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19.1 Guidelines
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19.1.5.2 Recommendation 35
For patients with deep vein thrombosis limited to femoral, popliteal, or calf veins,
early thrombus removal is not recommended. (Recommendation class III; Level of
evidence B).
19.1.5.3 Recommendation 36
For patients with deep vein thrombosis treated by early thrombus removal, with or
without stenting, it is recommended that the duration of anticoagulation should be
at least as long as if the patients were treated by anticoagulation alone and at the
discretion of the treating physician. (Recommendation class I; Level of evidence C).
19.1.5.4 Recommendation 38
For patients with calf deep vein thrombosis, a decision to anticoagulate based on
symptoms, risk factors for progression, and bleeding risk should be considered.
(Recommendation class IIa; Level of evidence C).
19.1.5.5 Recommendation 39
For patients with symptomatic calf deep vein thrombosis requiring anticoagulant
treatment, three months of therapy is recommended over shorter durations.
(Recommendation class I; Level of evidence A).
19.1.5.6 Recommendation 40
For patients with calf deep vein thrombosis requiring anticoagulation, direct oral
anticoagulants are recommended over low molecular weight heparin followed by
vitamin K antagonists. (Recommendation class I; Level of evidence C).
19.1.5.7 Recommendation 41
For patients with symptomatic calf deep vein thrombosis and active cancer, anticoagulation beyond 3 months should be considered. (Recommendation class IIa;
Level of evidence C).
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19.1.5.8 Recommendation 42
For patients with symptomatic calf deep vein thrombosis not receiving anticoagulation, clinical re-assessment and repeat whole leg ultrasound after 1week is recommended. (Recommendation class I; Level of evidence B).
19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
19.2 Results
19.2.1 Deep Vein Thrombosis
19.2.1.1 Meta-Analyses/Systematic Reviews
Thrombolytic Clot Removal Strategies
A Cochrane review assessed the effects of thrombolytic clot removal strategies and
anticoagulation compared to anticoagulation alone for the management of people
with acute deep vein thrombosis (DVT) of the lower limb [6]. The review included
a total of 19 RCTs, with 1943 participants. The review found moderate-certainty
evidence that thrombolysis effectively dissolved the clot so that complete clot
breakdown occurred more often with thrombolysis than with standard anticoagulant
therapy. Those receiving thrombolysis had more bleeding complications than with
standard anticoagulation (6.7% versus 2.2%). Most bleeding episodes occurred in
the older studies. Six trials (1393 participants) continued for over 6months and
found that slightly fewer people developed PTS when treated with thrombolysis;
50% compared with 53% in the standard anticoagulation treatment group. Two trials (211 participants) that continued for over 5 years showed that fewer people
developed PTS when treated with thrombolysis. Use of strict eligibility criteria
appears to have improved the safety of this treatment, which is effective delivered
directly to the clot by catheter or via the bloodstream from another vein. There was
no evidence that the position of the clot within the leg made it more or less likely for
people to get PTS.Evidence suggests that systemic administration of thrombolytics
and catheter-directed thrombolysis (CDT) have similar effectiveness.
Catheter-Based Intervention forAcute Proximal Deep Vein Thrombosis
A meta-analysis of randomized controlled trials assessing the efcacy of lytic
catheter- based interventions (LCBI) in proximal acute DVT for the prevention of
PTS was undertaken by Javed etal. [7]. Included articles were randomized controlled trials that studied the use of LCBIs with additional anticoagulation vs anticoagulation alone. Three trials were included in the nal meta-analysis, comprising
987 patients. Patients undergoing LCBIs had a reduced risk of PTS (relative risk
[RR], 0.84; 95% condence interval [CI], 0.74-0.95; P=.006) and a lower risk of
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developing moderate to severe PTS (RR, 0.75; 95% CI, 0.58-0.97; P=.03). LBCIs
increased the risk of having a major bleed (RR, 2.03; 95% CI, 1.08-3.82; P=.03).
In the iliofemoral DVT subgroup analysis, there was a trend toward decreasing the
risk of developing PTS and moderate to severe PTS (P=.12 and P=.05, respectively). There was no signicant difference in quality-of-life score (as measured by
the Venous Insufciency Epidemiological and Economic Study—Quality of Life/
Symptoms) between the two groups (P=.51). LCBIs in acute lower limb DVTs are
likely to reduce the development of PTS and moderate to severe PTS as measured
by the Villalta score; however, the magnitudes of risk reduction are not as large as
previously thought. The decreases in PTS development are accompanied by a small
but signicant increase in major bleeding complications. Hence, in light of the modest risk reduction, patient selection is paramount.
