The Role of Iliac Venous Obstruction and Pelvic Vein Dysfunction in Chronic

Venous Insufficiency

Society of Vascular Medicine

Friday June 15, 2018Chicago, Illinois

Joann M. Lohr, MD, FACS, RVT, CWSP

• July 1-2, 2011• Seoul, South Korea• Joann M. Lohr, MD,

FACS, RVT

Good Samaritan Hospital, Cincinnati, OH

Nothing to DiscloseI have no relevant financial relationship(s) with any proprietary entity producing health care goods or services related to the content of my talk

Iliac Vein Compression Syndrome

• Prevalence 14.8% (48/324)• Technical success endovascular treatment 95.8%• No difference thrombotic or nonthrombotic• Edema relief:

– Thrombotic 81.8%– Nonthrombotic 58.5%

• Cumulative recurrence free ulcer healing rate 71.4% 12 months after treatment

ZhenjieLiu, Ning Gao, Laigen Shen, Jin Yang, Yuefeng Zhu, Zhiming Li, and Yi Si, Hangzhou, China; and Madison, Wisconsin. Endovascular Treatment for Symptomatic Iliac Vein Compression Syndrome: A Prospective Consecutive Series of 48 Patients. Ann Vase Surg 2014; 28: 695-704.

May Thurner Syndrome Suprainguinal Anatomy

It is Not Just Reflux!

• Poor understanding importance of venous outflow obstruction in the pathophysiology of primary and secondary chronic venous diseases

• Sole reliance of infrainguinal Doppler studies for diagnosis of lower limb venous system

• Unknown at what percentage of venous stenosis becomes critical. Accurate noninvasive or invasive hemodynamic tests are therefore not available

• Diagnosis of occlusive or non-occlusive obstruction is based on morphological studies (>50% stenosis is considered significant – arbitrarily chosen based on clinical outcome)

Peter Neglen, MD, PhD. Stenting Is the "Method-of-Choice" to Treat Iliofemoral Venous Outflow Obstruction. J ENDOVASC THER 2009;16:492-493.

Do Not Overlook Subtle Clues• Lack of respiratory variation and poor augmentation on

Doppler wave form• Compare two bilateral common femoral waveforms• Vein size on duplex and CT scans• LCIV diameter 4.0 mm in DVT patients and 6.5 mm for

patients without DVT (p=.001) in another study 3.5 mm vs 11.5 mm (p<0.01)

• For each mm decrease in diameter increased odds of DVT by factor of 1.68

• Right iliac compression frequent CT finding• Iliac vein diameter can predict results of catheter-directed

thrombolysis in those with iliac vein compression syndromeJeffrey W Olin, Susan M Gustavson and Robert Lookstein. Images in vascular ultrasound. Vascular Medicine 2005; 10: 63-64.

Stephanie Carr, BS, Keith Chan, MD, Jarrett Rosenberg, PhD, William T. Kuo, MD, Nishita Kothary, MD, David M. Hovsepian, MD, Daniel Y. Sze, MD, PhD, and Lawrence V. Hofmann, MD. Correlation of the Diameter of the Left Common Iliac Vein with the Risk of Lower-extremity Deep Venous Thrombosis. J Vase Interv Radiol 2012; 23:1467-1472.

Feng Chen, Jun Deng, Xiao M Hu and Wei M Zhou. Compression of the right iliac vein in asymptomatic subjects and patients with iliofemoral deep vein thrombosis. Phlebology 2016, Vol. 31(7) 471-480.

Jin Woo Choi • Hwan Jun Jae • Hyo-Cheol Kim • Sang-H Min • Seung-Kee Min • Whal Lee • Jin Wook Chung. CT venography for deep venous thrombosis: Can it predict catheter-directed thrombolysis prognosis in patients with iliac vein compression syndrome? Int J Cardiovasc Imaging (2015) 31:417-126.

Levent Oguzkurt, Fahri Tercan, M. Ali Pourbagher, Osman Kizilkilic, Riza Turkoz, Fatih Boyvat. Computed tomography findings in 10 cases of iliac vein compression (May-Thurner) syndrome. European Journal of Radiology 55 (2005) 421-425.

IVUS

• Venogram underestimates degree of stenosis by 30%• Degree of stenosis accurately measured by planimetry –

invariably more extensive than shown by venography• Useful to guide stent placement• Appropriate diameter and length of stent can be

determined• Crucial to cover entire lesion in both non-occlusive and

occlusive disease to ensure long term stent patency• Ceplalad and caudal endpoints of stenting can be

adequately evaluated with better visualization of wall apposition of the stent and any recoil after stent insertion

Peter Neglen, MD, PhD. Stenting Is the "Method-of-Choice" to Treat Iliofemoral Venous Outflow Obstruction. J ENDOVASC THER 2009;16:492-493.

P. Neglent, M. A. Berry and S. Raju. Endovascular Surgery in the Treatment of Chronic Primary and Post-thrombotic Iliac Vein Obstruction. Eur J Vase Endovasc Surg 20, 560-571 (2000).

