Clinical tolerance of untreated reflux after iliac vein stent placement.

BACKGROUND: We have recently demonstrated in a large patient cohort that the prevalence and severity of reflux will improve in most limbs after stenting and that most limbs will not develop new-onset reflux. In the present report, we have focused on the long-term clinical outcomes associated with untreated reflux in the same patient cohort who had undergone iliofemoral venous stenting without correction of residual reflux. METHODS: The clinical outcomes data from 1379 limbs treated with only iliac vein stenting without correction of superficial or deep reflux from 1997 to 2018 were analyzed (23-year follow-up period). Of the 1379 limbs, 632 (46%) had had preexisting reflux before stenting and 747 (54%) had did not. The reflux data (reflux segmental score, air plethysmography, ambulatory venous pressure) for these patients have been previously reported in detail. The subsets were compared perioperatively with each other using the following variables: grade of swelling, visual analog scale for pain score, venous clinical severity score, venous stasis dermatitis, ulceration, and quality of life measures. RESULTS: Both groups demonstrated improvements in the venous clinical severity score, grade of swelling, visual analog scale score, and quality of life. No differences were found in ulcer healing (5% vs 3% for limbs with and without prestent reflux, respectively) and resolution of dermatitis (6% vs 5% for limbs with and without prestent reflux, respectively) between the two groups. Of the 632 limbs with preexisting reflux, 218 (34%) had had axial reflux and 414 had had nonaxial reflux (66%). The clinical outcomes were similar between the two groups. Using a multisegment reflux score, the limbs with prestent reflux (n = 632) were divided into two groups. A segmental score of ≥3 indicated severe reflux and a score of <3 indicated moderate reflux. Of these 632 limbs, 161 (25%) had severe reflux and 471 (75%) had moderate reflux. The two groups demonstrated similar outcomes for most clinical parameters. The post-thrombotic limbs and nonthrombotic limbs also showed similar outcomes. CONCLUSIONS: The long-term follow-up of patients after iliac vein stenting showed that uncorrected reflux is well tolerated by most patients across most clinical measures.

Role of lower extremity fasciectomy plus fasciotomy for patients with persistent leg pain after stenting for chronic iliofemoral venous obstruction.

Although clinical improvement after stenting for symptomatic iliofemoral venous obstruction has been demonstrated in multiple large studies, a small proportion of patients will experience persistent quality of life-impairing symptoms. Swelling in such a setting represents the concomitant presence of lymphedema and will respond to treatment directed at the lymphedema. In contrast, persistent pain likely arises from venous hypertension in the lower leg, leading to the development of chronic compartment syndrome. Evaluation of intracompartmental pressures in such patients can help confirm the diagnosis, and fasciectomy combined with fasciotomy will treat the issue. In the present series, we evaluated six patients (six limbs) who had undergone fasciectomy combined with fasciotomy and their outcomes.

Percutaneous laser recanalization in chronically occluded iliofemoral venous stents.

Occlusion is a challenging complication of endovenous stenting. The treatment of chronic iliofemoral stent occlusion involves wire recanalization followed by balloon angioplasty. However, this approach will not always be successful. To treat such cases, we have successfully used a laser recanalization technique in 34 limbs (31 patients). This technique involved the use of a laser to first create a channel through the chronically occluded stent, followed by balloon angioplasty to improve the caliber of this recanalized tract. The mean age of the patients was 52 ± 13.6 years (range, 24-73 years). No adverse events related to the use of the laser occurred. Following laser recanalization, the venous clinical severity score had improved from 8.2 ± 4 to 5.1 ± 3.3 (P < .0001). The visual analog scale score for pain had improved from 7.8 ± 2.5 to 4.9 ± 3 (P = .0009). The grade of swelling had improved from 2.7 ± 1.3 to 1.6 ± 1.4 (P = .0001). At 12 months after intervention, the primary stent patency was 60% (standard error of the mean, 9.3%), and the secondary stent patency was 80%. Excimer laser recanalization of chronically occluded venous stents appears to be a rarely required but useful modality with reasonable clinical outcomes. Further reinterventions might be required to maintain long-term stent patency.

Options in the treatment of superficial and deep venous disease in patients with Klippel-Trenaunay syndrome.

OBJECTIVE: Klippel-Trenaunay syndrome (KTS) is a congenital mixed mesenchymal malformation syndrome that includes varicose veins, capillary and venous malformations, lymphatic abnormalities, and hypertrophy of various connective tissue elements. The purpose of the present study was to describe the clinical characteristics and outcomes in a subset of patients with KTS in whom venous interventions, including iliofemoral venous stenting, were performed after failure of conservative therapy. METHODS: A single-center retrospective data review of 34 patients with KTS who had undergone interventions for venous disease between January 2000 and December 2020 was performed. RESULTS: Their mean age was 38.4 ± 17.5 years (range, 12-80 years). No gender predilection was found. Of the 34 patients, 61% had had all three features of the classic triad for KTS. Varicose veins were present in all 34 patients (100%), and 30% had had a history of bleeding varicosities. Most patients (79%) had CEAP (Clinical, Etiology, Anatomy, and Pathophysiology) class ≥C4. Of the 34 patients, 30% had a history of deep vein thrombosis and/or pulmonary embolism. Factor VIII elevation was the most common thrombophilia condition (12%). The venous filling index was elevated at baseline (5.9 ± 5.1 mL/s) and did not normalize despite intervention (3.5 ± 2.3 mL/s; P = .04). The superficial venous interventions (n = 35) included endovenous laser therapy; stripping of the great saphenous vein, small saphenous vein, anterior thigh vein, or marginal vein; ultrasound-guided sclerotherapy; and stab avulsion of varicose veins. One coil embolization of a perforator vein was performed. Deep interventions (n = 19) included endovenous stenting (n = 15), popliteal vein release (n = 3), and valvuloplasty (n = 1). The venous clinical severity score had improved from 9.4 ± 4.5 to 6.2 ± 5.6 (P = .04). The visual analog scale for pain score had improved from 5.5 ± 2.7 to 2.5 ± 3.3 (P = .008). Healing of ulceration was noted in 75% of the patients. Significant improvements in the total pain (P = .04) and total psychological (P = .03) domains were noted in the 20-item chronic venous disease quality of life questionnaire. CONCLUSIONS: Superficial and deep venous interventions are safe and effective in patients with KTS when conservative therapy has failed. Iliofemoral venous stenting is a newer option that should be considered in the treatment of chronic deep venous obstructive disease in patients with KTS in the appropriate clinical context. An aggressive perioperative deep vein thrombosis prophylaxis protocol should be in place to reduce thromboembolic complications in these patients.