Catheter-Based Intervention withPercutaneous Mechanical Thrombectomy
Li etal. [8] conducted a meta-analysis to investigate the effectiveness and safety of
adjuvant percutaneous mechanical thrombectomy (PMT) during catheter-directed
thrombolysis (CDT) compared with CDT alone in the treatment of acute iliofemoral
DVT.The meta-analysis included 20 eligible studies with a total of 1686 patients.
The rates of venous patency and thigh detumescence of the adjuvant PMT group
were higher than those of the CDT alone group. Compared with CDT alone, the
adjuvant PMT group experienced fewer incidences of major bleeding complications
(odds ratio, 0.45; 95% CI, 0.26-0.77) and occurrences of post-thrombotic syndrome
within 2years of the procedure (odds ratio, 0.55; 95% CI, 0.33-0.92). Furthermore,
the duration of thrombolytic therapy was shorter, and the total dose of administered
thrombolytics was lower with adjuvant PMT.Adjuvant PMT during CDT is associated with improved clinical outcomes and a lower incidence of major bleeding complications. The studies investigated were, however, single-center cohort studies, and
future randomized controlled trials are needed to substantiate these ndings.
19.2.1.2 Randomized Trials
Pharmacomechanical Catheter-Directed Thrombolysis Vs. Anticoagulation
In the ATTRACT (Acute Venous Thrombosis: Thrombus Removal with Adjunctive
Catheter-Directed Thrombolysis) trial 692 patients with acute proximal deep-vein
thrombosis were randomly assigned to receive either anticoagulation alone (control
group) or anticoagulation plus pharmacomechanical thrombolysis (cathetermediated or device-mediated intrathrombus delivery of recombinant tissue plasminogen activator and thrombus aspiration or maceration, with or without stenting)
[9]. Between 6 and 24months, there was no signicant between-group difference in
the percentage of patients with the post-thrombotic syndrome (47% in the
pharmacomechanical- thrombolysis group and 48% in the control group; P=0.56).
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19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
Pharmacomechanical thrombolysis led to more major bleeding events within
10 days (1.7% vs. 0.3% of patients, P = 0.049), but no signicant difference in
recurrent venous thromboembolism was seen over the 24-month follow-up period
(12% in the pharmacomechanical-thrombolysis group and 8% in the control group,
P=0.09). Among patients with acute proximal deep-vein thrombosis, the addition
of pharmacomechanical catheter-directed thrombolysis to anticoagulation did not
result in a lower risk of the post-thrombotic syndrome but did result in a higher risk
of major bleeding.
Elastic Compression Stockings toPrevent Post-Thrombotic Syndrome
Yang etal. [10] evaluated the effectiveness of elastic compression stockings (ECS)
in prevention of PTS in patients suffering from proximal DVT who did not undergo
thrombus removal procedures. Two hundred thirty-two patients were included in
this randomized trial. One hundred thirteen patients were in the ECS group and
119in the control group. For the ECS group, kneelength ECS producing a pressure
of 30 to 40mmHg were used during the day for at least 6days a week. Stockings
were routinely replaced per 6months or earlier if the stockings were torn or the leg
circumference changed. Patients in the ECS group were instructed to wear ECS for
24 months. Compliance with ECS was recorded. Eightyve patients (75.2%)
reported using the ECS at least 6days a week. The incidence of PTS was 42.0% in
the ECS group and 57.8% in the control group at 24months (P=.024). ECS can
prevent the postthrombotic syndrome in patients with iliofemoral venous thrombosis and femoral popliteal venous thrombosis who do not undergo thrombus removal
procedures.
19.2.1.3 Studies andRegistries
Catheter-Directed Thrombolysis forProximal Deep Venous Thrombosis
In the National Inpatient Sample (NIS) from 2005 to 2013, Tang etal. [11] identied a total of 138,049 patients who were discharged with a principal diagnosis of
proximal and caval DVT. 7097 of these patients received CDT (5.1%). From this
group, 2854 (40.2%) were treated with CDT alone, 2311 (32.6%) received adjunctive angioplasty alone, and 1932 (27.2%) received adjunctive angioplasty and stent.
