Iliac Stent Research Articles

Pelvic Venous Disorders (PeVD).

Pelvic venous disorders (PeVDs) have replaced the concept of pelvic congestion syndrome encompassing venous origin chronic pelvic pain (VO-CPP) in women. The evaluation of women with VO-CPP includes the assessment for other causes of pelvic pain as well as imaging evaluation for pelvic varicosities measuring greater than 5 mm diameter, ovarian vein diameter, and flow direction, as well as iliac vein diameter and signs of compression. Proper identification of these patients can lead to high degrees of success eliminating chronic pelvic pain following ovarian vein embolization and/or iliac vein stenting. Strong encouragement is provided to use the symptoms, varices, pathophysiology classification for these patients and upcoming research studies on the specific symptoms of patients with VO-CPP will help elucidate patient selection for intervention. Additional future randomized controlled trials are also upcoming to evaluate for outcomes of ovarian vein embolization and iliac vein.

MAY-THURNER SYNDROME: UNCOMMONLY COMMON

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: May-Thurner syndrome is a venous compression syndrome characterized by common iliac vein compression between the left lumbar spine and the common iliac artery. The most common pattern is left common iliac vein compression by the right common iliac artery. Clinical presentation can vary from asymptomatic to signs and symptoms of venous stasis. This can include lower extremity swelling, edema, pain, and ulceration. More advanced stenosis results in deep vein thrombosis (DVT). The exact incidence and prevalence of MTS are unknown; however, it is felt to be underdiagnosed. MTS can be attributed to 2-5% of all venous thromboembolism (VTE). We present a case of DVT and pulmonary embolism (PE) in a patient who was found to have MTS. CASE PRESENTATION: The patient was an 83-year-old male with diabetes mellitus and hypertension who presented to the emergency department (ED) for evaluation of dyspnea on exertion. In the ED he was noted to be in respiratory distress, but otherwise hemodynamically stable. He was hypoxic, requiring supplemental oxygen via nasal cannula. Serum studies and chest radiographs were unremarkable. Computed tomography angiography of the chest revealed saddle pulmonary embolism extending into bilateral upper lobar arteries. After a thorough history, it was felt the VTE was unprovoked. The patient was admitted to the ICU and underwent emergent catheter-directed pulmonary artery thrombectomy. Anticoagulation was initiated with unfractionated heparin infusion. An echocardiogram revealed normal left ventricular function and a moderately dilated right ventricle. Lower extremity ultrasound revealed extensive clot burden in the left femoral, popliteal, and tibial veins. Lower extremity angiography revealed compression of the left common iliac vein. He subsequently underwent venous thrombectomy and common iliac vein stenting. He tolerated the procedures and hospitalization well and was ultimately discharged in stable condition DISCUSSION: MTS is characterized by compression of the left common iliac vein by the right common iliac artery, with resultant stenosis and venous stasis. It is estimated to cause 2-5% of all VTE although the prevalence may be higher (1). Diagnosis requires a high clinical suspicion, as MTS does not present specific findings in the setting of VTE. Initial presentation could range from lower extremity swelling to pain, venous stasis, or ulcerations – all of which could be attributed to the DVT (2). Making the diagnosis is important, however, as it presents a chance for therapeutic endovascular intervention. CONCLUSIONS: Our case highlights first that MTS may be very underdiagnosed. Secondly, it is a cause of provoked venous thromboembolism. It may therefore present a therapeutic endovascular option and may alter the duration of anticoagulation. For these reasons, the clinician should consider MTS in the differential for all VTE, and especially for recurrent VTE Reference #1: 1. Sigua-Arce P, Mando R, Spencer L, Halalau A. Treatment of May–Thurner's syndrome and associated complications: A multicenter experience. Int J Gen Med. 2021;14:4705–10. Reference #2: 2. Knuttinen MG, Naidu S, Oklu R, Kriegshauser S, Eversman W, Rotellini L, et al. May-Thurner: Diagnosis and endovascular management. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S159–64. DISCLOSURES: No relevant relationships by Wajahat Khan No relevant relationships by Nelson Okoh

