Iliac vein recanalisation and stenting accelerate healing of venous leg ulcers associated with severe venous outflow obstruction.

Obstruction involving the iliac veins and/or inferior vena cava is highly comorbid in patients with chronic venous leg ulcers and is a barrier to healing. Intervention with venous stenting is recommended to promote wound healing; however, there is limited data to quantify the effects of venous outflow restoration on wound healing. We retrospectively identified patients with venous ulcers and comorbid venous outflow obstruction. Data regarding demographics, wound size, degree of obstruction, interventions, wound healing and recurrence were collected. Intervention was performed when possible and patients were grouped based on whether or not the venous outflow was reopened successfully and maintained for at least 1 year. Outcomes, including time to wound healing, wound recurrence, stent patency and ulcer-free time, were measured. Patients who maintained a patent venous outflow tract experienced higher rates of wound healing (79.3%) compared to those with persistent outflow obstruction (22.6%) at 12 months (p < 0.001). Ulcer-free time for the first year was also greater with patent venous outflow (7.6 ± 4.4 months versus 1.8 ± 3.0 months, p < 0.0025). Patients with severe obstruction of the venous outflow tract experience poor healing of VLUs despite appropriate wound care. Healing time is improved and ulcer-free time increased after venous intervention with stenting to eliminate obstruction.

Iliac vein obstruction: accuracy of Direct Multidetector Computed Tomographic Venography and duplex ultrasound.

OBJECTIVES: To evaluate the accuracy of direct computed tomographic venography (DCTV) and duplex ultrasound (DUS) in the identification of iliac vein obstruction in highly symptomatic patients with severe chronic venous disease (CVD) compared with intravascular ultrasound (IVUS). METHODS: this study involved patients who had advanced CVD (CEAP C3-6). All patients underwent DCTV, venous duplex scanning, and IVUS. The presence of iliac vein obstruction was detected, and degree of obstruction was classified into 3 grades (grade I, 0% to 49%; grade II, 50% to 79%; and grade III, 80% or greater). The sensitivity, specificity, PPV, NPV, and accuracy were calculated for each modality compared with IVUS. Inter-observer agreement was assessed using the κ coefficient. RESULTS: of 94 patients with CVD, IVUS identified iliac vein obstruction in 55 (58.5%) patients (25.5% was grade 1, 27.3% was grade 2, 47.3% was grade 3). The sensitivity, specificity of DCTV in diagnosing obstruction was (96%, 95% in grade 1; 100%, 100% grade 2; 100%, 100% in grade 3, respectively). The sensitivity, specificity of DUS was (63.9%, 65% in grade 1; 68%, 82% in grade 2, and 70%, 85% in grade 3, respectively). The overall agreement of DUS was 0.73 (95% CI, 0.70-0.79), and DCTV was 0.96 (95% CI, 0.91- 0.97). CONCLUSIONS: DUS is a reasonable initial imaging modality for the identification of significant iliac vein obstruction. DCTV provides an accurate reproducible imaging for accurate estimation needed for treatment planning. ADVANCES IN KNOWLEDGE: Direct CT Venography provides accurate reproducible radiological information required for treatment planning of patients with Iliac vein obstruction including accurate assessment of site of obstruction, its morphology, and degree of obstruction and it can replace the use of indirect CT venography using smaller amount of contrast media with accurate diagnosis.

Comparison between a dedicated venous stent and standard composite Wallstent-Z stent approach to iliofemoral venous stenting: Intermediate-term outcomes.