The primary outcome was a composite end point of all-cause mortality, gastrointestinal bleed, or intracranial hemorrhage. Adjunctive stenting had a signicantly
lower rate of primary composite outcome compared with CDT alone (2.7% vs
3.8%; P=.04). Stent placement was associated with a similar length of stay com-
pared with angioplasty and CDT alone groups and higher in-hospital charges
(Table19.3). Rate of adjunctive stenting increased from January 2005 to December
2013. One in four patients undergoing CDT is treated with adjunctive stent
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Table 19.3 Weighted outcomes of patients undergoing catheter-directed thrombolysis (CDT),
adjunctive angioplasty, and stent placement for proximal deep venous thrombosis (according
to [11])
CDT alone
Parameter
Primary composite
outcome: Death,
ICH, and GI
bleeding
Died during
hospitalization
GI bleeding 52.8 (1.9) 34.1 (1.5) 23.2 (1.2)
ICH 21.3 (0.7) 17.6 (0.8) 14.8 (0.8)
Blood transfusion 311.8 (10.9) 225.3 (9.6) 210.8 (11.0)
Hematoma 72.6 (2.5) 51.3 (2.2) 57.1 (3.0)
Procedure-related
Hemorrhage
Length of stay,
days
Charges, $ 80,441.63±74,024.98 98,089.82±72,921.94 115,164.01±76,985.31
IVC lter 935.3 (32.7) 840.9 (35.8) 697.0 (36.2)
Categorical variables are presented as number (%)
ICH intracranial hemorrhage, GI gastrointestinal, IVC inferior vena cava
(n=2857.17)
107.3 (3.8) 63.4 (2.7) 51.3 (2.7)
37.8 (1.3) 15.5 (0.7) 16.8 (0.9)
36.8 (1.3) 28.2 (1.2) 20.0 (1.0)
7.1 (0.5-13.6) 6.9 (1-12.9) 6.80 (1.5-12.1)
CDT+angioplasty
(n=2348.49)
CDT+angioplasty +
stenting (n=1923.57)
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placement in the United States. Adjunctive stenting does not adversely affect the
acute safety outcomes of CDT; in fact, it showed improvement in the primary composite outcome, which was mainly driven by all-cause mortality. The results suggest
that future studies can consider the consistent use of intravascular ultrasound
(IVUS), which would likely improve appropriate use of stents and help with understanding completeness of thrombus removal. In this study, only 2.1% of all CDT
cases used IVUS to determine the need for stenting of the residual outow venous
stenosis. 61% of those patients who had IVUS received a stent as opposed to only
27% of those who did not have IVUS, suggesting the poor sensitivity of venography
alone in detecting signicant residual venous stenosis.
Using the National Inpatient Sample database between January 2005 and
December 2013, Brailovsky etal. [12] identied 31,124 cancer patients with lower
extremity proximal or caval DVT. 1290 (4%) patients were treated with
CDT.Comparative outcomes as assessed in two matched groups of 1287 patients
showed that there was no signicant difference in in-hospital mortality of patients
undergoing CDT plus anticoagulation compared with those treated with anticoagulation alone (2.6% vs 1.9%; P = .23). However, the bleeding complications and
resource utilization were signicantly higher in the CDT group compared with anticoagulation alone (Table19.4). Therefore, in patients with cancer the upfront risk of
bleeding complications and higher resource utilization must be carefully weighed
against a potential reduction of PTS, and it would be prudent to screen high-risk
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Table 19.4 Matched outcomes of cancer patients with and without undergoing catheter-directed
thrombolysis (CDT) for proximal or venacaval deep venous thrombosis (DVT). According to
Brailovsky etal. [12]
Parameter
Death, n (%) 25 (1.9) 33 (2.6) .23
Blood transfusion, n (%) 168 (13.1) 239 (18.6) <.001
Gastrointestinal bleed, n (%) 30 (2.3) 28 (2.2) .89
Intracranial hemorrhage, n (%) 5 (0.4) 17 (1.3) .02
Procedure-related hemorrhage, n (%) 4 (0.3) 13 (1.0) .049
Procedure-related hematoma, n (%) 5 (0.4) 31 (2.4) <.001
IVC lter placed, n (%) 336 (26.1) 434 (33.7) <.001
Peripheral angioplasty, n (%) 37 (2.9) 765 (59.4) <.001
Peripheral stent, n (%) 14 (1.1) 386 (30.0) < .001
Acute kidney injury, n (%) 108 (8.4) 160 (12.4) <.01
Length of stay, days 4.0 (2.0-7.0) 6.0 (4.0-10.0) <.001
Hospital charges, US $, Median
(interquartile range)
19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
Anticoagulation, No CDT
(n=1287)
22,320 (11,482-41,005) 81,535
CDT group
(n=1287) P
< .001
(50,968-127,045)
cancer patients for brain metastases before initiating CDT therapy. Furthermore,
adjunctive percutaneous mechanical thrombectomy may be a reasonable approach
in cancer patients to decrease both duration of therapy and thrombolytic dose.
