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availability.Also,vesselsthatdemonstrateturbulentflow,suchasareasabovebifurcations,maybe
indistinguishablefromfillingdefectsonMRV.Finally,despitetheirhighsensitivityandspecificity,
bothMRVandCTimagingarelimitedbylevelofresolution,whichinsomeinstancesmaynotbe
sufficienttopickupsmallspursorsubtlewebsinthecommoniliacvein.Giventheselimitations,
MRV seems tobe more useful inpatients witha low pretestprobability of MTSwho have mild
disease.
3.ContrastVenography
Invasive contrast venography allows direct visualization in theevaluation of iliac vein obstruction in
suspectedMTSandisthegoldstandardfordiagnosis.Thisinvolvesinjectionofdyeviavenousaccess
(commonfemoralorpopliteal)throughacatheterwithfluoroscopicvisualization.13Itcanhelpidentify
thelocationandextentofocclusionorthrombosis,assessforanyconcomitantmalformations,andassess
the chronicity of the occlusion. Additionally, it allows for pressure measurement across a suspected
stenosisviapullbackgradient.Althoughthereisnoformalguidelineintheliteratureonwhatdegreeof
pressure gradient reflectsahemodynamicallysignificantstenosis,moststudiessuggestthat2-3 mmHg
gradient issufficienttocausesymptoms.9Intervention ispossible atthe timeofvenography, including
thrombolysis,balloonangioplasty,andstenting.
11
4.IntravascularUltrasound
IVUSisavaluableadjuncttovenographyandmaydetectiliacvenousoutflowmissedonconventional
contrastvenography.UsinganIVUScatheterintraluminally,whichisaspeciallydesignedcatheterwitha
miniaturizedultrasoundprobeattachedtothedistalend,a 360° two-dimensionalgray scale ultrasound
imagecanhelptovisualizethevessellumenandvesselwallstructure.Itcandetectthemorphologyand
degree of stenosis at the lesion “spur” as well as be useful in sizing the vessel before any stent
deployment.
IVUS offers improved visualization of intra- and extramural details, including external compression,
trabeculation,frozenvalves,andmuralthickeningasshowninastudybyNeglenetal.14Theyassessed
304limbsduringballoonangioplastyandstentingforiliacveincompression,withIVUSasthestandard,
andfoundthat venographyhad poorer sensitivity andnegativepredictive value(49%) todetect>70%
stenosis. Giventhe absence of adequate hemodynamic testing for important venous obstruction, IVUS
assessmentisthebestavailabletoolforassessmentofclinicallysignificantstenosis.
VI.TreatmentOptions
PatientswithMTSshouldonlybetreatedifsymptomatic.TreatmentforMTShasevolvedinrecentyears
andisdirectedatrelievingvenouscongestiontoavoidPTS,venousulceration,venousinsufficiency,and
venous claudication. Choice of initial strategy is dictated by the presence of coincident DVT for
determination of the need for anticoagulation. In the absence of DVT, patients with CEAP class 1-3
diseasearetreatedwithconservativetherapywithlegelevationandcompressionstockings.Patientswith
CEAP class 3 presentation and higher are reasonable candidates for invasive treatment to decrease
venoushypertensionafterfailureofconservativetherapy.InthepresenceofDVTwithconcernforMTS,
full-dose anticoagulation is indicated, although this is often insufficient. Catheter-directed or
pharmacomechanicalthrombolysisforreductionofclotburdenmaybenecessarywithmechanicalrelief
of outflow obstruction. Historically, surgical procedures to relieve compression in MTS included
autologousveinvenovenousbypass,retropositionoftheiliacarterywithexcisionoftheintraluminalspur
withpatchvenoplasty,andtissueslingcreationtomechanicallyelevatetherightiliacartery.Theseopen
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procedureshavebeenvariableinsuccess.Endovascularadvanceswithballoonangioplasty,stenting,and
selectivethrombolysishaveimprovedoutcomesrelatingtoavoidingPTS.
