Female Gender is a Predictor of Lower Iliac Vein Stenting Patency Rates.

BACKGROUND: Iliac venous stenting (IVS) for thrombotic and nonthrombotic venous disease is increasingly used as evidence of the safety, efficacy and durability of these interventions increases. Female gender has been implicated as a predictor of failure in arterial endovascular interventions. We hypothesize that female gender could be predictive of patency rates of iliac vein stenting. METHODS: Consecutive patients who underwent IVS for thrombotic or nonthrombotic venous disease at our institution from 2007 until 2019 were identified and divided into groups based on gender. Operative notes, venograms, and the electronic health record were then queried to obtain operative details, co-morbid conditions, postoperative outcomes and stent patency. Study outcome was long term patency rate. The data was analyzed using chi-square, logistic regression, and Kaplan-Meier analysis as appropriate. RESULTS: A total of 200 consecutive patients (231 limbs) were identified in our retrospective analysis, with a mean age of 48.8 ± 17.3, and BMI of 31.6 ± 8.6. Of those, 119 (59.5%) patients, (131 [56.8%] limbs) were female. Comparisons between the gender groups revealed no difference in age, BMI, or preoperative comorbidities. There was no difference in type of venous disease between male (85% thrombotic, 15% nonthrombotic) and female (84% thrombotic, 16% nonthrombotic), P= 0.830. The male cohort was more likely to present with leg ulceration (17% vs. 4.6%, P = 0.002), and the female cohort was more likely to present with leg edema (98.5% vs. 93.0%, P= 0.03). The male cohort had a higher rate of caval (48% vs. 33.6%, P= 0.027) and infrainguinal stent extension. (11% vs. 6.9%, P= 0.02). Females had a higher rate of left sided stenting (80.9% vs. 66/0%, P= 0.010). There was no difference in the median stent diameter used between the cohorts. Primary patency at 5 years was significantly higher for the male cohort (94.1% vs. 74.4%, P= 0.01) On adjusted multivariable cox regression female gender was a predictor of loss of primary patency within 5 years (HR, 4.04; P= 0.007). CONCLUSIONS: In this single center retrospective analysis of IVS, male patients were found to have better primary stent patency compared to female.

Single- versus multiple-stage catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis does not have an impact on iliac vein stent length or patency rates.

BACKGROUND: Incomplete venous thrombolysis and residual nonstented iliac vein disease are known predictors of recurrent deep venous thrombosis (DVT). Controversy exists as to whether the number of thrombolysis sessions affects total stent treatment length or stent patency. The goal of this study was to evaluate the outcomes of patients who underwent single vs multiple catheter-directed lysis sessions with regard to stent extent and patency. METHODS: Consecutive patients who underwent thrombolysis and stenting for acute iliofemoral DVT between 2007 and 2018 were identified and divided into two groups on the basis of the number of treatments performed (one vs multiple sessions). Operative notes and venograms were reviewed to determine the number of lytic sessions performed and stent information, including size, location, total number, and length treated. End points included total stent length, 30-day and long-term patency, and post-thrombotic syndrome (Villalta score ≥5). The χ2 comparisons, logistic regression, and survival analysis were used to determine outcomes. RESULTS: There were 79 patients who underwent lysis and stenting (6 bilateral interventions; mean age, 45.9 ± 17 years; 48 female). Ten patients (12 limbs) underwent single-stage treatment with pharmacomechanical thrombolysis, and the remaining 69 (73 limbs) had two to four operating room sessions combining pharmacomechanical and catheter-directed thrombolysis. Patients who underwent a single-stage procedure were older and more likely to have a malignant disease. These patients received less tissue plasminogen activator compared with the multiple-stage group (17.2 ± 2.2 mg vs 27.6 ± 11.6 mg; P = .008). Average stent length was 8.8 ± 5.2 cm for the single-stage group vs 9.2 ± 4.6 cm for the multiple-stage group (P = .764). Patients who underwent a single-stage procedure had no difference in average length of stay from that of patients who underwent multiple sessions (8.5 days vs 5.9 days; P = .269). The overall 30-day rethrombosis rate was 7.3%. Two-year patency was 72.2% and 74.7% for the single and multiple stages, respectively (P = .909). The major predictors for loss of primary patency were previous DVT (hazard ratio [HR], 5.99; P = .020) and incomplete lysis (HR, 5.39; P = .014) but not number of procedures (HR, 0.957; P = .966). The overall post-thrombotic syndrome rate was 28.4% at 5 years and was also not associated with the number of treatment sessions. CONCLUSIONS: Single- vs multiple-stage thrombolysis for DVT is not associated with a difference in extent of stent coverage. Patency rates remain high for iliac stenting irrespective of the number of lytic sessions, provided lysis is complete and the diseased segments are appropriately stented.