Hybrid Revascularization for Extensive Iliofemoral Occlusive Disease

Total occlusion of the iliac-femoral tract can cause a variety of life-limiting symptoms ranging from mild claudication to chronic limb-threatening ischemia. Efforts should be made to revascularize the symptomatic ischemic limb. Currently there are different options in the vascular surgeon's armamentarium to achieve this. The aim of the study was to verify the feasibility and outcomes of inflow hybrid revascularizations combining femoral endarterectomy and recanalization of iliac atherosclerotic occlusion. A retrospective review was conducted of all hybrid revascularizations involving femoral endarterectomy and endovascular treatment of iliac occlusion. The operations were performed in Helsinki University Hospital between January 2013 and December 2018. First, information about patients' baseline characteristics, indications and details of surgery and technical/hemodynamic success, and complications and mortality were obtained from the vascular registry and patients records. Secondarily, a prospective assessment of mid-term patency was performed through follow-up in November 2019. Immediate technical success, 30-day mortality, complications, and patency were considered major outcomes. Hemodynamic improvement, amputation rate, and overall mortality were also assessed. One hundred sixty three iliofemoral occlusions were performed on 147 patients during the period studied. Six patients (3.6%) had infrarenal aortic occlusion, 86 (52.7%) had common iliac, and 128 (78.5%) had external iliac artery occlusion. Technical success rate was 88.3% (n=144 occlusions recanalized). Primary technical success was somewhat lower in lesions ≥ 90mm (87.1%) compared to lesions shorter than 90mm (95.7%; χ2P=0.06). Iliac stent was deployed in 141 (94.6%) cases, 51 (34.3%) of which were covered stents. Significant residual stenosis remained in 1.2% of cases. Median operative time was 4hr 34min (interquartile range 2 hr 43min) and median estimated blood loss was 743mL (interquartile range 500mL). Five patients (3.0%) developed a deep groin infection and 12 (8.1%) suffered any major cardiovascular event or stroke perioperatively. Primary patency at 30day, 6months, 1 year, and 2years was 98.7%, 98.1%, 96.6%, and 93.7%, respectively. Hemodynamic success was documented in 107 patients (73%). By the end of the follow-up, 7 iliofemoral tracts (11.1%) reoccluded, 2 limbs (1.2%) required amputation, and 50 patients (3.0%) died. Good immediate success rate and mid-term patency can be achieved by hybrid revascularization of iliofemoral occlusions. Careful patient selection is mandatory because this population often suffers from universal atherosclerosis. The involvement of the aorta represents a significant determinant of worse long-term patency, although it did not preclude technical success.

The influencing mechanism of iliac vein stent implantation for hemodynamics at the bifurcation

In the intervention with stent implantation for iliac vein compression syndrome (IVCS), it remains unclear about the influencing mechanism of the structure and implantation position of the stent for the hemodynamics of the affected site. In this paper, an iliac vein model was established. Besides, the computational fluid dynamics (CFD) was utilized to analyze the time-averaged wall shear stress (TAWSS) and oscillatory shear index (OSI) in a sine period after stent implantation based on the three different implantation positions of two iliac vein stents (the left branch outlet, contralateral disturbed flow and main iliac vein). The influence of the structure and implantation position of the stent on blood flow was revealed. These findings were verified by the particle image velocimetry (PIV) experiment. The results indicated that the maximum blood flow velocity of the iliac vein decreased after the stent implantation. Among the three positions, the influence of stent implantation on the iliac vein blood flow was the least when the stent implantation was performed at the left branch outlet; the influence of stent implantation on the iliac vein blood flow was the greatest when the stent implantation was performed at the contralateral disturbed flow. Moreover, there was little influence of Venastent implantation on the blood flow. These results could provide a scientific foundation for implantation treatment and stent design related to IVCS.

