|Year : 2019 | Volume
| Issue : 2 | Page : 121-126
Venous angioplasty with stenting for obstructive iliac vein lesions: A case series
M Bathavatchalam, S Sasikumar, Jayakrishnan Ramakrishnan
Department of Vascular and Endovascular Sciences, Tamilnadu Government Multi Super Speciality Hospital, Madras Medical College, Tamilnadu Dr. M.G.R Medical University, Chennai, Tamilnadu, India
|Date of Web Publication||6-Jun-2019|
Dr. S Sasikumar
Department of Vascular and Endovascular Sciences, Tamilnadu Government Multi Super Speciality Hospital, Madras Medical College, Tamilnadu Dr. M.G.R Medical University, Chennai, Tamilnadu
Source of Support: None, Conflict of Interest: None
Background: Deep-vein reflux has been a major cause for chronic venous insufficiency (CVI). Secondary reflux due to obstructive lesions has been treated with conservative methods. The advent of dedicated venous stent and intravascular ultrasound has renewed interest in the correction of obstructive component in CVI pathophysiology. We have followed a protocol-based approach for identifying the patients who would probably be benefitted with iliac vein stenting. Materials and Methods: Of the 156 patients who have presented to our institution over a 3-year period (2015–2018) with chronic venous insufficiency, based on the inclusion criteria, 31 patients were included with a probable diagnosis of deep-vein reflux due to obstructive iliac vein lesion. All these patients were subjected to duplex study initially and all had deep-vein reflux. Twenty-three patients had presented with superficial vein reflux. Magnetic resonance (MR) venogram was performed in all patients prior to proceeding with digital subtraction venography. Iliac vein stenting was performed in seven patients using wall stent. All patients had lesion on the left side with lesion ranging from 4 to 12 cm. Results: Seven patients who had iliac stenting had significant improvement in symptoms. Three patients had superficial venous ablative procedure done after 3 months combined with foam sclerotherapy. There were no procedure-related complications. Six-month follow-up study revealed one recurrent ulceration with bleeding superficial varices. Stent patency at 1-month follow-up was 100%. Symptomatic relief was achieved in all patients. Conclusion: Iliac vein stenting is effective in controlling CVI symptoms in selected patients. Those patients with potentially correctable lesions were identified with the application of duplex criteria for initial screening. Clinical examination and duplex criteria had equivalent predictive value compared to MR study. Symptom relief was achieved in all patients after iliac stenting. Those presenting with recurrence had adjunctive procedures with optimal results.
Keywords: Venogram, venous reflux, venous stenting
|How to cite this article:|
Bathavatchalam M, Sasikumar S, Ramakrishnan J. Venous angioplasty with stenting for obstructive iliac vein lesions: A case series. Indian J Vasc Endovasc Surg 2019;6:121-6
|How to cite this URL:|
Bathavatchalam M, Sasikumar S, Ramakrishnan J. Venous angioplasty with stenting for obstructive iliac vein lesions: A case series. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Apr 9];6:121-6. Available from: http://www.indjvascsurg.org/text.asp?2019/6/2/121/259656
| Introduction|| |
Proximal (iliac) deep-venous obstruction of lower limbs followed by secondary valve incompetence, especially deep-venous reflux, is often found in patients with advanced stages of chronic venous insufficiency (CVI) (C-5 and C-6). Often, they are resistant to conservative therapy. Ulcer healing and substantial improvement of symptoms have been clearly documented to occur when the underlying deep reflux is corrected.
| Materials and Methods|| |
In this retrospective study, patients with CVI were analyzed at the outpatient department of our hospital. All the patients were initially screened with duplex of both lower-limb veins with iliac and inferior vena cava (IVC) screening for thrombosis. Patients with absent deep-vein reflux or minimal femoral reflux <250 m, with junctional incompetence, were excluded from the study and were treated with superficial venous ablative procedures.
Patients with screening criteria [Table 1] were included in the study and were subjected to further investigations. We have followed a protocol-based approach [Figure 4] for investigating the patients with suspected iliac vein obstruction.
| Results|| |
Of the 156 patients who were selected by the screening criteria to have suspected iliac vein obstruction, 23 patients were selected for further investigation. These patients had the duplex criteria selected for the study and were subjected to magnetic resonance (MR) venogram of both lower limb and iliac and IVC segments. Those with further positive findings in MR venogram were subjected to transfemoral diagnostic venogram. Based on the findings, seven patients were considered feasible for iliac vein stenting.
Those patients who had negative findings/findings not attributable to iliac vein obstruction were treated accordingly. Patients with iliac vein occlusion (n = 30) were primarily treated with conservative treatment with compression therapy, phlebotropics, antibiotics, and anticoagulation in case of positive D-dimer levels.
Those patients with minimal deep-vein reflux with junctional reflux (n = 86) were treated with a trial of compression therapy with Class 2 compression stockings followed by superficial venous ablative procedure. Foam sclerotherapy was performed in patients (n = 40) with bellow knee perforator incompetence and superficial/bleeding varices.