A.NoninvasiveTreatment
NoninvasiveoptionsfortreatmentofMTSincludeprimarypreventionoftheinitialDVTinpatientswith
known risk factors. However, in many patients, prevention of first DVT is not possible; therefore
preventionofPTSisparamount.TherapeuticanticoagulationshouldbeinitiatedonceDVTisconfirmed.
CompressionstockingsmaypreventprogressiontoPTSbytheoreticallydecreasingvenoushypertension
and reducing reflux. In one trial of 180 patients with proximal DVT on anticoagulation, one-half of
patientsdevelopedpostthromboticsequelaeat5years,withknee-highcompressionstockingsappliedfor
2yearsafterDVTdiagnosisreducingthisratebyalmost50%.15TheSOXtrial,amulticenterrandomized
trial,enrolled806patientstoactiveversusplacebocompression.TheyfoundthatincidenceofPTSwas
14.2%intheactivecompressiongroupcomparedwith12.7%intheplacebogroup,suggestingbasedon
thisstudythatcompressiondoesnotpreventPTSafterproximalDVT.16DataforcompressioninMTS
withDVTareextrapolatedfrompatientswithsymptomaticproximalDVT,anditisreasonabletomanage
patientswiththerapeuticanticoagulationaswellas2yearsofcompressionstockings.Unfortunately,there
are patient-level barriers to adherenceto compression,includingcostandvariablecoveragebyhealth
insurance providers, difficulty applying stockings especially at higher compression, and patient
discomfortwearingstockingsespeciallyinwarmerclimates.
1.SurgicalManagement
a. Surgicaloptionshavehadmixed success becauseofhighratesofmorbidity andvariable patency
rates. These options include contralateral saphenous vein graft bypass to the ipsilateral common
femoralveinwithcreationofatemporaryAVfistula(Palmacrossover),divisionofrightcommon
iliacarteryandrelocationbehindtheleftcommoniliacveinorinferiorvenacava,andveinpatch
venoplasty with encasement of the left common iliac vein in ePTFE grafts after removal of
intraluminalobstructions.Theserepresentmajorsurgerieswithneedforlifelonganticoagulationfor
patencyandare onlyreserved for patientswiththe mostsevere PTS. Additionally,thesesurgical
approachestoMTStreatmenthavenotshownsignificantlong-termimprovementforpatientsfroma
symptomatic or functional standpoint. Jost et al looked at venous reconstructions with Palma
procedure,ePTFEgrafts,andpatchvenoplastyandshowedprimaryandsecondarypatencyratesof
54%and62%at3years,withPalmaprocedureshavingthehighestpatencyrateof83%at4years
andePTFEbypassgraftsshowing45%patencyat2years.17In additiontovariablepatencyrates,
these proceduresare associatedwith high operative risklargelybasedonpatient-specific factors
such as the presence of obstructive disease in the femoral vessels, presence of concurrent
thrombosis,andcaliberofthebypassgraft.
b. CombinedsurgicalandendovenousmanagementofiliofemoralDVThasbeenreported.Mickleyand
colleagues reported a series of 77 patients with acute iliac DVT who were treated with
anticoagulationfor12monthsandtransfemoralvenousthrombectomywithconstructionoftemporary
inguinalAVfistula.Ofthepatientswhohadleft-sidedthrombosis,halfwerefoundtohavevenous
spurs on venogram. In the series, prior to 1994 those spurs were left untreated beyond oral
anticoagulation with rethrombosis in72% of patients compared with a 4% rate of recurrence in
patients without spurs. In the stented group after 1994, only 1 out of the 8 patients experienced
rethrombosis (13%).18 This and other studies suggest that surgical thrombectomy of iliofemoral
DVTalonemaynotbesufficientwithoutreliefofoutflowobstructionassociatedwithvenousspurs
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viaendovenousstenting.
