Facts About Iliofemoral Thrombosis

Antonios P Gasparis, MD

Professor of Surgery

Director, Stony Brook Vein Center

Distribution of DVT

• Distal• Femoral-popoliteal• Ilio-femoral (17-38%)

Partsch H. Therapy of deep vein thrombosis with low molecular weight heparin, leg compression and immediate ambulation. Vasa. 2001 Jul;30(3):195-204.

Klein SJ, Gasparis AP, Virvilis D, Ferretti JA, Labropoulos N. Prospective determination of candidates for thrombolysis in patients with acute proximal deep vein thrombosis. J Vasc Surg. 2010 Apr;51(4):908-12.

Incidence of IFDVT576 consecutive patients (mean age 58) referred for LE DVT assessment.

DVT was categorized by age (acute, chronic, and acute on chronic), anatomic location, and extent.

RESULTS:

Acute DVT was found in 14.8% of patients (85/576)

26 patients (30%) had isolated calf DVT

45 patients (53%) had femoropopliteal DVT

14 patients (17%) presented with iliofemoral DVT

Klein SJ, Gasparis AP, Virvilis D, Ferretti JA, Labropoulos N. Prospective determination of candidates for thrombolysis in patients with acute proximal deep vein thrombosis. J Vasc Surg. 2010 Apr;51(4):908-12.

Why is location of DVT important?

• Location of DVT has significant impact on thrombus resolution and severity of long-term complication

• Patients with more proximal thrombosis tend to have lower recanalization rates and a much higher incidence of CVI (90%)

IFDVT - Incidence of IVC involvement

• Thrombus extension to the IVC 20-50%

• Incidence is high in patients with IVCF

Klein SJ, Gasparis AP, Virvilis D, Ferretti JA, Labropoulos N. Prospective determination of candidates for thrombolysis in patients with acute proximal deep vein thrombosis. J Vasc Surg. 2010 Apr;51(4):908-12.

Avgerinos ED, et al. Impact of inferior vena cava thrombus extension on thrombolysis for acute iliofemoralthrombosis. J Vasc Surg Venous Lymphat Disord. 2016 Oct;4(4):385-91

IFDVT - Involvement of distal segment

• A retrospective analysis of all patients presenting with unilateral DVT – 1338 patients

• The anatomical site and extent of thrombus was registered and subdivided into five segments

• 506 (38%) with IFDVT • 8% – IF involvement only (Segments 4 or 5)

• 68% – involvement of Segment 1 or 2

De Maeseneer MG, Bochanen N, van Rooijen G, Neglén P. Analysis of 1,338 Patients with Acute Lower Limb Deep Venous Thrombosis (DVT) Supports the Inadequacy of the Term "Proximal DVT". Eur J Vasc Endovasc Surg. 2016 Mar;51(3):415-20.

Ouriel K, et al. The anatomy of deep venous thrombosis of the lower extremity.J Vasc Surg 2000;31:895-900

L/R

The anatomy of deep venous thrombosis of the lower extremity.2541 Venograms

- 885 patients DVTs

- Provoked and unprovoked

- Iliac involvement in 9%

- Overall L:R - 1.3:1

- 2.4:1 for iliac vs 1.3:1 for infrainguinal

Laterality in IFDVT

• Reported that LE DVT overall is more common on the Left

• This is true in patients with IFDVT

De Maeseneer MG, Bochanen N, van Rooijen G, Neglén P. Analysis of 1,338 Patients with Acute Lower Limb Deep Venous Thrombosis (DVT) Supports the Inadequacy of the Term "Proximal DVT". Eur J Vasc Endovasc Surg. 2016 Mar;51(3):415-20.

Incidence of iliac vein compression

• Compression is a common cause of obstruction

• Incidence reported 10-40%

• Can occur in variety of locations

• Many reports demonstrated that most patients with iliofemoral thrombosis have iliac vein compression

• Venous stenting occurs in 10-90% of patients IFDVT

Chen F. et al. Compression of left common iliac vein is independently associated with left-sided deep vein thrombosis. J Vasc Surg Venous Lymphat Disord. 2013 Oct;1(4):364-9.

Compression and association with DVT

Retrospective study looking at the influences of LCIV diameter and stenosis on the risk of DVT

• LDVT, RDVT, Control - The influences of LCIV diameter and stenosis on the risk of left DVT

• LCIV stenosis >75% - the risk of left DVT was associated with an 11-fold increase

• Left common iliac vein is independently associated with left-sided deep vein thrombosis

Chen F. et al. Compression of left common iliac vein is independently associated with left-sided deep vein thrombosis. J Vasc Surg Venous Lymphat Disord. 2013 Oct;1(4):364-9.

Iliac vein compression as risk factor for DVT

• 230 consecutive patients who had a CT prior to diagnosis of DVT

• Mean percentage compression was 36.6%• 30% had greater than 50% compression

• 7.2% had greater than 70% compression

• Increasing compression up to 70% was not associated with left DVT

• However, greater than 70% compression was associated with left DVT

Narayan A. et al. Iliac vein compression as risk factor for left- versus right-sided deep venous thrombosis: case-control study. Radiology. 2012 Dec;265(3):949-57

Recurrence in patients with IFDVT

• Well documented that proximal DVT has a higher recurrence than distal DVT

• Proximal vs. Distal (35% vs. 20%)

Does location and extent of proximal DVT effect recurrence?

