Iliac Vein Stent Placement Research Articles

Iliac Vein Stent Placement: Acute Venographic Changes and Relevance to Venous Biomechanics

PurposeTo describe acute venographic changes of external iliac vein (EIV) after ipsilateral common iliac vein (CIV) stent placement. Materials and MethodsRetrospective review was performed of 17 cases with placement of a single CIV stent. Central CIV stent diameter and minimal ipsilateral EIV diameter were measured on venogram; vein diameter was measured at the same 2 anatomic locations on venogram obtained before intervention. Relative CIV diameter increase was defined as the ratio of change in central CIV diameter after stent placement to CIV diameter before intervention. Relative EIV diameter reduction was defined as the ratio of change in diameter of EIV after stent deployment in CIV to EIV diameter before intervention. Diameters before and after intervention were compared using a 2-tailed, paired sample t test. Pearson coefficient was calculated for correlations. ResultsThere was a significant reduction of EIV diameter after ipsilateral CIV stent placement compared with before stent placement (mean 9.3 mm ± 3.1 vs 11.9 mm ± 3.8; P < .01); mean decrease in EIV diameter was 21.7% ± 15.8. There was a correlation between relative CIV diameter increase and relative EIV diameter reduction (r = .8917). ConclusionsSignificant venographic narrowing of the EIV occurs after placement of an adjacent CIV stent, and the degree of narrowing is associated with the relative increase in CIV diameter. These findings may be explained by the inherent anisotropic elasticity of veins. Further study is warranted to guide future venous interventions.

Contralateral Deep Vein Thrombosis after Iliac Vein Stent Placement in Patients with May-Thurner Syndrome

PurposeTo investigate the incidence and potential causes of contralateral deep vein thrombosis (DVT) after common iliac vein (CIV) stent placement in patients with May-Thurner syndrome (MTS). Materials and MethodsData of 111 patients (women: 73%) who had CIV stent implantation for symptomatic MTS at a single center were retrospectively analyzed. Mean patient age was 63.1 ± 15.2 years. Median follow-up was 36 months (range, 1–142 months). Stent location was determined by venogram and classified as extended to the inferior vena cava (IVC), covered the confluence, or confined to the iliac vein. Potential causes of contralateral DVT were presumed based on venographic findings. The relationship between stent location and contralateral DVT was analyzed. ResultsTen patients (9%, men/women: 4/6) exhibited contralateral DVT at a median timing of 40 months (range, 6–98 months). Median age was 69 years (range, 42–85 years). Median follow-up was 73.5 months (range, 20–134 months). Potential causes were venous intimal hyperplasia (VIH) (n = 7), “jailing” (n = 2), and indeterminate (n = 1). All patients with VIH had previous CIV stents overextended to the IVC. Overextension of CIV stent was associated with contralateral DVT (P < .001). The primary patency rate of the contralateral CIV stent was 70% at 20 months. ConclusionsContralateral DVT after CIV stent implantation has a relatively high incidence and often occurs late during follow-up. Overextension of the CIV stent to the IVC is associated with development of contralateral DVT, and VIH should be considered a potential cause.