2.EndovenousTreatmentOptions
a. More recently, endovascular treatment strategies have become more successful for treatment of
iliofemoralDVTandtheunderlyingiliacveincompression.Althoughendovascularvenoplastydates
back over 30 years, this was not explored in MTS until the 1990s when first case reports
demonstratingsuccessfulmanagementwithstentingwerepublishedasapromisingalternativetothe
existingdisappointingmedicalandsurgicalstrategies.Inthemid-1990s,theearliestcasereportsof
stent placement as treatment of iliac vein compression were published. Berger and colleagues
publishedone of theseearlycase reportsofa patientwithMTSeffectivelytreated with catheterdirectedthrombolysisandsubsequentstentplacement,notingthatballoonangioplastyalonewasnot
sufficient tomaintainpatencylikelyowing to high elastic recoil of thefibrotic, compressed iliac
vein.By 6 months’ follow-upthere was continuedresolutionof thepatient’s left legedema with
preservedstentpatencybyduplexultrasound.19Three yearslater,aneight-case seriesofleftiliac
veinangioplasty inpatients with symptomaticleft iliacvenousspur(definedasproximal DVTor
PTS)showedimmediatereductioninleftlegcircumferenceafterstentinginallpatientswith100%
stentpatencyat3-yearsfollow-up.20Thisprovidedencouragingevidence for stentingas aviable
first-linetreatmentoptionofiliacveincompression.
b. Subsequent studies have confirmed improved outcomes and high patency rates for MTS patients
treated with endovascular stenting. Hartung and colleagues corroborated the use of stenting in
patientswith iliacveinocclusive disease in conjunction with surgicalvenousthrombectomy. This
studyfollowedup29patientswhounderwentthrombectomywithcreationofanarteriovenousfistula
andangioplastywithiliacveinstenting.Ofthesepatients,22werefoundtohavecompressionofthe
leftcommoniliacveinbytherightcommoniliacartery,3werefoundtohavechronicleftcommon
iliacveinocclusion,3werefoundtohaveresidualclotwithintheleftcommoniliacvein,and1was
foundtohaveleftexternaliliacveincompressionbytheleftinternaliliacartery.Ofthosepatients
treatedwithstenting,primary,assistedprimary,andsecondarypatencyratesat1year,5years,and
10 years were 79%, 86%, and 86%, respectively. Additionally, this stented groupwas shown to
havehighratesofvalvularcompetenceandlowratesofrethrombosis.
21
c. More recently, Liu et al in 2014 demonstrated a 93% primary patency rate at 1 year among 48
patients with iliac vein compression syndrome whoreceived iliac veinstenting. This studyalso
divided the patients into thrombotic versus nonthrombotic groups, both treated similarly with
stenting, and founda dramaticreductioninreportedpaininboth groups aswellas an81.8% and
58.5%reductioninedemainthethromboticandnonthromboticgroups,respectively.22Notonlydo
thesestudiesexhibitimpressivepatencyratesforpatientstreatedwithstentingandcatheter-directed
thrombolysis (ifapplicable),but thelatterofferssome prognostic evidence,by demonstrating that
thromboticdiseasecanhaveanegativeimpactonthedegreeofedemaresolutionwithstenting.
d. The literature also supports use of catheter-directed thrombolysis in conjunction with stent
placementincaseswithconcurrentthrombosistopromotestentpatencyandvenoussufficiency.A
studyin2010investigatedthepatencyratesin30patientswithMTSandacuteiliofemoralDVTwho
were treated with catheter-directed thrombolysis and stent placement.Follow-up CT venography
wasperformedatvariousintervalsandprimaryandsecondarypatencyratesof83.3%and90%at1
and5yearsaftertreatment, respectively, were demonstrated.Park etalsimilarly showed primary
patency rates after CDTand iliac veinstenting of 95.8% at6 months,87.5% at 12 months, and
84.3%at24monthsin51patientswithsymptomaticMTS.