Endovascular Treatment of a Giant Iliac Vein Aneurysm After a Traumatic Arteriovenous Fistula

A 60 year old man with a history of a military mine injury 30 years previously presented with chronic leg swelling and a non-healing ulcer. Computed tomography angiography (CTA) revealed a giant iliac venous aneurysm (Figure A; red arrow) due to a chronic arteriovenous fistula (green arrows) in the proximal superficial femoral artery (SFA; mine fragments indicated by the blue arrows). An iliac limb stent graft (16 – 23 mm × 100 mm; W.L. Gore & Associates, Flagstaff, AZ, USA) was placed via an open antegrade common femoral artery approach into the SFA.

Relationship between iliofemoral venous stenting and femoropopliteal deep venous reflux

ObjectiveSevere presentations of chronic venous insufficiency can result from reflux or obstruction at the deep venous, perforator, or superficial venous levels. Iliofemoral venous stenting can be used to address central venous obstruction; however, its effects on deep venous reflux (DVR) have remained unclear. The purpose of the present study was to evaluate the effects of iliac vein stenting on femoropopliteal DVR with the hypothesis that ultrasound evidence of DVR would remain absent or would have improved after iliac vein stenting. MethodsThe present study was a retrospective review of patients who had undergone iliofemoral venous stenting from 2013 to 2018. The patients were divided into two cohorts according to the preprocedural presence (group A) or absence (group B) of femoropopliteal DVR. Baseline patient variables were collected, including age, gender, CEAP (clinical, etiologic, anatomic, pathophysiologic) class, presence of concomitant superficial or perforator reflux, deep vein thrombosis history, and additional venous interventions. The primary outcome evaluated was the persistent absence or resolution of DVR on the latest venous duplex ultrasound at follow-up. Other outcomes included the follow-up CEAP classification and the need for secondary deep venous interventions. ResultsA total of 275 consecutive patients had undergone iliofemoral venous stenting. Of the 275 patients, 58 had presented with DVR (group A). A comparison of groups A and B revealed that group A had had a greater likelihood of prior deep vein thrombosis (P = .0001) and a higher frequency of superficial venous ablation. The remaining demographic variables did not differ significantly between the two groups. Of the 58 patients in group A, DVR had resolved at follow-up in 17 (P = .0001). When stratified by level, 7 of these 17 patients had had isolated popliteal reflux. In group B, DVR had developed at follow-up in 6 of the 217 patients. The CEAP class had improved from before intervention (C0, 1.1%; C1, 0.4%; C2, 1.8%; C3, 41.4%; C4, 24.9%; C5, 5.9%; C6, 24.5%) to the latest follow up (C0, 4.9%; C1, 1.9%; C2, 5.7%; C3, 34.2%; C4, 22.8%; C5, 17.1%; C6, 13.3%). Significant improvement had occurred in C6 disease within both groups (group A, 16 of 58 [27.6%; P = .0078]; group B, 19 of 217 [8.8%; P = .0203]). ConclusionsFor patients who undergo iliofemoral venous stenting, DVR could improve if present initially and is unlikely to develop if not present before stenting. A cohort of patients had experienced persistent DVR and warranted further evaluation. Prospective studies are required to corroborate the safety, efficacy, and durability of iliofemoral venous stenting for patients with DVR.

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.

Clinical Efficacy of Venastent - A Novel Iliac Vein Stent for Non-Thrombotic Iliac Vein Lesions: A Multi-Centre Randomised Controlled Trial