Venous Stenting in Proximal Venous Outflow Obstruction: Outcome Predictors

The objective of this study was to identify risk factors, including patient and surgical characteristics, associated with postoperative outcomes after iliac vein stenting for chronic proximal venous outflow obstruction (PVOO). The study is based on a composite retrospective and prospective database of 628 patients who underwent iliac vein stent placement for chronic PVOO at a single institution from January 2013 to April 2017. Patient characteristics, clinical presentation, and outcomes at 30 days, 90 days, 6 months, 1 year, and >1 year were queried. Univariate and multivariate ordinal regression, with stepwise backward elimination, was used to determine predictors of postoperative outcomes at various time points. Demographic characteristics included 351 (55.9%) women and mean age of 59.7 years. Edema was present in 568 (93%) patients. History of varicose veins or presence of varicose veins at the time of surgery was observed in 431 (70.4%) patients. Active ulceration was present in 94 (15%) patients. Clinical, Etiology, Anatomy, and Pathophysiology class 3 was noted for 69.4%. Bilateral stenting was performed in 385 (63.2%) patients. Univariate analysis showed that improvement in outcomes at 30 days was associated with edema (odds ratio [OR], 2.7; confidence interval [CI], 1.4-5.0; P = .002) and active ulceration (OR, 1.6; CI, 1.0-2.6; P = .03). Poorer outcomes at 30 days were associated with bilateral stenting (OR, 0.62; CI, 0.44-0.88; P = .007). At 90 days, improvement was associated with varicose veins (OR, 1.6; CI, 1.0-2.4; P = .03), edema (OR, 3.2; CI, 1.5-6.8; P = .002), and history of vein surgery (OR, 1.7; CI, 1.2-2.5; P = .008). At 6 months, univariate analysis demonstrated that being female (OR, 0.62; CI, 0.40-1.00; P = .03) resulted in poorer outcomes. Patients who had edema had better outcomes at 1 year (OR, 5.5; CI, 1.8-17.4; P = .003) and at >1 year (OR, 6; CI, 1.5-24.5; P = .013). At 30 days, multivariate analysis showed that the effects of edema and bilateral stenting persisted. At 90 days, the effects of edema and history of vein surgery persisted. In addition, multivariate analysis revealed that a history of deep venous thrombosis (DVT; OR, 0.405; CI, 0.213-0.771; P = .0059) resulted in poorer outcomes at 90 days, whereas active ulcerations (OR, 2.447; CI, 1.337-4.479; P = .0037) resulted in better outcomes. The effect of sex on outcomes at 6 months persisted. At outcomes >1 year, multivariate analysis revealed that acute DVT (OR, 0.111; CI, 0.015-0.838; P = .0331), DVT history (OR, 0.313; CI, 0.116-0.843; P = .0216), and bilateral stenting (OR, 0.349; CI, 0.132-0.921; P = .0335) were associated with poorer outcomes. Outcomes of iliac vent stenting are affected by multiple factors. Patients with edema are likely to benefit from iliac vein stenting. The benefits of venous stenting in active ulcers warrant further investigation as unreported here is the frequency of negative venography and IVUS among patients with active ulcers. Our findings may guide selection of patients and better counsel patients about the outcomes of venous stents in chronic PVOO.

PC184 Delayed Conversion to Kissing Stent Configuration in the Setting of Unilateral Iliac Vein Stenting

Iliac vein stents are being increasingly used to treat chronic proximal venous outflow obstruction. Among patients with unilateral stenting in the proximal common iliac vein with extension into the inferior vena cava (IVC), a small number of patients presented with venous symptoms related to outflow obstruction of the contralateral common iliac vein. While the incidence of this complication of iliac vein stenting is unknown, this abstract presents one technical approach to this complication. We present 11 patients with outflow obstructive symptoms in the contralateral iliac vein after a prior IVC common iliac vein stent placement. Postanesthesia, ultrasound guidance is used to obtain access to the common femoral vein bilaterally. Inferior vena cavograms and venograms of the iliac veins are undertaken using contrast in digital subtraction mode. Intravascular ultrasound (IVUS) using a Volcano Visions PV .035 Digital IVUS catheter (Volcano Corporation, San Diego, Calif) is then used to evaluate the iliac veins and assess the degree of stenosis in each vein segment. The use of IVUS is critical to locate the narrow channel present between the contralateral stent and wall of the IVC, assist passage of the guidewire through this narrow channel, and ensure that the guidewire does not pass through the interstices of the stent (Fig 1). Balloon angioplasty is seldom necessary. The initial guidewire is then exchanged for a stiff 0.35-inch × 180-cm guidewire. Next, a 16-mm or 18-mm stent is positioned alongside the existing stent in a kissing iliac stents configuration. After the newly placed stent is deployed, both stents are simultaneously dilated with either 16-mm or 18-mm balloons (Fig 2). Finally, a completion venogram and IVUS confirm fully expanded stents. This procedure was performed in 11 patients (6 males, 5 females), with three performed on the right iliac vein and eight on the left iliac vein. The mean time to development of contralateral occlusive symptoms was 626 days from the initial stenting. Average follow-up time from the second stenting was 167 days, with no postoperative complications. Eight patients reported significant symptomatic improvement in their newly treated limb at 30 days postoperatively, while 10 patients did at 90 days postoperatively. No patients reported any worsening symptoms in either limb. Delayed conversion to a kissing stent configuration can be considered for treatment of contralateral iliac vein outflow obstruction in the setting of previous unilateral iliac vein stenting.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Clinical correlation with failure of endovenous therapy for leg swelling.

