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288 The Diagnosis and Treatment of Major Venous Obstruction in CVI
occlusion of long duration (Figure 20-5). Two patients presented with acute
IVC thrombosis; one had a focal intrahepatic web, and one had no identifi -
able lesion but had recently begun oral contraceptives. There is a wide range
of clinical presentation in patients with IVC occlusion (Table 20-4). We
have observed that varicosities in a teenager and ulceration in a young
patient can be signs of a proximal venous occlusion in the iliocaval region.
Since most of the patients we treated had chronic occlusion, there was
a higher percentage of limbs with CEAP 5–6 classifi cation. Among the
seven patients with unhealed ulcers, one had a 25-year history of caval
thrombosis and PTS. He had bilateral malleolar ulcers that healed within
40 days following stenting of the IVC and iliac veins (Figures 20-6 and
20-7). Among the other fi ve patients, four underwent successful IVC recon-
struction followed by ulcer healing within 30 days. One patient was not
successfully recanalized, and although nonelastic compression promotes
healing, his ulcer has occasionally reopened. On the other hand, 5/5 (100%)
of the successfully stented patients underwent redilatation of the stents
within the fi rst 24 months of follow-up. In-stent intimal hyperplasia caused
recurrence of the ulcer, which healed following reintervention.
Primary patency in the Thorpe-Osse iliocaval series was 63% at 1 year
and 45% at 2 years.
24
Rethrombosis or distal stents occurred in one patient
FIGURE 20-5 This 22-year-old patient experienced multiple episodes of DVT prior to
referral for evaluation and treatment of a nonhealing ulcer on the left and unresolving DVT
on the right. Studies revealed a completely occluded IVC, including the suprarenal segment.
The patient has only a left kidney and was born 2 months premature. Central-line placement
in infancy or in utero thrombosis may have caused the chronic IVC occlusion. The image
on the right shows the patient at 6-month follow-up.
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The Diagnosis and Treatment of Major Venous Obstruction in CVI 289
TABLE 20-4 Clinical Presentations of 26 Patients with
Iliocaval Obstruction/IVC Syndrome
n (%)
Acute bilateral DVT 5 (19)
Acute unilateral DVT 1 (4)
Chronic bilateral edema 3 (12)
Chronic unilateral edema 2 (8)
Nonhealing ulcer in young pt 4 (15)
BKA + ulcer on other limb
2 (8)
PTS <1 year after IVC fi lter
6 (23)
Hematuria 1 (4)
Abdominal collaterals 6(23)
Abdominal collateral + ulcer
2 (8)
Varicose vein s 13 (50)
FIGURE 20-6 Abdominal collaterals and distal varices and ulceration in a 52-year-old
patient with a 25-year history of IVC syndrome.
with stents extending from the popliteal to the suprarenal cava. The system
was reopened with thrombolysis. Despite two additional interventions for
restenosis, over the following 3 years, the stents were not patent at 5-year
follow-up. This patient did have two successful full-term pregnancies, with
C-section deliveries. The manipulation of anticoagulation may have
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290 The Diagnosis and Treatment of Major Venous Obstruction in CVI
contributed to stent failure along with restenosis. Other patients with
equally complex and long stent systems, designed to reconstruct multiple
occluded segments, have experienced uninterrupted long-term patency.
Patients with multiple stents remain on warfarin. After a mean follow-up
of 4 years, the assisted primary and secondary patency rates were 89% and
94%, respectively. The quality of life improvement is most signifi cant as
indicated in Figure 20-8 showing the change in disability scores. Acutely
thrombosed patients with focal chronic obstructions returned to a rela-
tively normal state following intervention. The patients with long-standing
PTS improved measurably.
SPECIAL ISSUES IN ENDOVENOUS THERAPY
IVUS
Intravascular ultrasound (IVUS) is an important tool in endovenous
therapy. It has application in two main areas: (1) assessing the nonthrom-
bosed common iliac segment and (2) in the follow-up examination of
patients with signs and symptoms of restenosis. In the fi rst instance, IVUS
has proven to be the best way to image and evaluate the iliac stenosis in
the May-Thurner syndrome.
