Early results of iliocaval reconstruction with stents for venous outflow obstruction patients are encouraging

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James Budge

“Endovascular reconstruction of the chronically obstructed iliocaval venous tract with stents is technically feasible, minimally invasive and has an acceptable safety rate, said James Budge, Department of Vascular Surgery, Guy’s and St Thomas’, London, UK.

“Patients who underwent this procedure reported overall significant early improvement in the severity of post-thrombotic syndrome. Still, longer-term data and larger studies are needed to evaluate procedural durability, clinical efficacy and cost-effectiveness,” he said.

Budge was speaking at The Vascular Societies’ annual scientific meeting (22–24 November, Manchester, UK) and reported the results from a study that aimed to investigate the early outcomes of endovascular iliocaval reconstructions with stents in a single centre.

Chronic iliocaval obstruction, particularly secondary to deep venous thrombosis, may result in disabling chronic venous insufficiency or post-thrombotic syndrome of the lower limbs. “Recent advances in venous stent technology have enabled such pathologies to be treated with minimally invasive endovascular iliocaval reconstruction, whilst it was previously amenable to unsatisfactory conservative therapy, or invasive open surgical reconstruction,” Budge explained.

Investigators obtained data from consecutive patients who underwent endovascular iliocaval reconstructions with stents for chronic iliocaval obstruction between 1 February 2013 and 1 August 2017.

The data were retrospectively identified from a prospectively collected patient database.“Outcome measures and data collected included patient demography; patency (primary, primary-assisted and secondary, or blockage). We also collected perioperative details, including technical details and complications in the period. Pre- and post-operative Villalta scores were collected and analysed,” he reported.

All patients were managed by a multidisciplinary team that included haematologists, interventional radiologists, vascular surgeons and clinical nurse specialists.“The most common stent configuration used in this study was a double-barrelled venous-specific nitinol stent, which, where necessary, entered into a single lumen stent cranially,” Budge reported.

Researchers included data from 36 patients (23 male; with a median age of 34 [19–73]). There were 32 patients with a previous deep venous thrombosis; three with previous pulmonary embolism; 13 with recognised thrombophilia and two who had undergone previous deep venous intervention. The median follow-up was 15 months.

“With regard to the distribution of the disease, there were 30 patients with infrarenal disease that may or may not have involved the iliacs. There other six patients had supra and infrarenal disease, with or without iliac involvement,” Budge said.

“There was no post-interventional statistically significant deterioration of renal function measured as serum creatinine and estimated glomerular filtration rate. In this study, we saw no symptomatic major haemorrhage, although three patients required a single unit of red blood cell transfusion; and there were no other immediate or major complications,” Budge noted.

“The results at one year showed a 47% primary patency rate; 67% primary-assisted patency and 80% secondary patency rate. We feel that our primary patency rate is comparable to other groups in the published literature, although the follow-up period is much shorter. The median Villalta score pre-intervention was 18, which corresponds to severe post-thrombotic syndrome. Post-intervention, this dropped to a median of 9.5, which corresponds to mild post-thrombotic syndrome, and this is a statistically significant improvement,” Budge concluded.

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