Single-stage treatment with iliac vein stenting and stripping of great saphenous veins for patients with left iliac vein compression syndrome

BACKGROUND

We sought to evaluate the safety and feasibility of single-stage treatment with left iliac vein stenting and saphenous stripping in patients with left iliac vein compression (LIVC) and left great saphenous vein (GSV) incompetence.

METHOD

s: We conducted a prospective cohort study of 72 patients diagnosed with LIVC and left GSV incompetence between June 2012 to Oct 2018. We evaluated the periprocedural, 30-day, and 1-year outcomes of venous clinical severity score (VCSS), Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), the success rate of stent placement, duration of intervention, length of hospital stay, duplex recurrence, and clinically visible recurrence.

RESULTS

There were 43 patients in the two-staged group and 29 patients in the single-staged group. The clinical characteristics of the two groups were similar. There were no differences between the two groups in the technical success rate, perioperative mortality, and surgical morbidity. There was no significant difference in the duplex and clinically visible recurrence. The length of hospital stay was significantly lower in the single-staged group. The single-staged group was associated with a higher complication rate of ecchymosis. There was no death, pulmonary embolism, or contrast-induced nephropathy among the patients. The 1-year primary patency rate was similar.

CONCLUSIONS

Both treatment approaches were equally effective and had a high technical success rate. The single-staged group had a higher complication rate of ecchymosis due to heparin applying during the procedure.

Comparing the efficacy of endovascular treatment for iliac vein compression syndrome with or without acute deep venous thrombosis: A single-center retrospective study

BACKGROUND

To compare the efficacy of endovascular treatment for iliac vein compression syndrome (IVCS) with or without acute deep venous thrombosis of lower extremity.

METHODS

This study retrospectively analyzed the clinical data of 300 IVCS patients, who received endovascular treatment between January 2013 and December 2017. According to whether IVCS was complicated by deep venous thrombosis or not, these patients were divided into non-thrombotic iliac vein lesion group (NIVL group, n = 127) and post-thrombotic iliac vein lesion group (PIVL group, n = 173). After endovascular treatment, all patients were followed up to assess the symptoms improvement and to evaluate the patency of iliac vein.

RESULTS

The technical success rate was 98% (294/300), and percutaneous transluminal angioplasty with stenting was adopted in 294 cases. The incidence of perioperative complications was 36.33% (109/300), but no severe complications occurred. During a mean follow-up of 22.3 months (range 6-30 months), 9(6.82%, 9/132) patients in PIVL group had recurrence of deep venous thrombosis, but nobody had deep venous thrombosis and varicose veins recurrence in NIVL group. The effective rate of endovascular treatment in NIVL group and PIVL group was 96.88% and 90.15% (P = 0.050), while the cumulative primary patency of iliac vein in NIVL group was significantly higher than that in PIVL group (P = 0.008).

CONCLUSIONS

The endovascular treatment is an effective, feasible, safe method for treating IVCS. There is no difference in the efficacy of IVCS patients with or without deep venous thrombosis, but the medium and long-term patency of patients with deep venous thrombosis is lower than that in patients without deep venous thrombosis.

Clinical outcomes and overview of dedicated venous stents for management of chronic iliocaval and femoral deep venous disease

OBJECTIVES

Venous stenting of the lower extremities has grown in popularity and is now considered a key component of the primary treatment strategy for the management of pathologically obstructive or stenotic lesions of the deep venous system. This review aims to provide an overview of the role of venous stenting in the management of chronic conditions affecting the deep venous system of the lower limbs.

METHODS

An overview of venous stents design and current role of stenting procedure in individuals presenting with Chronic Venous Insufficiency (CVI) and presenting the current trials of dedicated venous stenting in management of chronic deep venous lesions. This review provides a focused insight on venous stent design, physical properties and the available dedicated venous stents selected studies with their related patency outcome based on selective literature search of the PubMed database and Cochrane library.

CONCLUSIONS

Dedicated venous stent technology is advancing at a rapid pace alongside the increased undertaking of endovascular deep venous stent reconstruction in the management of iliocaval vein pathologies. The ideal design(s) for venous stents remain unknown, although it is hoped that the presence of new dedicated venous stents in clinical practice will allow the generation of experience and data to advance our understanding in this area.

Factors associated with the development of post-thrombotic syndrome in patients with iliofemoral deep venous thrombosis who underwent catheter-directed thrombolysis

OBJECTIVE

To identify predictors of post-thrombotic syndrome in patients with iliofemoral deep venous thrombosis who underwent catheter-directed thrombolysis.

METHODS

Fifty-two consecutive patients who underwent catheter-directed thrombolysis were included in this retrospective study. In addition to catheter-directed thrombolysis, aspiration thrombectomy or stent placement was performed if needed. At six months, duplex ultrasound was performed to assess iliofemoral patency and deep venous reflux. Post-thrombotic syndrome was assessed using the clinical, etiologic, anatomic, and pathophysiologic classification (post-thrombotic syndrome present ≥3 on a scale from 0 to 6). Univariate analysis and multivariate logistic regression were used to identify predictors of post-thrombotic syndrome.

RESULTS

Median follow-up was 52 months and post-thrombotic syndrome developed in nine patients (17.3%). In univariate analysis, stent placement (odds ratio 0.16, p = 0.022) was negatively associated with post-thrombotic syndrome, whereas iliofemoral venous obstruction with reflux at six months (OR 6.08, p = 0.037) was positively associated with post-thrombotic syndrome. Multivariate analysis indicated that stent placement was associated with reduced risk of post-thrombotic syndrome (OR 0.17, p = 0.043), and iliofemoral obstruction with reflux was associated with increased risk (OR 6.67, p = 0.046).

