Iliac Vein Recanalization Research Articles

The Effect of Balloon-Assisted Pharmacomechanical Catheter-Directed Thrombolysis on the Patency and Post-Thrombotic Syndrome in Patients with Acute Iliofemoral Deep Vein Thrombosis: Is it Really Necessary or Not?

The objective of this study was to describe the contribution and advantage of balloon-dilatation of iliac and femoral veins following pharmacomechanical catheter-directed thrombolysis (PCDT) on the development of post-thrombotic syndrome (PTS). From October 2018 and January 2022, 85 patients with acute total occlusion of the iliac and femoral veins were treated with PCDT. The cohort was divided into 2 groups depending on the utilization of concomitant balloon dilatation of iliac and femoral veins (Group 1, n=34, 40.0%) or not (Group 2, n=51, 60.0%) during the PCDT. All patients underwent duplex ultrasound scanning for evaluating the patency of iliac veins and recanalization rates at 3, 6, and 12months postoperatively. The Villalta score was used to score the severity of PTS at 12months postoperatively. Patients who underwent balloon-assisted PCDT (group 1) exhibited significantly higher primary patency rates in common iliac vein (CIV) (recanalization 84.3±14.6%, P=0.003), external iliac vein (EIV) (recanalization 82.8±17.2, P=0.003) and common femoral vein (CFV) (recanalization 88.1±12.1%, P=0.038) compared with the group 2 at the end of 12months follow-up. Only 2 patients underwent venous stenting in follow-up due to severe venous claudication, however, 13 patients were required iliac vein stenting due to severe PTS proved with a high Villalta score at 12-month follow-up. The d-dimer level at 1-year follow-up had also significantly lower in Group 1 due to higher rates of patency and lower thrombosis burden. The most common bleeding events were hematuria (n=4) or oozing in the puncture site (n=4). This study showed that balloon-assisted PCDT reduces the risk of PTS, is more successful in common iliac vein recanalization, reduces the need for the venous stent, and even lowers the D-dimer levels of the patients compared to routine PCDT alone.

Venous Recanalization and Stenting After Iliac Vein Injury

The objective of this study was to report an endovascular treatment for patients experiencing complications after iliac vein ligation. Management of venous injury consists largely of venous ligation or primary repair. Complications consist of lower extremity swelling, venous hypertension, venous thromboembolism, and compartment syndrome. Whereas conservative management is often successful for symptomatic swelling, there is little current literature regarding treatment of failed conservative therapy. A retrospective chart review performed from 2017 to 2020 identified three patients who underwent recanalization and venous stenting after previously ligated iliac vein. Case 1: A 23-year-old man suffered a gunshot wound to the left external iliac requiring ligation. He developed venous hypertension requiring fasciotomy of the left lower leg and thigh. Recanalization with stenting of the left external iliac vein with mechanical thrombectomy of the common femoral and external iliac vein was performed. Completion venography showed no residual stenosis. The patient was discharged on anticoagulation with normal flow on noninvasive studies 2 months later. Case 2: A 21-year-old man suffered a gunshot wound to the abdomen with injury to the inferior vena cava (IVC) and right iliac vein requiring ligation. Postoperatively, he developed iliac vein stenosis with symptomatic lower extremity swelling. Iliac vein recanalization with bilateral iliac vein stenting and IVC confluence reconstruction was performed. He was discharged on anticoagulation with patent venous stents and normal flow on noninvasive studies 2 months later. Case 3: A 44-year-old man presented with chronic swelling and left leg pain following ligation of the left iliac vein after iatrogenic injury during spinal surgery. Conservative compression therapy was unsuccessful. Preoperative computed tomography venography revealed chronic occlusion of the left iliac vein. Recanalization was performed, with improvement of flow through the left iliac system with filling into the IVC. The patient was discharged on anticoagulation, with patent stents on noninvasive studies at 6-month follow up. Venous recanalization with stenting is a successful treatment for complications after iliac vein ligation.

