IVUS use in venous procedures improves stent patency

Efthymios Avgerinos and Lillian Tran

A recent study on iliac vein stenting showed better short- and mid-term patency rates when intravascular ultrasound (IVUS) was utilised prior to stent deployment in addition to multiplanar venography compared to venography alone. The data were presented at VENOUS2021 (17–20 March, virtual), the annual meeting of the American Venous Forum. Speaking to Venous News, lead investigator Efthymios Avgerinos (University of Pittsburgh Medical Center, Pittsburgh, USA) comments: “This has been a strong assumption for years, but now we have good longitudinal data to back it up.”

Stenting of iliac venous outflow is becoming increasingly popular in the management of thrombotic and non-thrombotic peripheral venous disease, which relies on sensitive, high-quality imaging to ensure accurate and complete deployment. IVUS is an emerging imaging modality in the treatment of iliofemoral venous disease and, according to Avgerinos, plays a “critical role” in visualising and sizing clinically significant stenotic lesions.

Outcomes of the multicentre VIDIO (Venogram versus intravascular ultrasound for diagnosing and treating iliofemoral vein obstruction) study demonstrated a greater sensitivity and specificity of detecting iliofemoral disease using IVUS when compared with traditional multiplanar venography. Correlations with venous stent patency, however, have not yet been investigated.

The Pittsburgh group performed a retrospective study between 2014 and 2020 on 127 patients (172 limbs) who underwent iliac vein stenting for thrombotic or non-thrombotic indications. Patients were divided in two groups based on whether IVUS was utilised prior to stent deployment in addition to multiplanar venography compared to venography alone. Thirty-day and two-year stent patency rates were measured as primary endpoints of the study. Multivariate analysis was performed to determine if adjunct IVUS use, in addition to multiplanar venography, was protective against early and mid-term stent failure.

Lillian Tran, a fifth-year resident at the University of Pittsburgh Medical Center who presented the results at VENOUS2021, reported that the cumulative total length of stent deployed was significantly higher when IVUS examination was performed (128cm vs. 111cm; p=0.04). Additionally, IVUS use was associated with a higher rate of infra-inguinal stent extension (18% vs. 7%; p=0.02). These data indicate that IVUS utilisation resulted in extended stent coverage. Both 30-day (98.5% vs. 79.6%; p=0.03) and two-year (89.9% vs. 73.6%; p=0.04) primary patency were significantly higher in the IVUS cohort and IVUS use was found to protect against stent reintervention at two-years on adjusted Cox regression analysis (hazard ratio [HR], 0.22; 95% confidence interval [CI], 0.07–0.7]; p=0.01). When dividing the patient population based on thrombotic or non-thrombotic indications, adjunct IVUS use remained a significant protective factor indicating that the diagnostic advantages of IVUS utilisation with regards to stent patency are present regardless of indication for intervention.

“IVUS in venous interventions is widely accepted but there have been concerns for overdiagnoses of lesions and excessive stenting. Our results did confirm that adjunct IVUS use results in longer coverage of the iliofemoral veins and this was associated with higher stent patency when compared to stenting based on multiplanar venography alone”, explains Avgerinos.

He continues: “Many still question whether the clinical benefits of routine IVUS examination during iliac vein stenting justify the additional time and cost it generates. Our data, in conjunction with prior IVUS studies, support the push for its routine use during iliac vein stenting to optimise stent patency.”


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