1
|
Barbati ME, Avgerinos ED, Baccellieri D, Doganci S, Lichtenberg M, Jalaie H. Interventional treatment for post-thrombotic chronic venous obstruction: Progress and challenges. J Vasc Surg Venous Lymphat Disord 2024:101910. [PMID: 38777042 DOI: 10.1016/j.jvsv.2024.101910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/28/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
Chronic venous obstruction, including nonthrombotic iliac vein lesions and post-thrombotic syndrome, presents a significant burden on patients' quality of life and health care systems. Venous recanalization and stenting have emerged as promising minimally invasive approaches, yet challenges in patient selection, procedural techniques, and long-term outcomes persist. This review synthesizes current knowledge on the interventional treatment of post-thrombotic syndrome, focusing on the evolution of endovascular techniques and stenting. Patient selection criteria, procedural details, and the characteristics of dedicated venous stents are discussed. Particular emphasis is given to the role of inflow and other anatomical considerations, along with postoperative management protocols for an optimal long-term outcome.
Collapse
Affiliation(s)
- Mohammad E Barbati
- Clinic of Vascular and Endovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany.
| | | | | | - Suat Doganci
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara, Turkey
| | | | - Houman Jalaie
- Clinic of Vascular and Endovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany
| |
Collapse
|
2
|
Qamhawi Z, Kearns D, Wilton E, Wigham A. Thrombectomy of the Profunda Femoral Vein in Iliofemoral Deep Venous Thrombosis Using an Antegrade Popliteal Approach. Cardiovasc Intervent Radiol 2024; 47:379-385. [PMID: 38409560 DOI: 10.1007/s00270-024-03660-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 01/02/2024] [Indexed: 02/28/2024]
Abstract
PURPOSE Residual or undertreated inflow disease is a major cause of stent occlusion following endovascular thrombectomy for iliofemoral deep venous thrombosis (DVT). The profunda femoral vein (PFV) is an important inflow vessel alongside the femoral vein but is traditionally challenging to treat via an antegrade popliteal approach. This technical note describes a novel approach for PFV clearance in iliofemoral thrombectomy via the popliteal vein. MATERIALS AND METHODS Eight patients underwent PFV clearance as part of iliofemoral DVT thrombectomy via an antegrade popliteal approach. In seven patients, a popliteal-profunda communicating vessel was identified permitting PFV access and thrombectomy. In one patient, a popliteal-profunda communicator was not identified and an 'up and over' approach via the femoral bifurcation from the same popliteal access was utilised. Thrombectomy was performed using the Inari ClotTriever device or Penumbra's Indigo system. RESULTS Technical success in PFV thrombectomy was 100%. Six patients (75%) underwent stenting for an iliac stenotic lesion or May Thurner compression point. At the four-week ultrasound follow-up, the pelvic iliofemoral segment was patent in 7 patients (87.5%). The PFV was patent in 7 patients (87.5%) whereas the FV was only patent in 4 patients (50%). One patient underwent reintervention for iliofemoral stent occlusion. No PFV injury occurred and no post-procedure profunda reflux was identified. CONCLUSION PFV clearance can be achieved via an antegrade popliteal approach in iliofemoral thrombectomy to optimise inflow, negating the need for alternative or additional venous access. PFV may maintain upstream iliofemoral vein patency even with an occluded femoral vein. LEVEL OF EVIDENCE Level 4, Case Series.
Collapse
Affiliation(s)
- Zahi Qamhawi
- Department of Interventional Radiology, John Radcliffe Hospital, Oxford, OX3 9DU, UK.
| | - Daniel Kearns
- Department of Interventional Radiology, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Emma Wilton
- Department of Vascular Surgery, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Andrew Wigham
- Department of Interventional Radiology, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| |
Collapse
|
3
|
Murali N, Gupta R, Desai KR. The role of iliac vein stent placement in pelvic venous disorder management. J Vasc Surg Venous Lymphat Disord 2024; 12:101696. [PMID: 37977520 DOI: 10.1016/j.jvsv.2023.101696] [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: 06/23/2023] [Revised: 09/28/2023] [Accepted: 10/09/2023] [Indexed: 11/19/2023]
Abstract
Pelvic venous disease (PeVD) has historically been challenging to diagnose and treat. This paper describes a comprehensive approach to the diagnosis of PeVD and reviews the role of iliac vein stent placement in treatment. Patient selection is vital for non-thrombotic iliac vein lesions (NIVLs) as only a small subset of patients with an NIVL will benefit from stent placement. There is limited, inconclusive data on optimal treatment for patients with both primary ovarian vein reflux and an NIVL. Patients with chronic post-thrombotic outflow obstruction typically have a more favorable risk/benefit ratio for intervention but require anticoagulation and close follow-up due to poorer long-term stent patency. Intravascular ultrasound is a useful tool for identifying obstructive lesions, sizing stents, and planning landing zones. More research is needed to characterize underlying pathophysiology, validate thresholds for intervention, develop reliable methods for outcomes assessment, and determine treatment response. Until this data is produced, an individualized treatment approach is warranted.
