Iliac Vein Stent Placement and the Iliocaval Confluence.

ABSTRACT

OBJECTIVE: Prior literature has recommended routine iliac vein stent extension into the inferior vena cava (IVC) to assure adequate outflow for iliac vein stenting procedures. Our bias was that only the lesion should be stented without routine stent extension up to the IVC. We report our experience with this limited stenting technique. METHODS: From 2012 to 2015, 844 patients (1,216 limbs) underwent iliac vein stenting for nonthrombotic iliac vein lesions (NIVLs). All limbs were evaluated in accordance with the presenting sign of the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) score, and duplex scans and intravascular ultrasound (IVUS) showing more than 50% cross-sectional area or diameter reduction. All study patients had failed 3 months of conservative management. The procedures of iliac vein stenting were all office based. Two techniques were compared (1) placement of the iliac vein stent to cover the lesion and terminating cephalad into the IVC if the lesion involved the common iliac vein and (2) placement of the iliac vein stent to cover the lesion only and not passing the iliocaval confluence if the lesion only involved the external iliac vein. Complications were assessed during 30-day follow-up using the duplex scan technique to look for thrombosis. RESULTS: Of the total 844 patients, 543 (64%) were women. The average age was 66 (±14.2) years (range, 21-99 years). The stent was placed in the left lower limb in 474 patients and bilaterally in 370 patients. The presenting sign in accordance with the CEAP classification was C3 = 626, C4 = 404, C5 = 44, and C6 = 141. The average iliac vein stenosis by IVUS was 62% (±12% standard deviation [SD]). We had 715 patients with the iliac vein stent extending into the IVC, and of these, 8 patients had thrombosis within 30 days after the procedure. On the other hand, 501 patients had the iliac vein stent without crossing the iliocaval confluence, and of these, 4 patients had thrombosis within 30 days of the procedure. There was no difference between these 2 groups in regard to gender (P = 0.1) or age (P = 0.3). Laterality was statistically different (P < 0.0001) with more stents to be extended into the IVC if the lesion is in the left lower limb. Comparing these 2 groups in regard to 30-day thrombosis as a complication was not statistically significant (P = 0.6). There was no statistical difference between the 2 groups in regard to the presenting sign CEAP (P = 0.6). CONCLUSIONS: These results question the need for routine iliac vein stent extension into the IVC in patients with NIVLs. We were not able to demonstrate a significant risk of thrombosis with just placing the stent to cover the lesion only with short-term follow-up.