Background The development and use of minimally invasive procedures provide improved options for the management of symptoms of chronic venous insufficiency. While many patients with iliac venous occlusive disease and superficial venous insufficiency improve with combined iliac venous stenting and correction of superficial venous reflux, some patients have symptoms which persist. The goal of this study was to identify clinical factors related to persistent symptoms in patients with leg swelling after treatment of both iliac vein stenting and thermal ablation. Methods This observational study analyzed data for patients who underwent both iliac vein stent placement as well as endovenous ablation (either RFA or EVLT) as a management for chronic venous insufficiency between February 2012 and February 2014. Follow-up was performed after completion of both procedures and inquiring for improvement of swelling. Statistical analysis performed using Chi-square and student's t-test. Results Of the total 173 patients who underwent both endovenous closure and iliac vein stent placements, 55 (31.8%) patients were men; 29 (16%) patients stated they had no improvement after these procedures. The average age of patients who did not improve was 68.8 (±16.7 SD) years and 66.2 (±13.3 SD) years for patients who improved. Over all, the classification of the presenting symptoms by CEAP classification demonstrated 25.4%, 53.2%, 5.8%, and 15.6%, for C3-C6, respectively. There was no correlation with failure to improve the swelling with: age ( P = .44), gender ( P = .33), presenting symptom ( P = .67), use of calcium channel blockers ( P = .85), nitroglycerin ( P = .86), Plavix ( P = .07), aspirin ( P = .55), Synthyroid ( P = .55), Coumadin ( P = .14), angiotensin receptor blocker ( P = .81), β Blockers ( P = .61), angiotensin converting enzyme inhibitors ( P = .88), furosemide 40 mg ( P = .74), hydrochlorothiazide 12.5 mg ( P = .07), hydrochlorothiazide 25 mg ( P = .48), and EVLT vs. RFA ( P = .91). The use of furosemide (20 mg) was associated with continued swelling ( P = .01). The use of dual diuretics (furosemide and hydrochlorothiazide) was associated with persistent swelling even after these combined endovenous procedures P = .03). Conclusion These preliminary data suggest that the treatment with diuretics may be associated with failure to relieve lower extremity swelling despite combined endovascular therapy for chronic venous insufficiency.

Clinical research of catheter-directed thrombolysis for acute lower limb deep venous thrombosis by the posterior tibial vein

Objective To investigate the clinical efficacy and clinical value of catheter-directed thrombolysis for acute lower limb deep venous thrombosis by the posterior tibial vein. Methods Atotal of 46 patints with acute deep venous thrombosis in the department of vecular surgery of People's hospital of the xinjiang uygur autonomous region, under the protection of the inferior vena cava fillters, we treated by catheter directed thrombosisthrough the posterior tibial vein with urokinase continuous infusion. Results In the total gourp of 46 patients, 39 patients effectively relieve the swelling, 7 of which was ineffective, and 4 cases of patients ease the swelling after the expansion by the iliac vein balloon, 3 patients accepted the iliac vein balloon dilation and stent placement, 6 patients who were bleeding were treated with pressure dressing, andthere was no other complications. After the treatment, the venous patency score was low, and the patency rate was high and which have a statistical difference (P<0.05) before and after thrombolysis. Before and after thrombolytic therapy for lower limb swelling rate, there was statistically significant difference (P<0.05). Conclusions It is a safe and effective method to treat the deep venous thrombosis of lower limbs with catheter-directed thrombolysis by the protection of inferior vena cava filter.It can enhance the patency of the vein and shorten the swelling time. Key words: Low extremity; Deep venous thrombosis; Thrombolysis; Catheter directed thrombolysis; Inferior vena cava filter; Treatment outcome