Collapse
Affiliation(s)
- Nikitha Murali
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL
| | - Ramona Gupta
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL
| | - Kush R Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL.
| |
Collapse
|
4
|
Secemsky EA, Aronow HD, Kwolek CJ, Meissner M, Muck PE, Parikh SA, Winokur RS, George JC, Salazar G, Murphy EH, Costantino MM, Zhou W, Li J, Lookstein R, Desai KR. Intravascular Ultrasound Use in Peripheral Arterial and Deep Venous Interventions: Multidisciplinary Expert Opinion From SCAI/AVF/AVLS/SIR/SVM/SVS. J Vasc Interv Radiol 2024; 35:335-348. [PMID: 38206255 DOI: 10.1016/j.jvir.2023.11.006] [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: 06/01/2023] [Revised: 09/21/2023] [Accepted: 10/03/2023] [Indexed: 01/12/2024] Open
Abstract
Percutaneous revascularization is the primary strategy for treating lower extremity venous and arterial disease. Angiography is limited by its ability to accurately size vessels, precisely determine the degree of stenosis and length of lesions, characterize lesion morphology, or correctly diagnose postintervention complications. These limitations are overcome with use of intravascular ultrasound (IVUS). IVUS has demonstrated the ability to improve outcomes following percutaneous coronary intervention, and there is increasing evidence to support its benefits in the setting of peripheral vascular intervention. At this stage in its evolution, there remains a need to standardize the use and approach to peripheral vascular IVUS imaging. This manuscript represents considerations and consensus perspectives that emerged from a roundtable discussion including 15 physicians with expertise in interventional cardiology, interventional radiology, and vascular surgery, representing 6 cardiovascular specialty societies, held on February 3, 2023. The roundtable's aims were to assess the current state of lower extremity revascularization, identify knowledge gaps and need for evidence, and determine how IVUS can improve care and outcomes for patients with peripheral arterial and deep venous pathology.
Collapse
Affiliation(s)
- Eric A Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology and Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Herbert D Aronow
- Department of Medicine, Michigan State University, East Lansing, Michigan; Heart & Vascular Services, Henry Ford Health, Detroit, Michigan
| | - Christopher J Kwolek
- Harvard Medical School, Boston, Massachusetts; Newton-Wellesley Hospital, Wellesley, Massachusetts
| | - Mark Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Patrick E Muck
- Department of Vascular Surgery, Good Samaritan Hospital, Cincinnati, Ohio
| | - Sahil A Parikh
- Center for Interventional Cardiovascular Care, Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Ronald S Winokur
- Weill Cornell Vein Treatment Center and Division of Interventional Radiology, Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Jon C George
- Division of Interventional Cardiology and Endovascular Medicine, Pennsylvania Hospital, Philadelphia, Pennsylvania
| | - Gloria Salazar
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erin H Murphy
- Venous and Lymphatic Center, Division of Vascular Surgery, Sanger Heart and Vascular, Atrium Health, Charlotte, North Carolina
| | | | - Wei Zhou
- Division of Vascular Surgery, University of Arizona and Banner University Medical Center, Tucson, Arizona
| | - Jun Li
- Harrington Heart and Vascular Institute, University Hospitals, Cleveland, Ohio
| | | | - Kush R Desai
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| |
Collapse
|
5
|
Hoshino Y, Yokoi H. Ultrasound-guided stenting in the common femoral vein for accurate stent distal landing. J Vasc Surg Cases Innov Tech 2023; 9:101245. [PMID: 37799836 PMCID: PMC10547735 DOI: 10.1016/j.jvscit.2023.101245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/26/2023] [Indexed: 10/07/2023] Open
Abstract
Objective/Background Venous stenting has been reported with excellent clinical results; however, inadequate inflow can increase the risk of stent occlusion. When extending the stent into the common femoral vein (CFV), it is essential to ensure adequate inflow from the femoral vein, deep femoral vein (DFV), and great saphenous vein. Accurate identification of the distal landing zone (DLZ) of the stent is crucial to ensure adequate inflow. The DLZ is usually determined by venography or intravascular ultrasound (IVUS) with reference to bony landmarks. However, the uncertainty can lead to misidentification of the DLZ and inadequate stent placement, resulting in stent occlusion. Methods From December 2016 to December 2022, 42 venous stent placements were performed in 40 patients with post-thrombotic iliofemoral vein obstruction and/or stenosis. Three patients had developed early stent occlusion owing to a misidentified DLZ. To improve