Should non-thrombotic iliac vein lesion (NIVL) patients be given venous stents? That was the question raised to Gerry O’Sullivan (Galway, Ireland), a consultant interventional radiologist at the University Hospital Galway, and Stephen Black (London, UK) a consultant vascular surgeon at Guy’s and St Thomas’ NHS Foundation Trust and professor of venous surgery at King’s College London during a recent CX Vascular Live discussion moderated by Erin Murphy (Charlotte, USA), director of the venous and lymphatic program at Atrium Health’s Sanger Heart and Vascular Institute.
We’re going to be discussing one of the most interesting debates from the Charing Cross (CX) International Symposium venous session,” Murphy began, on the role of treating NIVLs for advanced disease C3 to C6.
The roundtable video discussion covered an earlier debate between O’Sullivan and Steve Elias (Englewood, USA), director of the Center for Vein Disease at Englewood Hospital, which centered on the motion “treatment of [NIVLs] in C3–C6 disease is supported by the clinical evidence”.
“I think the difficulty is conflating C3, 4, 5, and 6 disease into one group,” Black said. He went on to say that when dealing with C6 disease, there are few people who would argue against trying a stent. However, for patients who only have “a swollen leg at C3,” that’s where the debate lies.
“I think that’s the difficulty really, because a lot of patients now are having stents for what I would regard as dubious indications,” O’Sullivan stated. “It’s an easy thing for a doctor to put in a stent.” Though, O’Sullivan continues to say that putting a stent into a patient is not always the right thing to do, at least when beginning treatment.
When dealing with C6 patients who have healed ulcers, O’Sullivan agrees, “a stent is a very worthwhile thing to do.”
Murphy agreed, saying that, while some patients who suffer from C3 venous disease do benefit from receiving a stent, “it’s a difficult patient group to work through.”
Black stated that, what people need to understand is that “all swelling, to some extent, is lymphedema” and that the “lymphatics start to fail”.
“Once the lymphatics stop working, the patients don’t recover. So even in patients who have got venous hypertension driving their leg swelling, that is from a May-Thurner or NIVL lesion, stenting it may not improve the situation because it may be too late,” Black stated.
Murphy responded, stating that “setting patient expectations is one of the things that is important in that group.” She then continued, posing a question to O’Sullivan and Black. “Do you guys have some advice for people who are treating these patients and trying to sort through this group of difficult to diagnose patients with edema?”
O’Sullivan was first to answer, saying that imaging is an important factor. “I think you want to be comfortable with your imaging,” O’Sullivan began. “You want to be critical of your imaging as well, because imaging will tend to overcall a stenosis in my view.”
He also mentioned how intravascular ultrasound (IVUS) has recently been used and has benefits. O’Sullivan believes that what vascular surgeons are looking for is “a tool that would accurately measure or quantify where that iliac vein lesion is and whether a stent is going to benefit. I think that doctors are crying out for that specific tool right now.”
O’Sullivan then assessed the situation in practical terms, saying that the patient should be spoken with to determine what they are willing to do and to set expectations. He suggested asking patients, “Are you willing to wear stockings? Would you be willing to take anti-coagulants? Are you prepared to put up with a vague chance or an outside chance of things going wrong?” He also stated that you must explain to your patients that a stent is not something that can be taken out and is for life.
Black agreed with O’Sullivan, “I think those are all excellent points,” he responded. Black added that you should “take a really good history, examine your patients properly, make sure you understand what the other things are that could be driving leg swelling and you’ve eliminated those.”
Black also explained how he sets expectations for his patients, saying that he’ll tell patients that, if swelling is their primary issue with stenting, then “one, it’s a 50/50 shot whether it improves. It may not get better, [and I] make no promises on it. Two, it takes a long time to improve.”
He continued by saying that, if you plan on putting a stent in a C3 patient, you must be absolutely sure that you need to. Black referenced Elias’ argument that C3 disease should likely be looked at as a standalone diagnosis.
“Is it a worthwhile measure at all because there are so many causes of swelling?” O’Sullivan added. “I think if the debate today had been ‘is stenting indicated in or is there evidence to support stenting for C5 and 6 patients,’ I think the result would have been very different.”
O’Sullivan concluded by saying that he “firmly believes” stenting is the right choice of action for treating C5 and C6 patients. “Those patients really need a stent, because their ulcers are horrible and we spend our whole lives trying to avoid patients getting ulcers.”
“I think we can agree that the end result of today’s debate is, ‘we need more data’ in this group,” Murphy stated as the conversation came to a close.