To determine the efficacy of Venastent - a novel iliac vein stent for non-thrombotic iliac vein lesions (NIVLs). From October 2018 to January 2021, 256 NIVL patients were recruited at 19 Chinese hospitals. A randomised controlled trial was conducted to compare the efficacy of the new iliac vein stent-Venastent (Tianhong China) with Zilver stent (Cook USA). All patients were allocated randomly to two groups: the experimental group patients used Venastent, while the control group received the Zilver stent. The trial was registered in Chinese Clinical Trial Registry (ChiCTR2200057851). A total of 123 patients in the experimental group and 122 patients in the control group had a full set of data collected (p = ns). The technical success rate was 100% (n = 245/245). The patency rate was 100% (n = 123/123) in the experimental group and 98.4% (n = 120/122) in control group one year after operation (p = ns). The lower extremity swelling remission rate was 79.1% (n = 87/110) in the experimental group and 78.4% (n = 91/116) in the control group (p = ns). The lower extremity pain relief rate was 68.8% (n = 50/80) in the experimental group and 77.2% (n = 71/92) in the control group (p = ns). The ulcer healing rate was 90% (n = 18/20) in the experimental group and 87% (n = 20/23) in the control group (p = ns). There was no difference in stent re-stenosis or clinical remission between the two groups. The new iliac vein stent, Venastent, had a comparable high patency rate and safety profile as the Zilver stent (Cook) in NIVLs patients. Venastent significantly reduced symptoms of chronic venous disease.

Stent patency rates and prognostic factors of endovascular intervention for iliofemoral vein occlusion in post-thrombotic syndrome

ObjectivePost-thrombotic syndrome (PTS), an important complication of deep venous thrombosis (DVT), adversely affects patients’ quality of life. Endovascular intervention in PTS can relieve symptoms rapidly with high therapeutic value. This study mainly focuses on how to improve postoperative stent patency rates and aims to find prognostic factors impacting patency.MethodsAccording to the specific inclusion and exclusion criteria, PTS patients who underwent endovascular intervention at the First Affiliated Hospital of Sun Yat-sen University from December 1, 2014, to December 31, 2019, were included in this single-center prospective study. Follow-up data were collected and analyzed regularly over 2 years.ResultsOverall, 31 PTS patients were enrolled in the study. The mean age of these patients was 55.39 ± 11.81, including 19 male patients. Stent implantation was successful in 22 PTS patients, with a technical success rate of 70.97%. The average Villalta scores of the stent-implanted group and the non-stent-implanted group were 5.95 ± 2.57 and 5.78 ± 2.95, respectively, with no significant difference observed. In the stent-implanted group, the perioperative patency rate was 81.81% (18/22), and the follow-up patency rates were 68.18% (15/22) within 3 months, 59.09% (13/22) within 6 months, 45.45% (10/22) within 1 year, and 36.36% (8/22) within 2 years. Based on the stent placement segments, the 22 PTS patients were divided into two subgroups: the iliofemoral vein balloon dilation + iliofemoral vein stent implantation (FV-S) subgroup and the iliofemoral vein balloon dilation + iliac vein stent implantation (FV-B) subgroup. In the FV-S subgroup, the perioperative patency rate was 100.00% (14/14), and the follow-up patency rates were 85.71% (12/14), 71.43% (10/14), 57.14% (8/14) and 50.00% (7/14), which were higher than those for overall stent patency of all patients. The postoperative patency rates in the FV-B subgroup were 50.00% (4/8), 37.50% (3/8), 37.50% (3/8), 25.00% (2/8), and 12.50% (1/8). The secondary postoperative patency rates in the FV-B subgroup were 100.00% (8/8), 87.50% (7/8), 75.00% (6/8), 62.50% (5/8) and 50.00% (4/8).ConclusionsFor PTS patients with iliofemoral vein occlusion but patent inflow, iliofemoral vein stent implantation is a more efficient therapeutic option than iliofemoral vein balloon dilation with iliac vein stent implantation for PTS patients.

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.

A Clinical Trial of Venous Stent Placement for Post-thrombotic Syndrome: Current Status and Pandemic-related Changes.