23
e. RandomizeddataforCDTinMTSdonotyetexist;wecanextrapolatefrompatientspresentingwith
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acute iliofemoral DVT. In the largest randomized controlled trial of CDT for deep venous
thrombosis, the CAVenT study randomized 209 patients with first episode of acute DVT (<21 d
duration) to standard therapy or standard therapyplus alteplase infusion. Absolute risk reduction
was14.4%ofPTSat24monthswiththenumberneededtotreattopreventoneepisodeofPTSof7.
24
Five-year follow-up is available and shows absolute risk reduction of 28% and the number
neededtotreattopreventonePTS case of4.25Interestingly, quality-of-life scores did notdiffer
significantlyineithergroup.ThesoontobepublishedATTRACTRCTtrialevaluatedoutcomesof
patients with femoropopliteal and iliofemoral DVT randomized to pharmacomechanical
thrombolysiswithanticoagulationversusanticoagulationalone.At2years,anticoagulationalonein
themajorityofpatientsislikelysufficient,andCDTwasnotshowntodecreasePTS.Interestingly,
theynoted that CDT-treatedpatients had lowerseverity PTSandthere was anonsignificant trend
towardlessPTSiniliofemoralDVTpatientsreceivingCDT,althoughthestudywasnotpoweredfor
this (SocietyofInterventionalRadiology2017AnnualScientificSessions4-9March, Washington,
DC,USA).
VII.EndovascularApproachestoManagementofMay-Thurner
Syndrome
With evidencesupporting newer endovascular approaches tomanagementof MTS, consensus opinion
recommends dividing patients into three categories based on clinical presentation with treatment
strategiesoutlinedinthesectionsthatfollow.
A.IliacVeinCompressionWithAcuteDeepVeinThrombosis
1. The favored management for iliac vein compression with acute DVT currently involves
anticoagulationpossiblycombinedwithadditionalthrombolysisorthrombectomyandoutflowobstruction
relief. The aim of treatment is to prevent pulmonary embolus, treat DVT and decrease symptoms
associatedwithit,andpreventdownstreamcomplicationsincludingPTS.Catheter-directedthrombolysis
allowsfordeliveryofthethrombolyticagentdirectlytotheclot,mostandiseffectivewhenadministered
within3weeksofsymptomonset.AnticoagulationisthemainstayoftreatmentwithDVT.Theadditionof
catheter-directedthrombolysisiniliofemoralDVTismoreeffectiveatclotremovalandreductionofPTS
sequelaethananticoagulationalone.24FormorechronicDVTthathasundergonefibrosis,directinjection
ofthethrombolyticagentmaybeinsufficienttobreakuptheclot,andmechanicalthrombectomymaybe
requiredformorerapidclotdebulkingandfasterrecanalization.
26
2.TheadditionofultrasoundpulsationtoCDTacceleratesfibrinolysisanddecreasestimeofexposureto
thrombolysis. An in vitro analysis of ultrasound-accelerated CDT found that using low-power, highfrequencymicrosonicenergycanprovideincreaseduptakeandpenetrationofthethrombolyticagentinto
thethrombus, thus allowingimprovedtotal-clotlysis.27Grommesandcolleaguesevaluated safetyand
feasibility of ultrasound-accelerated CDT treatment in 12 patients with DVT who were treated with
standardanticoagulationandcompressionstockingstoavoidPTS.Theyfoundthatultrasound-accelerated
thrombolysisresultedin>90%clotlysisin85%ofcaseswithonlyonecaseofbleedingatthecatheter
insertionsite,withthemajorcomplicationbeingpulmonaryembolismsecondarytomechanicaldisruption
oftheclot.28RecentlyannouncedresultsoftheACCESSPTStrialof73patientswithiliofemoralDVT
prospectively followed up after 3 months of conservative therapywho were treated with ultrasoundassistedthrombolysisandballoonangioplastyshowedthattherewassignificantimprovementinVillalta
scoresof34%at30daysand21%improvementinqualityoflifebyVEINES-QOL(SocietyforVascular
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Medicine28thAnnualScientificSessions14-17June,NewOrleans,USA).
