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Bai H, Kibrik P, Shaydakov ME, Singh M, Ting W. Indications, technical aspects, and outcomes of stent placement in chronic iliofemoral venous obstruction. J Vasc Surg Venous Lymphat Disord 2024; 12:101904. [PMID: 38759753 PMCID: PMC11523355 DOI: 10.1016/j.jvsv.2024.101904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 04/13/2024] [Accepted: 04/22/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Iliofemoral venous stent placement (IVS) has evolved to a well-established endovascular treatment modality for chronic iliofemoral venous obstruction (CIVO). Dedicated venous stents gained approval from the US Food and Drug Administration in 2019 and solidified IVS as a defined intervention with clear indications, contraindications, risks, benefits, and procedural management principles. This review focuses on the indications, technical aspects and outcomes of stenting for CIVO. Other aspects pertaining to IVS are covered in other articles that are a part of this series. METHODS This study conducted a literature search limited to English articles. Three search strategies were used, and references were managed in Covidence software. Four investigators screened and evaluated articles independently, excluding meta-analyses, clinical trial protocols, and nonrelevant studies. Eligible studies, focused on clinical outcomes and stent patencies, underwent thorough review. RESULTS The literature search yielded 1704 studies, with 147 meeting eligibility criteria after screening and evaluation. Exclusions were based on duplicates, irrelevant content, and noniliac vein stent placement. CONCLUSIONS Successful IVS for CIVO relies on meticulous patient selection, consistent use of intravascular ultrasound examination during procedures and attention to the technical details of IVS.
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Affiliation(s)
- Halbert Bai
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pavel Kibrik
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Maxim E Shaydakov
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburg, PA
| | - Mandeep Singh
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Windsor Ting
- Division of Vascular Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY.
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Yang Y, Zhao Y, Chen Z, Wang Z, Wang X, Li F, Liu H. The effect of stent compression on in-stent restenosis and clinical outcomes in iliac vein compression syndrome. Quant Imaging Med Surg 2021; 11:2245-2252. [PMID: 34079698 DOI: 10.21037/qims-20-915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background To evaluate the effect of stent compression on in-stent restenosis (ISR) and clinical outcomes in patients with iliac vein compression syndrome (IVCS) after iliac vein stenting. Methods Fifty patients with IVCS treated with iliac vein stenting (Smart Control, Cordis, USA) between March 2017 and October 2018 were consecutively enrolled in this study. Computed tomography venography (CTV) was performed to assess stent compression and ISR. Based on the degree of stent compression, patients were allocated to a significant stent compression (SSC) group and an insignificant stent compression (ISC) group. The incidence of ISR was analyzed between the SSC and ISC groups. Patients' venous clinical severity scores (VCSSs) and responses to the chronic venous insufficiency questionnaire (CIVIQ) one year after stenting were compared between the two groups to evaluate the clinical improvement of venous insufficiency. Results In total, 34% of patients had SSC. There were significant differences in the incidence of ISR (52.9% vs. 21.2%, P=0.023), and in each group, there was one case of stent occlusion (5.88% vs. 3.03%, P=0.999). Patients in the SSC group had a higher VCSS score (8.41±5.92 vs. 3.15±2.87, P=0.04) and a lower CIVIQ score (83.35±8.86 vs. 92.21±4.32, P=0.001). Conclusions SSC has a significant effect on the incidence of ISR and the clinical outcomes of venous insufficiency. Thus, a dedicated iliac venous stent with sufficient radial resistive force, crush resistance, and outward radial force is needed to prevent the occurrence of stent compression.
