Deep Venous Obstructive Disease Research Articles

Options in the treatment of superficial and deep venous disease in patients with Klippel-Trenaunay syndrome

ObjectiveKlippel-Trenaunay syndrome (KTS) is a congenital mixed mesenchymal malformation syndrome that includes varicose veins, capillary and venous malformations, lymphatic abnormalities, and hypertrophy of various connective tissue elements. The purpose of the present study was to describe the clinical characteristics and outcomes in a subset of patients with KTS in whom venous interventions, including iliofemoral venous stenting, were performed after failure of conservative therapy. MethodsA single-center retrospective data review of 34 patients with KTS who had undergone interventions for venous disease between January 2000 and December 2020 was performed. ResultsTheir mean age was 38.4 ± 17.5 years (range, 12-80 years). No gender predilection was found. Of the 34 patients, 61% had had all three features of the classic triad for KTS. Varicose veins were present in all 34 patients (100%), and 30% had had a history of bleeding varicosities. Most patients (79%) had CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class ≥C4. Of the 34 patients, 30% had a history of deep vein thrombosis and/or pulmonary embolism. Factor VIII elevation was the most common thrombophilia condition (12%). The venous filling index was elevated at baseline (5.9 ± 5.1 mL/s) and did not normalize despite intervention (3.5 ± 2.3 mL/s; P = .04). The superficial venous interventions (n = 35) included endovenous laser therapy; stripping of the great saphenous vein, small saphenous vein, anterior thigh vein, or marginal vein; ultrasound-guided sclerotherapy; and stab avulsion of varicose veins. One coil embolization of a perforator vein was performed. Deep interventions (n = 19) included endovenous stenting (n = 15), popliteal vein release (n = 3), and valvuloplasty (n = 1). The venous clinical severity score had improved from 9.4 ± 4.5 to 6.2 ± 5.6 (P = .04). The visual analog scale for pain score had improved from 5.5 ± 2.7 to 2.5 ± 3.3 (P = .008). Healing of ulceration was noted in 75% of the patients. Significant improvements in the total pain (P = .04) and total psychological (P = .03) domains were noted in the 20-item chronic venous disease quality of life questionnaire. ConclusionsSuperficial and deep venous interventions are safe and effective in patients with KTS when conservative therapy has failed. Iliofemoral venous stenting is a newer option that should be considered in the treatment of chronic deep venous obstructive disease in patients with KTS in the appropriate clinical context. An aggressive perioperative deep vein thrombosis prophylaxis protocol should be in place to reduce thromboembolic complications in these patients.

Stent characteristics of 32 patients with early (

ObjectiveEndovascular treatment with percutaneous transluminal angioplasty and stenting has quickly gained popularity for treatment of deep venous obstructive disease. Early thrombosis after stenting in iliofemoral veins is uncommon. The treatment and analysis of the underlying factors leading to the rethrombosis of stents placed in the previous 14 days are reported in this study. MethodsPatients diagnosed with early in-stent thrombosis after iliofemoral stenting were reviewed in this retrospective analysis. Patients with acute occlusion were routinely treated by catheter-directed thrombolysis (CDT), and the underlying causes of early occlusion were identified during the procedure. After successful CDT procedures, patients received additional interventions (percutaneous transluminal angioplasty with or without stenting) if indicated. ResultsA total of 527 patients underwent stenting in the iliofemoral veins, and 32 patients (20 men [63%]) with acute thrombosis in iliofemoral venous stents placed in the previous 14 days were treated in our center from January 2015 to December 2018. The mean time from the onset of symptoms to the intervention was 6 days. Successful thrombolysis was achieved in 31 of the 32 patients, and additional stents were implanted in 16 patients. Patency was achieved in all cases. The underlying factors of early stent thrombosis were technical failure of the initial procedure, such as suboptimal positioning, failure owing to stent characteristics (stent kinking, compression, and angulation), in-stent residual thrombus, and inadequate anticoagulation. In all cases, recanalization was achieved through successful thrombolysis with or without restenting. ConclusionsTreatment with CDT and stenting of early in-stent thrombosis is effective and feasible. Recanalization of stented segment(s) can be achieved in most cases of recent thrombosis (<14 days). Early stent-related occlusion is mainly caused by stent-related problems and technical inadequacies.

The predictive value of haemodynamic parameters for outcome of deep venous reconstructions in patients with chronic deep vein obstruction - A systematic review.