42
Whereas the phlebogram will generally
demonstrate widening of the transverse diameter of the common iliac
segment and decrease in the intensity of contrast, IVUS will clearly reveal
the severity of the antero-postero narrowing causing high venous resis-
tance. The presence of collaterals was previously thought to be necessary
for diagnosis of a hemodynamically signifi cant iliac lesion. Information
from IVUS has shown that not all signifi cant narrowings are accompanied
FIGURE 20-7 Pre- and poststenting of the IVC. The phlebogram on the left shows
collaterals and a partially recanalized IVC following 36 hours of bilateral catheter-directed
thrombolysis with a popliteal approach. The image on the right shows the reconstructed
iliocaval system, which reduced the patient’s pain and swelling and allowed the bilateral
ulcers to heal.
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The Diagnosis and Treatment of Major Venous Obstruction in CVI 291
by collaterals that can be demonstrated phlebographically in the supine
position.
Restenosis
Restenosis is an important issue in stenting. Monitoring the patency of
iliac stents has proven less straightforward than the initial placement. Rela-
tively few iliac stents rethrombose, particularly in patients without malig-
nancy, but identifi cation and treatment of restenosis are less obvious. When
patients present with recurrent symptoms of limb edema or discomfort, the
intensity is generally much less than the initial clinical presentation. The
routine duplex exam will generally show patency of the stents. The wave-
form will remain phasic. Intimal hyperplasia, or in-stent-restenosis, is best
imaged with IVUS. Before we had access to IVUS, we would redilate
stents in patients with recurrent pain or edema. The symptoms and signs
resolved. As little as 30% to 35% luminal decrease by intimal hyperplasia
can cause recurrence of symptoms. In 2004, Neglen and Raju reported
their observations of restenosis in venous stents and concluded that risk
factors included a history of venous thrombosis, a positive test for throm-
bophilia, and longer stent systems extending below the inguinal ligament.
43
Gender and side had no signifi cance. After 42 months of observation in
324 limbs treated with stenting, 23% had no sign of luminal narrowing on
phlebography, 61% showed >20% narrowing, and 15% showed >50% nar-
rowing. The value of identifying restenosis is in maintaining long-term
DISABILITY SCORE
0
0.5
1
1.5
2
2.5
3
ACUTE P<.001 CHRONIC P<.001
PRE
POST
FIGURE 20-8 Signifi cant Difference in Disability Score Before and After
Endovascular
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292 The Diagnosis and Treatment of Major Venous Obstruction in CVI
patency of the stents. The study by Neglen and Raju showed that re-inter-
vention optimizes long-term patency. At 3 years, primary, primary-assisted,
and secondary patencies were 75%, 90%, and 93%, respectively.
Anticoagulation
Once fl ow is reestablished with stents, anticoagulation is important in
patients with thrombophilia and those with signifi cant residual distal
thrombus and vein wall irregularity from previous DVT. Both conditions
are risk factors for recurrent DVT despite good iliac fl ow. However, in
patients with normal distal veins, the presence of a single or double iliac
stent does not require long-term anticoagulation, per se. The use of anti-
coagulation and antiplatelet agents varies among clinicians. Low molecular
weight heparin is used to bridge subtherapeutic INR levels, particularly in
patients who must travel more than 2 hours to return home. Plavix®, 75 mg
per day, is started prior to stenting and continued for 30 days. Patients not
on warfarin also take 80 mg aspirin. It should be noted that rethrombosis
of a metallic stent is a matter of urgency. In our experience, it is much more
diffi cult, and sometimes not possible, to reopen chronic in-stent thrombo-
sis. Unlike organized thrombus in native veins, the old thrombus in occluded
stents is very hard to traverse.
