Pathology of Postthrombotic venous disease (PTS) has been known to be a combination of obstruction and reflux. Recent use of IVUS has found that obstructive non-thrombotic iliac vein lesions (NIVL) are found in over 90% of symptomatic ‘primary' cases with reflux as well. Correction of the obstructive component alone in both types of chronic venous insufficiency (CVI) yielded unexpected substantial symptom relief minimizing the need for correction of associated reflux with complex open surgery.
Patients and Methods
From 1997 to 2008 (11yrs) iliac vein stent procedures were performed in 1487 limbs to relieve obstruction. 513 had associated deep reflux (with superficial reflux in 366, 71%). Superficial reflux alone was present in 345 and excluded. Clinical (CEAP) classification was C2 (pain) in 4%; C3 in 44%; C4 in 21%; C5 in 6%; and C6 in 25%. Etiology was ‘primary' in 213 (42%) and postthrombotic in 300 (58%) limbs. Reflux segment score was 3, (0-8) (median, range). Severe reflux (reflux segment score ≥3 and/or axial reflux) was present in 296 (58%) which also included 271 limbs with ‘axial reflux.' Median (range) percentage drop & VFT (ambulatory venous pressure) were 62 % (10-90) mm Hg & 16 sec. (1-23) respectively; median VFI 90 (APG) was 2.8 sec (0.5-16.6).
Results
Cumulative secondary stent patency (6 Yrs) was 100 % and 87 % respectively for NIVL and PTS limbs. Complete relief of pain occurred in 83 % and significant improvement (≥ 3 VAS) in 89% post-stent. Complete relief of swelling occurred in 46% and significant improvement (≥ 1 grade) in 71% post-stent. Complete healing/freedom from recurrence (C 4,5,6) was 63% at 5 years. QOL (CIVIQ) improved significantly. Clinical outcomes were similar (p= NS) between NIVL and PTS limbs and between severe or lesser reflux subsets. Reflux parameters did not get worse post stent: percentage drop- 63% mmHg (10-90) and VFT 16 sec. (1-23) were unchanged; VFI90 2.1 sec. (0.5-13.2) was improved (p=0.002).
Conclusions
Combined obstruction/reflux is often present in CVI of post-thrombotic or primary aetiologies. Substantial symptom relief is obtained by percutaneous stenting alone ie. CVI responds to partial correction of combined pathology with stent and the residual reflux is well tolerated. These findings provide the basis for a new paradigm in the treatment of CVI.
1University of Mississippi Medical Center, Jackson, MS
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