Editor's Choice - Reconstruction of the femoro-ilio-caval outflow by percutaneous and hybrid interventions in symptomatic deep venous obstruction.

OBJECTIVE/BACKGROUND: Deep venous obstruction is relatively prevalent in patients with chronic venous disease. Endovascular treatments and hybrid interventions can be used to relieve venous outflow obstructions. This paper assesses mid-term clinical outcomes and patency rates in a large cohort after percutaneous and hybrid interventions. METHODS: This was a prospectively analysed cohort study. Patients with symptomatic deep venous obstruction who presented at a tertiary referral hospital were divided into three groups: patients who underwent percutaneous stenting for non-thrombotic iliac vein compression syndrome (IVCS group); patients with post-thrombotic syndrome (PTS) treated by percutaneous stent placement (P-PTS group); and PTS patients with obstruction involving the veins below the saphenofemoral junction in which a hybrid procedure was performed, combining stenting with open surgical disobliteration (H-PTS group). Patency rates, complications, and clinical outcomes were analysed. RESULTS: A total of 425 lower extremities in 369 patients were treated. At 60 months, primary patency, assisted primary patency, and secondary patency rates were 90%, 100%, and 100% for IVCS, and 64%, 81%, and 89% for the P-PTS group, respectively. The H-PTS group, showed patency rates of 37%, 62%, and 72%, respectively, at 36 months. Venous claudication subsided in 90%, 82%, and 83%, respectively. At the 24 month follow-up, mean Venous Clinical Severity Score decreased for all patients and improvement in Villalta score was seen in post-thrombotic patients. The number of complications was related to the extent of deep venous obstruction in which patients in the H-PTS group showed the highest complication rates (81%) and re-interventions (59%). CONCLUSION: Percutaneous stent placement to treat non-thrombotic iliac vein lesions, and post-thrombotic ilio-femoral obstructions are safe, effective, and showed patency rates comparable with previous research. Patients with advanced disease needing a hybrid procedure showed a lower patency rate and more complications. However, when successful, the clinical outcome was favourable at mid-term follow-up and the procedure may be offered to selected patients.

Endophlebectomy of the common femoral vein and arteriovenous fistula creation as adjuncts to venous stenting for post-thrombotic syndrome.

BACKGROUND: Good results have been reported for angioplasty and stenting of post-thrombotic lesions of the iliac and proximal femoral veins. If lesions at the origin of the superficial femoral and profunda veins are stented, the intraluminal synechiae can be pushed against the orifices of inflow vessels, potentially decreasing stent inflow. Surgical disobliteration of the common femoral vein (endophlebectomy) has been suggested to mitigate this problem. Because of a temporary increase in thrombogenicity, this procedure may be accompanied by arteriovenous fistula creation. METHODS: Data on consecutive patients treated by hybrid venous reconstruction, between December 2010 and May 2015, were analysed. Standard recording consisted of clinical scoring systems (including Villalta scale) and imaging. Patency was assessed with duplex ultrasonography. RESULTS: Seventy-six legs (70 patients) were included. Median follow-up was 379 (range 73-1508) days. Primary, assisted primary and secondary patency rates at 12 months were 51, 70 and 83 per cent respectively. Sixty per cent of loss of primary patency (24 of 40 legs) was related to common femoral vein stenosis, and the rest to rethrombosis. Other complications included wound infection (29 per cent) and lymphatic leak (39 per cent). The Villalta score had decreased by a median of 7 points at 1-year follow-up. CONCLUSION: The combination of venous stenting, endophlebectomy and arteriovenous fistula creation for patients with extensive post-thrombotic vein damage and severe post-thrombotic syndrome is feasible.

Intravenous pressure changes in patients with postthrombotic deep venous obstruction: results using a treadmill stress test.

UNLABELLED: Essentials Little is known about the hemodynamic consequences of deep venous obstructive disease. We investigated pressure changes in 22 patients with unilateral postthrombotic obstruction. Common femoral vein pressure significantly increased after walking, compared to control limbs. Common femoral vein hypertension could explain the debilitating effect of venous claudication. Click to hear Dr Ten Cate's perspective on postthrombotic syndrome SUMMARY: Background Little is known about the hemodynamic consequences of deep venous obstructive disease. Objectives The aim of this study was to investigate the hemodynamic effect of postthrombotic obstruction of the iliofemoral veins and to determine what pressure parameters differentiate best between limbs with post-thrombotic obstructive disease of the iliofemoral veins and those without obstruction. Methods Twenty-two participants with unilateral obstruction of the iliac and common femoral veins underwent a standardized treadmill test with simultaneous bilateral invasive pressure measurements in the common femoral vein and dorsal foot vein. Results Mean age was 42.8 ± 11.9 years and 86.4% of participants were female. Postthrombotic limbs showed a mean common femoral vein (CFV) pressure increase of 28.1 ± 21.0 mmHg after walking, compared with 2.1 ± 6.2 mmHg in control limbs (26.0 mmHg difference; 95% confidence interval [CI], 17.1-34.9). Less difference was observed in the dorsal foot vein (net drop of 36.8 ± 22.7 mmHg in affected limbs vs. 48.7 ± 23.1 mmHg in non-affected limbs, 11.9 mmHg difference; 95% CI, -1.3 to 25.0). Change in CFV pressure after walking yielded the best discrimination between affected and non-affected limbs (area under the receiver operated characteristic curve of 0.94 [95% CI, 0.85-1.00], compared with 0.57 [95% CI, 0.37-0.76] in the dorsal foot vein, P < 0.001). Conclusions Common femoral vein pressure significantly increases during ambulation in patients with iliofemoral postthrombotic obstruction, which could explain the debilitating effects of venous claudication. This is an indication that patients with an iliofemoral obstruction may benefit from further treatment that resolves the deep vein obstruction. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/show/NCT01846780.