Stent Patency in Patients With Advanced Chronic Venous Disease and Nonthrombotic Iliac Vein Lesions

Midterm patency results of iliac vein stents placed for nonthrombotic iliac vein lesions (NIVL) are not known. Two published large series of patients with iliac vein stent placement have not differentiated the outcomes between thrombotic and nonthrombotic lesions. To further study this issue, we reviewed our series of 170 iliac vein stents placed for NIVL. Retrospective analysis was performed of 126 patients who underwent common or external iliac vein angioplasty and stent placement between January 2013 and December 2014. Only patients with CEAP scores of C3, C4, or C5 were included. Patients were excluded if they had either active ulcer disease or signs of post-thrombotic lesions at initial venography. Duplex was performed postoperatively and at follow-up visits. Length of follow-up and stent patency were based on the last previous duplex available. A total of 170 procedures were performed in 126 patients. Stent placement was needed in bilateral lower extremities in 122 patients. A total of 112 of 170 procedures (66%) were performed on female patients. The average age of our patients was 72 (SD ± 13.4) years. A total of 90 of 170 procedures (53%) were performed on the left lower extremity. CEAP classification of lower extremity venous disease was 59%, 31%, and 9% for C3, C4, and C5, respectively. Our average follow-up period was 437 days (median, 460 days; range, 1 to 943 days). We had a postprocedure follow-up time of >6 months, 1 year, and 2 years of 70%, 52%, and 22%, respectively. During this period, 4 of 170 limbs (2.35%) experienced in-stent thrombosis. Primary stent patency of 99.4%, 98.8%, and 97.6% was noted at 6 months, 1 year, and 2 years of follow-up, respectively. The midterm patency results for iliac vein stents placed in patients for advanced chronic venous disease is excellent (97%).

Endovascular Stent Placement for May–Thurner Syndrome in the Absence of Acute Deep Vein Thrombosis

PurposeTo assess the clinical utility of iliac vein stent placement for patients with chronic limb edema or pelvic congestion presenting with nonocclusive May–Thurner physiology. Materials and MethodsAll patients (N = 45) undergoing stent placement for May–Thurner syndrome (MTS) without an associated acute thrombotic event between 2007 and 2014 were retrospectively reviewed; 11 were excluded for poor follow-up. A total of 34 patients (28 female) were studied (mean age, 44 y; range, 19–80 y). Average follow-up time was 649 days (median, 488 d; range, 8–2,499 d). ResultsThe technical success rate was 100% (34 of 34). No major and two minor (5%) complications occurred, and 68% of patients (23 of 34) had clinical success with relief of presenting symptoms on follow-up visits. Technical parameters including stent size and number, stent type, concurrent angioplasty, access site, and resolution of collateral iliolumbar vessels were not found to be statistically related to clinical success (P > .05). Similarly, no significant relation to clinical success was seen for clinical factors such as the type of symptoms, presence of chronic deep vein thrombosis (DVT), or concurrent coagulopathy (P > .05). Female sex was found to correlate with clinical success (82% vs 18%; P = .04). ConclusionsIliac stent placement in patients presenting with chronic limb or pelvic symptoms from MTS without acute DVT is associated with clinical success in the majority of patients.

Stenting of iliac vein obstruction following catheter-directed thrombolysis in lower extremity deep vein thrombosis