3.PTAalonewithoutstentplacementisassociatedwithlowerpatencyrates,with73%recurrencerateof
acuteleft-sidediliofemoralDVTinonestudy.18Inanothersmallstudyof21patients,18receivediliac
stentingafterCDTand3receivedPTAaloneafterCDT.AllofthethreepatientstreatedwithPTAalone
showedrecurrent thrombosis.29A retrospective studyof36 patients whoreceived iliofemoral venous
stenting forchronicvenoushypertensionshowedapatencyrateof78%at2years,withhigherratesin
MTSpatientscomparedwithlowerratesinpatientswiththrombophilias.30Thesesignalsintheliterature
suggestthatstentsareeffectiveatreestablishingthenormalcaliberofthevessel,preventingcompression,
anddisruptinganyvenousspurspresentfromchronicveincompression.
4. After stent placement, anticoagulation is continued, with duration of anticoagulation necessarily
determinedbytheclinicalcontext.InthecaseofunprovokedDVT,recommendedtreatmentisusuallya
for minimum of 3 months, with lifelong anticoagulation indicated for patients with certain underlying
hypercoagulableconditionsorcomplications.11Therearenostudiestodatecomparingoptimaltypeand
duration of anticoagulation strategies after endovenous intervention for DVT. Antiplatelet agents are
prescribedroutinelyfollowingstenting,buttherearenodatasupportingefficacyonstentpatencyversus
bleedingriskinthesecases.
9,31
5.In summaryforacuteDVTandiliacveincompression,theSociety forInterventionalRadiologyand
SocietyofVascularSurgeryrecommendearlythrombusremoval(catheter-based oropenthrombectomy
based onpatient-specificfactorsandlocal expertise) in patientswith acuteiliofemoral DVT<14days
durationwithlowbleedingriskandgoodfunctionalstatus,especiallyifthereislimb-threateningvenous
ischemia.RoutineplacementofinferiorvenacavafiltersinconjunctionwithCDTisnotendorsedandis
only to be determined on a patient-based level. Finally, they recommend the use of self-expanding
metallicstentsforanyobstructiveiliacoutflowlesionsafterthrombusremoval.
32
B.IliacVeinCompressionWithPostthromboticSyndrome
1. Selected patients with established PTS benefit from stent recanalization of occluded iliac veins.
Historically,surgicalvenousbypasshadbeenusedtoprovidesymptomaticoutflowreliefwithvariable
patencyrates.Endovenoustechniquesofdirectrecanalizationwithballoonvenoplastyandstentingwith
decreasedperiproceduralriskandimprovedpatency rateshavesupplantedsurgicaltechniquesasfirstline therapies. Several studies suggest improvement in PTS symptoms, healing venous ulcers, and
improved quality of life with outflow obstruction relief via stenting. In a retrospective series of 36
patients withsymptomatic iliocaval venous stenosis, occlusion, or venous compression, patientswere
divided into two groups: those with MTS and those without. Of the 22 patients with MTS, 18 had
successfulangioplasty andstenting with orwithoutCDTwithsymptomaticimprovementin94%anda
decreaseinCEAPscorein83%.
33
2.In2007,Neglénandcolleaguespublishedaprospectivestudyof982patientswithoutacutethrombosis
who received iliofemoral venous stents. They were divided into “thrombotic” and “nonthrombotic”
cohorts,wherethe“thrombotic”groupincludedanypatientswithhistoryofpriorDVTorpostthrombotic
changes evident on imaging. Patients underwent venous Doppler, venography, and IVUS to diagnose
obstructive iliacveinlesions defined as>50%stenosisandwere then stented.Therewas a significant
reductioninpainscorefrom55%to11%afterstentingwithareductionoflegswellingscorefrom44%
to 18%. Additionally, at 5-years follow-up, stented patients exhibited a 58% rate of ulcer healing.
