Improvement following restoration of inline flow argues against comprehensive thrombus removal strategies and for selective stenting in acute symptomatic iliofemoral venous thrombosis

Outcomes following stenting for symptomatic chronic iliofemoral venous stenosis - a comparison of three stent types

OBJECTIVE

Venous stenting has become the standard of care for patients with iliofemoral venous stenosis who have failed conservative therapy. Although outcome data following such stenting exist for Wallstents and Wallstent-Zenith (Z) stent combination, such data for dedicated stents is sparse outside of industry-sponsored trials. This study aims to address this gap by comparing the outcomes of matched cohorts of limbs that underwent stenting with either the Medtronic Abre stent (Medtronic Inc), the Bard Venovo stent (Becton, Dickinson, and Co), or Wallstent-Z stent combination (Boston Scientific; Cook Medical Inc).

METHODS

Contemporaneously entered data on matched cohorts of patients who underwent stenting from 2016 to 2022 for quality of life (QoL)-impairing iliofemoral venous stenosis (not occlusion) after failing conservative therapy were analyzed. The venous clinical severity score (VCSS, 0-27), grade of swelling (GOS, 0-4), visual analog scale pain score (VAS pain score, 0-10), and CIVIQ-20 QoL scores were evaluated initially and post stenting to assess the effects of stenting. Analysis of variance and paired t-tests were used to compare clinical and QoL variables, whereas Kaplan-Meier analysis was used to examine primary, primary-assisted, and secondary stent patencies, with log-rank test used to discriminate between different curves.

RESULTS

There were a total of 198 limbs that had undergone stenting, including 68 in the Abre, 60 in the Venovo and 70 in the Wallstent-Z stent groups. The median age for the entire cohort was 65 years (range, 21-101 years). The cohort included 141 women and 57 men. Left laterality (112 limbs) was more common than right laterality (86 limbs). Post-thrombotic syndrome was seen in 146 limbs and nonthrombotic iliac vein lesions/May-Thurner syndrome in 52 limbs. The median body mass index was 35 kg/m2. Median follow-up was 20 months. For the entire cohort, post stenting, VCSS improved from 6 to 4.5 at 3 months (P < .0001), further improved to 4 at 6 months (P < .0001), and remained at 4 at 12 months (P < .0001) and 24 months (P < .0001). GOS for the entire cohort improved from 3 to 1 at 3 months (P < .0001) and remained at 1 at 6 months, (P < .0001), 12 months (P < .0001), and 24 months (P < .0001). VAS pain score for the entire cohort improved from 8 to 2 at 3 months (P < .0001), increased to 3 at 6 months (P < .0001) before dropping to 2 at 12 months (P < .0001), and remained at 2 at 24 months (P < .0001). The CIVIQ-20 score for the entire cohort improved from 61 to 38 (P < .0001) over the duration of follow-up. The primary patencies for the Abre, Bard, and Wallstent-Z stent groups at 32 months were 93%, 86%, and 92%, respectively (P = .37). Primary assisted patencies for all three groups at 32 months was 100% (P = .08). There were no stent occlusions in any of the groups. Reintervention was pursued for QoL-impairing recurrent clinical manifestations in 13 limbs (7%), without a significant difference between groups (P = .46).

CONCLUSIONS

For patients undergoing stenting for QoL-impairing symptoms of iliofemoral venous stenosis after failing conservative therapy, Abre, Venovo, and Wallstent-Z stent combination all appear to provide similar clinical and QoL improvement. A significant difference between stent patencies for the three stent types was also not detected. Stent selection for treatment of stenotic lesions of the iliofemoral venous territory can be based on stent availability and the preference/expertise of the interventionalist.

Angioplasty or stenting for deep venous thrombosis

BACKGROUND

The best medical treatment (BMT) for treating deep venous thrombosis (DVT) includes anticoagulation and compression stockings. Angioplasty and stenting restore vessel patency and facilitate blood flow. In some people with DVT, angioplasty or stenting is used to minimise complications such as post-thrombotic syndrome (PTS), but their effects are under discussion.