accuracy in identifying the DLZ during venous stenting, ultrasound-guided placement was performed in the CFV of five patients (four on the left and one on the right) with post-thrombotic changes in the CFV and occlusion of the common iliac vein and external iliac vein. The distal end of the stent was adjusted just above the saphenofemoral junction in two cases and just proximal to the DFV confluence in three cases. Stent placement was verified using both long-axis ultrasound and fluoroscopy. Results Ultrasound images of the CFV region provided clear visualization of the stent deployment site and accurate landmark locations, such as the saphenofemoral junction and DFV confluence, allowing for precise adjustments during stent deployment. This technique enabled easier and more definitive identification of other branches of the CFV than previously provided by IVUS and venography. No complications were observed in any of the 42 cases, and long-term patency was achieved at the final follow-up after stenting (average, 10 months; range, 3-14 months). Conclusions Ultrasound-guided stenting in the CFV allows for real-time and accurate stent deployment with precise adjustment to the optimal DLZ. Using this technique, combined with venography and IVUS, missed distal lesions and subsequent stent occlusion can be prevented, potentially contributing to better treatment outcomes.
Collapse
Affiliation(s)
- Yuji Hoshino
- Section of Vascular Surgery, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Hiroyoshi Yokoi
- Division of Cardiovascular Medicine, Fukuoka Sanno Hospital, Fukuoka, Japan
| |
Collapse
|
6
|
Robertson B, Shapiro J, Muck A, Fellner AN, Recht M, Kulwicki A, Broering M, Kuhn B, Muck P. Venous stent patency is independent of total stented length in nonthrombotic iliac vein and post-thrombotic venous stenoses. J Vasc Surg Venous Lymphat Disord 2023; 11:339-345. [PMID: 36007799 DOI: 10.1016/j.jvsv.2022.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 06/30/2022] [Accepted: 07/09/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Venous stenting has become the preferred treatment of symptomatic outflow obstruction due to nonthrombotic iliac vein lesions (NIVLs) and post-thrombotic venous stenoses (PTs). A paucity of data exists regarding the effect of stent length on patency rates after intervention. We evaluated the association between stent length and patency in patients treated for iliofemoral venous outflow obstruction. METHODS The institutional review board approved the present study. A total of 161 patients had undergone venous stenting for NIVLs and thrombotic disease from January 2016 to April 2021. For thrombotic disease, patients with PTs and those with acute deep vein thrombosis (DVT) with underlying outflow obstruction were included. The patient characteristics evaluated included gender, age, body mass index, diagnosed thrombophilia, a history of venous thromboembolism, and CEAP (clinical, etiologic, anatomic, pathophysiologic) score. All the patients had undergone multiplanar venography and intravascular ultrasound during the index procedure. The intravascular ultrasound findings were used to determine the diameter and length of the implanted stents. The patients were placed into two groups, those with stented lengths ≤100 mm and those with stented lengths >100 mm. The primary end point was stent patency between the two groups using duplex ultrasound at 6 months. RESULTS A total of 108 patients (58.3% female) had had 6-month duplex ultrasound scans available for review. Their mean age was 55.6 ± 17.2 years. The mean body mass index was 31.7 ± 6.9 kg/m2. Overall, the 6-month patency was 89.9%. Of the 108 patients, 56 (51.9%) had had a total stented length of ≤100 mm with a 6-month patency of 92.9%. The remaining 52 patients (48.1%) had had a total stented length >100 mm with a 6-month patency of 86.5%. The rate of patency did not differ significantly between the two groups (P = .222). Stent patency at 6 months for patients with NIVLs was 98% (40 of 41). Stent patency for patients with PTs was 84% (32 of 38). Patency for patients with acute DVT who had undergone stenting after thrombectomy was 86% (25 of 29). Overall, 10 patients with thrombotic disease, including PT and acute DVT, had developed stent thrombosis. The total stented length was not predictive of the loss of patency. CONCLUSIONS These findings suggest that the length of stent coverage does not confer an increased likelihood of stent thrombosis for patients with iliofemoral venous obstruction. Interventionalists should treat the affected venous segments identified on intravascular ultrasound and effectively stent from normal to normal venous areas, regardless of the stent length required. These results suggest that the total stented length is not a risk factor for stent thrombosis for both NIVL and thrombotic iliofemoral venous lesions.
