Unexpected major role for venous stenting in deep reflux disease

Intravascular ultrasound (IVUS) scan appearance of a post-thrombotic stenosis. Lumen compromise and wall thickness are evident. The electronic scale (graticule shown) and planimetry capabilities of IVUS instrumentation allow accurate assessment of diffuse and focal stenoses.

Transfemoral antegrade venogram in a limb with a primary obstructive lesion. A translucent slight broadening of the iliac-caval junction can be noted on close inspection, but the venogram appears otherwise unremarkable (left). An obstructive lesion was obvious on intravascular ultrasound (IVUS) examination. Subsequent balloon dilatation prior to stenting shows tight focal “waisting” (right).

Diffuse post-thrombotic iliac vein stenoses occur from a constricting perivenous fibrotic sheath that prevents collateral formation as originally described by Rokitanski. Such lesions are easily overlooked on venography. Close inspection in this instance shows an iliac vein that is substantially more narrowed as compared to the femoral vein as highlighted by arrows (left). A uniform diameter of the vein is achieved after iliac vein stent placement (right).

Cumulative secondary stent patency in 395 limbs with combined obstruction and reflux. Separate cumulative curves are shown for primary, post-thrombotic, and combined etiologies (SEM <10%).

Cumulative rate of pain relief after stent placement in 323 patients complaining of pain prior to treatment. Curves representing limbs with complete relief (no residual pain) and limbs with substantial improvement are given (SEM <10%). VAS, Visual analog scale.

Cumulative rate of swelling relief after stent placement in 367 patients complaining of swelling prior to treatment. Curves representing limbs with complete relief (no residual swelling) and substantial improvement are given (SEM <10%).

Cumulative rates of ulcer-free C₅ limbs (ie, limbs with healed ulcers at the time of stenting, n = 32), dermatitis-free C_4a limbs (limbs with active dermatitis at the time of stenting, n = 57), and healed ulcers in C₆ limbs (limbs with active ulcer at the time of stenting, n = 114; SEM <10%). A grace period of 4 months for initial healing of limbs with active leg ulcer was allowed at which time limbs with unhealed ulcers were censored. Similarly, a 5-month grace period was given for dermatitis to heal before the limbs with on-going dermatitis were censored. This explains the drop of the curves at 4 and 5 months (33% and 8%, respectively).