Those patients with negative findings in diagnostic venogram were subjected to a trial of conservative therapy for 6 months and if not improved were subjected to repeat investigations.
Of the patients who had iliac vein stenting, there were no procedure-related complications. Moreover, all stents were patent at 1-month follow-up, and there was symptomatic improvement (ulcer size, pain relief, and decrease in heaviness) in all the patients at 3-month follow-up. Three patients had superficial venous ablative procedures at 3-month follow-up.
- Clinical examination: Positive clinical findings are listed in [Table 1]
- Duplex venogram: All patients with positive clinical findings were subjected to duplex venous system of both lower limbs, with iliac vein and IVC screening for thrombosis. Inclusion criteria for duplex study is summarized in [Table 2]
- MR venogram: Patients with positive duplex criteria were subjected to MR venogram of IVC and both iliac and both lower limbs. It was performed with 1.5 T Magnetom equipment with the application of time-of-flight technique. The positive MR findings are listed in [Table 3]
- Diagnostic venogram: Patients with positive MR finding and patients with failed conservative therapy were subjected to digital subtraction venography (DSV) through transfemoral approach. Ascending venogram/descending venogram/with Valsalva maneuver was performed, and pressure monitoring was not done. All possible views were used to confirm the presence of the significant lesion. Pre- and post-angioplasty status of the collaterals were also noted. Positive DSV criteria are listed in [Table 4].
Lesion length ranged from 40 to 70 mm in the left common iliac segment. All stents [Figure 1], [Figure 2], [Figure 3] had some degree of extension onto IVC. Predilatation was done with the balloon of diameter equivalent to the venous diameter proximal to the lesion. Poststenting, the landing zones were dilated with balloon equivalent to the stent diameter. Wall stent from Boston scientific WALLSTENT Endoprosthesis (BostonScientific Corporation) was used with varying diameters of 14, 16, and 18 mm with lengths 60–90 mm. All cases [Figure 1], [Figure 2], [Figure 3] surprisingly had left-sided venous lesions, and only single stents with appropriate length were used for each case. Hybrid procedure was not performed in our study.
|Figure 1: Case 1: A 54-year-old male with a history of chronic venous insufficiency changes in the left lower limb with no prior history of deep-venous thrombosis, digital subtraction venography was done after initial investigations, pre- and post-stenting|
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|Figure 2: Case 2: A 34-year-old male with heaviness of the left lower limb with chronic venous insufficiency changes. There was ulceration in the goiter area, with a history of deep-venous thrombosis 2 years back. Diagnostic venogram was done prestenting|
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|Figure 3: (a) Case 3: A 51-year-old male with a history of atypical varices with chronic venous insufficiency changes in the left lower limb, with no history of prior deep-venous thrombosis, failed conservative management prestenting. (b) Poststenting|
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Superficial venous ablation was done with radiofrequency ablation (ClosureFast™-VNUS ®, Covidien, Dublin, Ireland, VNUS-ClosureFast, Covidien) for cases with minimal deep-vein reflux and junctional reflux. Foam sclerotherapy was done with 10% sodium tetradecyl sulfate for perforator incompetence and superficial, bleeding varicosities.
All patients were put on dual-antiplatelet therapy from the day before stenting and continued indefinitely postangioplasty. Anticoagulation was given only in the perioperative period and discontinued after discharge.
All patients who underwent venous stenting [Figure 1], [Figure 2], [Figure 3] were followed up at an interval of 1, 3, and 6 months with both ultrasound Doppler and clinical methods. During follow-up ultrasound, stent patency and levels of deep-vein reflux were assessed. Clinical follow-up included evaluation of the relief of presenting symptoms and recurrence/new symptoms of CVI compared with the preoperative presentation.
| Response|| |
No periprocedural complication was noted in any of the patients. All patients were on strict dual-antiplatelet therapy and anticoagulation in the perioperative period. No stent-related intraoperative complication was encountered. Moreover, no access-site complication was seen.
At 1-month interval, all stents were patent with good flow and phasic variation and augmentation.
Recurrence and failure
One case presented with recurrent ulceration after 1 year, which was treated with skin graft after confirming the patency of the stented veins.
Admitting symptom relief was taken as a criterion for follow-up, and all patients had symptom relief with decrease in size of the ulcer, decreased heaviness of the limb, and decrease in dependent edema of the limb. One patient had development of new ulceration, which was treated conservatively with skin grafting.