Collapse
Affiliation(s)
- Brent Robertson
- Division of Vascular Surgery, TriHealth-Good Samaritan Hospital, Cincinnati, OH.
| | - Jacob Shapiro
- Division of Vascular Surgery, TriHealth-Good Samaritan Hospital, Cincinnati, OH
| | - Audrey Muck
- Division of Vascular Surgery, TriHealth-Good Samaritan Hospital, Cincinnati, OH
| | | | - Matthew Recht
- Division of Vascular Surgery, TriHealth-Good Samaritan Hospital, Cincinnati, OH
| | - Aaron Kulwicki
- Division of Vascular Surgery, TriHealth-Good Samaritan Hospital, Cincinnati, OH
| | - Mark Broering
- Division of Vascular Surgery, TriHealth-Good Samaritan Hospital, Cincinnati, OH
| | - Brian Kuhn
- Division of Vascular Surgery, TriHealth-Good Samaritan Hospital, Cincinnati, OH
| | - Patrick Muck
- Division of Vascular Surgery, TriHealth-Good Samaritan Hospital, Cincinnati, OH
| |
Collapse
|
7
|
Morris R, Black S, Saha P. Response to: "The Stent's Gatekeeper: Inflow Disease". Eur J Vasc Endovasc Surg 2022; 64:739. [PMID: 35872343 DOI: 10.1016/j.ejvs.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 01/11/2023]
Affiliation(s)
- Rachael Morris
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, St. Thomas' Hospital, London SE1 7EH, UK
| | - Stephen Black
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, St. Thomas' Hospital, London SE1 7EH, UK
| | - Prakash Saha
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, British Heart Foundation Centre of Research Excellence, King's College London, St. Thomas' Hospital, London SE1 7EH, UK.
| |
Collapse
|
8
|
Li N, Ferracane J, Andeen N, Lewis S, Woltjer R, Rugonyi S, Jahangiri Y, Uchida B, Farsad K, Kaufman JA, Al-Hakim R. Impact of Postthrombotic Vein Wall Biomechanics on Luminal Flow during Venous Angioplasty and Stent Placement: Computational Modeling Results. J Vasc Interv Radiol 2022; 33:262-267. [PMID: 35221046 DOI: 10.1016/j.jvir.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/04/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022] Open
Abstract
This study characterized the impact of vein wall biomechanics on inflow diameter and luminal flow during venous angioplasty and stent placement, using postthrombotic and healthy biomechanical properties from an ovine venous stenosis and thrombosis model. Finite element analysis demonstrated more pronounced inflow channel narrowing in the postthrombotic vein compared with the healthy control vein during angioplasty and stent placement (relative inflow diameter reduction of 42% versus 13%, P < .0001). Computational fluid dynamics modeling showed increased relative areas of low wall shear rate in the postthrombotic vein compared with the normal vein (0.46 vs 0.24 for shear rate < 50 s-1; 0.13 vs 0.07 for shear rate < 15 s-1; P < .05), with flow stagnation and recirculation. Since inflow narrowing and low wall shear rate are associated with in-stent restenosis and reintervention, these computational results based on experimentally obtained biomechanical values highlight the significance of postthrombotic venous properties in optimizing venous intervention outcomes.
Collapse
Affiliation(s)
- Ningcheng Li
- Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon
| | - Jack Ferracane
- School of Dentistry, Oregon Health and Science University, Portland, Oregon; Department of Biomaterials and Biomechanics, Oregon Health and Science University, Portland, Oregon
| | - Nicole Andeen
- Department of Pathology, Oregon Health and Science University, Portland, Oregon
| | - Steven Lewis
- School of Dentistry, Oregon Health and Science University, Portland, Oregon; Department of Biomaterials and Biomechanics, Oregon Health and Science University, Portland, Oregon
| | - Randy Woltjer
- Department of Pathology, Oregon Health and Science University, Portland, Oregon
| | - Sandra Rugonyi
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, Oregon
| | - Younes Jahangiri
- Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon
| | - Barry Uchida
- Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon
| | - Khashayar Farsad
- Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon
| | - John A Kaufman
- Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon
| | - Ramsey Al-Hakim
- Dotter Interventional Institute, Oregon Health and Science University, Portland, Oregon.