In a retrospective monocentre study, Pouncey etal. [13] compared the outcomes
of patients with iliofemoral deep venous thrombosis (DVT) treated with additional
AngioJet pharmacomechanical thrombectomy (PCDT) vs. catheter directed lysis
(CDT) alone. A total of 151 limbs were treated, 70 limbs with PCDT and 81 limbs
with CDT alone. The primary outcome, as assessed by the 6 month and 12month
Villalta scores showed no statistically signicant difference between the two groups.
At 1year, 22.2% of PCDT cases vs. 24.7% of CDT cases were observed to have
PTS (p = .74), with 9.5% vs. 4.1% of all cases classied as moderate to severe
(p= .30). This study was not signicantly powered to show a difference in major
and minor bleeding, but there was a trend towards reduced bleeding in the PCDT
cohort (6.3% vs 17.1%). Use of PCDT resulted in a reduction in lysis duration (40h
vs 53h; p<.001) and reduction in lytic dose (49mg vs 57mg; p=.011) vs. CDT.In
conclusion, PCDT and CDT had similar long-term outcomes, but PCDT was associated with a reduction in both treatment time and lytic dose.
Midterm outcome of pharmacomechanical catheter-directed thrombolysis
(PCDT) combined with stenting for treatment of iliac vein compression syndrome
(May-Thurner syndrome) was assessed by Jiang etal. [14] in a retrospective study.
PCDT combined with stenting in the treatment of 46 patients with iliac vein compression syndrome and acute iliofemoral deep venous thrombosis resulted in 100%
technical success and no 30-day mortality. There was a signicant reduction in
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Venous Registry Index (9.82±1.74 to 1.15±1.02; P<.05) after the procedure. The
6-, 12-, and 24-month primary patency rates were 97.8%, 95.7%, and 91.1%,
respectively. Only one patient developed mild post-thrombotic syndrome (PTS) and
none developed severe PTS. Pharmacomechanical catheter-directed thrombolysis
combined with stenting to treat patients with acute proximal deep venous thrombosis caused by iliac vein compression syndrome was feasible with excellent patency
and no severe PTS at 24months.
Outcomes of iliac vein stenting after catheter-directed thrombolysis for acute
iliofemoral thrombosis were reported by Avgerinos etal. [15]. In 77 stented limbs
of 73 patients with acute iliofemoral deep venous thrombosis (DVT), 3-year primary patency and secondary patency were 75% and 82%, respectively. DVT
recurred perioperatively in nine (12.3%) patients. Four of them (six limbs) had
incomplete thrombolysis (<50%); the rest recurred despite successful lysis (>50%).
None of these recurrences had progressed to phlegmasia or limb-threatening venous
congestion. Twelve stents extended below the inguinal ligament; three (25%)
thrombosed. The overall rate of PTS (Villalta score≥5) in the stented cohort at 2
and 5years was 12.0% and 14.4%. Stent placement below the inguinal ligament did
not affect the patency but was associated with a higher PTS rate. A strategy of complete thrombus removal for acute iliofemoral DVT is recommended. Stent extension
into the contralateral iliac vein or below the inguinal ligament appears to be an
acceptable adjunct to thrombolysis and iliac vein stenting for DVT.
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19.2.2 Postthrombotic Syndrome
19.2.2.1 Systematic Reviews
Risk ofPost-Thrombotic Syndrome after Isolated Distal Deep Vein Thrombosis
Isolated distal DVT (IDDVT), also referred to as calf vein DVT, in which thrombosis occurs below the level of the knee, is considered an altogether more benign clinical entity. A systematic review and meta-analysis aimed to dene the risk of PTS
after IDDVT, with the secondary aim of reporting PTS severity [16]. The results
showed a post-thrombotic rate of 17% (95% CI 11–26%) (seven studies, 217 cases,
1105 participants). Heterogeneity was high. Three studies (302 participants)
reported the severity of post-thrombotic syndrome: 78% were mild (Villalta score
5–9); 11% were moderate (Villalta score 10–14), and 11% were severe (Villalta
score ≥ 15). This meta-analysis is the rst to report the pooled risk of postthrombotic syndrome across studies after isolated distal deep vein thrombosis. It
demonstrates that post-thrombotic syndrome affects around one in ve people and
one in 50 will progress to severe post-thrombotic syndrome.