Asbeutah AM, Riha AZ, Cameron JD, McGrath BP. Five-year outcome study of deep vein thrombosis in the lower limbs. J Vasc Surg 2004;40(6):1184–1189.

Labropoulos N, Jen J, Jen H, Gasparis AP, Tassiopoulos AK. Recurrent deep vein thrombosis: long-term incidence and natural history. Ann Surg. 2010 Apr;251(4):749-53.

Recurrence in patients with IFDVT

• 1,149 patients with symptomatic proximal DVT

• Classified as: Popliteal, Femoral, or Iliofemoral.

• All patients were anticoagulated and followed for 3 months.

RESULTS:

• Overall recurrence at 3 months was 5.5% (63/1,149). • Popliteal vein thrombosis was 5.1% • Femoral vein thrombosis was 5.3% • Iliofemoral vein thrombosis was (6/51) 11.8% • Risk factors with an increased risk: IFDVT - OR = 2.4; Cancer - OR = 2.6

Douketis JD, Crowther MA, Foster GA, Ginsberg JS. Does the location of thrombosis determine the risk of disease recurrence in patients with proximal deep vein thrombosis? Am J Med. 2001 May;110(7):515-9.

Fate of thrombosis

Propagation-Proximal-Distal

Embolism -Pulmonary

-Stroke (paradoxical)

Recanalization-Partial-Complete

Permanent occlusion-Fibrosis-Vein wall contraction

IFDVT and PE

• Consecutive patients with suspected iliofemoral DVT diagnosed by duplex ultrasonography and verified by radionuclide venography

• Perfusion and when necessary ventilation scans were performed for diagnosis of PE in all patients immediately after admission

• 140 patients with confirmed IFDVT

• Lung scans: 47% patients had objectively verified PE

• Symptomatic: 13.5%

Partsch H, et al. Frequency of pulmonary embolism in patients who have iliofemoral deep vein thrombosis and are treated with once- or twice-daily low-molecular-weight heparin. J Vasc Surg. 1996 Nov;24(5):774-82.

Spontaneous and complete recanalization occurs in:

90% of popliteal/calf DVT vs.

50% of femoral DVT

10 - 30% of iliac vein thromboses recanalize

Thomas ML, McAllister V. The radiological progression of deep venous thrombus.Radiology 1971;99(1):37–40.Mavor GE, Galloway JM. Iliofemoral venous thrombosis. Pathological considerations and surgicalmanagement. Br J Surg 1969;56(1):45–59.

Natural History IFDVT

Early Results (6 months) of Anticoagulation vs Thrombolysis in

Iliofemoral Venous Thrombosis

Elsharawy M, Elzayat E. early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis: a randomised clinical trial. Eur J Vasc Endovasc Surg. 2002; 24:209-214.

35 patients were randomized

Anticoagulation alone (17) Thrombolysis (18)

Patency 12% 72%

Reflux 41% 11%

Natural History IFDVT

• Chronological changes of venous obstruction and physiology after acute IF-DVT over 5 years treated with anticoagulation

• 70% had residual obstructive lesions of the iliac veins• Only minor changes occurring from 6 months to 5 years• Physiologic venous outflow improved with time but

hemodynamics deteriorated

Natural History IFDVT

Akesson H et al . Venous function assessed during a 5 year period after acute ilio-femoral venous thrombosis treated with anticoagulation. Eur J Vasc Surg 1990;4(1):43–48.

Labropoulos N et alArch Surg 1997; 132:46

- Post Thrombotic Limbs -Location Rest Hyperemic

Iliofemoral 6.3 mmHg 8.9 mmHg

Femoral-popliteal 4.4 mmHg 7.3 mmHg

Popliteal 1.5 mmHg 3.1 mmHg

Controls 1.0 mmHg 2.7 mmHg

Hemodynamics of Venous Obstruction

Clinical outcomes

when comparing patients with

proximal and distal DVT

IFDVT Clinical outcomes

Asbeutah AM, Riha AZ, Cameron JD, McGrath BP. Five-year outcome study of deep veinthrombosis in the lower limbs. J Vasc Surg 2004;40(6):1184–1189.

Proximal DVT had worse outcome

CEAP (4-6) - 56% vs. 11% at 60m

Findings

IFDVT patients had the most severepost-thrombotic morbidity vs. distal DVT

(OR 2.23; p<0.001)

Outcomes After Anticoagulation Alone

Ann Int Med 2008; 149:698

CEAP classification in patients with vein thrombosis in multiple segments

Labropoulos N, et al. J Vasc Surg. 2008;48:407-12

Effect of Venous Thrombus Location and Extent on Developing PTS

47%

29%

105 patientsFirst episode DVT 1 year follow up

IFDVT Long-term effects anticoagulation alone

• High degree of obstruction

• Marked hemodynamic impairment

• 95% Venous Insufficiency

• 15% Venous Ulceration

• Venous claudication developed in almost 50%

• Limited ambulation in 15%

• Markedly reduced QOL

Delis KT et al

Ann Surg 2004;239(1):118

Akesson H

Eur J Vasc Surg 1990

Observations @ 5 Years

Summary

• IFDVT incidence is 10-30%

• Extension to IVC or peripheral veins occurs in 10-30%

• Location and extent of thrombus determines recurrence and PTS

• PE is present in 10-50%

• IFDVT has impact on venous hemodynamics due to poor recanalization

• Significant impact on progression of disease and QoL