Venous Stenting Using Intravascular Ultrasound

Deep venous insufficiency may manifest as limb edema, chronic leg pain, stasis dermatitis, or ulceration, and the symptoms may be chronically disabling. Initial therapy is directed at ulcer healing and control of symptoms with wound care and compression. Once conservative measures have been instituted, the next step may be evaluation for any surgically correctable contributors to the symptomatology. Although valvular dysfunction and consequent venous reflux are a major cause of the venous hypertension that underlies the clinical manifestations of chronic venous insufficiency (CVI), recent studies suggest that iliac venous outflow obstruction plays a more important role in the pathogenesis of CVI than previously estimated. Any combination of superficial, perforator, and/or deep venous reflux can result in various stages of CVI, but when multiple segments of venous system are affected, the manifestations of CVI increase in severity. The combination of reflux and obstruction produces the highest levels of venous hypertension and the most severe clinical symptoms. This chapter discusses iliocaval vein obstructions and pelvic venous congestion.

The postthrombotic syndrome in relation to venous hemodynamics, as measured by means of duplex scanning and strain-gauge plethysmography

Postthrombotic syndrome (PTS) can cause both venous outflow obstruction and deep venous reflux, and results in severe symptoms of chronic venous disease. Venous stenting in the chronic iliocaval venous obstruction has been shown to be a safe and efficacious procedure. The long-term studies have shown the high patency rate, the good symptom relief, and the low recurrence rate of healed venous ulcerations. Although venous stenting has become a widely accepted treatment option in PTS with chronic venous occlusion or severe stenosis, it is not yet covered by insurance in Japan, and is being performed at limited facilities using off-label arterial stents. In this study, we performed venous stenting in 30 patients with the moderate and severe PTS. All patients showed significant improvement in their venous scores postoperatively, the Villalta score changed from a median of 16 before treatment to a median of 7 after treatment. Likewise, the Venous Clinical Severity Score and the Venous Disability Score dropped from a median of 13, 2.4 before treatment to 6, 1.2 after treatment, respectively. The primary patency and the secondary patency at 40 months were 93% and 96%, respectively. We report the excellent results and discuss current issues and future perspective in Japan. (This is secondary publication from J Jpn Coll Angiol 2021; 61: 99-105.).

Cardiac output during exercise increases by as much as fivefold in the untrained man, and by as much as eightfold in the elite athlete. Increasing venous return is a critical but much overlooked component of the physiological response to exercise. Cardiac disorders such as constrictive pericarditis, restrictive cardiomyopathy and pulmonary hypertension are recognised to impair preload and cause exercise limitation; however, the effects of peripheral venous obstruction on cardiac function have not been well described. This manuscript will discuss how obstruction of the iliocaval venous outflow can lead to impairment in exercise tolerance, how such obstructions may be diagnosed, the potential implications of chronic obstructions on sympathetic nervous system activation, and relevance of venous compression syndromes in heart failure with preserved ejection fraction.

Background: Endovascular venous stenting with dedicated venous stents for the treatment of chronic venous outflow obstruction is developing as efficacious alternative to conservative therapy or open surgery. However, so far, mid- and long-term evidence on effectiveness and safety is poor. Patients and methods: The prospective, single-center, observational study enrolled consecutive patients with chronic non-thrombotic iliac vein lesions (NIVL) or post-thrombotic iliofemoral obstructions (PTO). From February 2016 to April 2017, patients underwent implantation of open cell, self-expandable dedicated venous stents. Short-term symptomatic improvement, patency, and complication rate were favorable. Evaluation at 2-years included improvement in the revised venous clinical severity score (rVCSS), patency, stent migration, major target limb events, clinically important pulmonary embolism, major bleeding, and all-cause mortality. Results: A total of 79 patients (57 ± 16 years, 44 female) were evaluated. At 2 years, rVCCS improved by 4.3 ± 2.7 (p < 0.001). Substantial clinical improvement of ≥ 2 score points was achieved in 86.4% (38 of 44) of patients. Improvement was not associated with thrombotic pathogenesis (regression coefficient [B] with PTO = 0.6 [95%CI: -1.1 to 2.3], p = 0.48). At 2 years, all ulcers (in 8 of 79 patients) were healed and none recurred. Two-year primary patency was 95.5% (95%CI: 86.5 to 98.5) with no difference between NIVL- and PTO-patients (log-rank p = 0.83). Target vessel revascularization was conducted in two PTO- and one NIVL-patients in the period of 34 days to 156 days from index procedure, resulting in a secondary patency of 100%. No stent migration, target limb deep vein thrombosis, major amputation, pulmonary embolism, or death occurred. Conclusions: Venovo venous open cell self-expanding stent implantation for chronic outflow obstruction was efficacious and provided a sufficient level of safety throughout 2 years.

The Incidence of Contralateral Iliac Venous Thrombosis After Stenting Across the Iliocaval Confluence in Patients With Acute or Chronic Venous Outflow Obstruction

Postthrombotic syndrome (PTS) is the most common complication after iliofemoral deep vein thrombosis. It reduces quality of life and increases deep vein thrombosis (DVT)-related costs. The clinical symptoms and severity of PTS may vary; the most common symptoms include edema, pain (venous claudication), hyperpigmentation, lipodermatosclerosis, and ulceration. PTS is based on the principle of outflow obstruction, which may be caused by venous hypertension and may lead to valvular damage and venous reflux or insufficiency. Recent technical developments and new stent techniques now allow recanalisation of even complex venous outflow obstructions within the iliac vein and the inferior vena cava. This manuscript gives an overview on the latest standards for venous recanalisation.