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19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
Venous Stenting forLower Extremity Occlusive Disease
Williams and Dillavou [17] reviewed the efcacy and safety of venous stenting for
lower extremity occlusive disease. 3812 stented limbs from 23 published studies
and two national presentations were included in this systematic review. Dedicated
venous stents were used in 740 patients, and standard stents were used in 3072
patients. The overall major complication rate was <1%. Median symptomatic
improvement and ulcer healing were seen in 79% and 71% of the standard stented
limbs, respectively. For standard stents, the median primary, assisted primary, and
secondary patency rates were 71%, 89%, and 91%, respectively, with a median
study follow-up of 23.5months. Dedicated venous stents had an overall primary
patency of 78.8% at 12months, with lower patency (73%) seen in post-thrombotic
vs compressive (96%) disease. Iliocaval venous stenting appears to be a safe and
effective treatment of chronic venous disease.
Antithrombotic Management after Venous Stenting
Notten etal. [18] performed a systematic review to assess the available evidence on
postinterventional antithrombotic management after venous stenting of the (post)
thrombotic iliofemoral tract. 64 (56 original) studies were selected. Overall, a mean
primary patency rate of 82.3% was seen 1 year after the intervention, which
decreased to 73.3% after 2years. In the majority (43 of 56 studies, 77%), treatment
was based on use of vitamin K antagonists, either with (18%) or without (59%) use
of antiplatelet drugs. Only two studies (4%) directly assessed the effect of antithrombotic therapy on treatment outcomes. The impact of postinterventional antithrombotic therapy on stent patency remains unknown because of limited and
insufcient data available in current literature. Further clinical research should more
clearly address the role of antithrombotic therapy for preservation of long-term
patency following venous stenting.
19.2.2.2 Clinical Trials
Accelerated Thrombolysis forPost-Thrombotic Syndrome
The aim of the prospective ACCESS PTS study (Accelerated Thrombolysis for
Post-Thrombotic Syndrome Using the AcousticPulse Thrombolysis Ekosonic
Endovascular System) was to evaluate the effectiveness of combined percutaneous
transluminal venoplasty (PTV) and ultrasound-accelerated thrombolysis (USAT) to
improve PTS-related symptoms and venous disease–related QOL in subjects with
PTS in the presence of chronic veno-occlusive disease [19]. The primary efcacy
outcome was a reduction of ≥4 points in the Villalta score 30days after procedure.
The primary safety outcomes were major bleeding episodes within 72hours and
symptomatic pulmonary embolism during the index hospitalization. A total of 82
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421
limbs (78 patients) were treated. The primary end point was met in 64.6% (51/79).
Iliofemoral venous stenting was performed in 42 patients, with similar improvements seen in all outcomes, regardless of stenting status. One patient developed
severe bleeding within 72h of the intervention and died at 32days after procedure
(1.3% mortality rate). At 1year, 77.3% (51/66) of limbs continued with a Villalta
reduction ≥4. At 365days, >90% of segments had patency with ultrasound ow
present. For patients experiencing PTS from chronic venous obstruction, combined
percutaneous transluminal venoplasty and ultrasound-accelerated thrombolysis
interventions resulted in improvement in clinical PTS, as measured by the Villalta
scale and Venous Clinical Severity Score as well as durable venous patency.
ACCESS PTS intervention also resulted in signicant improvement in quality
of life.
Venous Stent Patency
A multicentre study assessed primary stent patency predictive factors in three
groups of patients with history of lower limb (LL) vein thrombosis: non-thrombotic
iliac vein lesion (NIVL), acute deep vein thrombosis (aDVT), and PTS [20]. 377
patients were included: 134 NIVL, 55 aDVT, and 188 PTS. Primary patency was
statistically signicantly higher in the NIVL group (99.3%) compared with the PTS
group (68.6%) (p<.001) and the aDVT group (83.6%) (p=.002). PTS patients
received a statistically signicantly greater number of stents (p< .001) and had
more stents below the inguinal ligament (p < .001). Median follow up was
28.8months. Discontinuation of anticoagulation therapy at the last assessment was
93.2% for NIVL, 25.0% for aDVT, and 70.3% for the PTS group (p<.001). The
only predictor of worse primary patency in the aDVT group was long term anticoagulation before stenting. No anticoagulation or antiplatelet treatment regimen was
associated with improved stent patency in this study. The study showed that the
primary patency of venous stents depended on the indication for stenting; and in
acute venous thrombosis requiring stenting, patients with long term anticoagulation
before stenting had lower primary patency. The best anticoagulant treatment regimen after venous stenting has not yet been established. PTS patients on indenite
anticoagulation (VKA or DOACs) before the procedure should continue anticoagulation after the procedure. If there is no indication for indenite anticoagulation,
post-operative anticoagulation should be prescribed. The optimal duration is not
known, guidelines recommend that anticoagulant treatment should be continued for
at least 6months after intervention.