Stents
Self-expanding metallic stents are used in venous stenting. The 12–
14 m m-Wa l ls ten t
TM
(Boston Scientifi c, Natick, MA) has been used more
than other stents because of the good long-term patency rates, the visibility
under fl uoro, and the ability to reposition. Stent migration is rare
44,45
but
can occur with any stent if it is undersized and the vein expands. Tandem
Wallstents will not interlock as the SmartStent
TM
(Cordis Corporation,
New Brunswick, NJ) will. The foreshortening of the Wallstent requires
experience, and there are times when a stent that does not foreshorten is
ideal. A single, high-grade focal stenosis requires a suffi ciently long stent
to prevent the stent from slipping (like a watermelon seed) to either side.
In our experience, long-term success of these interventions is also related
to establishing continuity of fl ow within the deep system of the entire lower
extremity. Poor infl ow from the tibio-popliteal segment or the femoral
segment may compromise long-term patency as much as poor outfl ow
caused by understenting the iliac compression. Stents must extend into the
IVC to completely treat the iliac compression.
IVC Filters
It is not generally thought to be necessary to place a caval fi lter while
performing catheter-directed thrombolysis. The incidence of PE has been
remarkably low because the thrombus does not fragment without undue
manipulation. However, mechanical thrombectomy for removal of acute
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The Diagnosis and Treatment of Major Venous Obstruction in CVI 293
FIGURE 20-9 Ankle ulcer in a 44-year-old man with multiple thrombophilias with a
6-year history of PE and IVC thrombosis complicated by heparin-induced thrombocytope-
nia. The image on the right was taken 1 month after stenting.
FIGURE 20-10 An occluded Simon Nitinol fi lter was recanalized with kissing Wall-
stents 1 year after the initial bilateral iliac reconstruction. The thrombolytic therapy initially
cleared the IVC fi lter, but progressive narrowing occurred at the fi lter level and this resulted
in rethrombosis. The image on the right shows parallel stents passing through the fi lter.
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294 The Diagnosis and Treatment of Major Venous Obstruction in CVI
FIGURE 20-11 Pre- and postcaval reconstruction in a 38-year-old woman who experi-
enced postpartum PE/DVT 2 years prior to intervention. The image on the left shows an
early contrast image during thrombolysis. Following 48 hours of bilateral catheter-directed
thrombolytic therapy, the iliocaval system was reconstructed with stents. Parallel stents pass
through the Greenfi eld fi lter, which was chronically occluded.
thrombus poses the risk of embolism. In this case, temporary fi lters have
been placed and subsequently removed. Occluded IVC fi lters can be safely
and effectively managed with endovascular methods.
Occluded IVC Filters
We have passed single and kissing Wallstents through and alongside all
types of occluded fi lters without complication. Once the exchange guide
wire has traversed this area of occlusion, serial balloon dilation will expand
the tissue and allow stent deployment (Figures 20-9 and 20-10). Mechani-
cal thrombectomy and thrombolysis can be effectively and safely used to
restore fl ow in acutely thrombosed IVC-bearing fi lters.
46
In our iliocaval
series, successful recanalization of chronically occluded fi lters has also
been performed with remarkable long-term patency
24
(Figure 20-11).
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The Diagnosis and Treatment of Major Venous Obstruction in CVI 295
SUMMARY
Endovenous therapy represents a signifi cant advance in the treatment
of chronic venous insuffi ciency. The clinical options for treatment of resid-
ual obstruction, following DVT, now include reconstruction of the native
axial veins with stents. The evolution of the tools and techniques is ongoing
because the majority of the procedures have been adapted from arterial
interventions. But experience and careful observation of clinical outcomes
constantly help us refi ne technique and patient selection. However, there
are far too many patients who need treatment given the relatively few
physicians who safely and willfully perform endovenous procedures.
Chronic venous insuffi ciency is that “something old” that seems to be in a
Renaissance in the midst of new pharmaceutical discoveries and the emerg-
ing fi eld of endovenous surgery. We hope that continued innovation, mul-
tidisciplinary efforts, and clinical evidence will all support our efforts to
better prevent and treat post-thrombotic chronic venous insuffi ciency.
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