Fast-track thrombolysis protocol: A single-session approach for acute iliofemoral deep venous thrombosis.

OBJECTIVE: Catheter-directed thrombolysis in the treatment of acute iliofemoral deep venous thrombosis (IFDVT) often requires more than one interventional session to yield successful outcomes. Catheter-directed thrombolysis is generally expensive, requiring prolonged hospital stay that may be associated with increased local and systemic hemorrhagic complications. We developed the fast-track thrombolysis protocol (FTTP) to address these issues. The goal of FTTP is to restore patency during the initial session of thrombolysis, thereby minimizing costs and complications associated with prolonged thrombolysis. METHODS: A retrospective analysis of 38 patients treated for acute IFDVT using FTTP at our institution from January 2014 to February 2019 was performed. The protocol includes periadventitial injection of lidocaine at the venipuncture site under ultrasound guidance, contrast venography of the entire target segment, pharmacomechanical rheolytic thrombectomy of the occluded venous segment, tissue plasminogen activator infusion along the occluded segment, balloon maceration of the thrombus, and, if indicated, venous stent placement in areas of significant (≥50%) stenosis refractory to thrombolysis and balloon angioplasty. Once the thrombus was cleared, patients were prescribed oral antithrombotic therapy. RESULTS: Thirty-eight primary FTTPs (45 total interventions) were performed in 38 patients. The median age was 66 years (range, 39-93 years); 60.5% were female. Initial venous access was most often obtained through the popliteal vein, followed by the femoral and great saphenous veins. The mean operative time was 122 minutes (range, 59-249 minutes), and the median volume of tissue plasminogen activator infused was 10 mg (range, 4-20 mg). The median cost per procedure, including devices and medication, was $5374.45. Median postoperative length of stay was 1 day (range, 1-45 days). Successful single-session FTTP, as determined by completion venography, was accomplished in 81.5% (n = 31/38) of cases. The remaining seven cases (18.5%) required one additional session. Of the 38 patients, 30 (79%) required iliac vein stenting. Periprocedural complications consisted of one patient with retroperitoneal hemorrhage that was managed conservatively. No patients experienced rethrombosis within 30 days of FTTP. During the 5-year study period, there were no cases of pulmonary embolism, significant local or systemic hemorrhage, limb loss, or mortality. CONCLUSIONS: FTTP, as presented herein, appears to be a safe, effective, and cost-effective technique in the resolution of acute IFDVT.

Managing iliofemoral deep venous thrombosis of pregnancy with a strategy of thrombus removal is safe and avoids post-thrombotic morbidity.

