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Friday, September 28, 2018

Stent Extension below the Common Femoral Vein in Extensive Chronic Iliofemoral Venous Obstructions


Summary


The percutaneous endovascular treatment of post thrombotic syndrome can be challenging due to the presence of fibrotic venous obstructive lesions below the inguinal ligament. Stent placement below this level is not widely supported due to the fear that a stent in this location may negatively impact patency due to fractures or external compression. However, if iliocaval stenting is performed alone, there is a considerable risk of in-stent thrombosis due to poor inflow.

The authors of this retrospective review looked at 14 symptomatic patients with ultrasound (US) or magnetic resonance (MR) documented postthrombotic venous changes extending peripheral to the common femoral vein (CFV) who underwent primary stent placement peripheral to the femoral confluence. The deep femoral vein (DFV) was the target vein in all patients studied. Venous Clinical Severity Score was obtained before intervention for 13 patients (mean score 8.9 ± 4.4; range, 3–20). Venous Clinical Severity Score decreased significantly in the 13 patients evaluated (from mean score 8.9 ± 4.4; range, 3–20 to mean score 6.4 ± 3.5; range, 1–12; P 1⁄4 .03). There was a mean decrease of 5.7 points in the Villalta scale in these 13 patients before and after intervention with a mean score of 11.7 ± 4.3 (range, 5–20) before intervention and 6.0 ± 3.6 (range, 0–13) after intervention (P 1⁄4 .003). Venous claudication symptoms were present in 12 patients (92%) and it subsided in 8 of the patients, for an incidence of 38% (P 1⁄4 .016). A combined primary patency, assisted primary patency, and secondary patency of 92% was demonstrated with a median follow-up of 481 days (range, 411–792 d). During the entire follow-up period, 1 patient (7%) experienced stent occlusion.



Commentary


Postthrombotic syndrome is a debilitating disease process which in many cases does not respond well to conservative therapies. Open and hybrid surgical options have modest patency rates and high morbidity. Percutaneous techniques carry considerably less morbidity but may ultimately fail if there is fibrotic disease involving and peripheral to the CFV, a not uncommon scenario in these patients, and iliocaval stenting alone is performed. The data obtained from this study is important because it shows encouraging results for stent placement peripheral to the CFV. Furthermore, the results suggest that stent placement into the DFV can be a viable option if the FV has extensive chronic disease and the DFV is the dominant inflow vessel. Of course, more patients must be studied and randomized controlled trials performed, but the data presented here offers a promising percutaneous treatment algorithm for this difficult group of patients.

Click here for abstract

Van Vuuren T, Wittens C, de Graaf R. Stent Extension below the Common Femoral Vein in Extensive Chronic Iliofemoral Venous Obstructions. J Vasc Interv Radiol. 2018; 29: 1142-1147.

Post Author:
Zagum Bhatti, MD
Assistant Professor
Department of Radiology, Interventional Radiology Division
University of Texas Health Science Center at Houston, Houston, TX
@UTHouston_IR
@ZagumBhatti

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