OBJECTIVES

To assess the effects of adjunctive angioplasty or stenting on a background treatment of anticoagulation and thrombolysis, compared with BMT, sham procedure, thrombolysis, or any combination of these treatments, in people with DVT.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, IBECS, CINAHL, and AMED databases, as well as the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers, to 20 April 2023. We checked the bibliographies of included trials for further references to relevant trials and contacted specialists in the field, manufacturers, and authors of the included trials for any unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing angioplasty or stenting on a background treatment of anticoagulation and thrombolysis, compared with BMT, sham procedure, thrombolysis, or any combination of these treatments, in the management of people with acute obstruction due to DVT. We excluded participants who had a baseline PTS diagnosis or who had received any form of mechanical thrombectomy, as this was investigated in a separate Cochrane review.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcomes were PTS and venous thromboembolism (VTE); secondary outcomes were mortality, major bleeding, secondary patency, duration of hospitalisation, quality of life (QoL), and adverse events. We used the Cochrane RoB 1 tool to assess the risk of bias for RCTs and GRADE to assess the certainty of evidence. We performed meta-analysis where appropriate.

MAIN RESULTS

We included two RCTs (134 participants) that were conducted in China and presented comparisons for acute obstruction after DVT based on length of follow-up (12 months (early), 24 months (intermediate), and 36 months (long term)). Angioplasty or stenting plus BMT and thrombolysis versus BMT and thrombolysis for acute obstruction due to DVT (intermediate time point) In the intermediate time point, angioplasty or stenting may have little to no effect on PTS (Venous Clinical Severity Score (VCSS): mean difference (MD) -3.21, 95% confidence interval (CI) -7.74 to 1.33; 2 studies, 133 participants; very low-certainty evidence) and adverse events (limb pain) (risk ratio (RR) 0.68, 95% CI 0.04 to 10.33; 1 study, 67 participants; very low-certainty evidence), but the evidence is very uncertain. Angioplasty or stenting may increase secondary patency (RR 0.26, 95% CI 0.11 to 0.59; 2 studies, 133 participants; very low-certainty evidence), but the evidence is very uncertain. The evidence is very uncertain about the effect of angioplasty or stenting on quality of life (MD 10.54, 95% CI -1.34 to 22.41; 2 studies, 133 participants; very low-certainty evidence), and is not estimable for VTE, mortality, or major bleeding. We downgraded the certainty of evidence for all reported outcomes in this comparison by two levels due to serious study limitations (risk of performance and other bias), and another level for imprecision (small numbers of events and participants). The imbalance between study group size and different vein access may also have contributed to the high heterogeneity seen in the analyses of these outcomes. We downgraded the certainty of evidence for PTS and quality of life by one level for inconsistency (no similarity of point estimates in any of the included studies, no overlap of CIs, and considerable heterogeneity in results). There is an additional difficulty with blinding personnel in this type of intervention, but the trialists should have reported blinding of outcome assessment.

AUTHORS' CONCLUSIONS

Although angioplasty or stenting may increase secondary patency in people with acute obstruction due to DVT, the evidence is very uncertain; the evidence is also very uncertain about the effect of angioplasty or stenting on PTS, quality of life, and adverse events in people with acute obstruction due to DVT. The effects on VTE, mortality, and major bleeding were not estimable or not assessed by the included studies. Future trials must be large enough to detect significant clinical outcomes, and provide data on original stenosis before angioplasty or stenting and differing times from the initial event, among other essential characteristics.

The role and principles of stenting in acute iliofemoral venous thrombosis

Catheter-directed interventions for acute iliofemoral deep venous thrombosis (DVT) have been increasingly used over the past 15 years to target severe symptomatology and prevention of post-thrombotic syndrome incidence or reduce its severity if it were to develop. Aside from successful thrombus removal, adjunctive stents are frequently required to treat an uncovered lesion or significant residual thrombus to ensure quality of life improvement besides retarding DVT recurrence and post-thrombotic syndrome. As the evidence is mounting, the need and role for stenting, as well as the principles of an optimal technique, in the acute DVT setting are now better understood. Accumulating experience appears to favor stenting in the acute setting. The diameter of the stent, the length, the extent of overlapping, and the landing zones are crucial determinants of a successful durable outcome. This article endeavors to guide the interventionalist on stenting when encountering a patient with acute symptomatic iliofemoral DVT with concerns of quality of life impairment.

Acute venous problems: Integrating medical, surgical, and interventional treatments

"Acute venous problems" refers to a group of disorders that affect the veins and result in sudden and severe symptoms. They can be classified based on the pathological triggering mechanisms, such as thrombosis and/or mechanical compression, and their consequences, including symptoms, signs, and complications. The management and therapeutic approach depend on the severity of the disease, the location, and the involvement of the vein segment. Although summarizing these conditions can be challenging, the objective of this narrative review was to provide an overview of the most common acute venous problems. This will include an exhaustive yet concise and practical description of each condition. The multidisciplinary approach remains one of the major advantages in dealing with these conditions, maximizing the results and the prevention of complications.