Background Catheter-directed thrombolysis (CDT) for deep venous thrombosis (DVT) of the lower extremity has good effect, but whether iliac vein stent placement after thrombolytic therapy is still controversial. The goal of this study was to evaluate the efficacy of stent placement in the iliac vein following CDT in lower extremity DVT. Methods This was a single-center, prospective, randomized controlled clinical trial. After receiving CDT, the major branch of the distal iliac vein was completely patent in 155 patients with lower extremity DVT, and 74 of these patients with iliac vein residual stenosis of &gt;50% were randomly divided into a control group (n=29) and a test group (n=45). In the test group, stents were implanted in the iliac vein, whereas no stents were implanted in the control group. We evaluated the clinical indicators, including patency of the deep vein, C in CEAP classification, Venous Clinical Severity Score (VCSS), and Chronic Venous Insufficiency Questionnaire (CIVIQ) Score. Results All patients had postoperative follow-up visits for a period of 6–24 months. Venography or color ultrasound was conducted in subjects. There was a significant difference between the patency rate at the last follow-up visit (87.5% vs. 29.6%) and the 1-year patency rate (86.0% vs. 54.8%) between the test and control groups. The change in the C in CEAP classification pre- and post-procedure was significantly different between the test and control groups (1.61±0.21 vs. 0.69±0.23). In addition, at the last follow-up visit, VCSS and CIVIQ Score were both significantly different between the test and control groups (7.57±0.27 vs. 0.69±0.23; 22.67±3.01 vs. 39.34±6.66, respectively). Conclusion The stenting of iliac vein obstruction following CDT in lower extremity DVT may increase the patency of the deep vein, and thus provides better efficacy and quality of life.

Functional Outcomes Following Catheter-Based Iliac Vein Stent Placement

Although previous reports have demonstrated the efficacy of catheter-directed thrombolytic therapy and iliac vein stent placement for the management of iliofemoral deep vein thrombosis (DVT), functional outcomes remain undefined. The purpose of this study was to determine midterm outcomes and functional quality of life among patients treated with iliac vein stenting. Records of all the patients treated with iliac vein stent placement between March 2004 and March 2011 were examined for primary patency, assisted primary patency, and secondary patency. Midterm functional outcomes were measured quantitatively, including ongoing symptoms and return to work status. Over the study interval, 32 patients (33 limbs) underwent iliac vein stent placement. In all, 72% (n = 23) of these patients were female, with an average age of 43 years. In all, 78% (n = 25) of the patients were diagnosed with acute DVT, 89% of which occurred in the left leg. Catheter-directed thrombolysis was utilized in 92% (23 of 25) of the patients with acute DVT. All patients treated with thrombolysis and stent placement presented with pain and edema in the affected limb. One-year primary, assisted primary, and secondary patencies were 75%, 96%, and 96%, respectively. Freedom from reintervention at 1 year was 83%. Treatment was associated with a sustained significant reduction in pain (91% vs 6%, P < .001) and edema (97% vs 12%, P < .001) at a mean follow-up of 29 months (range 5-83 months), at which time 89% of the patients reported to be at their pre-DVT functional status. Aggressive therapy of symptomatic iliac vein stenosis or occlusion with venography, catheter-directed thrombolysis, and iliac vein stent placement provides durable patency and freedom from reintervention. Most patients can anticipate good functional recovery with decreased pain, decreased edema, and high likelihood of returning to work.

Endovenous management of venous leg ulcers.

Compression is the current "standard" in the treatment of venous leg ulcers, and corrective surgery is ancillary. The emergence of safe and effective minimally invasive corrective techniques prompts a reappraisal of this paradigm. Among 192 consecutive limbs with venous leg ulcers, 189 were treated by (1) endovenous laser ablation (n= 30), (2) iliac vein stent placement (n= 89), or (3) both (n= 69). Residual deep reflux was not treated. No specialized wound care was used, and 38% of patients did not use stockings. Outcome measures were time to heal the ulcer and cumulative long-term healing. Sixty percent of the limbs were post-thrombotic. The median reflux segment score was 3 (range, 0-7). Thirty-seven percent had deep axial reflux. Median intravascular ultrasound-detected stenosis was 70% (range, 0%-100%) in stented patients. Sensitivity of venography to iliac vein obstruction was 52%. Postprocedural mortality was 0%, and 2% had deep venous thrombosis (<30 days). By 14 weeks, 81% of the small ulcers approximately ≤1 inch in diameter had healed. Larger ulcers were slower in healing (P< .001). Post-thrombotic etiology, presence of uncorrected deep reflux, demographic factors, or stocking use had no bearing on healing time. Long-term cumulative healing at 5 years overall was 75%. Healing was better in nonthrombotic limbs compared with post-thrombotic limbs (87% vs 66% at 5 years; P< .02) but was similar among the various demographic subsets, procedures, and whether or not patients used compression. Quality-of-life measures improved significantly. Cumulative long-term healing was unaffected by residual axial reflux and was unrelated to hemodynamic severity (air plethysmography, ambulatory venous pressure). However, long-term ulcer healing was inferior in limbs with reflux segment score of ≥3 (P< .03). Post-thrombotic limbs with a reflux score of ≥3 had the lowest cumulative healing among cohorts, but even in this category, 60% of limbs had durable healing with very few recurrences. Most venous leg ulcers in this consecutive series achieved long-term healing with the described minimally invasive algorithm. Uncorrected residual reflux was not an impediment to ulcer healing. Ulcers sized ≤1 inch required no specialized or prolonged wound care. Compression was not necessary to achieve or maintain healing after interventional correction.