In a retrospective multi-center study, 698 patients treated by stenting for PTS in
15 French centers were analyzed [21]. Technical success, dened as successful
recanalization and stent deployment restoring rapid anterograde ow in the targeted
vessel, was obtained in 668 (95.7%) patients with a complication rate of 3.9%. No
procedural-related death occurred during or within 1month after the intervention.
After a mean follow-up of 21.0months, primary patency, primary assisted patency,
and secondary patency were achieved in 537 (80.4%), 566 (84.7%), and 616 (92.2%)
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19 Deep Vein Thrombosis oftheLower Limb andPost-Thrombotic Syndrome
of the 668 patients, respectively. The mean improvements of Villalta and Chronic
Venous Insufciency Questionnaire in 20 questions (CIVIQ-20) scores were
7.0±4.7 points (p<.0001) and 19.1±14.8 points (p<.0001), respectively. Venous
patency was strongly correlated to the severity of post-thrombotic lesions in
the thigh.
Symptoms of chronic venous insufciency secondary to obstructive iliofemoral
disease are often bilateral. The impact of iliofemoral stenting of the more symptomatic lower extremity on clinical outcomes in the less affected contralateral extremity
is not clear. Jayaraj etal. [22] evaluated the impact of stenting on contralateral leg
symptoms in 304 patients. In this contralateral group, at 12months, the VAS pain
score improved from 5 to 0 (P<.0001), the grade of swelling went from 3 to 1
(P<.0001), and VCSS went from 5 to 3 (P<.0001) after stenting of the ipsilateral
side. During the median follow-up of 20months, 15 contralateral limbs underwent
stenting. Median time to stenting of the contralateral limb after ipsilateral stenting
was 9months. Patients with bilateral obstructive iliofemoral venous lesions often
experience improvement of the contralateral limb symptoms (95%) after stenting of
the worse ipsilateral limb. Only 15 of 304 (5%) symptomatic contralateral limbs had
to undergo stenting during the follow-up period because of a worsening clinical
picture. Based on this, a staged approach to iliofemoral stenting in patients with
bilateral symptoms focusing initially on the more symptomatic limb is suggested.
Venous Stent Conguration
From the Swiss and Arnsberg Venous Stent Registries, Moeri etal. [23] analyzed
150 patients with post-thrombotic syndrome (mean age, 44 +/− 16 years; 48%
women) with laser-cut (n=101) or braided nitinol (n= 49) stents placed into the
common femoral vein across the inguinal ligament. The primary study outcomes
were the primary and secondary patency rates at 12months. The 1-year primary
patency rate was 67.3% for patients with laser-cut nitinol stents and 86.7% for
patients with braided nitinol stents used to cross the inguinal ligament. Stent fractures were observed in four patients (4%) with laser-cut stents but did not occur in
patients with braided stents. Braided nitinol stents might be less prone to fracture
and reocclusion at the inguinal ligament compared with laser-cut nitinol stents.
Jayaraj etal. [24] evaluated the clinical and stent related outcomes following use
of composite stenting (combination of a Wallstent body and a Z stent top) in the
management of symptomatic chronic obstructive iliofemoral venous disease. Of the
545 limbs that underwent stenting, 183 were in men and 362 were in women. Postthrombotic syndrome was seen in 441 limbs and nonthrombotic iliac vein lesions/
May-Thurner syndrome in 104 limbs. At 24months, visual analog scale pain score
went from 5 to 2 (P<.0001), grade of swelling went from 3 to 1 (P<.0001), and
Venous Clinical Severity Score went from 6 to 4 (P<.0001). Ulcers were present in
67 limbs and had healed in 49 limbs (73%) over a median follow-up of 26months.
Cumulative primary, primary-assisted, and secondary patencies at 60months were
70%, 99% and 91%, respectively. One hundred eleven limbs (20%) underwent
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