Extension of iliac vein stent into the profunda femoral vein for salvage.

BACKGROUND: The extension of iliac vein stents into the common femoral vein is often required to correct stenoses found at or near the inguinal ligament. Very rarely, an extension of the iliac stent into the profunda femoris vein may be required because of severe disease at the femoral trijunction. Profunda extension of iliac vein stents is a rare but useful technique for salvage. Our experience with extensions of iliac vein stents into the profunda femoris vein is described. METHODS: A search of our electronic medical records identified 20 limbs (0.75%) among a total of 2641 stented limbs (years 2006-2017) in whom the iliac vein stent was extended into the profunda femoris vein. Patients had been followed at 6 weeks, 3 months, 6 months, and yearly thereafter following the index procedure. Routine follow-up consisted of a detailed clinical evaluation, including the Venous Clinical Severity Score, visual analogue pain scale assessment, and edema grading by physical examination. Stent surveillance was performed at the follow-up visits. The iliac vein stent was declotted if needed and then extended into the profunda femoris vein at the same sitting. Antegrade access of the profunda femoris vein was preferred by direct puncture near the lesser trochanter or through a popliteal approach when a profunda-popliteal connection was present. An internal jugular access was used when an antegrade approach failed. RESULTS: Stent extension into the profunda was a secondary procedure after the initial iliac-common femoral vein stent failed in 17 of 20 limbs (85%). In three limbs (15%), the profunda extension was carried out at the initial iliac vein stent procedure because there was severe stenosis at the femoral confluence. One or more reinterventions after profunda extension were required in 50% of the limbs to maintain secondary patency or functionality. Fifteen of 20 limbs (75%) with profunda extensions remained patent on long-term follow-up. The median duration of secondary patency of stents that remained patent and those that occluded, and overall were 23 months, 3 months, and 10 months, respectively. Thirty percent of stents remained patent at 5 years. CONCLUSIONS: The extension of an iliac vein into the profunda femoris vein is a rarely required but useful procedure for stent salvage and symptom relief. Corrective reinterventions are often required but can result in long term patency extending to many years.

Long-term improvement of limb reflux prevalence and severity after iliac vein stent placement.

BACKGROUND: The effect of iliac vein stenting on ipsilateral limb reflux is unknown and has remained a matter of speculation. It has been suggested that the propensity for reflux might worsen when proximal stenosis is corrected. This could allow for retrograde flow with coughing and the Valsalva maneuver, stressing the valve. We examined this hypothesis by an analysis of the long-term effects of iliac vein stenting on limb reflux using a single-center, retrospective analysis of prospectively collected data. METHODS: Reflux data from duplex ultrasound of 1387 limbs in 1228 patients who had undergone iliac vein stenting from 1997 to 2018 were analyzed. Of the 1387 limbs, 632 (46%) had had ipsilateral duplex ultrasound-determined valve reflux before stenting, and 747 limbs (54%) had not had reflux; data were missing for 8 limbs. Reflux status before and after stenting was available for seven individual segments for each limb in the database for analysis (total, 9653 segments). The stented patients were examined for reflux at least annually during the follow-up period (range, 1-26 years). Segmental reflux prevalence was detected using duplex ultrasound. We have referred to this as "duplex reflux" or simply "reflux." Reflux severity was graded using (1) a reflux segmental score, assigning one point each for refluxing segments in the limb; (2) air plethysmography (venous filling index [VFI90]); and (3) ambulatory venous pressure (venous filling time [VFT]). RESULTS: Prestent duplex reflux was present in a combination of superficial, deep, and perforator segments. Reflux prevalence ranged from 7% of deep femoral segments to 51% at the popliteal segment. Post-stent reflux resolution varied from 21% at the femoral vein segment to 58% at the perforator segments. Reflux had completely resolved in 23% of the limbs. New-onset reflux was rare, with a median incidence of 7% for all segments at risk, with cumulative improvement (Kaplan-Meier curve) in reflux severity (segment score, VFI90, and VFT) for most limbs. These metrics were unimproved, with residual reflux in only 18%, 11%, and 6% (segment score, VFI90, and VFT, respectively) of the limbs at long-term follow-up. CONCLUSIONS: Long-term follow-up of limbs after iliac vein stenting has shown that the associated ipsilateral reflux prevalence and severity will improve in most limbs over time.