Althoughtherewerevariousetiologiestoexplainchronicvenousobstructioninthispatientsubset,IVUS
findings suggested that about half of the “nonthrombotic” group had underlying compression of the
externaliliacveinbythe internal iliacartery, suggestingapplicabilityofthis studytoMTSpatients to
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supportstentinginthesettingofPTS.
31
C.IliacVeinCompressionWithSymptomaticNonthromboticChronic
VenousInsufficiency
1. Patients withMTS canexhibit venous obstruction owing to compressionofthe commoniliac vein
withoutevidence of activeor prior DVT.Their presenting symptom may bevenous hypertension,with
sequelaeofchronic venous insufficiency,edema, pain, and venous ulceration. Inselectedpatients with
moderate to severe symptoms, there may be symptomatic benefits from stenting of the iliac outflow
obstruction.In fact, thesepatients mayreceive thelargestbenefitfrom stenting,evidencedbysuperior
long-termpatencyratescomparedwithpatientswithPTStreatedwithstenting.30In2012,KaichuangYe
etalperformedaretrospectivestudyof205patientswithnonthromboticiliacveincompressionlesions
treatedwithstentingandfoundaprimarypatencyrateof98%at1year.
34
2.Inthesepatients,shareddecision-makingbetweenthepatientandtheproviderisnecessary,especially
inthecaseofyoungpatientswhowillhaveyearsofpoststentingfollow-upandpossibilityforlong-term
restenosis. Conservative therapy with compression is always first-line treatment followed by
determinationofwhetherinvasivetreatmentiswarrantedbytheclinicalpicture.
D.TreatmentStrategySummary
To summarizetreatment strategies for MTS, a consolidated approach to MTS incorporates the use of
noninvasive and invasive therapies based on the individual risk-benefit profile after diagnostic
confirmation.Currently,initiationoftreatmentforMTSisonlyindicatedinpatientswhoaresymptomatic
(CEAP 4-6 or CEAP3 with massive painful edema notalleviated by compression).6 Upon symptom
onset, the use of graduated compression stockings is highly recommended as the initial step in
management.Additionally,patients withMTSmayexhibitsomedegreeofsuperficialvenousreflux, in
whichcaseablationofthegreatersaphenousveinmayproviderelief.Thedecisiontoproceedtomore
invasivetreatmentoptionsdependonpresentationwithseveresymptomsorhemodynamicallysignificant
venous outflow obstruction or collateral vessel formation present on venogram. Although newer
endovenousinterventionsareminimallyinvasiveincomparisonwiththeopensurgicalbypassprocedures
thatwereoncemoreroutinelyperformedforMTS,theystillcarryrisksthatmustbediscussedwitheach
patientcarefullyinaprocessofshareddecision-making.Goalsoftherapyshouldbediscussedtoinclude
symptomatic and functional improvement, aswell asthe preventionofcomplicationssuchas recurrent
thrombosis,pulmonaryembolism,andPTS.
9
VIII.DeterminantsofStentPatency
A.EndovenousInterventionWithBalloonAngioplastyandStenting
Endovenous intervention with balloon angioplasty and stenting for management of MTS has greatly
improvedsymptomaticandfunctionaloutcomesforpatients.Initialconcernsforstentpatencyduetolowflowvenous systemhavenotbeenshownintheliterature,withpatencyratesgreaterthan95%insome
studiesdiscussedabove.PatencyratesinpatientswithoutDVTaresignificantlygreaterasoutlinedabove
thaninthosewiththrombosis.Althoughhighpatencyratesseemsimilarinmultiplestudies,therearevery
littledatadefiningthefactorsrelatingtolong-termpatency.NeglenandRajuevaluatedrestenosisinMTS
patients(324limbs)treatedwithstentingat42-monthsafterstentplacement.Only23%oflimbshadno
restenosis, 61% had >20%restenosis, and15% had >50% in-stentrestenosis.Therewassignificantly
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more restenosis in cases where there was coincident thrombotic disease. They concluded that the
presenceofthrombosis,underlyingthrombophilia,andlesionsrequiringlongerstentsextendingpastthe
inguinal ligament were associated with higher risks of in-stent recurrent stenosis.35 Knipp and his
colleagues publisheda retrospective chart review in2007 thatuseda Cox proportionalriskmodelto
analyzepatencyratesafterstenttreatment.Thisstudyreportedthatintheirrelativelysmallsampleof58
patients, male gender, age under 40 years, and history of recent trauma predicted decreased primary
patencyrates.Infact,withoutanyoftheseriskfactors,patencyratesintheirstudywere94.4%and63%
at1 and 5 years after stentplacement,respectively.Inthe eventoftwo ormore riskfactors,however,
patencyratesdecreasedto28.6%and14.3%at1and2years,respectively.
