiple clear fluid-filled cysts throughout the length of the specimen with viable and unremarkable proximal and distal resection margins. Patient recovered well from surgery and was discharged with no further complaints. DISCUSSION: PCI is an unusual condition caused by a myriad of underlying pathophysiological processes that range from benign to life-threatening conditions. Primary PCI is rare (15%), while underlying conditions for secondary PCI can be divided into several groups; traumatic, mechanical, inflammatory, autoimmune, infectious, pulmonary and drug (steroids and chemotherapeutic agents) induced. Conservative management is preferable except in cases of clinical deterioration. This case is unique because even after the resolution of free intraperitoneal air the patient continued to have lower abdominal and pelvic pain with worsening of pneumatosis on repeat CT scan several months later. It is possible that sigmoid anatomic changes due to pneumatosis resulted in chronic intermittent venous obstruction of pelvic veins leading to gonadal veins dilation and tortuosity and hence secondary PCS which resulted in ongoing lower abdominal pain. This case highlights the fact that persistent PCI, with ongoing abdominal symptoms even in the absence of any obvious etiology warrants laparoscopic exploration to rule out any underlying disease process.

Chronic venous obstruction during cardiac device revision: Incidence, predictors, and efficacy of percutaneous techniques to overcome the stenosis

In recent years, upgrade and revision procedures of cardiac implantable electronic devices (CIEDs) have become increasingly frequent. Patency of the access veins is critical for procedural success. The purpose of this study was to determine the incidence of venous obstruction at the time of system revision, to identify predictors of venous stenosis, and to evaluate the efficacy and safety of percutaneous techniques for overcoming stenosis. All patients admitted to our division from January 2004 to January 2017 for CIED revision with the intent to add 1 or more leads were included. Each patient underwent ipsilateral contrast venography. The degree of venous stenosis was determined with the support of quantitative coronary angiography and categorized as significant (75%-90%), subocclusive (90%-99%), or occlusive (100%). Of 227 patients, 61 (27%) showed a stenosis >75%. Different techniques were performed to overcome stenosis: direct vein access, distal venous puncture central to the stenosis, and percutaneous venoplasty in 25 (41%), 26 (43%) and 9 (15%) cases. respectively. All procedures were successful, without major complications. At multivariate analysis, having 3 leads before revision (odds ratio 0.444; 95% confidence interval 0.212-0.920; P=.029) and a previous system revision with lead insertion (odds ratio 0.323; 95% confidence interval 0.124-0.841; P=.021) were independent predictors of venous stenosis. Chronic venous obstruction is a relatively frequent finding after CIED implantation. The number of implanted leads seems to be an independent predictor of venous obstruction. In case of stenosis, the preprocedural angiography-guided structured approach allowed preservation of both contralateral access and functioning leads.