Endophlebectomy of the common femoral vein and endovascular iliac vein recanalization for chronic iliofemoral venous occlusion

BackgroundChronic post-thrombotic occlusion of the iliofemoral veins causes significant morbidity, which can be alleviated if venous drainage is restored. We report our technique of surgical endophlebectomy and patchplasty of the common femoral vein (CFV) in conjunction with iliac vein stenting to restore venous flow from the infrainguinal venous system to the vena cava. MethodsThere were 157 patients who underwent CFV endophlebectomy combined with iliocaval recanalization. Questionnaires were completed both preoperatively and postoperatively to allow comparison. These included the Clinical, Etiology, Anatomy, and Pathophysiology clinical classification; the Venous Clinical Severity Score; the Villalta scale; the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms; and the 36-Item Short Form Health Survey quality of life questionnaire. ResultsMean follow-up duration was 14.4 ± 2.9 months (range, 10-29 months). The mean preoperative Venous Clinical Severity Score was 15.3 ± 2.2, and this fell to 6.1 ± 1.8 after treatment (P < .001). The mean preoperative Villalta score dropped from 12.7 ± 2.6 to 6.3 ± 1.4 (P < .001). The quality of life and symptom severity scores were improved after 3 months by 17.2 points for quality of life (P < .001) and 20.5 points for symptom severity (P < .001). Primary patency was 81% (124/153) and secondary patency was 89.5% (137/153) at 12 months. Wound complications related to groin incision and lymphatic fistulas were observed in 22.8% (35/153) and 28.7% (44/153), respectively. ConclusionsThe hybrid operation of CFV endophlebectomy in conjunction with iliac vein recanalization should be considered a safe and effective treatment option in patients with severe post-thrombotic syndrome and iliofemoral veno-occlusive disease.

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

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

Underlying CT anatomy and subtype diagnosis of iliac vein compression syndrome

Objective To explore the underlying anatomy of iliac vein compression syndrome (IVCS) using CT, and discuss the imageological index for subtype diagnosis and potential clinical significance. Methods We retrospectively analyzed the imageological data of 69 IVCS patients from July, 2009 to June, 2014. According to CT findings, patients were categorized to simple IVCS (sIVCS, the iliac vein is compressed by only the anterior iliac artery, n=22), lumbar degeneration-related IVCS (dIVCS, besides the iliac artery, the lower lumbar degenerative changes including osteophyte, protruded disc, etc. pressed the iliac vein from the back, n=33) and other IVCS causes (oIVCS, including tuberculosis, inflammation and fracture hematoma of the lumbar spine, n=14); meanwhile, 69 age- and sex-matched subjects was set as a control group. Evaluated indexes were onset age, course of lower limb swelling and pain, size of the iliac vein tunnel ahead lumbar (IVTAL), lower lumbar spine forward curvature angle (LLSCA), iliac vein-pressed signs by lower lumbar degeneration, compression sites, scope of deep venous thrombosis and interventional therapeutic effect. The differences of those indexes of various groups were compared. Data as onset age, course of disease, sizes of IVTAL and LLSCA were evaluated using variance analysis of the general linear model, with Bofferroni test correction for multiple comparisons. Data as iliac vein-pressed site, scope of venous embolism and therapeutic effect were assessed by crossing table χ2 test. All statistical analyses were performed using SPSS17.0 software (SPSS company, Chicago, USA). Bilateral P≤0.05 were considered to be significant. Results The onset mean age was (61.5±10.6) yr. in dIVCS, (42.3±6.5) yr in sIVCS. and (53.1±16.8) yr. in oIVCS with a significant difference (F=11.030, P<0.01). Mean sagittal diameter of the IVTAL and LLSCA were (2.3±0.5) mm and (121.8±5.4) ° in dIVCS and (2.5±0.5) mm and (124.4±3.9) ° in sIVCS, respectively; which were smaller than those of control group [ (6.4±1.6) mm and (127.5±7.3) °, respectively] and oIVCS [ (5.9±2.3) mm and (129.5±5.9) °, respectively] (F=125.275, P<0.01 for sigittal diameter and F=7.95, P<0.01 for LLSCA) . The degenerative changes compressing the iliac vein of dIVCS had 41 sites of 33 patients which were respectively the discal forward protrusion or bulge (51%, 17/33), vertebral anterior osteophyte (50%, 16/33)and lower lumbar vertebrae slippage (19%,8/33). The compression sites of dIVCS located exactly anterior to the fifth lumbar (18/33, 56%) , the intervertebral disk between the fourth and fifth lumbar (9/33, 26%) , the right front (3/33, 9%) and left front (3/33, 9%) of the fifth lumbar, however, that of sIVCS sited the right front (14/22, 64%) , exactly the front (4/22, 18%) of the fifth lumbar and exactly anterior (4/22, 18%) to the intervertebral disk between the fourth and fifth lumbar, with a significant difference of location distribution (χ2=19.305, P<0.01) . In sIVCSs, deep vein thrombosis of all exceeded the iliac vein length and implicated the femoral vein by 27% (6/22) and the popliteal vein by 73% (16/22) , while in dIVCSs 18% (6/33) patients had deep vein thrombosis in the iliac vein, 30% (10/33) in the femoral vein and 52% (17/33) in the popliteal vein, and in oIVCSs, 30% (4/14) patients had deep vein thrombosis in the iliac vein, 40% (6/14) in the femoral vein and 30% (4/14) in the popliteal vein, with a significant difference of thrombosis scope (χ2=9.28, P<0.01) . 86% sIVCSs needed intravenous stent-implanted operation to obtain effective treatment, only 52% dIVCSs were performed stent-implanted operation for effective therapy, none of oIVCSs had stent-implanted operation before the iliac vein recanalization. Conclusion CT can precisely display the pathological anatomy features of different IVCS patients, which can potentially help clinicians plan accurate treatment strategy. Key words: Iliac vein compression syndrome; Degenerative lumbar disease; Radiology, interventional