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Affiliation(s)
- Yuheng Yang
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhao
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zheng Chen
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhe Wang
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuehu Wang
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fenghe Li
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hong Liu
- Department of Vascular Surgery, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Toh MR, Tang TY, Lim HHMN, Venkatanarasimha N, Damodharan K. Review of imaging and endovascular intervention of iliocaval venous compression syndrome. World J Radiol 2020; 12:18-28. [PMID: 32226586 PMCID: PMC7061234 DOI: 10.4329/wjr.v12.i3.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/04/2020] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
Iliocaval venous compression syndrome (ICS) is the extrinsic compression of the common iliac vein by the overlying iliac artery against the vertebra. Chronic compression can lead to venous stenosis and stasis, which manifests as chronic venous disease and treatment resistance. Therefore, early recognition of ICS and prompt treatment are essential. Clinical presentations of ICS can be ambiguous and diagnosis requires a high index of suspicion with the relevant imaging studies. The initial imaging test is typically a Duplex ultrasound for vessel assessment and pelvic ultrasound to exclude a compressive mass, which is followed by computed tomography (CT) or magnetic resonance (MR) venography. CT and MRI can identify the anatomical causes for venous compression. In patients with high clinical suspicion for ICS, negative findings on CT and MR venography would still warrant further investigations. Definitive diagnosis can be established using catheter-based venography complemented with intravascular ultrasonography but the nature of their invasiveness limits its utility as a routine imaging modality. In this review paper, we will discuss the evidence, utility and limitations of the existing imaging modalities and endovascular intervention used in the management of ICS.
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Affiliation(s)
- Ming Ren Toh
- Duke-NUS Medical School, Singapore 544886, Singapore
| | - Tjun Yip Tang
- Department of Vascular surgery, Singapore General Hospital, Singapore 169608, Singapore
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Mando R, Sigua-Arce P, Spencer L, Halalau A. Slippery Stents: A Case Report and Review of the Literature Describing Patients with May-Thurner Syndrome That Experienced Stent Migration. Case Rep Vasc Med 2019; 2019:7606727. [PMID: 30956838 PMCID: PMC6425386 DOI: 10.1155/2019/7606727] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 02/17/2019] [Accepted: 02/19/2019] [Indexed: 11/17/2022] Open
Abstract
Endovascular stent placement is an effective treatment for relieving chronic venous obstruction in patients with May-Thurner Syndrome (MTS) with or without the presence of thrombotic lesions. Stent migration is a rare but potentially life-threatening complication of endovascular stenting. Herein, we describe a case of stent migration from the left common iliac vein into the right heart, requiring open-heart surgery. We also completed a literature review of MTS patients with stent migration in hopes of raising awareness of this rare and life-threatening complication.
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Affiliation(s)
- Ramy Mando
- Department of Internal Medicine, Beaumont Health System, Royal Oak, MI, USA
| | | | - Lisa Spencer
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
| | - Alexandra Halalau
- Department of Internal Medicine, Beaumont Health System, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester Hills, MI, USA
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Ochoa Chaar CI, Aurshina A. Endovascular treatment of duplicated inferior vena cava compression from retroperitoneal fibrosis. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2019; 4:311-314. [PMID: 30761375 PMCID: PMC6298941 DOI: 10.1016/j.jvscit.2018.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/07/2018] [Indexed: 11/15/2022]
Abstract
A 68-year-old man with a history of retroperitoneal fibrosis was referred to our clinic because of disabling bilateral lower extremity swelling and venous claudication, worse on the right side than on the left. He was noted to have a duplicated inferior vena cava and an iliac vein obliteration from retroperitoneal fibrosis. The patient underwent bilateral iliac vein stenting and had complete relief of symptoms through follow-up of 46 months with no recurrence.