Postthrombotic Syndrome: Feasibility of a Strategy of Imaging-guided Endovascular Intervention

PurposeTo describe the short-term efficacy of a strategy of imaging-guided endovascular intervention for the treatment of patients with established postthrombotic syndrome (PTS). Materials and MethodsThe medical records of 183 patients with venous disease who were seen in a single interventional radiology clinic were retrospectively reviewed. Study inclusion criteria were (i) endovascular intervention performed to treat established PTS from January 1, 2000, to March 10, 2009; (ii) patient age greater than 18 years; and (iii) availability of follow-up records. A total of 44 patients (20 men, 24 women; mean age, 42.2 y ± 14.1) with PTS who had received 72 interventions (iliac vein stent placement [n = 52] and endovenous laser ablation [EVLA; n = 20]) were identified. A reviewer who did not participate in their care evaluated the follow-up records; recorded the presence or absence of pain, swelling, and active ulceration; and categorized the degree of symptom improvement. ResultsOf 45 treated limbs in 40 patients with available follow-up, complete, partial, or no improvement of overall symptoms was observed in 46.7%, 33.3%, and 20.0%, respectively. The proportions of limbs with pain (35.0% after treatment vs 82.5% before; McNemar test, P < .01) and swelling (50.0% after treatment vs 90.0% before; P < .01) were significantly reduced after treatment with iliac vein stent placement and/or EVLA. Six of seven ulcerated limbs showed significant healing. ConclusionsThe use of an endovascular strategy to treat patients with established PTS was associated with complete or partial symptom relief in 80% of patients at short-term follow-up.

Endovascular treatment of iliac vein compression syndrome (May–Thurner)

May-Thurner syndrome is a rare condition that results from narrowing of the left common iliac vein (CIV) lumen due to pulsatile compression from the right common iliac artery (CIA) as it crosses anterior to it. We present a case of 24-years old female with left lower limb deep venous thrombosis (DVT). Duplex ultrasonography revealed extensive left-sided DVT. Magnetic resonance venogram suggested DVT with left CIV being compressed by right CIA. Pharmaco-mechanical catheter directed thrombolysis-thrombectomy followed by left iliac vein stent placement restored patency to the venous system, with resolution of symptoms.

Long-Term Outcomes of Stent Placement for Symptomatic Nonthrombotic Iliac Vein Compression Lesions in Chronic Venous Disease