CONCLUSION

Stent placement and iliofemoral venous obstruction with reflux, respectively, were important protective and risk factors for post-thrombotic syndrome in patients who underwent catheter-directed thrombolysis.

Critical Review of Large Animal Models for Central Deep Venous Thrombosis

OBJECTIVE

To review the existing literature on large animal models of central venous thrombosis (CVT) and to evaluate its relevance in regard to the development and testing of dedicated therapeutics applicable to humans.

METHODS

A systematic literature search was conducted in PubMed and Embase. Articles describing an in vivo experimental protocol of CVT in large animals, involving the iliac vein and/or the vena cava and/or the brachiocephalic vein, were included. The primary aim of the study, animal characteristics, experimental protocol, and thrombus evaluation were recorded.

RESULTS

Thirty-eight papers describing more than 30 different protocols were included. Animals used were pigs (53%), dogs (21%), monkeys (24%), and cattle (3%). The median number of animals per study was 12. Animal sex, strain, and weight were missing in 18 studies (47%), seven studies (18%), and eight studies (21%), respectively. CVT was always induced by venous stasis: solely (55%), or in addition to hypercoagulability (37%) or endothelial damage (10%). The size of the vessel used for thrombus creation was measured in four studies (10%). Unexpected animal death occurred in nine studies (24%), ranging from 3% to 37% of the animals. Twenty-two studies (58%) in the acute phase and 31 studies in the chronic phase (82%) evaluated the presence or absence of the thrombus created, and its occlusive characteristic was reported, respectively, in five and 17 studies. Histological examination was performed in 24 studies (63%) with comparison to human thrombus in one study.

CONCLUSION

This review showed advantages and weaknesses of the existing large animal models of CVT. Future models should insist on more rigour and consistency in reporting animal characteristics, as well as evaluating and comparing the thrombus created to human thrombus.

Venography versus intravascular ultrasound for diagnosing and treating iliofemoral vein obstruction

OBJECTIVE

The Venogram vs IVUS for Diagnosing Iliac vein Obstruction (VIDIO) trial was designed to compare the diagnostic efficacy of intravascular ultrasound (IVUS) with multiplanar venography for iliofemoral vein obstruction.

METHODS

During a 14-month period beginning July 2014, 100 patients with chronic Clinical, Etiologic, Anatomic, and Pathophysiologic clinical class C4 to C6 venous disease and suspected iliofemoral vein obstruction were enrolled at 11 U.S. and 3 European sites. The inferior vena cava and common iliac, external iliac, and common femoral veins were imaged. Venograms were measured for vein diameter; IVUS provided diameter and area measurements. Multiplanar venograms included three views: anteroposterior and 30-degree right and left anterior oblique views. A core laboratory evaluated the deidentified images, determining stenosis severity as the ratio between minimum luminal diameter and reference vessel diameter, minimal luminal area, and reference vessel area. A 50% diameter stenosis by venography and a 50% cross-sectional area reduction by IVUS were considered significant. Analyses assessed change in procedures performed on the basis of imaging method and concordance of measurements between each imaging method.

RESULTS

Venography identified stenotic lesions in 51 of 100 subjects, whereas IVUS identified lesions in 81 of 100 subjects. Compared with IVUS, the diameter reduction was on average 11% less for venography (P < .001). The intraclass correlation coefficient was 0.505 for vein diameter stenosis calculated with the two methods. IVUS identified significant lesions not detected with three-view venography in 26.3% of patients. Investigators revised the treatment plan in 57 of 100 cases after IVUS, most often because of failure of venography to detect a significant lesion (41/57 [72%]). IVUS led to an increased number of stents in 13 of 57 subjects (23%) and the avoidance of an endovascular procedure in 3 of 57 subjects (5%). Overall, IVUS imaging changed the treatment plan in 57 patients; 54 patients had stents placed on the basis of IVUS detection of significant iliofemoral vein obstructive lesions not appreciated with venography, whereas 3 patients with significant lesions on venography had no stent placed on the basis of IVUS.

CONCLUSIONS

IVUS is more sensitive for assessing treatable iliofemoral vein stenosis compared with multiplanar venography and frequently leads to revised treatment plans and the potential for improved clinical outcome.

Contemporary management of acute and chronic deep venous thrombosis

INTRODUCTION

This review aims to provide an update on the management of deep vein thrombosis (DVT).

SOURCES OF DATA

A systematic search of PubMed, Google Scholar and Cochrane databases was carried out.

AREAS OF AGREEMENT

Direct oral anticoagulants (DOACs) are as effective and easier to use than vitamin K antagonists for the treatment of DVT. Catheter-directed thrombolysis can reduce post thrombotic syndrome in patients with iliofemoral DVT. Compression bandaging can help heal a venous ulcer.

AREAS OF CONTROVERSY

Compression hosiery to prevent post thrombotic syndrome. Long-term evidence to show clinical benefit of using endovenous therapies to restore deep vein patency.

GROWING POINTS

Developing imaging methods to identify patients who would benefit from venous thrombolysis. The evolution of dedicated venous stents.

AREAS TIMELY FOR DEVELOPING RESEARCH

Understanding the mechanisms that lead to stent occlusion and investigation into the appropriate treatments that could prevent in-stent thrombosis is required.

Thrombus age is ideally measured by history or MRV prior to thrombus removal

Many factors are known to be important in order to achieve optimal results after thrombus removal for iliofemoral DVT. Not much is published in the literature about timing the treatment, though many guidelines recommend treatment within 14 days. This time span lies within the phrase of acute DVT according to the definition given in many reporting standards. This article will highlight the value of information acquired from patients directly regarding onset of symptoms versus information acquired from imaging with the purpose of a more precise selection of patients for catheter-directed thrombolysis for iliofemoral DVT. What is the value of clinical information acquired from patients and does the information from imaging have additional value?