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Affiliation(s)
- Cassius Iyad Ochoa Chaar
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Afsha Aurshina
- Section of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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Chick JFB, Jo A, Meadows JM, Abramowitz SD, Khaja MS, Cooper KJ, Williams DM. Endovascular Iliocaval Stent Reconstruction for Inferior Vena Cava Filter–Associated Iliocaval Thrombosis: Approach, Technical Success, Safety, and Two-Year Outcomes in 120 Patients. J Vasc Interv Radiol 2017; 28:933-939. [DOI: 10.1016/j.jvir.2017.04.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/17/2017] [Accepted: 04/17/2017] [Indexed: 10/19/2022] Open
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Nakashima N, Sueta D, Kanemaru Y, Takashio S, Yamamoto E, Hanatani S, Kanazawa H, Izumiya Y, Kojima S, Kaikita K, Hokimoto S, Tsujita K. Successful treatment of deep vein thrombosis caused by iliac vein compression syndrome with a single-dose direct oral anti-coagulant. Thromb J 2017; 15:4. [PMID: 28163657 PMCID: PMC5286566 DOI: 10.1186/s12959-017-0128-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 01/18/2017] [Indexed: 01/30/2023] Open
Abstract
Background Although vein stenting is popular for treatment for venous thromboembolism due to mechanical compression, some cases are forced to avoid inserting align agents because of immunodeficiency. Case presentation An 82-year-old man with left extremity redness and swelling presented to a hospital for a medical evaluation. The patient was immunodeficient because of the adverse effects of his treatment for Castleman’s disease. A contrast-enhanced computed tomography scan revealed a venous thromboembolism in inferior vena cava and the left lower extremity. Magnetic resonance venography showed that the iliac artery was compressing the iliac vein. We were reluctant to place a stent in the iliac vein has because of the patient’s immunodeficient status. Three months of treatment using single-dose edoxaban (30 mg daily) resulted in complete resolution of the thrombus. This is the first report demonstrating that single-dose edoxaban without acute-phase parenteral anticoagulation is effective in the treatment of iliac vein compression. Conclusions A single-dose direct oral anti-coagulant without acute-phase parenteral anticoagulation is effective for mechanical compression
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Affiliation(s)
- Naoya Nakashima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Yusuke Kanemaru
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Eiichiro Yamamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Shinsuke Hanatani
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Hisanori Kanazawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Sunao Kojima
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Koichi Kaikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Seiji Hokimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo, Chuo-ku, Kumamoto 860-8556 Japan
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Dean SM, Tytle TL. Acute right lower extremity iliofemoral deep venous thrombosis secondary to an anomalous inferior vena cava: a report of two cases. Vasc Med 2016; 11:165-9. [PMID: 17288122 DOI: 10.1177/1358863x06074829] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A congenital anomaly of the inferior vena cava is an increasingly identified risk factor for iliocaval deep venous thrombosis in young patients. We present two cases of acute right lower extremity iliofemoral deep venous thrombosis in 16 and 18-year-old patients that were ultimately diagnosed with an underlying anomalous iliocaval venous system. In one patient, the inferior vena cava was congenitally absent and the right iliac vein was diffusely stenotic with a proximally located high-grade stricture. In the other subject, the infrarenal inferior vena cava and right iliac vein were diffusely hypoplastic. Compensatory venous flow in both subjects was via large perilumbar venous collateral veins and a prominent azygous system. Both patients were successfully treated with a combination of initial catheter-directed thrombolysis followed by balloon angioplasty and venous stent placement.
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Affiliation(s)
- Steven M Dean
- Noninvasive Peripheral Vascular Laboratory, Oklahoma Cardiovascular Associates/Oklahoma Heart Hospital, 4050 W. Memorial Road, Oklahoma City, OK 73120, USA.
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O'Donnell TF, Passman MA, Marston WA, Ennis WJ, Dalsing M, Kistner RL, Lurie F, Henke PK, Gloviczki ML, Eklöf BG, Stoughton J, Raju S, Shortell CK, Raffetto JD, Partsch H, Pounds LC, Cummings ME, Gillespie DL, McLafferty RB, Murad MH, Wakefield TW, Gloviczki P. Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum. J Vasc Surg 2014; 60:3S-59S. [PMID: 24974070 DOI: 10.1016/j.jvs.2014.04.049] [Citation(s) in RCA: 412] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Mousa AY, AbuRahma AF. May–Thurner Syndrome: Update and Review. Ann Vasc Surg 2013; 27:984-95. [DOI: 10.1016/j.avsg.2013.05.001] [Citation(s) in RCA: 139] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 05/07/2013] [Accepted: 05/08/2013] [Indexed: 01/27/2023]
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Affiliation(s)
- Ronnie Word
- Department of Surgery, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449, USA.
