Chronic Venous Outflow Obstruction Research Articles

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.

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.

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.

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.

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.

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.

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.

Performance of Open and Closed Cell Laser Cut Nitinol Stents for the Treatment of Chronic Iliofemoral Venous Outflow Obstruction in Patients Treated at a Single Centre

A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction. A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency. A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 – 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 – 6.62, p < .001). OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design.

Performance of Open and Closed Cell Laser Cut Nitinol Stents for the Treatment of Chronic Iliofemoral Venous Outflow Obstruction in Patients Treated at a Single Centre

A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction. A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency. A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 - 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 - 6.62, p < .001). OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design.

Chronic venous outflow obstruction: An important cause of chronic venous disease.

Chronic venous outflow obstruction is a significant cause of chronic venous disease and therefore chronic morbidity. When conservative measures fail, intervention through deep venous reconstructive techniques should be considered. Referral should be considered in all patients with features of chronic venous disease that are life-affecting. Imaging relies primarily on duplex ultrasonography, supplemented by computed tomographic and magnetic resonance venography, and intraoperatively by intravascular ultrasonography. Intervention is primary endovenous, using angioplasty and stenting. Open surgical procedures are used in very select patients.

Comparison of Iliofemoral Vein Stenting in Octogenarians and Older to the Younger Population

Octogenarians and nonagenarians represent a significant proportion of patients undergoing vein stenting for chronic proximal venous outflow obstruction (PVOO). This study compares symptomatic improvement after iliac vein stenting in this patient cohort with younger patients undergoing intervention.

Improvement in Thoracic Outlet Syndrome Symptoms After Iliac Vein Stenting for Iliac Vein Proximal Venous Outflow Obstruction

An association between chronic proximal venous outflow obstruction (PVOO) in iliac veins and thoracic outlet syndrome (TOS) has not been previously reported. We observed some patients with iliac vein PVOO to have concurrent TOS symptoms. After iliac vein stenting, we witnessed not only the expected improvement in lower extremity venous symptoms but also significant improvement in TOS symptoms. This study states our findings and investigates this phenomenon.

A Comparison of Open versus Closed Cell Dedicated Venous Stents for Treatment of Chronic Iliofemoral Venous Outflow Obstruction

A Comparison of Open versus Closed Cell Dedicated Venous Stents for Treatment of Chronic Iliofemoral Venous Outflow Obstruction

Trends in Pharmacologic Management After Iliac Venous Stent Placement

The optimal pharmacologic regimen after vein stent placement for chronic proximal venous outflow obstruction (PVOO) varies significantly amongst vascular surgeons. This study was conducted to highlight this concern, and support the need for a uniform treatment algorithm for pharmacological management following venous stent placement.