Short-Term Clinical Experience with a Dedicated Venous Nitinol Stent: Initial Results with the Sinus-Venous Stent.

OBJECTIVE: Deep venous stenting has become the primary treatment option for chronic venous obstructive disease, both for iliac vein compression and post-thrombotic venous lesions. Until recently, only stents aimed at arterial pathology were used, because no dedicated venous stents were available. However, three such stents have now become available. These venous stents are characterized by increased length, diameter, flexibility, and radial force. This study reports an early experience with one of these devices; the sinus Venous stent (OptiMed GmbH, Ettlingen, Germany). METHODS: Between March 2012 and July 2014, 75 patients were treated with the sinus Venous stent: 35 cases of iliac vein compression syndrome and 40 cases of unilateral chronic obstruction in post-thrombotic syndrome (PTS). Diagnosis of relevant obstruction was made using clinical evaluation, duplex ultrasound, and magnetic resonance venography. Patency during follow up was assessed with duplex ultrasound. Clinical improvement was assessed by VCSS, Villalta score, rate of ulcer healing, and improvement of venous claudication. RESULTS: The cumulative patency rates at 3, 6, and 12 months were 99%, 96%, and 92%, respectively. The cumulative assisted primary patency rates were 99% at 3, 6, and 12 months. The cumulative secondary patency rate at 12 months was 100%. Differences exist in patency rate between the subgroups of non-thrombotic and post-thrombotic, with the first showing no re-occlusions. All re-thromboses in the PTS group were treated by ancillary treatment modalities. VCSS and Villalta score decreased significantly after stenting, as did venous claudication. Morbidity was low without clinically relevant pulmonary embolism, and mortality was nil. Although two out of seven ulcers healed temporarily, no ulcer remained healed at 12 months follow up. CONCLUSION: Short-term clinical results using the sinus Venous stent are excellent, with significant symptom reduction, low morbidity rates, and no mortality. Loss of stent patency is seen less often compared with arterial stents described in the literature.

Hemodynamic significance of collateral blood flow in chronic venous obstruction.

INTRODUCTION: Complaints related to the post-thrombotic syndrome do not always correlate well with the extent of post-thrombotic changes on diagnostic imaging. One explanation might be a difference in development of collateral blood flow. The aim of this study is to investigate the hemodynamic effect of collateralisation in deep venous obstruction. METHODOLOGY: Resting intravenous pressure of the common femoral vein was measured bilaterally in the supine position of patients with unilateral iliofemoral post-thrombotic obstruction. In addition, pressure in control limbs was also measured in the common femoral vein after sudden balloon occlusion in the external iliac vein. RESULTS: Fourteen patients (median age 42 years, 12 female) were tested. In eleven limbs post-thrombotic disease extended below the femoral confluence. Median common femoral vein pressure was 17.0 mmHg in diseased limbs compared to 12.8 mmHg in controls (p = 0.001) and 23.5 mmHg in controls after sudden balloon occlusion (p = 0.009). Results remained significant after correcting for non-occlusive post-thrombotic disease. CONCLUSION: This study shows that common femoral vein pressure is increased in post-thrombotic iliofemoral deep venous obstruction, though not as much as after sudden balloon occlusion. The latter difference could explain the importance of collateralisation in deep venous obstructive disease and the discrepancy between complaints and anatomical changes; notwithstanding, the presence of collaterals does not eliminate the need for treatment.

Arteriovenous fistula geometry in hybrid recanalisation of post-thrombotic venous obstruction.

INTRODUCTION: Post-thrombotic obstruction can be adequately treated by percutaneous transluminal angioplasty and stenting. When post-thrombotic trabeculations extend below the femoral confluence, proper inflow can be facilitated by endophlebectomy and creation of an arteriovenous fistula. The aim of this study was to investigate whether it is more favourable to place the arteriovenous fistula at the cranial or caudal end of the endophlebectomy to prevent stenosis or occlusion. METHODOLOGY: We retrospectively analysed the clinical data of all patients who underwent a hybrid procedure in our two centres. Demographics, interventional details and post-operative imaging were collected. RESULTS: Data on 42 limbs with cranially and 23 limbs with caudally placed arteriovenous fistulas were collected. Post-thrombotic disease of the profunda femoral vein alone or in combination with the femoral vein was observed more often in the cranial group. The caudal group more often received a smaller sized and straight polytetrafluoroethylene fistula, while the cranial group comprised a significantly higher amount of stented segments. Logistic regression showed that only reduced femoral inflow (hazard ratio 2.934 (95%CI, 1.148-7.494)) was a significant predictor of stent stenosis and/or occlusion. Logistic regression for risk of occlusion showed a significant influence of stent-related complications (hazard ratio 4.691 (95%CI, 1.205-18.260)) and a tendency towards influence of arteriovenous fistula geometry in favour of the cranially placed fistula. CONCLUSION: Placement of the arteriovenous fistula in the cranial part of the endophlebectomy during hybrid recanalisation may result in a more favourable outcome, yet this tendency was not statistically significant. Moreover, femoral inflow is pivotal in maintaining patency and should thus be adequately assessed pre-operatively.