Stenting for Iliac Veins Post-thrombotic Obstructive Lesions: Results of a Multicentric Retrospective Study

Abstract

Background: Stenting was recognized as the method of choice for treatment of femoroiliac veins obstructive disease. We report the experience of three European centers in the endovascular treatment of post-thrombotic obstructive lesions, which are recognized as the most challenging. Methods: From January 1996 to July 2009, 130 limbs in 109 consecutive patients (66 women; median age, 44 years; thrombophilia, 28 patients) were admitted for endovascular treatment of nonmalignant post-deep vein thrombosis (DVT) iliac veins obstructive disease. Limbs were classified CEAP C1 in 1 limb, C2 in 1, C3 in 42, C4 in 28, C5 in 11, and C6 in 47. All patients were symptomatic and disabled despite medical treatment, including 49 with venous claudication. Median delay since DVT was 12 years. Lesions were bilateral in 21 patients. The inferior vena cava (IVC) was involved in 21 cases and the common femoral vein in 33; moreover, 80 limbs (61%) had at least one occluded venous segment. Four IVC filters and two IVC clips were in place. The endovascular procedure was performed through percutaneous access of the femoral vein. Recanalization was performed when needed; then, self-expanding stents were deployed. Results: Sixty-three patients had general anesthesia, and 46 had local anesthesia, associated with sedation in 44 cases. Recanalization failed in 22 limbs (15 patients), and the procedure was stopped. Moreover, recanalization failed in three limbs, but the ipsilateral ascending lumbar vein was stented. A total of 181 stents were deployed to treat 149 venous segments. One IVC clip was removed. No perioperative death or pulmonary embolism occurred. One superficial femoral artery tear was treated with a stent graft. Postoperative complications included four early rethrombosis (3 had left iliac vein recanalization with common femoral vein involvement and 3 were successfully treated by venous thrombectomy), one right hemothorax, and two hematomas. Median length of stay was 3 days (range, 1-14 days). During a median 27 months' follow-up (range, 1-157 months), one patient died at 18 months, four symptomatic restenosis needed iterative endovascular procedure, and five late rethrombosis were diagnosed (2 had successful venous thrombectomy). Moreover, one patient with contralateral femoroiliac DVT was successfully treated by venous thrombectomy. Primary, assisted primary, and secondary patency rates in intention to treat were, respectively, 76%, 77%, and 80% at 1 year, and 66%, 70%, and 77% at 5 and 10 years (90%, 91%, and 93% at 1 year, and 77%, 82%, and 86% at 10 years in case of technical success). AllC6 limbs but two had healed at the end of the follow-up. Conclusions: Late results confirm that stenting is a safe and effective technique. It is also a durable way to treat post-thrombotic obstructive disease in iliac veins.