Quality of life outcomes for patients undergoing venous stenting for chronic deep venous disease

Venous obstruction: An analysis of one hundred thirty-seven cases with hemodynamic, venographic, and clinical correlations

Patients with Postural Orthostatic Tachycardia Syndrome (POTS) and Orthostatic Intolerance (OI) commonly present with symptoms suggestive of Pelvic Venous Disorders (PeVD). The presence of PeVD may contribute to orthostatic symptoms in these patients due to venous obstruction with stasis and pooling. Iliac vein compression, a PeVD, has historically been treated with iliac venous stenting. The authors hypothesize that patients with POTS frequently have findings of PeVD, that venous outflow obstruction from iliac vein compression exacerbates POTS/OI symptomatology, and that treating PeVD improves POTS/OI symptoms. This paper reports results from two studies at two different institutions with a partially overlapping patient population. The first was a retrospective cross-sectional observational study of patients with POTS/OI who presented to Emory University Cardiology (Atlanta, GA, USA) from October 2019 to June 2023. We aimed to evaluate the prevalence of concurrent POTS/OI and PeVD using screening pelvic venous ultrasound, MR and/or CT, compared to venogram with intravascular ultrasound (IVUS). We secondarily evaluated the efficacy of each imaging modality in screening accuracy for PeVD. The second study was a retrospective review of medical records for 271 female patients with POTS/OI who received treatment of PeVD with iliac vein stenting from June 2019 to November 2024 at Minimally Invasive Procedure Specialists (Highlands Ranch, CO). The primary objective of this study was to explore quality of life (QoL) outcomes in female patients with POTS/OI before and after treatment. The secondary objective was to record the prevalence of associated pelvic pain, systemic symptoms, and response to therapy in this population. In the first cohort, 129 patients (84% cis female) with a diagnosis of POTS/OI and symptoms of PeVD were assessed by standard imaging for venous pathology. 107 patients (83%) had confirmed pelvic venous compression (iliac vein, renal vein, or both) or pelvic venous congestion on imaging with at least one screening modality. All screening modalities were relatively insensitive in detecting iliac venous compression compared with venography and IVUS. In the second cohort, following iliac vein stenting, significant improvements were seen in Orthostatic Hypotension Questionnaire (OHQ) composite scores at three months (p < 0·001) and at 12 months (p < 0·001). The OHQ Symptom Assessment (OHSA) and Daily Activities Scale (OHDAS) subscores, International Pelvic Pain Society (IPPS) score, Pelvic Congestion Syndrome (PCS) score, Pelvic Pain and Urgency/Frequency Symptom Scale (PUF) score, and Ancillary symptom score all demonstrated statistically significant decreases at three months that persisted at 12 months (all p < 0·001) as well. The high prevalence of PeVD in POTS/OI patients suggests an association between the two diagnoses. In the absence of expert clinical review, screening with US, CT, and MR may not be sufficient to rule out PeVD. Significant improvements were seen in QoL in patients with POTS/OI and PeVD who underwent iliac vein stenting. These results call for additional trials to examine the clinical and hemodynamic effects of venous stenting on POTS/OI symptomatology and associated systemic symptoms, including pelvic pain. These studies received no funding.

Objectives: To define the significance of perforator and deep vein pathology in patients with chronic venous disease (CVD). Methods: Consecutive patients with CVD were referred for venous evaluation (group A). Both saphenous veins and all the deep veins including those in the calf area were evaluated. A separate group of patients with deep venous reflux and/or obstruction was identified from our database and analysed separately (group B). The CEAP classification (clinical, aetiological, anatomical and pathological) was used to grade the clinical severity of CVD. Results: Age, duration of disease and history of thrombosis increased significantly with disease severity ( P &lt;0.02). Reflux in the superficial veins was the most common pathology in group A and it was present in 75% of limbs in group B. The overall contribution of deep venous disease was 26% in group A and it increased significantly with the severity of disease in both groups. Isolated deep vein disease in group A was significantly less compared with group B (8% vs 23%, P&lt;0.0001). Reflux in deep veins of post-thrombotic limbs was significantly longer compared with those with primary disease. The prevalence of incompetent perforator veins was higher in patients with skin damage from both groups. No patient had isolated perforator vein reflux. Reflux was the most common pathology in both groups, while obstruction alone was rare. Other than superficial reflux, which is very common, ipsilateral recurrent deep venous thrombosis (DVT), combined reflux and obstruction, and popliteal vein reflux were the strongest predictors for development of skin damage. Conclusions: Perforator and deep vein involvement increases significantly with the severity of CVD. Isolated deep vein disease in post-thrombotic limbs is more common than in consecutive venous patients. Reflux is the most common pathology and obstruction alone is rare. In post-thrombotic limbs, the most important predictors for skin damage are ipsilateral recurrent DVT, popliteal vein reflux and a combination of reflux and obstruction.

Monitoring of partial and full venous outflow obstruction in a porcine flap model using laser speckle contrast imaging

May-Thurner Syndrome Presenting With Pelvic Pain in a Healthy 22-Year-Old Woman Successfully Treated With Intravascular Ultrasound Guided Stenting of the Left Common Iliac Vein

Venous stent patency is independent of total stented length in nonthrombotic iliac vein and post-thrombotic venous stenoses

Regarding "A spontaneous rupture of the external iliac vein revealed as a phlegmasia cerulea dolens with acute lower limb ischemia: case report and review of the literature".