| |
Collapse
|
9
|
Risk Factors and Classification of Reintervention Following Deep Venous Stenting for Acute Iliofemoral Deep Venous Thrombosis. J Vasc Surg Venous Lymphat Disord 2022; 10:1051-1058.e3. [DOI: 10.1016/j.jvsv.2022.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/15/2022] [Indexed: 11/18/2022]
|
10
|
Majeed GM, Lodhia K, Carter J, Kingdon J, Morris RI, Gwozdz A, Saratzis A, Saha P. A Systematic Review and Meta-Analysis of 12-Month Patency After Intervention for Iliofemoral Obstruction Using Dedicated or Non-Dedicated Venous Stents. J Endovasc Ther 2021; 29:478-492. [PMID: 34758673 PMCID: PMC9096580 DOI: 10.1177/15266028211057085] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endovascular stenting of the deep venous system has been proposed as a method to treat patients with symptomatic iliofemoral outflow obstruction. The purpose of this systematic review and meta-analysis was to compare the effectiveness of this treatment at 1-year following the development of dedicated venous stents. METHOD AND RESULTS We searched MEDLINE and EMBASE for studies evaluating the effectiveness of venous stent placement. Data were extracted by disease pathogenesis: non-thrombotic iliac vein lesions (NIVL), acute thrombotic (DVT), or post-thrombotic syndrome (PTS). Main outcomes included technical success, stent patency at 1 year and symptom relief. A total of 49 studies reporting outcomes in 5154 patients (NIVL, 1431; DVT, 950; PTS, 2773) were included in the meta-analysis. Technical success rates were comparable among groups (97%-100%). There were no periprocedural deaths. Minor bleeding was reported in up to 5% of patients and major bleeding in 0.5% upon intervention. Transient back pain was noted in 55% of PTS patients following intervention. There was significant heterogeneity between studies reporting outcomes in PTS patients. Primary and cumulative patency at 1 year was: NIVL-96% and 100%; DVT-91% and 97%; PTS (stents above the ligament)-77% and 94%, and; PTS (stents across the ligament)-78% and 94%. There were insufficient data to compare patency outcomes of dedicated and nondedicated venous stents in patients with acute DVT. In NIVL and PTS patients, stent patency was comparable at 1 year. There was inconsistency in the use of validated tools for the measurement of symptoms before and after intervention. When reported, venous claudication, improved in 83% of PTS patients and 90% of NIVL patients, and ulcer healing occurred in 80% of PTS patients and 32% of NIVL patients. CONCLUSIONS The first generation of dedicated venous stents perform comparably in terms of patency and clinical outcomes to non-dedicated technologies at 1 year for the treatment of patients with NIVL and PTS. However, significant heterogeneity exists between studies and standardized criteria are urgently needed to report outcomes in patients undergoing deep venous stenting.
Collapse
Affiliation(s)
- Ghulam M Majeed
- Academic Department of Vascular Surgery, St. Thomas' Hospital, School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Krishan Lodhia
- Academic Department of Vascular Surgery, St. Thomas' Hospital, School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Jemima Carter
- Academic Department of Vascular Surgery, St. Thomas' Hospital, School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Jack Kingdon
- Academic Department of Vascular Surgery, St. Thomas' Hospital, School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Rachael I Morris
- Academic Department of Vascular Surgery, St. Thomas' Hospital, School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Adam Gwozdz
- Academic Department of Vascular Surgery, St. Thomas' Hospital, School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | | | - Prakash Saha
- Academic Department of Vascular Surgery, St. Thomas' Hospital, School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| |
Collapse
|
11
|
Piao L, Barbati ME, Shekarchian S, Jacobs MJ, Razavi M, Rass K, Jalaie H. Comparison of endovascular strategy versus hybrid procedure in treatment of chronic venous obstructions involving the confluence of common femoral vein. J Vasc Surg Venous Lymphat Disord 2021; 10:334-341. [PMID: 34478907 DOI: 10.1016/j.jvsv.2021.08.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 08/15/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Treatment of extensive chronic venous obstruction (CVO) with post-thrombotic trabeculation involving the common femoral vein with extension into the femoral vein or deep femoral vein remains a challenge and the best treatment technique for such cases is not clear. In the present study, we compared the results of endovascular alone vs endovascular with additional endophlebectomy (hybrid) procedures for such patients. METHODS The medical records of 102 consecutive patients (108 limbs) treated between 2015 and 2020 for iliofemoral CVO extending to the femoral confluence were retrospectively reviewed. The patients were divided into two groups: the hybrid procedure (HP) and endovascular treatment (EN) groups. The HP group consisted of those treated with stent implantation and endophlebectomy of the common femoral vein with creation of an arteriovenous fistula. The EN group included those who had undergone stent implantation alone. The patency rates, complications, and clinical outcomes were analyzed. RESULTS Of the 102 patients, 47 (49 limbs) were in the EN group and 55 (59 limbs) were in the HP group. The demographics of the two groups were similar with no statistically significant differences in cumulative primary, assisted primary, or secondary patency rates at 36 months (33.7% vs 36.3%, P = .839; 59.8% vs 64%, P = .941; 69% vs 72.7%, P = .851; respectively). The patients in the EN group, however, had better clinical improvement with a lower postoperative complication rate (P = .012), shorter procedure duration (P < .001), and shorter hospital stay (P = .025). CONCLUSIONS The EN and HP both provided similar patency rates for patients with CVO extending into the femoral confluence. The endovascular strategy has the benefit of fewer postoperative complications and a shorter procedure duration and hospital stay compared with the HP.