CT showing congenital absence of IVC Please note large lumbar collaterals

11

SMV filling portal vein

12

IMV Too Large Just to the Left of the Aorta IMV Pelvic Collaterals

Systemic to Portal Shunt

IVC Occlusion After Retrievable Filter Removal Atresia Infrarenal IVC with Collaterals

IVC Occlusion

Gone but not forgotten

Large uterine fibroids causing compression of the inferior vena cava at the level of the kidneys and right

hydronephrosis

PP Mass JF Chronic Venous Calcification

DM 2004

DM 2010 In Stent restenosis

DM 2018 KV Chronic Occlusion MRI

Avoiding Injury

Venous Stents vs Arterial Stents

• Increased radial force and flexibility• Greater diameter and length

M.A.F. de Wolf, R. de Graaf , R.L.M. Kurstjens , S. Penninx , H. Jalaie , C.H.A. Wittens. Short-Term Clinical Experience with a Dedicated Venous mtinol Stent: Initial Results with the Sinus-Venous Stent. Eur J Vase EndovascSurg (2015) 50, 518-526.

Stent Patency

• Endovascular treatment technically successful 225/233 patients (96.6%)

• All treated with percutaneous transluminal angioplasty and stent placement

• No severe procedure-related complications• Cumulative 1, 3 and 5 year primary patency rates at mean

follow-up of 34 months were 93.2%, 84.3% and 74.5%, respectively

• Independent predictors for in-stent obstruction were use of multiple stents and irregular stocking use

• Mayo clinical primary assisted patency rates at 1 and 3 years was 94% and 90% respectively; secondary patency 95%

Wan-Yin Shi, Jian-Ping Gu, Chang-Jian Liu, Xu He, Wen-Sheng Lou. Endovascular treatment for iliac vein compression syndrome with or (ftxwithout lower extremity deep vein thrombosis: A retrospective study on mid-term in-stent patency from a single center. European Journal of Radiology 85 (2016) 7-14.

Andrew K. Kurklinsky, M.D., Haraldur Bjarnason, M.D., Jeremy L. Friese, Waldemar E. Wysokinski, M.D., PhD, Robert D. McBane, M.D., Andrew Misselt, M.D., Sigridur Margret Moller, M.D., and Peter Gloviczki, M.D. OUTCOMES OF VENOPLASTY WITH STENT PLACEMENT FOR CHRONIC THROMBOSIS OF THE ILIAC AND FEMORAL VEINS: single-center experience. J Vase IntervRadiol. 2012 August; 23(8): 1009-1015

Results of Stenting in Chronic Iliofemoraland Inferior Vena Cava Thrombosis

• In patients with venous outflow obstruction and complicated chronic venous disease (C3 – C6)

• Ameliorated venous claudication• Normalizes outflow• Enhance calf muscle pump function• Significant clinical improvement and wound

healing• Resolution chronic pelvic pain and dyspareuniaKonstantinos T. Delis, MD, PhD, FRCSI, Haraldur Bjarnason, MD, f Paul W. Wennberg, MD, Thorn W. Rooke, MD,f and Peter Gloviczki, MD. Successful Iliac Vein and Inferior Vena Cava Stenting Ameliorates Venous Claudication and Improves Venous Outflow, Calf Muscle Pump Function, and Clinical Status in Post-Thrombotic Syndrome. Annals of Surgery • Volume 245, Number 1, January 2007.

Stephen F. Daugherty, MD, FACS, FACPh, RVT, " and David L. Gillespie, MD, FACS, RVT. Venous angioplasty and stenting improve pelvic r-congestion syndrome caused by venous outflow obstruction. J Vase Surg: Venous and Lvm Pis 2015;3:283-9.

Iliac-Femoral Stenting for Lower Extremity Stasis Symptoms

• 56 limbs managed conventional methods – leg elevation, compression, GSV and perforator ablation if needed

• 3 months• Ulcers not healed 3 months

– Venography and IVUS (>50% reduction cross sectional area on IVUS)

• Post thrombotic 17.8%• Incompetent perforators 12.5%• Incompetent superficial system 48.2%• Deep reflux 51.8%• 29 of 56 limbs needed stenting for stenotic lesions• Ulcers healed in 58% stented group over a period of 1 week

to 8 months

Saadi Alhalbouni. Anil Hingorani. Alexander Shiferson, Kapil Gopal, Daniel Jung. Danny Novak. Natalie Marks, and Enrico Ascher. Iliac-Femoral Venous S tenting for Lower Extremity Venous Stasis Symptoms. Ann Vase Sura 2012: 26: IS5-189.

Predictors of In-Stent Recurrent Stenosis in Stents Placed in the Lower Extremity

Venous Outflow Tract• Severe > 50% in-stent restenosis uncommon

short term• Risk factors

– Presence of thrombotic disease– Positive thrombophilic test results– Stent extending below inguinal ligament (long

stents)

Stephanie Carr, BS, Keith Chan, MD, Jarrett Rosenberg, PhD, William T. Kuo, MD, Nishita Kothary, MD, David M. Hovsepian, MD, Daniel Y. Sze, MD, PhD, and Lawrence V. Hofmann, MD. Correlation of the Diameter of the Left Common Iliac Vein with the Risk of Lower-extremity Deep Venous Thrombosis. J Vase Interv Radiol 2012; 23:1467-1472.

Phlebolymphedema

Phlebolymphedema (Secondary Lymphedema in Venous Insufficiency)

• Recumbent position– Arterial pressure 100 mm Hg– Venous pressure 8 mm Hg

• Standing increase pressure LE– Hydrostatic pressure increase directly proportional to

height and vertical distance from heart to bottom of feet• Standing passive hyperemia in blood capillaries ultra

filtrated– Reabsorption of fluid does not occur– Walking decreases venous pressure to approx. 25 mm Hg –

calf muscle pump affect on ambulatory venous hypertension

Raju; AVF Tucson February 2018

Life Long Learning a Never Ending Path