BACKGROUND: Extensive deep venous thrombosis (DVT) during pregnancy is usually treated with anticoagulation alone, risking significant post-thrombotic syndrome (PTS) in young patients. Catheter-directed thrombolysis (CDT) and operative venous thrombectomy have been safely and effectively used in nonpregnant patients, demonstrating significant reduction in post-thrombotic morbidity. This report reviews short- and long-term outcomes of 13 patients with extensive DVT of pregnancy treated with a strategy of thrombus removal. METHODS: From 1999 to 2013, 13 patients with iliofemoral DVT during pregnancy were offered CDT, pharmacomechanical thrombolysis (PMT), and/or venous thrombectomy. Gestational age ranged from 8 to 34 weeks. Fetal monitoring was performed throughout hospitalization. Radiation exposure was minimized with pelvic lead shields, focal fluoroscopy, and limited angiographic runs. Follow-up included objective vein evaluation using venous duplex and PTS assessment using the Villalta scale. RESULTS: CDT and/or PMT were used in 11 patients. Two patients underwent venous thrombectomy alone, and one patient had operative thrombectomy as an adjunct to CDT and PMT. Each patient had complete or near-complete thrombus resolution and rapid improvement in clinical symptoms. Eight of 11 having CDT or PMT underwent venoplasty and stenting of the involved iliac veins. Twelve of the 13 delivered healthy infants at term. One patient opted for termination of her pregnancy. Mean patient and gestational ages were 26 years and 26 weeks, respectively. Mean follow-up was 1.3 years, with only one recurrence. Duplex ultrasonography demonstrated patent veins in all but one patient and normal valve function in 10 patients. Eleven patients had Villalta scores <5 (considered normal), with a mean score of 0.7. CONCLUSIONS: Extensive DVT of pregnancy can be effectively and safely treated with a strategy of thrombus removal, resulting in a patent venous system, normal valve function in many, prevention of PTS, and reduction in recurrence.

Chronic deep venous obstruction: definition, prevalence, diagnosis, management.

Ilio-caval venous obstruction has an important role in the expression of symptomatic chronic venous disease regardless of aetiology. The presence of obstruction has been more or less previously ignored and emphasis placed on reflux alone. Stenting of the ilio-femoral veins guided by intravascular ultrasound (IVUS) can now be performed with low morbidity and mortality using appropriate technique. Current diagnostic modalities do not allow a definitive assessment of haemodynamically critical venous obstruction, which hampers selection of limbs for treatment. The diagnosis must be based on morphological studies (preferably IVUS) in patient selected with specific history, signs and symptoms. A high index of suspicion and generous use of morphological investigations are critical in the initial recognition of venous outflow obstruction. Stenting of the ilio-femoral vein appears to be durable with a substantial improvement in limb pain and swelling, high rate of ulcer healing, enhanced quality of life and decreased disability. The beneficial clinical outcome occurs regardless of the presence of remaining reflux, adjunct saphenous procedures or aetiology of obstruction.

Lower limb vein trauma: a long-term clinical and physiological assessment.

The aim of this study was to assess the long-term clinical and physiological sequelae of lower limb venous trauma in a civilian practice. Twenty-six patients who had undergone surgery for lower limb venous trauma (median elapsed time 19.5 months) underwent assessment. Injuries had been sustained to the external iliac, common femoral superficial femoral and popliteal veins in two, four, nine and eleven limbs respectively. Using clinical assessment, photoplethysmography recovery time, the presence of popliteal reflux and venographic evidence of thrombosis, the final outcome was graded as good, fair or poor. Fourteen patients had pedal oedema, including two with a postphlebitic limb. The overall photoplethysmography recovery time (mean and s.d.) was 20.6 (8.7) s in the injured and 32.1 (6.7) s in the non-injured limbs (P = 0.002). Patients with a venographically occluded vein had a shorter photoplethysmography recovery time than those in whom the vein was patent (13.4 (5.6) versus 21.6 (8.7) s; P = 0.07). Popliteal reflux was present in 12 injured limbs. Seven of 12 venograms performed on limbs with a vein repair had evidence of previous thrombosis. Vein ligation carried considerable morbidity and all end-to-end anastomoses initially failed. In retrospect, saphenous vein grafts were too narrow for the recipient veins and panel grafts might have been more appropriate. Overall 11 of 26 patients (42 per cent) had a poor result. The repair of choice is a saphenous vein patch for lesser injuries and a saphenous panel graft for major injuries. Vein ligation should be avoided unless another life-threatening injury demands priority.