Treatment of iliac vein obstruction George Geroulakos Professor of Vascular Surgery, University of Athens, Professor of Vascular Surgery, Imperial College, London

Surgical bypass for occluded iliac veins has now been largely replaced by endovenous stenting.

Iliac/ IVC vein stenting is a recent development Many of the endovenous techniques that are used are based on prior arterial experience

Morphologic and pathologic features of venous lesions are different from those of arterial stenosis. Modification of standard techniques used in the management of arterial stenosis is necessary to obtain best results in endovascular interventions in the venous system.

Definitions It is not known at what degree venous stenosis is haemodynamically significant Morphological obstruction >50% as measured by IVUS has arbitrarily been chosen for stenting.

Systemic review of endovenous stenting in chronic venous disease secondary to iliac vein obstruction. Conclusion: The quality of evidence to support this is weak, with the main flaw being the lack of control groups to illustrate the observed benefits are not part of natural history progression of CVD. Seager et al; Eur J Vasc Endovasc Surg 2016

The ATTRACT randomised controlled trial, showed that the addition of catheter-based intervention to anticoagulation failed to significantly decrease the occurrence of post-thrombotic syndrome in DVT patients who received this treatment strategy when compared to its occurrence in patients who received anticoagulation alone (F-Up 6-24 months).

Stenting for total occlusions of the iliac vein In a 9 year period 167 limbs in 159 post-thrombotic patients with total chronic occlusions of the iliac vein were treated. Technical success: 83% Cumulative pain relief at 3 years: 79% Cumulative swelling relief at 3 years: 66% Ulcer healing at 33 months: 56% Raju, J Vasc Surg 2009

Venous stenting across inguinal ligament Arterial stenting is not recommended across the inguinal ligament because of increased risk of focal neointimal hyperplasia or compression/fracture. Venous stents can safely be placed across the inguinal ligament with no effect on log term patency.

Venous stenting across inguinal ligament 177 limbs had stents placed in the iliofemoral venous outflow across the inguinal ligament into the common femoral vein. Results compared with outcomes of 316 limbs with stents terminating above inguinal ligament. Cumulative patency was similar for both groups (7% versus 11% respectively) Neglen, J Vasc Surg 2008

9 had severe ovarian vein reflux Venous angioplasty and stenting improve pelvic congestion syndrome caused by venous outflow obstruction. 19 patients with combined severe non thrombotic venous outflow obstruction of the CIV or IVC and symptoms of pelvic congection syndrome were studied. 9 had severe ovarian vein reflux Daugherty et al 2015, J Vasc Surg Venous Lymphat Disord

Follow-up of 1 to 59 months (median, 11 months) Venous angioplasty and stenting improve pelvic congestion syndrome caused by venous outflow obstruction. Follow-up of 1 to 59 months (median, 11 months) complete resolution of pelvic pain in 15 of 19 patients and of dyspareunia in 14 of 17 sexually active patients. Of the 15 patients who experienced left lower extremity pain or edema before treatment, 13 experienced complete resolution after treatment.

Reflux & Obstruction mL/s Venous filling index VFI = 90VV / VFT90 Venous drainage index VDI = 90VDV/VDT90 mL/s

Josef Pflug Vascular Laboratory, Ealing Hospital & Imperial College Venous drainage improves significantly after iliac stenting but this may result in faster venous filling Lattimer CR Kalodiki E Azzam M Schnatterbeck P Geroulakos G Josef Pflug Vascular Laboratory, Ealing Hospital & Imperial College http://josefpflugvascular.com No Disclosures

Aim To assess the hemodynamic impact of stenting in non-thrombotic iliac venous lesions (NIVLs)

Patients 14 iliac veins in 10 patients stented C0=1; C3=1 C4a=4; C4b=3; C5=3; C6=2 13 NIVL, 1 iliac occlusion VFI & VDI pre/post stenting CTV minor diameter (% stenosis) IVUS: >50% area reduction = stent

RESULTS - clinical improvement All legs improved (except 1 symptomless leg) VCSS pre: 11 (7-12) post: 5 (4-8) p=.001 Subjective Softer in the ankle region Lighter in colour in the ankle region Lighter leg in weight/motion Less swollen (10/14) - Lack quantitative measurements

Pre – Post Stenting

Iliac vein occlusion

Conclusion The VDI is responsive to stenting in NIVLs Clinical uses of the VDI may include - Screening for obstruction Assessment of CVI patients without reflux Assessment of PTS patients with reflux Selection for stenting Monitoring stents