OBJECTIVE: Dedicated venous stents have not been used in the management of symptomatic chronic iliofemoral venous obstruction (CIVO) until recently. The Bard Venovo stent (Becton, Dickinson, and Co, Franklin Lakes, NJ) is one such stent noted to have an increased chronic outward force and radial resistive force compared with the Wallstent (Boston Scientific, Marlborough, MA). In the present study, we evaluated the outcomes following the use of the Bard Venovo stent vs a matched cohort of limbs that had undergone stenting with the Wallstent-Zenith (Z) stent (Cook Medical Inc, Bloomington, IN) composite configuration. METHODS: A review of contemporaneously entered electronic medical record data for 167 patients (167 limbs) with initial iliofemoral stents placed from 2019 to 2020 for quality of life (QOL)-impairing CIVO that had failed conservative therapy was performed. The visual analog scale for pain score (score, 0-10), grade of swelling (score, 0-4), venous clinical severity score (score, 0-27), and the 20-item chronic venous insufficiency quality of life questionnaire instrument for QOL were evaluated before and after intervention to assess the effects of stenting. A Kaplan-Meier analysis was used to examine primary, primary-assisted and secondary stent patency, and analysis of variance with repeated measures was used to compare clinical outcomes. RESULTS: A total of 167 limbs had undergone Bard Venovo stenting (56 men and 111 women). Their median age was 61 years. The laterality was right and left in 70 and 97 limbs, respectively. Post-thrombotic syndrome was seen in 84 limbs and nonthrombotic iliac vein lesions/May-Thurner syndrome in 83 limbs. At 6 months, the venous clinical severity score had improved from 7 to 4 in the limbs with a unilateral Venovo (UV) stent and from 5 to 4 in the composite Wallstent-Z stent group (P = .9). The grade of swelling had improved from 3 to 1 in the UV group and from 3 to 1 in the composite group (P = .6), and the visual analog scale for pain score had improved from 7 to 2 in the UV group and from 5 to 0 in the composite group (P = .007). At 12 months, ulcers had healed in 53% (8 of 15) of the UV group and 56% (5 of 9) of the composite group (P = .7). The global 20-item chronic venous insufficiency quality of life questionnaire scores had improved from 58 to 28 in the UV group and from 59 to 40 in the composite group (P = .6). The cumulative primary, primary-assisted, and secondary patency at 18 months was 81%, 97%, and 98% in the UV group and 87%, 98%, and 100% in the composite group, respectively (P > .4). No difference in the reintervention rates was noted between the two groups (P = .5). CONCLUSIONS: For patients who had undergone stenting for QOL-impairing CIVO, the results with the Bard Venovo venous stent were comparable to those with the composite Wallstent-Z stent configuration for clinical outcomes, QOL improvement, and stent patency. Further study is, however, required to confirm this improvement in the long term.

Non-enhanced multimodal magnetic resonance imaging in assessment of iliac vein obstruction with or without thrombosis.

OBJECTIVE: To evaluate the diagnostic accuracy of a contrast-free multimodal magnetic resonance (MR) protocol (including M2DIPEAR, THRIVE, BTFE-SPAIR, and FLAIR sequences) in the detection of iliac vein obstruction with or without thrombosis. MATERIALS AND METHODS: From May 1st, 2015, to May 1st, 2016, a total of 73 patients (aged 51.33 ± 4.21 years) who received both digital subtraction angiography (DSA) and the multimodal MR imaging were included. The protocol of the multimodal MR included M2DIPEAR and BTFE-SPAIR for presenting iliac vein obstruction, and THRIVE and FLAIR for revealing the co-existed thrombosis. Three observers who were blinded to clinical and DSA results independently analyzed all multimodal MR datasets. Per-patient evaluations on presence or absence of iliac vein obstruction were performed to calculate the diagnostic performance of MR imaging (DSA regarded as gold reference) in terms of overall accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Capability to display the co-existing venous thrombus was also evaluated per-MR sequence using a 3-point scale system. RESULTS: Iliac vein obstruction was depicted with DSA in 64 patients. In per-patient evaluation, the multimodal MR imaging yielded accuracy of 95.9% (70/73), sensitivity of 96.9% (62/64), specificity of 88.9% (8/9), positive predictive value of 98.4% (62/63), and negative predictive value of 80% (8/10), respectively. In the multimodal MR sequences, balanced turbo field echo-spectral attenuated inversion recovery (BTFE-SPAIR) sequence was superior to other sequences in depicting the iliac vein configuration, but fluid attenuated inversion recovery (FLAIR) and T1 high-resolution isovolumetric examination (THRIVE) seemed superior in detecting co-existing venous thrombosis. CONCLUSIONS: M2DIPEAR and BTFE-SPAIR sequence can reveal iliac vein obstruction while THRIVE and FLAIR can detect the co-existed thrombosis. The proposed multimodal MR protocol can accurately depict the iliac vein obstruction and accurately detect the co-existing venous thrombosis comparable with that of DSA.

Comparison of computed tomography venography and intravascular ultrasound in screening and classification of iliac vein obstruction in patients with chronic venous disease.