Collapse
Affiliation(s)
- Long Piao
- Department of Vascular Surgery, University Hospital Aachen, Aachen, Germany.
| | | | - Soroosh Shekarchian
- Department of Vascular Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michael J Jacobs
- Department of Vascular Surgery, University Hospital Aachen, Aachen, Germany
| | | | - Knuth Rass
- Center for Venous and Peripheral Arterial Diseases, Eifelklinik St Brigida, Simmerath, Germany
| | - Houman Jalaie
- Department of Vascular Surgery, University Hospital Aachen, Aachen, Germany
| |
Collapse
|
12
|
Abstract
Historically, the stents used in the venous system were not dedicated scaffolds. They were largely adapted arterial stents. An essential feature of a venous stent is compliance, in order to adapt its crosssectional area to the vein. It should also be crush resistant, corrosion resistant and fatigue resistant. The material should be radiopaque, for follow-up. Another characteristic of the ideal venous stent is flexibility, to adapt its shape to the vein, not vice versa. The scaffold should be uncovered too, in order to avoid the occlusion of collaterals. The ideal venous stent should not migrate, so it is necessary a large diameter and a long length. The radial force is important to prevent migration. However, current stents derived from arterial use display high radial force, which could affect the patency of the thin venous wall. Alternatively, if the stent has an anchor point, that permits a passive anchoring, the radial force required to avoid migration will be lower. Dedicated venous stents were not available until very recently. Furthermore, there is a preclinical study about a new compliant nitinol stent, denominated Petalo CVS. Out of the commonest causes of large veins obstruction, dedicated venous stent could also treat other diseases described more recently, such as the jugular variant of the Eagle syndrome, JEDI syndrome and jugular lesions of the chronic cerebrospinal venous insufficiency that result unfavorable for angioplasty according to Giaquinta classification.
Collapse
|
13
|
Badesha AS, Singh Bains PR, Singh Bains BR, Khan T. A systematic review and meta-analysis of the treatment of obstructive chronic deep venous disease using dedicated venous stents. J Vasc Surg Venous Lymphat Disord 2021; 10:267-282.e4. [PMID: 33965610 DOI: 10.1016/j.jvsv.2021.04.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/18/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES This review aims to summarise the efficacy and safety of dedicated venous stenting for the treatment of obstructive chronic deep venous disease. The approaches to stenting and post-procedural management of different vascular units are also highlighted. METHODS MEDLINE and Embase were searched to identify relevant literature on dedicated venous stents published from January, 2010 to May, 2020. The patient population and study characteristics; procedural characteristics; and outcomes related to post-stenting symptoms, health-related quality of life, patency and complications were analysed. RESULTS Sixteen single-arm observational studies were included from 2,366 studies identified from key-word searches. In total, 1,688 patients were included, of which 70.5% had post-thrombotic syndrome and the remainder had non-thrombotic iliac vein lesions. Nine studies (n = 848), stated whether lesions were stenotic (36.6%) or occlusive (63.4%). Seven studies did not report the lesion characteristics (n = 840). Eight different dedicated venous stent brands were employed. 73.4% of ulcers healed at last follow-up. The remaining symptomatic changes were described narratively; sustained improvements in pain, venous claudication and oedema following stenting were observed. Significant post-stenting improvements in health-related quality of life were noted, as measured by the Chronic Venous Insufficiency Questionnaire-20 instrument. Overall, the most frequently reported complications were in-stent occlusion (n = 204), in-stent stenosis (n = 149) and minor bleeding (n = 77). At 12 months, the primary patency ranged from 59% to 94%, whilst the secondary patency ranged 87% to 100%. The pooled-primary and secondary stent patency rates at 12 months were 74.0% and 90.4%, respectively. The incidence of major and minor bleeding was 1.9% and 4.7%, respectively; bleeding complications were more common in patients undergoing hybrid intervention. CONCLUSION Deep venous stenting using dedicated venous stents is a safe technique to treat obstructive chronic deep venous disease and within the limitations of this study, is associated with good patency outcomes and symptomatic improvement.
