New research indicates that stenting below the inguinal ligament does not result in inferior outcomes

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Brian DeRubertis

Endovascular treatment of iliocaval and infrainguinal post-thrombotic venous obstruction results do not appear to be adversely affected by extension of the iliac vein stents into the femoral venous system, according to a US report in the Journal of Vascular Surgery: Venous and Lymphatic Diseases.

Deep venous thrombosis remains a significant problem with well over 500,000 people affected in the USA alone, the report states. Over a quarter of these patients will experience post-thrombotic syndrome (PTS), despite appropriate anti-coagulation. Patients with iliocaval thrombosis face a three-fold risk of PTS. Treatment of the complications of PTS, including leg swelling, venous claudication, skin changes and ulceration, results in US healthcare costs estimated at US$7–10 billion per year.

Popularised by Seshadri Raju and Peter Neglen, venous stenting for symptomatic patients has increased significantly in this setting. Several large series since then have demonstrated safety, efficacy and good durability of this technique in iliocaval obstruction. Questions, however, remain as to the outcomes with regards to aetiology (ie. thrombotic versus non-thrombotic occlusion) and 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.

Researchers from UCLA, led by vascular surgeon Brian DeRubertis, retrospectively evaluated their single-centre experience with percutaneous treatment of post-thrombotic iliocaval obstruction. 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/stent in 81% with extension into the femoral system (38%), resulted in 100% technical success. Of those with inferior vena cava (IVC) filters, 46% were able to be removed.

At an average of 15 months of follow-up (range 2–49 months), the following results were achieved:

  • Improvement in pain/swelling in 84% of patients
  • Resolved pain/swelling in 42% of patients
  • Decreased CEAP classification in 65% of patients
  • One-year primary stent patency in 66% of patients
  • One-year secondary stent patency in 75% of patients.

Those patients requiring infrainguinal extension of the stent saw no significant difference in primary stent patency at one year compared to 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% of cases.

“Our aim was to better understand risk factors for poor clinical outcomes in patients undergoing percutaneous intervention for symptomatic chronic venous obstruction secondary to post-thrombotic lesions,” comments first author Johnathon Rollo. “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.”

This data suggests a role for early filter removal after, or not even placing them at all, during iliocaval lytic therapy.

The authors emphasise stenting from normal vein above to normal vein below the occlusive disease, if technically possible. Based on these results, going below the inguinal ligament to achieve adequate inflow “makes sense”, they say.

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