36
B.RecurrentStenosis
Among patients who experience recurrent stenosis, the majority of cases occur in the early months
postinterventionwithluminalpatencypreserved inlong-termfollow-up.Jeonandcolleaguesevaluated
30patientswithacuteiliofemoralDVTsecondarytoMTSdiagnosedbyCTvenographyandtreatedwith
CDTandstenting.Follow-upCTvenographywasperformedforprimarypatencywiththefindingthat4
patientssufferedin-stentthrombosisandonewithstentcollapseatthefirstCTfollow-upwithinthefirst
year.Overallstentpatencywas83%and90%at1and5-yearsfollow-up.
37
IX.Follow-up
Asyet,thereare noformal guidelinestoguidelong-term management andfollow-upforMTSpatients
afterendovenousstenting.However,itisgenerallyagreedthatpatientsshouldbegivendualantiplatelet
therapyforatleast4weeksafterstentplacementtopreventstentthrombosis(usuallyaspirin81mgdaily
andclopidogrel 75mgdaily). Aftershortterm dualantiplatelet treatment, thepatient maycontinue on
eitheraspirinorclopidogrelindefinitely,althoughtherearenostudiescomparingthetypeordurationof
appropriate antiplatelet agents after venous stenting;these regimens are adapted from arterial stenting
studies.Patients whopresent with acuteDVTare anticoagulatedfor3 months forunprovoked DVTor
longer for thrombophilias or recurrent DVT. Although designated follow-up intervals have not been
established, most practitioners follow MTS patients with periodic duplex ultrasonography of the
iliofemoral veins to assess for patency. Generally, neither CT venogramnor conventional venography
withIVUSisnecessaryforfollow-upunlessthepatienthasrecurrentsymptomsornewsignsofvenous
occlusionorthrombosis.
38
X.Summary
Insummary,MTSpatientsshouldbetreatedfirst-linewithcompressionandanticoagulationinthesetting
ofDVT.Inthecaseofseveresymptomsandfailureofconservativetherapy,severesymptomsandfailure
ofconservativetherapyandprovidesexcellentlong-termpatency.Medicaltherapypoststentingincludes
anticoagulation for DVT if present with short-term dual antiplatelets followed by single antiplatelet
treatmentthereafter.
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C H A P T E R 2 4
SuperficialVenousDiseaseoftheLegsand
Treatment
RobertR.AttaranMD,FACC,FASE,FSCAI,RPVI
I.Introduction
II.CompressionTherapy
A.CompressionStockings
B.C5/C6Disease
C.Evidence
III.LaserAblation
A.EndovenousLaserAblation
B.EndovenousLaserAblationTreatment
C.EndovenousLaserAblationComplications
IV.RadiofrequencyAblation
A.VNUSClosureSystem
B.MedtronicClosureFastDevice
C.RadiofrequencyAblationComplications
D.EndothemalHeat–InducedThrombosisWithAblation
V.MechanochemicalAblation
A.ClariVeinDevice
B.MechanochemicalAblationVersusRadiofrequencyAblation
VI.Sclerotherapy
A.VaricoseVeins
B.LiquidorFoamApplication
C.LiquidorFoamApplicationWithUltrasoundGuidance
D.Varithena
VII.Cyanoacrylate
A.Application
B.eSCOPEStudy
VIII.ComparisonStudies
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