Objective The aim of this study was to investigate the predictive value of haemodynamic parameters on success of stenting or bypass surgery in patients with non-thrombotic or post-thrombotic deep venous obstruction. Methods EMBASE, MEDLINE and trial registries were searched up to 5 February 2016. Studies needed to investigate stenting or bypass surgery in patients with post-thrombotic obstruction or stenting for non-thrombotic iliac vein compression. Haemodynamic data needed to be available with prognostic analysis for success of treatment. Two authors, independently, selected studies and extracted data with risk bias assessment using the Quality in Prognosis Studies tool. Results Two studies using stenting and two using bypass surgery were included. Three investigated plethysmography, though results varied and confounding was not properly taken into account. Dorsal foot vein pressure and venous refill times appeared to be of influence in one study, though confounding by deep vein incompetence was likely. Another investigated femoral-central pressure gradients without finding statistical significance, though sample size was small without details on statistical methodology. Reduced femoral inflow was found to be a predictor for stent stenosis or occlusion in one study, though patients also received additional surgery to improve stent inflow. Data on prediction of haemodynamic parameters for stenting of non-thrombotic iliac vein compression were not available. Conclusions Data on the predictive value of haemodynamic parameters for success of treatment in deep venous obstructive disease are scant and of poor quality. Plethysmography does not seem to be of value in predicting outcome of stenting or bypass surgery in post-thrombotic disease. The relevance of pressure-related parameters is unclear. Reduced flow into the common femoral vein seems to be predictive for in-stent stenosis or occlusion. Further research into the predictive effect of haemodynamic parameters is warranted and the possibility of developing new techniques that evaluate various haemodynamic aspects should be explored.

Abdominal and pubic collateral veins as indicators of deep venous obstruction.

Chronic deep venous obstruction can cause a significant loss of quality of life, although it can be treated successfully by stenting. A clear referral pattern for additional imaging is warranted in patients with lower limb complaints. The aim of this study was to determine the value of clinically visible abdominal wall collateral veins in the diagnosis of a potentially treatable deep venous obstruction. A total of 295 patients referred for evaluation at a tertiary venous clinic with a collateral vein on the abdominal wall or pubic bone, visible on physical examination, were retrospectively analyzed and compared with a randomly selected control group of 365 patients without such a collateral vein. Duplex ultrasound, magnetic resonance venography, computed tomography venography, and conventional venography were used to determine the presence or absence of deep venous obstruction. Mean age of the group with a positive collateral was 43.5± 13.7 (6-76) years compared with 44.7± 14.2 (16-89) years in the control group. In the collateral group, 66.1% werefemale compared with 63.3% in the control group. Sensitivity of the abdominal wall collateral vein for any obstruction atthelevel of the groin or more proximal was53%(95% confidence interval [CI], 48-57); specificity, 86% (95%CI, 79-91); positive predictive value, 93% (95% CI, 90-96); and negative predictive value, 32% (95% CI, 28-37). Sensitivity was 68% (95%CI, 62-73) for higher degrees of post-thrombotic obstruction and 27% (95%CI, 19-36) in iliacveincompression. A collateral vein on the abdominal wall or acrossthe pubic bone in patients with complaints of the lowerlimb has an excellent positive predictive value for deepvenous obstructive disease at the level of the groin orhigher.Such collateral veins should therefore not be removed, and symptomatic patients could be offered furtherdiagnostics and treatment.

Intravenous pressure changes in patients with postthrombotic deep venous obstruction: results using a treadmill stress test

Essentials Little is known about the hemodynamic consequences of deep venous obstructive disease. We investigated pressure changes in 22 patients with unilateral postthrombotic obstruction. Common femoral vein pressure significantly increased after walking, compared to control limbs. Common femoral vein hypertension could explain the debilitating effect of venous claudication. Click to hear Dr Ten Cate's perspective on postthrombotic syndrome Background Little is known about the hemodynamic consequences of deep venous obstructive disease. Objectives The aim of this study was to investigate the hemodynamic effect of postthrombotic obstruction of the iliofemoral veins and to determine what pressure parameters differentiate best between limbs with post-thrombotic obstructive disease of the iliofemoral veins and those without obstruction. Methods Twenty-two participants with unilateral obstruction of the iliac and common femoral veins underwent a standardized treadmill test with simultaneous bilateral invasive pressure measurements in the common femoral vein and dorsal foot vein. Results Mean age was 42.8±11.9years and 86.4% of participants were female. Postthrombotic limbs showed a mean common femoral vein (CFV) pressure increase of 28.1±21.0mmHg after walking, compared with 2.1±6.2mmHg in control limbs (26.0mmHg difference; 95% confidence interval [CI], 17.1-34.9). Lessdifference was observed in the dorsal foot vein (net drop of 36.8±22.7mmHg in affected limbs vs. 48.7±23.1mmHg in non-affected limbs, 11.9mmHg difference; 95% CI, -1.3 to 25.0). Change in CFV pressure after walking yielded the best discrimination between affected and non-affected limbs (area under the receiver operated characteristic curve of 0.94 [95% CI, 0.85-1.00], compared with 0.57 [95% CI, 0.37-0.76] in the dorsal foot vein, P<0.001). Conclusions Common femoral vein pressure significantly increases during ambulation in patients with iliofemoral postthrombotic obstruction, which could explain the debilitating effects of venous claudication. This is an indication that patients with an iliofemoral obstruction may benefit from further treatment that resolves the deep vein obstruction. https://clinicaltrials.gov/show/NCT01846780.

The value of hemodynamic measurements by air plethysmography in diagnosing venous obstruction of the lower limb.