On 6-month follow-up, two patients with venous ulcer had complete ulcer healing at 6 months, of which one patient had recurrence at 1-year follow-up. Four of the seven patients who had one of the symptoms of CVI (heaviness, edema, and lipodermatosclerosis) had complete relief at 6-month follow-up. Patients with residual CVI symptoms were screened for superficial reflux and three had superficial venous ablation for junctional reflux and foam sclerotherapy for perforator incompetence. Stent patency was confirmed in all patients at 6-month and 1-year follow-up. Reduction in deep-vein reflux was noted in all patients at 6-month follow-up (measured by a minimum reduction of one level or reduction in reflux duration of 250 ms-Duplex), though complete resolution of reflux was not noted.
| Discussion|| |
With this study, we would like to suggest that iliac venous stenting significantly improves the clinical outcome in patients with combined iliac venous outflow obstruction and deep-venous reflux. Venous stenting controls symptoms in the majority of patients with deep reflux secondary to proximal obstruction. Left common iliac vein stenosis frequently occurs where the vein crosses beneath the right common iliac artery. Chronic, repetitive compression at this site causes fibrosis of the vein, with synechiae and spurs that result in stenosis or even occlusion of the lumen. This condition, which is becoming increasingly recognized, is called Non-thrombotic Iliac Vein Lesions or May–Thurner syndrome. An obstructive component is also commonly present in limbs with CVI of both postthrombotic and nonthrombotic etiology. One must maintain a high index of suspicion to recognize iliac vein compression. With the widespread use of venography in patients who are undergoing percutaneous procedures, it is now possible to identify a culprit lesion in some patients. Once identified, these lesions can be easily treated with percutaneous venoplasty and stenting.,,
In limbs with primary nonthrombotic disease, the obstructive lesions occur at arterial crossover points, not only at the “classic” proximal location as previously known, but commonly also at distal locations at the hypogastric artery crossing behind the inguinal ligament. These so-called nonthrombotic iliac vein lesions (NIVLs) are found on both sides, in both genders, and in all age groups. In postthrombotic disease, the obstructive lesions are typically segmental with focal accentuations at compression points across the iliac vein.
The obstructive component is seldom investigated in clinical practice today because the main tool for diagnosis is a duplex ultrasonography scan. A positive test supports further investigations, but a negative test cannot exclude the presence of a significant obstruction.
The diagnosis of occlusive or nonocclusive obstruction is, therefore, based on morphologic studies (50% stenosis is considered significant). Since ultrasound scanning of the pelvic outflow is suboptimal in the detection of obstruction, additional studies, involving transfemoral venography, MR, or computed tomography (CT)-venography, may be performed in patients with severe chronic venous disease. Venographic indications of iliac vein lesions are often subtle and require a high index of suspicion for proper identification of obstruction.
Intravascular ultrasound (IVUS) investigation is highly accurate and should probably be used more liberally, especially in patients in whom there is a clinical suspicion of outflow obstruction, with symptoms of pain and swelling and a history of deep-venous thrombosis. Trabeculation and axial collateral vessels show up well on the IVUS image, and accurate measurements of venous diameter for stent sizing are also provided. The IVUS accurately displays postdilation flaps or venous-wall irregularities and confirms that the stent has completely conformed to the venous wall. Generous use of IVUS is suggested in both diagnosis and treatment since phlebography is unreliable.
O'Sullivan et al. reported a retrospective analysis of 39 patients who had venous outflow obstruction resulting from May–Thurner syndrome. Initial technical success was achieved in 87%, patency at 1 year in >90%, and symptomatic relief in 85%. Collectively, these data support the use of endovascular therapy for chronic venous outflow obstruction.
Self-expanding stents have the advantages of longer lengths, large diameters, flexibility at the groin, and less susceptibility to permanent deformation by the pulsatile artery and the inguinal ligament. Hartung et al. have described treating left common iliac vein lesions with readily available stents that are 16 mm in diameter and at least 60 mm long.
The most extensive experience has been reported by Raju et al., who described their results after the treatment of 304 limbs with symptomatic chronic venous insufficiency. Their actuarial primary and secondary stent patency rates at 24 months were 71% and 90%, respectively. The median degree of swelling and pain was significantly reduced: the pain level recorded on a Visual Analog Scale from 0 to 10 declined from a median level of 4–0 (P < 0.001). Complete pain relief was achieved in 71% of patients, from 17% before stenting. Stasis dermatitis or ulceration was present in 69 of the 304 limbs. The cumulative recurrence-free ulcer healing rate was 62% at 24 months. Quality of life was also significantly improved. Overall, balloon angioplasty and stenting is safe and effective, and the complication rate is likely to decrease as technology evolves and our experience increases.
In this study, healing of stasis ulceration was possible after stenting even in the presence of deep reflux. Superficial vein ablative treatment was done in three patients who presented with severe junctional incompetence with bleeding superficial varices.
The open repair of the deep valves has not been widely adopted because of their complexity. As partial correction of the venous pathology may result in substantial improvement or complete relief of symptoms, initial minimally invasive techniques are advisable for multilevel involvement.
The current report suggests that surgical correction of deep-vein reflux can be initially ignored after correcting the obstruction with stent placement. Conservative management should be continued for the persistent reflux with compression stockings. Complex open surgeries to correct obstruction or reflux are only performed when percutaneous and conservative treatments fail.
| Conclusion|| |
Iliac Vein Stenting is effective in controlling symptoms related to CVI secondary to Obstructive Iliac vein lesions. This protocol based approach helps in effective management of patients with atypical presentations.
This study is an ongoing study and based of 2-year data with small sample size. It does not compare the patients who were on conservative treatment to know the real efficacy of iliac stenting over conservative treatment. IVUS was not available, and we had to rely on DSV for decision-making. Hybrid procedures were not performed which will add to the sample size.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]