|Year : 2014 | Volume
| Issue : 1 | Page : 14-15
Deep Veins: From Valve Surgery to Iliac Stents: The Journey and the Future
The Rane Center, Jackson, MS, USA
|Date of Web Publication||9-Oct-2014|
The Rane Center, Jackson, MS
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Raju S. Deep Veins: From Valve Surgery to Iliac Stents: The Journey and the Future. Indian J Vasc Endovasc Surg 2014;1:14-5
In a signal study published in 1995, Standness et al. showed that combined obstruction/reflux was present on duplex examination in 65% of patients with postthrombotic syndrome (PTS). With intravascular ultrasound with its greater sensitivity, the prevalence is even higher, > 90%. However, the earlier focus was on the reflux component, which has been considered for over a century as the key pathophysiology in chronic venous disease (CVD). Valve reconstruction in PTS in the last two decades has had moderate success in relieving PTS symptoms, though the results were significantly inferior to valve repair results in nonthrombotic disease. Valve reconstruction has remained the only corrective option in nonthrombotic deep vein reflux for nearly half a century. Some reappraisals of these treatment paradigms has occurred since the recent finding that correction of the obstruction with stent technology appears to yield excellent results  even in the presence of uncorrected reflux.  It has been known for a long time that partial correction of complex pathology is often effective in advanced CVD unlike in critical limb ischemia. One difference between the efficacy of correcting reflux alone or obstruction alone in combined obstruction/reflux in PTS is that the latter appears to be more durable albeit in a separate series. This may reflect a fundamental difference in the pathophysiological importance of obstruction versus reflux.
The emergence of venous stent technology has rendered traditional open veno-venous bypass techniques (prosthetic veno-venous bypass, Palma bypass etc.) into obsolescence. Currently, they are used only in cases of stent failure. Even chronic total occlusions of the iliac vein can be percutaneously recannalized in about 85% and about 50% when part or the entire inferior vena cava is occluded as well. ,, The technique of iliac venous stenting differs significantly from arterial endovascular technique (see separate presentation "technical tips and tricks"). Attention to these technical details is essential for a successful outcome.
The results of venous stenting in the iliac-caval venous segment have been surprisingly good , counterintuitive to expectations for use of endoluminal prosthetics in the low flow thrombogenic environment. In an analysis of 982 iliac vein stent placements for CVD,  there was no mortality and morbidity minor. Early (< 30 day) deep vein thrombosis occurred in 1.5% and later (> 30 days) in 1%. 23 (3%) stents occluded during the observation period. Stent thrombosis was exclusive to postthrombotic obstruction, none occluded in limbs stented in nonthrombotic disease (nonthrombotic iliac vein lesion). Cumulative long-term stent patency was 100% in primary limbs and 86% in postthrombotic limbs at 6 years. Only aspirin was used for stent maintenance (the majority of limbs) except in cases of thrombophilia or previously instituted warfarin therapy. Iliac vein stent placement can be combined with percutaneous saphenous ablation in a single session. 
From a broader perspective, the surprising clinical results of iliac-caval stenting have raised questions regarding many basic premises that underlie our current understanding of CVD. Central pelvic venous obstruction is as important, perhaps more so than reflux.  Since stent placement is an outpatient percutaneous procedure that appears to be relatively simple, safe, and effective compared to the more complex open procedures that are required for correction of deep reflux or obstruction, a paradigm shift in the way highly symptomatic CVD patients are treated is evolving.
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