Air plethysmography (APG) is a functional, noninvasive test that can assess volumetric changes in the lower limb and might therefore be used as a diagnostic tool in chronic deep venous disease. However, use of APG in chronic deep venous obstructive disease remains debatable. This study assessed the clinical value of APG in identifying chronic deep venous obstruction. All patients referred to our tertiary, outpatient clinic between January 2011 and August 2013 with chronic venous complaints and suspected outflow obstruction underwent an outflow fraction (OF), ejection fraction (EF), and residual volume fraction (RVF) test using APG. Duplex ultrasound and magnetic resonance venography were used to establish whether and where obstruction was present. Diagnostic values of these tests were assessed for obstructions at different levels of the deep venous system. A total of 312 limbs in 248 patients were tested. Mean age was 45.5± 14.0 years, and 62.5% were female. Inpost-thrombotic disease, specificity and positive predictive value for OF were as high as 98.4% and 95.0%, respectively; however, sensitivity was 34.8% and negative predictive valuewas 29.6%, with no clinically relevant positive or negative likelihood ratios. No clinically relevant differences were observed in stratifying for level of obstruction. EF and RVFwere as inconclusive. Neither could these parameters beused in diagnosing nonthrombotic iliac vein compression. We found a poor correlation between OF, EF, or RVF, determined by APG, and the presence of chronic deep venous obstruction. Therefore, use of its relative parameters is unwarranted in daily clinical practice.

The Diagnostic Value of the Pubic Collateral in Deep Venous Obstructive Disease.

The Diagnostic Value of the Pubic Collateral in Deep Venous Obstructive Disease.

Hemodynamic Consequences of Deep Venous Obstructive Disease.

Hemodynamic Consequences of Deep Venous Obstructive Disease.

Randomized Double-Blinded Study Comparing Clinical Versus Endovascular Treatment of Iliac Vein Obstruction.

Randomized Double-Blinded Study Comparing Clinical Versus Endovascular Treatment of Iliac Vein Obstruction.

Subfascial endoscopic perforator vein surgery combined with saphenous vein ablation: results and critical analysis.

This study was undertaken to determine the results of subfascial endoscopic perforator vein surgery (SEPS) combined with ablation of superficial venous reflux. Clinical data were retrospectively analyzed for 74 consecutive limbs (65 patients) in which this combination treatment was performed at a university medical center. Preoperatively, 58 lower extremities had an open venous ulcer (CEAP clinical class 6 [C(6)]) and 16 had healed ulceration (C(5)). Preoperative and postoperative ulcer care remained constant. Main outcomes measured included perioperative complications, ulcer healing, and ulcer recurrence. Clinical severity and disability scores were tabulated before and after surgery. Mean patient follow-up was 44 months. Greater saphenous vein (GSV) stripping and varicose vein excision accompanied SEPS in 57 limbs (77%), and SEPS was performed alone or with varicose vein excision in 17 limbs that had previously undergone GSV stripping. Postoperative complications occurred in 12 limbs (16%), all with C(6) disease (P =.04). Ulcer healing occurred in 91% (53 of 58) of limbs with C(6) disease at a mean of 2.9 months (range, 13 days-17 months). Multivariate analysis demonstrated that ulcer healing was negatively affected by previous limb trauma (P =.011). Ulceration recurred in 4 limbs (6%) at 7, 20, 21, and 30 months, respectively. This was associated with a history of limb trauma (P =.027) and preoperative ultrasound evidence of GSV reflux combined with deep venous obstruction (P(R,O); P =.043). Clinical severity and disability scores improved significantly after surgery (both, P <.0001). Most venous ulcers treated with SEPS with ablation of superficial venous reflux heal rapidly and remain healed during medium-term follow-up. Ulcer healing is adversely affected by a history of severe limb trauma, and ulcer recurrence is similarly affected by a history of limb trauma in addition to superficial venous reflux combined with deep venous obstructive disease. Overall, there was marked improvement of postoperative clinical severity and disability scores compared with those obtained before surgery.

Patients evaluated for venous disease may have other pathologic conditions contributing to symptomatology

Of the more than 200 patients recently evaluated for venous disease, 8 were diagnosed with lower extremity masses. Three patients were referred for superficial phlebitis and four for deep venous obstructive disease. The eighth mass was found during work-up for varicose veins. Five masses were identified by palpation, and three were identified by duplex scan. All were confirmed by magnetic resonance imaging (MRI) or computed tomography (CT). Of the eight masses, three were malignant: a metastatic melanoma, a histiocytoma, and a myxoid liposarcoma. Nonmalignant masses included a hematoma, an inflammatory lesion, a hemangioma, and an intramuscular lipoma. One patient presented with deep venous thrombosis secondary to an occluded popliteal artery aneurysm compressing the popliteal vein. Thus, patients presenting with ostensible venous disease may have other pathologic conditions responsible for symptomatology. Careful physical examination will reveal a mass in a majority of patients who have one. Duplex scanning will identify masses that should be confirmed by MRI or CT. Definitive diagnosis should be made by biopsy, due to the high possibility of malignancy.