Collapse
Affiliation(s)
- Arshpreet Singh Badesha
- Manchester Medical School, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom.
| | - Prab Rajan Singh Bains
- Manchester Medical School, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Bal Rajan Singh Bains
- Manchester Medical School, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Taha Khan
- Manchester Vascular Service, Manchester, United Kingdom
| |
Collapse
|
14
|
Zhou Y, Guan Y, Xue M, Zheng X, Chen X. Clinical Outcomes of Stenting Extending Below the Inguinal Ligament for Treatment of Chronic Iliofemoral Venous Obstruction. Ann Vasc Surg 2021; 75:259-266. [PMID: 33823261 DOI: 10.1016/j.avsg.2021.01.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 12/27/2020] [Accepted: 01/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with chronic iliofemoral venous obstructive lesions that often require stenting extending below the inguinal ligament. However, the issue of stents crossing the inguinal ligament is currently controversial. Some guidelines suggest that it should be avoided, and some guidelines suggest that in order to ensure adequate flow, the inguinal ligament can be crossed if necessary. The aim of this study was to evaluate the technical aspects and examine patency rates of stent placement across the inguinal ligament for managing iliofemoral venous obstruction. METHODS A retrospective analysis of 127 patients with chronic iliofemoral venous obstruction were treated with interventional surgery in a single institution from January 2012 to January 2018 was conducted. All patients underwent balloon dilatation and placement of at least 2 stents extending below inguinal ligament. Inflow condition, technical success, operation duration, stent patency rates, anticoagulant selection and duration, and complications were recorded after the interventions. RESULTS The technical success rate was 100%. No major perioperative complications occurred. The mean number of stents was 2.14 ± 0.37. Follow up periods ranged from 12 to 60 months (28.79 ± 10.90 months). Overall cumulative primary, assisted primary, and secondary stent patency rates were 81.9%, 90.5%, and 92.9% at 12 months and 70.4%, 80.9%, and 86.0% at 24 months, and 64.2%, 72.3%, and 74.3% at 36months, respectively. Cumulative patency rates at 12 months, 24 months and 36 months were significantly greater in the patients with "good" inflow as compared to "fair" inflow. The symptoms of all patients improved. None of the stents were compressed, fractured or migrated. CONCLUSIONS Stenting across the inguinal ligament for treatment of the patients with chronic iliofemoral venous obstruction was a feasible and safe treatment with good patency and clinical results in short and midterm follow up, and stents with good inflow have better patency.
Collapse
Affiliation(s)
- Yadong Zhou
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Yunbiao Guan
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China.
| | - Ming Xue
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Xuexun Zheng
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Xingsheng Chen
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| |
Collapse
|
15
|
Sebastian T, Gnanapiragasam S, Spirk D, Engelberger RP, Moeri L, Lodigiani C, Kreuzpointner R, Barco S, Kucher N. Self-Expandable Nitinol Stents for the Treatment of Nonmalignant Deep Venous Obstruction. Circ Cardiovasc Interv 2020; 13:e009673. [PMID: 33272030 DOI: 10.1161/circinterventions.120.009673] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Angioplasty with stent placement is a therapeutic option for patients with acute thrombotic, postthrombotic, and nonthrombotic obstruction of the iliofemoral veins or inferior vena cava. Previous studies of steel-alloy stents described variable patency rate across indications. METHODS The prospective Swiss Venous Stent Registry includes patients treated with self-expandable nitinol stents for deep venous obstruction. Routine follow-up visits include serial duplex ultrasound for stent patency assessment. The primary outcome was primary stent patency. The secondary outcome was venous thromboembolisms. We studied the rate of stent occlusion and potentially contributing factors. RESULTS We included 379 patients: 160 with acute thrombotic, 193 with postthrombotic, and 26 with nonthrombotic deep vein obstruction. The mean age was 46±18 years; 55% were women. The cumulative 3-year primary patency rate was 80.5% (95% CI, 73.0%-88.0%) for acute thrombotic, 59.2% (95% CI, 50.4%-68.0%) for postthrombotic, and 100% for nonthrombotic obstruction (log-rank, P<0.0001). Annualized rates of stent occlusion or venous thromboembolism were 7.8 (acute thrombotic), 15.0 (postthrombotic), and 0 (nonthrombotic) events/100 patient-years. In a multivariable Cox regression model, postthrombotic femoral veins at baseline (hazard ratio, 2.64 [95% CI, 1.53-4.56]) and the number of stents (hazard ratio, 1.22 [95% CI, 1.06-1.40]) were associated with stent occlusion after conditioning for age, sex, and clinically relevant factors. CONCLUSIONS The rate of stent occlusion (patency loss) and venous thromboembolism varies substantially across indications, also with dedicated venous nitinol stents. Patients with postthrombotic femoral veins and those who received multiple stents were characterized by the highest risk. Registration: URL: https://clinicaltrials.gov. Unique identifier: NCT02433054.