OBJECTIVE: To investigate power of computed tomography venography (CTV) to identify and characterize iliac vein obstruction (IVO) compared with intravascular ultrasound (IVUS) examination in highly symptomatic patients with chronic venous disease (CVD). METHODS: CVD CEAP C3-6 limbs with visual analog scale for pain score of greater than 3 and/or Venous Clinical Severity Scale of greater than 8 were prospectively investigated with CTV and IVUS examination. The segment of maximum IVO was verified and categorically classified: group I, 0% to 49%; group II, 50% to 79%; and group III, 80% or greater. The CTV's screening power to detect the point and degree of maximum IVO was compared with IVUS. RESULTS: The CTV point of maximum IVO was 80% in the left limb, 10% in the right limb, 10% bilaterally; 2% in the inferior vena cava; 91% in the common iliac vein (CIV) confluence (41.6% below the CIV confluence, 34.5 at the CIV confluence, and 23.9% above the CIV confluence); 7% at the external iliac vein (kappa index 0.841; P < .001, when compared with IVUS). The distal venous segment considered free of obstruction was above inguinal ligament: 68% (CIV, 47%; external iliac vein, 21%) 32% below the inguinal ligament (common femoral vein, 26%; deep femoral vein, 6%) (kappa index 0.671; P = .023, when compared with IVUS). The power of CTV to detect an IVO of 50% or greater (groups II and III) when compared with IVUS achieved a sensitivity and specificity ratio of 94.0% and 79.2%, respectively. The positive predictive value was 94%, the negative predictive value was 79.1%, accuracy was 86.7% (kappa, 0.733), and interobserver agreement was 92.1% (95% confidence interval, 87.1-97.7; kappa, 0.899). CONCLUSIONS: CTV is a powerful screening method in determining the precise point of compression and classifying IVO in limbs with symptomatic CVD when compared with IVUS. The prevalence of an obstruction above the iliac vein confluence is significant and should be considered in iliac vein stenting treatment strategy. The tomographic classification system proposed here may help to define the optimum technique of treatment, prognosis, and comparison of outcome results.

Contralateral limb improvement after unilateral iliac vein stenting argues against simultaneous bilateral stenting.

OBJECTIVE: Symptoms of chronic venous insufficiency secondary to obstructive iliofemoral disease are often bilateral. The impact of iliofemoral stenting of the more symptomatic lower extremity on clinical outcomes in the less affected contralateral extremity is not clear. Such benefit, secondary to offloading of collaterals, may potentially be of the magnitude that the contralateral extremity does not require intervention. METHODS: A retrospective review of contemporaneously entered electronic medical record data of 368 patients/limbs with initial unilateral iliocaval stents (240 left and 128 right) placed during a 3-year period from 2015 to 2017 was performed. Patients who underwent simultaneous bilateral stenting or had occlusive disease were excluded. Of the remainder, the impact of stenting on contralateral leg symptoms was evaluated by analyzing visual analog scale (VAS) pain score (1-10), grade of swelling (1-3), and Venous Clinical Severity Score (VCSS). The duration of any improvement and need for intervention on the contralateral side were also appraised. Kaplan-Meier analysis was used to assess stent patency after intervention, whereas paired t-tests were used to examine clinical outcomes. RESULTS: Of the 368 limbs that underwent stenting with a combination of a Wallstent (Boston Scientific, Marlborough, Mass) with a Z stent (Cook Medical, Bloomington, Ind) for stenotic lesions, 304 patients (89 men and 215 women) had contralateral symptoms (200 left and 104 right). The cause was post-thrombotic syndrome in 229 limbs and May-Thurner syndrome or nonthrombotic iliac vein lesion in 75 limbs. In this contralateral group, at 12 months, the VAS pain score improved from 5 to 0 (P < .0001), the grade of swelling went from 3 to 1 (P < .0001), and VCSS went from 5 to 3 (P < .0001) after stenting of the ipsilateral side. During the median follow-up of 20 months, 15 contralateral limbs underwent stenting. Median time to stenting of the contralateral limb after ipsilateral stenting was 9 months. The median VAS pain score, grade of swelling, and VCSS in this group before stenting were 6.5, 2, and 5 compared with 0 (P < .0001), 1 (P = .27), and 3 (P = .0021), respectively, in those members of the contralateral group who did not require stenting. Primary and primary assisted patencies at 12 months after contralateral stenting were 78% and 100%, respectively. There were no stent occlusions after contralateral stenting. CONCLUSIONS: Patients with bilateral obstructive iliofemoral venous lesions often experience improvement of the contralateral limb symptoms (95%) after stenting of the worse ipsilateral limb. Only 15 of 304 (5%) symptomatic contralateral limbs had to undergo stenting during the follow-up period because of a worsening clinical picture. Based on this, a staged approach to iliofemoral stenting in patients with bilateral symptoms focusing initially on the more symptomatic limb is suggested.