Patients with post-thrombotic syndrome (PTS) and iliac vein obstruction have lower extremity symptoms, activity limitation and impairment of health-related quality of life. Preliminary studies suggest that iliac vein stent placement, which eliminates venous outflow obstruction, may reduce the clinical severity of PTS. However, stent placement is associated with patient risk, inconvenience and cost. Therefore, the Chronic Venous Thrombosis - Relief with Adjunctive Catheter-directed Therapy (C-TRACT) trial was launched to rigorously assess the risk-benefit ratio of stent placement for the treatment of moderate or severe PTS. In the trial, patients in both treatment groups receive a high quality of multimodality PTS care that includes medical, compressive, and ulcer therapies. Due to the COVID-19 pandemic, the trial protocol and practices were modified to enhance the study feasibility while preserving its ability to answer its primary question. This review summarises the current status of the trial and the potential impact of the pandemic-related adaptations to future venous clinical practice and research.

Clinical outcomes of AngioJet rheolytic thrombectomy in the treatment of May-Thurner syndrome-related deep venous thrombosis.

ObjectiveMay–Thurner syndrome (MTS) is an anatomic stenotic variation associated with deep vein thrombosis (DVT) of the left leg. The classical DVT treatment strategy is medical treatment without thrombus removal. This study was performed to assess the clinical outcomes of the combination of AngioJet™ rheolytic thrombectomy and stenting for treatment of MTS-related DVT.MethodsWe conducted a retrospective cohort study of patients treated for MTS-related DVT from January 2017 to June 2020 at a single institution.ResultsFourteen patients (nine women) underwent AngioJet™ rheolytic thrombectomy for MTS-related DVT during the study period. The median DVT onset time was 8 days (interquartile range (IQR), 3–21 days). The median procedure time was 130 minutes (IQR, 91–189 minutes), and the median hospital stay was 7 days (IQR, 5–26 days). One patient had a residual thrombus and occluded iliac stent and underwent adjuvant catheter-directed thrombolysis for revascularization. The primary patency rate for the iliac stent was 92.9% at 12 months.ConclusionConcomitant AngioJet™ rheolytic thrombectomy and stenting of MTS-induced lesions may be beneficial for patients with MTS-related DVT.

Efficacy of one-stop endovascular intervention in treatment of left iliac vein compression syndrome complicated with deep venous thrombosis of lower limbs.

To evaluate the clinical effect and safety of one-stop endovascular intervention in treatment of left iliac vein compression syndrome (IVCS) complicated with deep venous thrombosis (DVT) of lower limbs. Clinical data of 26 patients with secondary DVT due to IVCS admitted in the Department of Vascular Surgery, Hebei General Hospital from January 2018 to December 2021 were retrospectively analyzed. All patients underwent one-stop endovascular intervention procedure, including ultrasound-guided deep venipuncture, Angiojet catheter aspiration, iliac vein balloon dilation, stent implantation and simultaneous filter retrieval. The operation time and catheter aspiration time were documented; the preoperative and postoperative left lower extremity deep vein venous patency, circumferences of bilateral limbs at 15 cm above the knee and 10 cm below the knee, and the levels of hemoglobin, creatinine, alanine aminotransferase (ALT), aspertate aminotransferase (AST), total bilirubin and indirect bilirubin were measured. The incidence of post-thrombotic syndrome (PTS) and iliac vein stent patency were recorded through follow-up. The one-stop endovascular intervention was successfully performed in 26 patients, with the operation time of (171±35) min and the thrombolysis time of (263±89) s. After treatment, the left lower extremity deep vein venous patency, circumferences of bilateral limbs at 15 cm above the knee and 10 cm below the knee were decreased (all P<0.01); the hemoglobin level were decreased, the creatinine, ALT, AST, total bilirubin and indirect bilirubin levels were increased (all P<0.01). Patients were followed up for 1-12 months. Stent thrombosis occurred in 1 patient 7 months after procedure, and the symptoms were improved after conservative treatment; the stents were unobstructed in all patients, 1 patient had stent mural thrombosis, in whom the stent blood flow was not affected. No PTS was observed during the follow-up. The one-stop endovascular interventional treatment of IVCS complicated with DVT of left lower limb is safe and effective. Attention should be paid to the changes of liver and kidney function caused by catheter aspiration during the treatment, and corresponding intervention should be given in time to avoid the occurrence of related complications.

