The clinical impact of iliac venous stents in the management of chronic venous insufficiency

AbstractPurpose: The purpose of this study was the presentation of the results of iliac venous stent placement in the management of chronic venous insufficiency (CVI). Methods: Balloon dilation and stent placement for the relief of iliac vein stenoses was performed in 304 limbs with symptomatic CVI. Sixty-one limbs had concomitant saphenous vein ablation. The median age was 52 years (range, 14 to 83 years). The ratio of postthrombotic to nonthrombotic CVI was 1 to 0.9. The CEAP classification clinical scores were: C2, 24; C3, 158; C4, 60; C5, 13; and C6, 49. Associated reflux was present in 57% of the limbs. The procedure was performed on an outpatient basis. Intravascular ultrasound scanning was routinely performed because transfemoral venography had poor sensitivity for the detection of iliac vein stenosis Results: The actuarial primary and secondary stent patency rates at 24 months were 71% and 90%, respectively. The median degree of swelling (graded 0 to 3, for none, pitting, ankle edema, to gross leg edema) declined from grade 2 to grade 1 after surgery (P <.001). The limbs without any swelling increased from 12% before stenting to 47% after stenting (P <.01). The pain level recorded on a visual analogue scale from 0 to 10 declined from a median level of 4 to 0 after stent placement (P <.001). The limbs that were completely free of pain increased from 17% before stenting to 71% after stent placement (P <.001). Stasis dermatitis/ulceration was present in 69 limbs. The improvement in swelling and pain was similar in ulcerated and nonulcerated limbs. The cumulative recurrence-free ulcer healing rate was 62% at 24 months. The rate of ulcer healing was similar whether or not concomitant saphenous ablation was performed. Quality of life has significantly improved Conclusion: The correction of iliac vein outflow obstruction with the placement of stents results in the significant relief of major symptoms of CVI. The procedure is minimally invasive, can be performed on an outpatient basis, has minimal complications with a high patency rate, and does not preclude subsequent open surgery for the correction of restenosis or the associated reflux. If these preliminary results are sustained for a long-term period, stent placement for the correction of iliac vein stenoses may represent a useful advance in the management of CVI. (J Vasc Surg 2002;35:8-15.

Spontaneous Onset of Bacterial Cellulitis in Lower Limbs with Chronic Obstructive Venous Disease

AbstractBackgroundCellulitis, often recurrent is a common complication of severe chronic venous disease (CVD) when dermatitis or ulcer is present. The skin breakdown obviously provides easy entry for bacteria but other factors such as oedema and lymphatic dysfunction likely play a role in pathogenesis as well. An iliac obstructive lesion is commonly present and correction with stent(s) often heals dermatitis/ulcer and relieves cellulitis. The current manuscript focuses on a relatively infrequent “spontaneous” variety of cellulitis which also occurs in obstructive venous disease in the absence of overt skin breakdown. Stenting results are of particular interest in this subset because its therapeutic efficacy can be related to factors other than healing of dermatitis/ulceration (portal of entry).Material and methodsOne thousand and nine limbs underwent iliac vein stenting for symptomatic CVD over a 7 year period; 29 limbs that were stented to treat spontaneous recurrent cellulitis of two or more prior attacks and 16 additional limbs with only one prior episode (stented for other indications) are analysed. Eighty two percent of the limbs had obvious swelling and the remainder had none at the time of stenting when cellulitis was inactive. Iliac vein outflow obstruction was found by intravascular ultrasound (IVUS) and all limbs were stented.ResultsMedian age was 54 and male to female ratio 1:2. Aetiology of iliac obstruction was post-thrombotic in 33% and non-thrombotic in 67%. Preoperatively, lymphatic abnormalities were present in 17 (38%) of the limbs: no activity in 7, delayed flow in 8 and pooling of isotope in the lower leg in 2 limbs. Swelling and pain improved significantly after stent placement. Cumulative freedom from recurrent attacks of cellulitis was 76% at 3 years.ConclusionIliac vein outflow obstruction may underlie CVD limbs afflicted with cellulitis. IVUS examination is recommended if cellulitis is recurrent and conventional therapy had failed. Correction of outflow obstruction by venous stent placement appears to yield moderate freedom from repeat infections in the near term

Popliteal vein entrapment: A benign venographic feature or a pathologic entity?

AbstractPurpose: Asymptomatic morphologic popliteal vein entrapment is frequently found in the healthy population (27%). In our institution, popliteal vein compression on plantar flexion was observed in 42% of all ascending venograms. Some authorities consider the lesion benign, without pathologic significance. This study examines the pathophysiologic importance in select patients, describes treatment with surgery, and suggests a diagnostic tool. Method: Thirty severely symptomatic patients with venographic evidence of popliteal entrapment were selected to have popliteal vein release after a process of elimination (ie, other causes of chronic venous insufficiency [CVI] were ruled out by means of comprehensive hemodynamic and morphologic studies). In the last nine limbs, popliteal vein pressure was also measured by means of the introduction of a 2F transducer tip catheter. Patients were clinically and hemodynamically assessed before and after surgery, and anatomical anomalies encountered during surgery were recorded. Results: Popliteal vein release was performed without mortality or serious morbidity. Anomalies of the medial head of the gastrocnemius muscle caused entrapment in 60% of the patients; anatomic course venous anomalies were infrequent (7% of the patients). Significant relief of pain and swelling occurred in the patients who had surgery. Stasis ulceration/dermatitis resolved in 82% of patients. Popliteal venous pressures had normalized in the six patients who were studied postoperatively. Conclusion: Popliteal vein entrapment should be included in the differential diagnosis of CVI in patients in whom other, more common etiologies have been excluded on the basis of comprehensive investigations. Popliteal vein compression can be demonstrated venographically in a large proportion of patients with CVI, but the lesion is likely pathological only in a small fraction of these patients. A technique for popliteal venous pressure measurement is described; it shows promise as a test for functional assessment of entrapment. Immediate results of popliteal vein release surgery are encouraging; long-term follow-up is necessary to judge the efficacy of surgical lysis of entrapment in symptomatic patients who fail to improve with conservative treatment measures. (J Vasc Surg 2000;31:631-41.