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Hölper P, Kotelis D, Attigah N, Hyhlik-Dürr A, Böckler D. Longterm Results After Surgical Thrombectomy and Simultaneous Stenting for Symptomatic Iliofemoral Venous Thrombosis. Eur J Vasc Endovasc Surg 2010; 39:349-55. [DOI: 10.1016/j.ejvs.2009.09.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2009] [Accepted: 09/27/2009] [Indexed: 10/20/2022]
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Hartung O, Barthelemy P, Arnoux D, Boufi M, Alimi YS. Management of pregnancy in women with previous left ilio-caval stenting. J Vasc Surg 2009; 50:355-9. [DOI: 10.1016/j.jvs.2009.01.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 01/06/2009] [Accepted: 01/09/2009] [Indexed: 12/13/2022]
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Late results of surgical venous thrombectomy with iliocaval stenting. J Vasc Surg 2008; 47:381-7. [PMID: 18241761 DOI: 10.1016/j.jvs.2007.10.007] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 10/09/2007] [Accepted: 10/10/2007] [Indexed: 01/02/2023]
Abstract
PURPOSE Iliac vein occlusive disease leads to 73% of rethrombosis that occurs after venous thrombectomy when left untreated. The goal of this study is to present our long-term results of stenting of iliocaval occlusive lesions persisting after surgical venous thrombectomy. METHODS From November 1995 to April 2007, 29 patients (19 women), with a median age of 38 years, had surgical venous thrombectomy with creation of an arteriovenous fistula and angioplasty and stenting. All were admitted for acute (<10 days) deep venous thrombosis (DVT) involving the iliocaval segment, of which eight had concomitant acute pulmonary embolism. Six patients had a history of DVT (2 with previous venous thrombectomy), two were pregnant, and three had postpartum DVT. No patients had short- or mid-term life-threatening factors. The underlying lesion was left iliocaval compression (May-Thurner syndrome) in 22 patients, chronic left common iliac vein occlusion in 3, residual clot in 3, and compression of the left external iliac vein by the left internal iliac artery in 1. RESULTS Neither perioperative death nor pulmonary embolism occurred. Four early complications occurred after stenting (13.8%). Median hospital length of stay was 8 days (range, 5-22 days). Median follow-up was 63 months (range, 2-137 months). Three late complications occurred (10.3 %): one rethrombosis due to stent crushing during pregnancy and two restenosis, which were treated by iterative stenting. At the end of the follow-up, the median venous clinical severity score was 3 (range 1-12) and the venous disability score was 1 (range 0-2). Primary, assisted primary and secondary patency rates were, respectively, 79%, 86%, and 86% at 12, 60, and 120 months. Patients with patent iliocaval segments had significantly fewer infrainguinal obstructive lesions (4% vs 50%) and a higher rate of valvular competence (76% vs 0%) than those who experienced rethrombosis. Venous scores were also worse in patients with rethrombosis. CONCLUSION Stenting is a safe, efficient, and durable technique to treat occlusive iliocaval disease after venous thrombectomy. Its use can prevent most of the rethrombosis that occurs after venous thrombectomy without major adverse effects.