Abstract No. 607 Hypercoagulable states in stented thrombotic iliac vein compression syndrome with comparison of re-intervention and anticoagulation regimens

Endovascular therapy is playing an increasing role in the treatment of iliofemoral venous disease. Iliac stent patency is multifactorial, and current management is based on best clinical practices, varying by institution. Our goal is to evaluate the prevalence and compare how thrombophilia influences management and outcomes of patients who undergo venous stenting for thrombotic iliac vein compression syndromes.

Coronary Artery Disease Does Not Influence Outcomes of Iliac Vein Stenting

Although coronary artery disease (CAD) is a well-known prognosticator for worse outcomes of peripheral artery revascularization, the influence of CAD on the outcomes of lower extremity venous intervention is unknown. Our objective was to determine the impact of CAD on patient symptoms and reintervention rates after iliac vein stenting. We analyzed patients at a large tertiary care institution undergoing iliac vein stenting from August 2011 to June 2021. The venous clinical severity score was used to quantify symptoms. We stratified patients into two cohorts: those with CAD at the time of index procedure (CAD+) and those without (CAD−). Major reoperation was defined as any procedure using venography and minor reoperation as endovenous sclerotherapy or laser ablation. The two cohorts were compared with the 1-tailed independent samples t test for continuous variables and χ2 tests for categorical variables. Univariate and multivariate odds ratios (OR) of minor and major reintervention were determined using logistic regression models. Kaplan-Meier log-rank analysis was used to assess reintervention-free survival. Among 634 patients, we identified 76 (12.0%) CAD+ and 558 (88.0%) CAD−. The CAD+ group was significantly older, had a larger mean body mass index, and a larger mean CEAP class (Table). In addition, CAD+ patients had significantly higher rates of diabetes, hypertension, smoking history, and cancer (Table). CAD+ patients were also more likely to have an active venous leg ulcer at the time of iliac vein stent. The OR for a patient needing major reintervention was significantly higher for the CAD+ cohort on univariate analysis (OR: 1.93 [95% confidence interval [CI]: 1.06-3.39], P = .025), but only trended toward significance on multivariate analysis (OR: 1.79 [95% CI: 0.93-3.35], P = .072). The OR for any reoperation, major or minor, did not differ significantly between cohorts on univariate (OR: 1.12 [95% CI: 0.66-1.94], P = .686) or multivariate analysis (OR: 1.51 [95% CI: 0.85-2.74], P = .166). The CAD+ cohort had a larger mean number of reoperations, but the difference was not significant (2.1 vs 1.8, P = .128). The change in venous clinical severity score from the time of the index vein stent procedure did not significantly differ between the two cohorts at any follow-up time point in the 6 years after iliac vein stent (Table). Although CAD has a detrimental effect on the outcomes of peripheral artery disease interventions, this study indicates that CAD has no such impact on the outcomes of iliac vein stents.TablePreoperative characteristics, perioperative details, and postoperative outcomes of coronary artery disease (CAD)+ vs CAD− cohortsVariableCAD− (n = 558)CAD+ (n = 76)P valueDemographics and comorbidities Age (SD)60.3 (13.4)67.8 (10.7)<.001 Sex: male219 (39.4%)35 (46.7%).28 Diabetes105 (18.8%)38 (50.0%)<.001 HTN63 (82.9%)63 (82.9%)<.001 BMI (SD)26.2 (5.1)29.4 (7.5)<.001 Smoking Hx104 (18.6%)23 (30.3%).026 Cancer Hx51 (9.1%)20 (26.3%)<.001Perioperative details VCSS composite (SD)10.7 (3.7)11.4 (5.1).164 CEAP class mean (SD)3.5 (1.0)3.8 (1.4).037 Stent positionUnilateral224 (40.1%)33 (43.4%).673Bilateral334 (59.9%)43 (56.6%) Number of stents placed (SD)2.2 (1.0)2.1 (1.0).32Postoperative outcomes Days of follow-up (SD)770.8 (676.9)1001.1 (865.7).012 Number of total reoperations (SD)1.1 (1.3)1.4 (1.5).078 Number of reoperations in patients w/ ≥1 reoperation (SD)1.8 (1.2)2.1 (1.4).128 Univariate OR major reoperation1.93 [95% CI: 1.06-3.39].025 Multivariate OR major reoperation1.79 [95% CI: 0.93-3.35].072 Univariate OR any reoperation1.12 [95% CI: 0.66-1.94].686 Multivariate OR any reoperation1.51 [95% CI: 0.85-2.74].166 ΔVCSS 1st postoperative visit (SD)3.6 (4.4)3.3 (4.4).509 ΔVCSS 1-year follow-up (SD)6.4 (5.4)5.7 (6.9).289 ΔVCSS 2-year follow-up (SD)7.4 (5.6)7.7 (6.3).7 ΔVCSS 3-year follow-up (SD)8.2 (5.3)7.7 (5.7).406 ΔVCSS 4-year follow-up (SD)8.8 (4.9)8.5 (5.9).538 ΔVCSS 5-year follow-up (SD)9.1 (4.8)9.0 (5.4).839 ΔVCSS 6-year follow-up (SD)9.4 (4.7)9.1 (6.2).61BMI, Body mass index; CEAP, Clinical, Etiology, Anatomic, Pathophysiology; CI, confidence interval; HTN, hypertension; OR, odds ratio; SD, standard deviation; VCSS, venous clinical severity score. Open table in a new tab