Collapse
Affiliation(s)
- Tim Sebastian
- Clinic for Angiology, University Hospital Zurich, Switzerland (T.S., S.G., L.M., R.K., S.B., N.K.)
| | - Suvetha Gnanapiragasam
- Clinic for Angiology, University Hospital Zurich, Switzerland (T.S., S.G., L.M., R.K., S.B., N.K.).,Medical Faculty, University of Zurich, Switzerland (S.G., L.M.)
| | - David Spirk
- Institute of Pharmacology, University of Bern, Switzerland (D.S.)
| | | | - Laura Moeri
- Clinic for Angiology, University Hospital Zurich, Switzerland (T.S., S.G., L.M., R.K., S.B., N.K.).,Medical Faculty, University of Zurich, Switzerland (S.G., L.M.)
| | - Corrado Lodigiani
- Center for Thrombosis and Hemorrhagic Diseases, Humanitas Clinical and Research Hospital, Rozzano, Milano, Italy (C.L.)
| | - Robert Kreuzpointner
- Clinic for Angiology, University Hospital Zurich, Switzerland (T.S., S.G., L.M., R.K., S.B., N.K.)
| | - Stefano Barco
- Clinic for Angiology, University Hospital Zurich, Switzerland (T.S., S.G., L.M., R.K., S.B., N.K.)
| | - Nils Kucher
- Clinic for Angiology, University Hospital Zurich, Switzerland (T.S., S.G., L.M., R.K., S.B., N.K.)
| |
Collapse
|
16
|
Li N, Mendoza F, Rugonyi S, Farsad K, Kaufman JA, Jahangiri Y, Uchida BT, Bonsignore C, Al-Hakim R. Venous Biomechanics of Angioplasty and Stent Placement: Implications of the Poisson Effect. J Vasc Interv Radiol 2020; 31:1348-1356. [PMID: 32682711 DOI: 10.1016/j.jvir.2020.02.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/15/2020] [Accepted: 02/19/2020] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To characterize the Poisson effect in response to angioplasty and stent placement in veins and identify potential implications for guiding future venous-specific device design. MATERIALS AND METHODS In vivo angioplasty and stent placement were performed in 3 adult swine by using an established venous stenosis model. Iron particle endothelium labeling was performed for real-time fluoroscopic tracking of the vessel wall during intervention. A finite-element computational model of a vessel was created with ADINA software (version 9.5) with arterial and venous biomechanical properties obtained from the literature to compare the response to radial expansion. RESULTS In vivo angioplasty and stent placement in a venous stenosis animal model with iron particle endothelium labeling demonstrated longitudinal foreshortening that correlated with distance from the center of the balloon (R2 = 0.87) as well as adjacent segment narrowing that correlated with the increase in diameter of the treated stenotic segment (R2 = 0.89). Finite-element computational analysis demonstrated increased Poisson effect in veins relative to arteries (linear regression coefficient slope comparison, arterial slope 0.033, R2 = 0.9789; venous slope 0.204, R2 = 0.9975; P < .0001) as a result of greater longitudinal Young modulus in veins compared with arteries. CONCLUSIONS Clinically observed adjacent segment narrowing during venous angioplasty and stent placement is a result of the Poisson effect, with redistribution of radially applied force to the longitudinal direction. The Poisson effect is increased in veins relative to arteries as a result of unique venous biomechanical properties, which may be relevant to consider in the design of future venous interventional devices.
Collapse
Affiliation(s)
- Ningcheng Li
- Dotter Interventional Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
| | - Francine Mendoza
- Department of Biomedical Engineering, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239; Department of Biomedical Engineering, Oregon State University, Corvallis, Oregon
| | - Sandra Rugonyi
- Department of Biomedical Engineering, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
| | - Khashayar Farsad
- Dotter Interventional Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
| | - John A Kaufman
- Dotter Interventional Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
| | - Younes Jahangiri
- Dotter Interventional Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
| | - Barry T Uchida
- Dotter Interventional Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239
| | | | - Ramsey Al-Hakim
- Dotter Interventional Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Portland, OR 97239.
| |
Collapse
|