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Mahanty HD, Posselt AM, Lipshutz GS, Schneider DB, Freise CE. Catheter-directed therapy for DVT after pancreas transplantation. Clin Transplant 2007; 21:748-54. [PMID: 17988269 DOI: 10.1111/j.1399-0012.2007.00733.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Iliac vein deep venous thrombosis (DVT) ipsilateral to the pancreas transplant can lead to severe leg edema and compromise graft function. Treatment modalities for iliac vein DVT in the pancreas transplant recipient are limited. METHODS Medical records of patients receiving pancreas transplants at a single center from November 1989 to July 2003 were reviewed retrospectively, identifying patients with iliac vein DVT. There were 287 pancreas transplants performed during this time. Pancreas transplantation in all recipients was performed in the right iliac fossa with the arterial supply consisting of a donor iliac artery Y interposition graft. Systemic venous drainage was to the iliac vein. Exocrine drainage was enteric or to the bladder. RESULTS Four (1.4%) cases of iliac DVT were identified. All patients manifested lower extremity edema ipsilateral to the pancreas transplant. DVT was detected by ultrasound on days 4, 5, 13, and 60 post-transplant. In all cases, the iliac vein caudad to the pancreatic venous anastomosis was noted to be stenotic. Management involved balloon dilatation and endovascular stent placement in one patient, thrombolysis with tissue plasma antigen (t-PA) followed by stent placement in one patient, and percutaneous mechanical thrombectomy in two patients. All patients had improvement in leg edema and two patients continue to have good pancreatic allograft function. CONCLUSIONS Iliac DVT is a rare complication of pancreas transplantation that usually develops in an area of stenosis caudad to the pancreatic venous anastomosis. Catheter-based treatment modalities with use of endovascular stents for treatment of underlying stenoses can serve as an adjunct in treating these complications.
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Affiliation(s)
- Harish D Mahanty
- Department of Transplantation, California-Pacific Medical Center, San Francisco, CA 94115, USA.
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Giordano P, Weber K, Davis M, Carter E. Acute thrombosis of the inferior vena cava. Am J Emerg Med 2006; 24:640-2. [PMID: 16938618 DOI: 10.1016/j.ajem.2005.12.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2005] [Accepted: 12/17/2005] [Indexed: 10/24/2022] Open
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Hartung O, Otero A, Boufi M, De Caridi G, Decaridi G, Barthelemy P, Juhan C, Alimi YS. Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease. J Vasc Surg 2005; 42:1138-44; discussion 1144. [PMID: 16376204 DOI: 10.1016/j.jvs.2005.08.012] [Citation(s) in RCA: 111] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2005] [Accepted: 08/09/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND The goal of this article is to present clinical and patency results of endovascular treatment of nonmalignant, iliocaval venous obstructive disease and to discuss the evolution of technical details. METHODS From November 1995 to June 2004, 44 patients (female-male ratio, 3.9:1; left-right lower limb ratio, 8.6:1; median age, 42 years; range, 21-80 years) had treatment for chronic disabling obstructive venous insufficiency with iliocaval stenosis or occlusion. The clinical class of CEAP was 2 in 11 limbs, 3 in 31, 4 in 4, 5 in 1, and 6 in 1; etiology was primary in 32 patients, secondary in 10, and congenital in 2. Anatomic involvement included superficial veins in 16 patients and perforator veins in 11. Obstruction was associated with superficial reflux in 4 patients, deep reflux in 13, and both in 13. Ten patients had occlusion. All procedures were performed in the operating room with perioperative angiography and angioplasty with or without self-expanding stent implantation. Venous clinical severity and disability scores were obtained before and after treatment. Patency and restenosis were evaluated by duplex Doppler ultrasonography. RESULTS No perioperative death or pulmonary embolism occurred. The technical success rate was 95.5% (two recanalization failures), and two (4.5%) perioperative stent migrations occurred. One early thrombosis (2.4%) was treated by thrombectomy and creation of an arteriovenous fistula. One late death and one thrombosis occurred. Restenoses were found in five patients and were all treated successfully (four needed iterative stenting). Median follow-up was 27 months (range, 2-103 months). Median venous clinical severity score improved from 8.5 to 2, and median venous disability score improved from 2 to 0. Cumulative primary, assisted primary, and secondary patency rates of the venous segments at 36 months were 73%, 88%, and 90%, respectively, in intention to treat. The survival rate was 100% at 12 months and 97.3% at 60 months. CONCLUSIONS Endovascular treatment of benign iliocaval occlusive disease is a safe and efficient minimally invasive technique with good mid-term patency rates. Moreover, it improves cases with obstruction only, as well as cases with associated reflux and obstruction. Primary stenting should always be performed by using self-expanding stents deployed under general anesthesia to avoid lumbar pain. In case of failure, the endovascular procedure does not preclude further surgical reconstruction.