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

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.

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.

Real-World Data Showing Lack of Complications Without Use of Closure Devices in the Office-based Vascular Procedure Center

Closure devices are available in a range of different schemata to close the percutaneous arteriotomy. Although they may contribute to room turnover and increased time to ambulation, they carry the risk of dissection, thrombosis, failure, and expense that may bring a patient back for an avoidable operation, causing undue stress to a patient who elected to avoid the hospital to seek office-based care. In addition, there is hardship of a foreign object in the skin, increasing inflammation and scarring should the groin need to be reaccessed or exposed. In an office-based setting where adequate manual pressure can be held, their use may be obviated and unnecessary. Without real-world examples of protocols and complication rates, many surgeons may be uncomfortable with this transition. Using our Vascular Quality Initiative database, all patients who underwent an office-based endovascular procedure in which groin access was employed (aortic, iliac, or peripheral stenting, balloon angioplasty, atherectomy, and diagnostic angiograms) from 2015 to 2021 were identified. These procedures were elective and mainly for occlusive disease. Preoperative patient characteristics, procedure characteristics, and access-related outcomes were analyzed. Access guidance was uniformly obtained with ultrasound imaging. In our protocol, protamine is administered routinely. Fifteen minutes of pressure is uniformly held on each groin by the surgical technician, over an area marked out by the surgeon. The patient lays flat for 3-4 hours afterward, depending on sheath size. Patients are reached by telephone 1-3 days after their procedure to assess their immediate postprocedure status. Five hundred eighty-three patients met inclusion criteria. These were 61% male, 67% White, and 30% African American, with an average body mass index of 28. Thirty-six percent needed assistance with daily activities. Thirty percent had coronary artery disease, 22% chronic obstructive pulmonary disease, 45% diabetes mellitus, and 45% were smokers. Preoperative medications that included 73% aspirin and 57% clopidogrel. Redo-groin status was in 61% of patients. On average, largest sheath size was 6F, ranging from 4F to 8F. Protamine was administered in >80% of cases. Access site complication requiring additional observation was 0.5% (n = 3) and these were all hematomas. There were no postprocedure bleeds on follow-up. Any sort of postprocedure complication was 0.9%. Complication causing hospital admission was 0.2%, and none were related to access. The use of closure devices incurs the added risk. These data show a 6-year experience in the office-based setting that not using closure devices and instead using manual pressure is safe without significant complication. This should prompt discussion regarding the necessity of using closure devices in office-based endovascular procedures.