Single-Center Study Evaluates Postthrombotic Venous Obstructions and Stenting Across the Inguinal Ligament
October 24, 2017—The Society for Vascular Surgery (SVS) announced the publication of a study showing that the results of endovascular treatment of iliocaval and infrainguinal postthrombotic venous obstruction do not appear to be adversely affected by the extension of iliac vein stents into the femoral venous system.
According to the SVS, venous stenting for symptomatic patients has increased significantly in this setting. Several large series have demonstrated safety, efficacy, and good durability of this technique in iliocaval obstruction. However, questions remain as to the outcomes with regard to etiology (ie, thrombotic versus nonthrombotic occlusion) and the extent of stenting (ie, extension below the inguinal ligament). Concern for the latter is raised as the mobility of the common femoral vein may result in stent fracture and thrombosis.
The study was published by Johnathon C. Rollo, MD, et al in Journal of Vascular Surgery: Venous and Lymphatic Diseases (2017;5:789–799).
As summarized by the SVS, the study investigators retrospectively evaluated their single-center experience with percutaneous treatment of postthrombotic iliocaval obstruction. The investigation was led by Brian G. DeRubertis, MD, at the David Geffen School of Medicine at the University of California at Los Angeles in Los Angeles, California.
In this series, 31 patients (42 limbs) presented with pain/swelling (100%) including venous claudication (81%) and active ulceration (10%). Percutaneous interventions, including iliocaval angioplasty/stenting in 81% with extension into the femoral system (38%), resulted in 100% technical success. Of those with inferior vein cava (IVC) filters, 46% were able to be removed.
According to the SVS, at an average of 15 months follow-up (range, 2–49 months), the following results were achieved: improvement in pain/swelling (84%), resolved pain/swelling (42%), decreased CEAP classification (65%), 1-year primary stent patency (66%), 1-year secondary stent patency (75%).
Those patients requiring infrainguinal extension of the stent realized no significant difference in primary stent patency at 1 year compared with those who did not (68% vs 65%). However, in those whose IVC filter could not be removed, resolution of symptoms was achieved in only 17%.
In the SVS announcement, Dr. Rollo commented, “Our aim was to better understand risk factors for poor clinical outcomes in patients undergoing percutaneous intervention for symptomatic chronic venous obstruction secondary to postthrombotic lesions. Our results suggest that stenting below the inguinal ligament does not result in inferior outcomes, at least in the short-term, and may be necessary in a higher percentage of patients than previously reported. Additionally, the failure to remove an IVC filter in this setting appears to result in inferior outcome and an attempt to safely remove the filter should be made in this high-risk population.”
As noted by the SVS, the data suggest a role for early filter removal after or not even placing them at all during iliocaval lytic therapy.
In addition, the investigators emphasize stenting from the normal vein above to the normal vein below the occlusive disease, if technically possible. Based on these results, going below the inguinal ligament to achieve adequate inflow makes sense.