Ye et al ( 1 Ye K. Lu X. Li W. et al. Long-term outcomes of stent placement for symptomatic nonthrombotic iliac vein compression lesions in chronic venous disease. J Vasc Interv Radiol. 2012; 23: 497-502 Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar ) report the long-term outcomes of iliac vein stent placement in a large series of patients with primary disease. Their experience broadly parallels results from other centers and typifies some of the surprising features of stent application in this disease. Of particular note is the near absence of stent thrombosis, as reported in several other series, even those that used only aspirin for long-term stent maintenance. This is remarkable, considering the natural potential for thrombosis that exists in the venous system. Also noteworthy is the excellent clinical outcome, particularly the healing of venous ulcers. The authors do not reveal the incidence of deep reflux in their study group; only the number with superficial reflux is provided. In the author's experience, approximately 50% of patients have deep reflux alone or in combination with superficial reflux. The belief that venous ulcers are caused by reflux is widely held. Healing of venous ulcers with stent treatment therefore brings into question conventional concepts. More surprising, such ulcers seem to heal with stent placement alone, even in the presence of severe reflux that is left uncorrected ( 2 Raju S. Darcy M.D. Neglen P. Unexpected major role for venous stenting in deep reflux disease. J Vasc Surg. 2010; 51: 401-408 Abstract Full Text Full Text PDF PubMed Scopus (162) Google Scholar ). Long-Term Outcomes of Stent Placement for Symptomatic Nonthrombotic Iliac Vein Compression Lesions in Chronic Venous DiseaseJournal of Vascular and Interventional RadiologyVol. 23Issue 4PreviewTo assess the clinical and patency results of stent placement for the management of symptomatic nonthrombotic iliac vein compression lesions (NIVCLs) in chronic venous disease (CVD). Full-Text PDF

Spontaneous retroperitoneal hematoma associated with iliac vein rupture

Spontaneous retroperitoneal hematoma (SRH) associated with iliac vein rupture is a rare but life-threatening emergency with high operative mortality. This study summarizes our experience in providing diagnostic and therapeutic management for this rare clinical entity. Between May 2002 and May 2009, nine patients were admitted to our hospital for SRH and acute deep venous thrombosis (DVT). Medical data for demographics, clinical presentation, auxiliary examinations, treatment modalities, outcomes, and follow-up were retrospectively analyzed. Nine patients (8 women, 1 man) were enrolled in this study. All were aged>45 years (range, 46-70 years). The common clinical manifestations were sudden onset of left lower abdominal or lumbar pain, swelling of the left lower extremity, anemia, and hypotension. Most patients were diagnosed by duplex ultrasound imaging and computed tomography scan. Three patients were treated conservatively, and six underwent surgical or combined treatments, comprising 2 repairs of iliac vein, 1 iliac vein ligation and Palma-Dale bypass graft, 1 pelvic vein ligation, 1 removal of hematoma, and 1 repair of iliac vein, thrombectomy, and endovascular stent placement. The iliac vein ruptured in five patients. May-Thurner syndrome was found in three patients. One patient died after surgery (operative mortality, 16.7%). Postoperative morbidity was 50%. Mean volume of perioperative blood transfusion was 900±640 mL (range, 0-2000 mL). Mean lengths of stay were 2.7±1.4 days (range, 2-5 days) in the intensive care unit and 16.9±2.4 days (range, 14-21 days) in the hospital. Eight patients were postoperatively treated with 6 months of warfarin. Mean follow-up was 30.5±15.0 months (range, 6-50 months). The occurrence rate of chronic venous insufficiency was 87.5% during follow-up. SRH with concomitant DVT, especially in women aged >45, should be considered in patients with sudden lower abdominal or lumbar pain, leg swelling, anemia, and shock. Spontaneous iliac vein rupture and the presence of May-Thurner syndrome should be considered in these patients. Surgical interventions were associated with high mortality and morbidity. In our experience, conservative therapy was safer than open surgical procedures.