Endovenectomy of the common femoral vein and intraoperative iliac vein recanalization for chronic iliofemoral venous occlusion

Chronic postthrombotic occlusion of the iliofemoral venous segments produces severe morbidity, which can be alleviated if venous drainage is restored. The common femoral vein (CFV) cannot always be fully recanalized with percutaneous endovenous techniques alone. We report the technique combining operative endovenectomy and patch venoplasty of the CFV with intraoperative iliac vein venoplasty and stenting to restore unobstructed venous drainage from the infrainguinal venous system to the vena cava. This procedure led to reduced pain, edema, and healing of a long-standing venous ulcer, with a marked reduction in postthrombotic morbidity.

Percutaneous iliac vein recanalization 17 years after thrombotic occlusion

Persistent venous outflow obstruction of the iliac veins is one of the mechanisms that seem to portend the greatest risk for late development of severe complications. We report the case of a 42-year-old male with postthrombotic occlusion of the left external iliac artery since the age of 25. We managed to recanalize the obstructed vessel and establish a good flow into the inferior vena cava by venous stenting. After successful intervention the patient reported instant symptom relief and was free from venous claudication and leg heaviness at the 6 month follow-up examination. Even after long history of postthrombotic syndrome, venous stenting can be an option for patients with chronic outflow obstructions of the iliac veins.

Endovascular Treatment for Chronic Iliofemoral Venous Obstruction

Treatment of chronic iliac vein thrombosis using endoluminal stents has become a therapeutic alternative for a clinical problem that is often severe. Spontaneous recanalization of chronically occluded deep veins is almost always possible, but iliac vein recanalization is much less frequent in patients who have poor inflow or have associated thrombosis of the inferior vena cava. The technical success rate of iliac vein stenting is quite good, and both clinical outcomes and patency rates are satisfactory. This article focuses on the technical aspects of the procedure as well as on clinical and procedural outcomes.

Iliac compression syndrome and recanalization of femoropopliteal and iliac venous thrombosis: A prospective study with magnetic resonance venography

Objectives Poor iliac vein recanalization has been associated with compression of the left common iliac vein by the right common iliac artery (RCIA/LCIV compression); however, this finding has been difficult to confirm. In a baseline study, RCIA/LCIV compression was detected with magnetic resonance imaging in patients with deep venous thrombosis. We compared recanalization of left femoropopliteal and iliac thrombosis with and without RCIA/LCIV compression. Methods This was a prospective blinded study carried out in a 1355-bed university hospital. Thirty-one patients were recruited from consecutive cohorts of patients with iliofemoral and femoropopliteal DVT who underwent direct thrombus magnetic resonance imaging, venous enhanced peak arterial magnetic resonance venography, and magnetic resonance arteriography as part of the baseline study relating RCIA/LCIV compression to extent of thrombosis. Magnetic resonance venography was performed 6 weeks, 6 months, and 1 year after diagnosis of deep venous thrombosis. Femoropopliteal and iliac venous segments that were occluded at diagnosis were classified as occluded, partially occluded, or patent on follow-up scans. Results At 6-week follow-up, recanalization of all segments was incomplete. At both 6-month and 1-year follow-up, recanalization of left iliac segments associated with RCIA/LCIV compression was poorer compared with recanalization of left iliac segments not associated with compression (6 of 6 occluded vs 1 of 6 occluded and 1 of 6 partially occluded at 6 months, P =.015; 6 of 6 occluded vs 5 of 5 patent at 1 year, P = .002). This was due to complete failure of recanalization of left common iliac veins associated with RCIA/LCIV compression in 6 of 6 cases. All other iliac and femoropopliteal segments including left external iliac veins associated with RCIA/LCIV compression had high rates of recanalization at both 6 months and 1 year. Conclusion RCIA/LCIV compression is associated with persistent occlusion of the left common iliac vein. The recanalization rate for all other femoropopliteal and iliac segments was high.