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Affiliation(s)
- Olivier Hartung
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Nord, Marseille, France.
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Hartung O, Grisoli D, Boufi M, Marani I, Hakam Z, Barthelemy P, Alimi YS. Endovascular stenting in the treatment of pelvic vein congestion caused by nutcracker syndrome: Lessons learned from the first five cases. J Vasc Surg 2005; 42:275-80. [PMID: 16102626 DOI: 10.1016/j.jvs.2005.03.052] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Accepted: 03/30/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Compression of the left renal vein between the aorta and the superior mesenteric artery is a rare but possibly underestimated condition. Surgical correction (42 cases reported in the literature) can be performed by means of a variety of different techniques. Although endovascular stenting is well accepted for iliocaval occlusive disease, it has been poorly evaluated in this indication. We describe five patients who were treated for nutcracker syndrome by using stenting and analyze the nine cases previously reported. METHODS From November 2002 to September 2004, five women (mean age, 34.7 years) were admitted for endovascular treatment of a nutcracker syndrome. They all had incapacitating pelvic congestion syndrome, including two with a history of left ovarian vein embolization; moreover, two had left lumbar pain, and three had hematuria. The mean preoperative venous disability score was 2.4. The patients underwent a gynecologic examination and laparoscopy to eliminate other causes of pelvic pain. The laparoscopy revealed large pelvic varicose veins and no signs of endometriosis. Duplex scan, computed tomographic scan, and iliocavography revealed left renal vein compression, with proximal distention and collateral pathways, with dilatation and permanent reflux in the left ovarian vein in the three patients who had not had prior embolization. The mean renocaval pullback gradient was 4.3 mm Hg. A percutaneous endovascular procedure, during in which a self-expanding metallic stent was implanted, was performed under general anaesthesia. RESULTS Technical success was achieved in all cases. One case of stent migration occurred: the stent was pulled down in the inferior vena cava, with uneventful follow-up (mean, 14.3 months). One month later, patients were all improved and stents were patent at the duplex scan examination, without restenosis. The mean venous disability score was 1. No further left ovarian vein reflux was evident at duplex scan in patients who did not have prior embolization. Pelvic pain recurred in one patient who had initially improved, and endometriosis was diagnosed 15 months after the procedure. Two other patients, who received 40-mm-long stents, had a secondary recurrence of the symptoms caused by stent dislodgement. The two other patients were asymptomatic. CONCLUSIONS This study shows that stenting is feasible, but some guidelines should be followed, mainly the use of long stents protruding into the inferior vena cava. Stenting can eliminate the symptoms of the condition, and the technique is only very slightly invasive. Further experience and follow-up are needed before accepting such a procedure for treatment of the nutcracker syndrome.
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Affiliation(s)
- Olivier Hartung
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Nord, Marseille, France.
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Schwarzbach MHM, Schumacher H, Böckler D, Fürstenberger S, Thomas F, Seelos R, Richter GM, Allenberg JR. Surgical Thrombectomy Followed by Intraoperative Endovascular Reconstruction for Symptomatic Ilio-femoral Venous Thrombosis. Eur J Vasc Endovasc Surg 2005; 29:58-66. [PMID: 15570273 DOI: 10.1016/j.ejvs.2004.09.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To evaluate the efficacy of surgical thrombectomy combined with endovascular reconstruction for acute ilio-femoral/caval venous thrombosis. METHODS Twenty consecutive patients with acute, symptomatic ilio-femoral/-caval thrombosis underwent valve-preserving thrombectomy with immediate endovascular repair between October 1996 and October 2003. Thrombectomy was classified by intraoperative venography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because endovascular repair was not performed. RESULTS Left-sided venous thrombosis predominated (90%). Lesions were located in the common iliac vein (85%), the external iliac vein (10%), and the inferior vena cava (5%). Three TYPE II lesions and 17 TYPE III lesions (11 spurs, one hypoplasia, one fibrosis, one haematoma, and three others) were diagnosed. Catheter-directed recanalisation (thrombectomy/thrombolysis) resolved TYPE II lesions in three patients. Balloon angioplasty (one patient), iliac stenting (15 patients [two with thrombolysis]), and caval stenting (one patient) were employed in TYPE III stenoses. No serious complication or death occurred. Mean follow-up was 21 months. Of 20 patients clinical results were excellent in 18 patients who maintained patency of their reconstructed iliac veins. Primary and secondary patency rates were 80 and 90%, respectively. CONCLUSIONS Ilio-caval venous obstructions detected intraoperatively can be reconstructed in a one-stage combined procedure. The specific endovascular approach depends on the type of residual venous obstruction. Excellent mid-term results indicate that the proposed thrombectomy classification (TYPE I-IV) and treatment algorithm optimises the results in selected patients with symptomatic venous thrombosis.