Unexpected major role for venous stenting in deep reflux disease

Treatment of chronic venous insufficiency (CVI) has largely focused on reflux. Minimally-invasive techniques to address superficial and perforator reflux have evolved, but correction of deep reflux continues to be challenging. The advent of intravascular ultrasound (IVUS) scan and minimally invasive venous stent technology have renewed interest in the obstructive component in CVI pathophysiology. The aim of this study is to assess stent-related and clinical outcomes following treatment by iliac venous stenting alone in limbs with a combination of iliac vein obstruction and deep venous reflux. A total of 528 limbs in 504 patients, ranging in age from 15 to 87, underwent IVUS-guided iliac vein stent placement to correct obstruction over an 11-year period. The etiology of obstruction was nonthrombotic in 196 (37%), post-thrombotic in 285 (54%) limbs, and combined in 47 (9%). Clinical severity class of CEAP was C3 in 44%, C(4,5) in 27%, and C6 in 25% of stented limbs. Deep venous reflux was present in all limbs, associated with superficial and/or perforator reflux in 69%. Reflux was severe in 309/528 (59%) limbs (reflux multisegment score > or = 3) and 224/528 (42%) limbs had axial reflux. Venography and other functional tests had poor diagnostic sensitivity to detect obstruction, which was ultimately diagnosed by IVUS. The IVUS-guided iliac vein stenting was the only procedure performed and the associated reflux was left uncorrected. There was no mortality; morbidity was minor. Cumulative secondary stent patency was 88% at 5 years; no stent occlusions occurred in nonthrombotic limbs. Cumulative rates of limbs with healed active ulcers, freedom of ulcer recurrence in legs with healed ulcers (C5), and freedom from leg dermatitis at 5 years were 54%, 88%, and 81%, respectively. Cumulative rate of substantial improvement of pain and swelling at 5 years was 78% and 55%, respectively. Quality of life improved significantly. Reflux parameters did not deteriorate after stenting. Iliac venous stenting alone is sufficient to control symptoms in the majority of patients with combined outflow obstruction and deep reflux. Partial correction of the pathophysiology in limbs with multisystem or multilevel disease can provide substantial symptom relief. Percutaneous stent technology in concert with other minimally-invasive techniques to address superficial and/or perforator reflux offers such partial correction in limbs with advanced CVI and complex venous pathology. Open correction of obstruction or reflux is now required only infrequently as a "last resort".

May-Thurner Syndrome: Case Report and Review of the Literature Involving Modern Endovascular Therapy

May-Thurner syndrome is a rare clinical entity involving venous obstruction of the left lower extremity. Obstruction occurs secondary to compression of the left common iliac vein between the right common iliac artery and the underlying vertebral body. Current management largely involves endovascular therapy. A review was conducted of six studies containing at least five patients with May-Thurner syndrome treated by endovascular therapy. We compiled data on 113 patients, analyzing patient demographics, treatment details, and outcome. An 18-year-old female presented 1 week after the onset of left lower extremity pain and swelling. Duplex ultrasonography revealed extensive left-sided deep venous thrombosis (DVT). Thrombolysis followed by iliac vein stent placement restored patency to the venous system, with subsequent resolution of symptoms. Review of 113 patients revealed that the majority were females (72%) presenting with DVT (77%), most of which was acute in onset (73%). Therapy consisted of catheter-directed thrombolysis and subsequent stent placement in the majority of patients, resulting in a mean technical success of 95% and a mean 1-year patency of 96%. Endovascular therapy is the current mainstay of treatment for May-Thurner syndrome. Review of the current literature supports treatment via catheter-directed thrombolysis followed by stent placement with good early results.

Iliofemoral Venous Thrombosis Caused by Compression of an Internal Iliac Artery Aneurysm: A Minimally Invasive Treatment

To report the success of a minimally invasive treatment for phlegmasia cerulea dolens without gangrene caused by compression from an internal iliac artery aneurysm. An 81-year-old male with a 1-month history of paralysis owing to a hemorrhagic stroke presented with massive edema and skin mottling of the right lower extremity. Imaging confirmed right iliofemoral deep vein thrombosis caused by compression from a 4-cm internal iliac artery aneurysm. With thrombolysis ruled out, a minimally invasive treatment plan was undertaken, featuring percutaneous coil embolization of the aneurysm and surgical venous thrombectomy with proximal arteriovenous fistula creation and iliac vein stent placement. Failure of the coils to embolize the iliac aneurysm prompted the use of an endovascular graft to exclude the aneurysm. The patient's symptoms subsided, and he has a patent right iliofemoral venous system and internal iliac artery at his latest (16-month) follow-up. This case demonstrates that minimally invasive endovascular and open techniques can be combined to achieve an optimum outcome in patients at high risk for standard surgical approaches.