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Affiliation(s)
- M H M Schwarzbach
- Department of Vascular and Endovascular Surgery, University of Heidelberg, D-69120 Heidelberg, Germany.
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Neglén P, Raju S. In-stent recurrent stenosis in stents placed in the lower extremity venous outflow tract. J Vasc Surg 2004; 39:181-7. [PMID: 14718837 DOI: 10.1016/s0741-5214(03)01028-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE This study was undertaken to describe development of in-stent recurrent stenosis (ISR) in stents placed in the iliocaval outflow tract and to examine possible contributing factors. METHOD After iliocaval balloon angioplasty and stent insertion to treat chronic nonmalignant obstruction, single-plane transfemoral venography was performed at least once in 324 limbs, twice in 123 limbs, three times in 40 limbs, and four times in 4 limbs. ISR was measured with a caliper, and expressed as percentage diameter reduction of patent lumen on the venograms. Left-right limb ratio was 2.3:1; thrombotic-nonthrombotic disease ratio, 1.2:1; negative-positive thrombophilia test ratio, 1.6:1; and above-below inguinal ligament stent placement ratio, 4.5:1. Median stent length was 9 cm (range, 4-35 cm), and median lumen area before and after stenting was 0.41 cm(2) (range, 0-1.65 cm(2)) and 1.70 cm(2) (range, 0.65-4.00 cm(2)), respectively. Limbs were divided into groups with no ISR, any degree of ISR, greater than 20% diameter reduction, and greater than 50% diameter reduction. Cumulative ISR and patency rates were analyzed. Possible contributing factors were examined. RESULTS At 42 months, only 23% of limbs demonstrated no ISR. Cumulative rate of limbs with greater than 20% diameter reduction was 61%, and of limbs with greater than 50% diameter reduction was 15%. Patient gender or sidedness of the treated extremity did not affect outcome. At 36 months, limbs with thrombotic disease had higher ISR rates than did limbs without thrombotic disease (63% and 41% of limbs with >20% narrowing, and 23% and 4% of limbs with >50% narrowing, respectively; P <.01). Similarly, higher rates of ISR were found in patients with thrombophilia and long stents extending below the inguinal ligament. Primary, assisted primary, and secondary patency rates for the entire population at 3 years were 75%, 92%, and 93%, respectively. There was a significant increase in ISR in individual limbs, but analysis of groups of stents did not unequivocally show progression. CONCLUSION Severe (>50%) ISR of iliofemoral venous stents is uncommon over the short term. The three major risk factors appear to be presence of thrombotic disease, positive thrombophilia test results, and stent extending below the inguinal ligament (long stents). Although stented limbs that eventually became occluded during the study demonstrated similar risk factors, no conclusion regarding a cause-effect relationship can be drawn from the present data. Whether late occlusion is due to acute thrombosis or to gradual development of true intimal hyperplasia requires further study.
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Affiliation(s)
- Peter Neglén
- River Oaks Hospital, 1020 River Oaks Drive, Suite 480, Jackson, MS 39232, USA.
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