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Risk factors for stent occlusion in the treatment of May-Thurner syndrome with iliofemoral deep venous thrombosis

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Taimur Saleem
Taimur Saleem
Taimur Saleem
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© Quantitative Imaging in Medicine and Surgery. All rights reserved. Quant Imaging Med Surg 2023 | https://dx.doi.org/10.21037/qims-23-12
I read with great interest the manuscript by Kim et al. (1)
that was published recently and wanted to congratulate the
authors for their excellent management of patients with
May-Thurner syndrome. I wanted to clarify a few points
that may be of interest to our esteemed readers:
(I) Severity of iliac venous stenosis has not been found
to correlate with the severity of venous symptoms.
Similarly, the degree of iliac venous stenosis in
non-thrombotic iliac venous lesions does not
appear to affect stent patency (2). However, in
the aforementioned study (1), symptomatology
was little discussed. Symptoms were assigned in a
generic way and objective data on symptomatology
seemed scarce.
(II) The primary determinants of stented conduit
patency are the presence of an adequate inow and
outow. This remains true for venous bypasses as
well as endovenous conduits (3). The inflow can
be considered as a “gate keeper” of the stent (3).
All stents were placed above the inguinal ligament
in this series (1). This may have led to potentially
inadequate treatment of inflow lesions or injuries
in the common femoral vein, resulting in impaired
ow and consequently an impaired patency for the
stents. Stent extension across the inguinal ligament
in veins appears to be a feasible prospect based
on Neglen et al.’s experience from Wallstents (4)
and trial data from newer dedicated nitinol venous
stents.
(III) Although some studies have reported incomplete
thrombolysis to be a negative predictor for clinical
outcomes, two recent studies from our center have
called that observation into question (5). Incomplete
thrombectomy, as adjudged by intravascular
ultrasound (IVUS), still portended clinical
improvement in symptoms and longer term venous
patency (5). Therefore, partial thrombectomy may
actually play a role in relieving symptoms, even if it
does not restore complete patency of the vessel.
(IV) Although catheter-directed thrombolysis (CDT) is
effective, we have moved away from this modality
at our center due to three primary reasons: (i)
potential of complications from CDT, (ii) non-
availability of intensive care unit (ICU) beds due
to the COVID-19 pandemic, and (iii) presence
of contraindications to the use of thrombolytic
agents in many patients (5). Whenever possible,
our preference now is to perform mechanical
Letter to the Editor
Risk factors for stent occlusion in the treatment of May-Thurner
syndrome with iliofemoral deep venous thrombosis
Taimur Saleem^
The RANE Center for Venous and Lymphatic Diseases, Jackson, MS, USA
Correspondence to: Taimur Saleem, MD. The Rane Center for Venous and Lymphatic Diseases, 971 Lakeland Drive, Ste 401, Jackson, MS 39216,
USA. Email: taimur@gmail.com.
Comment on: Kim MS, Park HS, Hong HP, et al. Risk factors for stent occlusion after catheter-directed thrombolysis and iliac vein stenting in the
treatment of May-Thurner syndrome with iliofemoral deep vein thrombosis: a retrospective cohort study. Quant Imaging Med Surg 2022;12:5420-32.
Keywords: Intravascular ultrasound (IVUS); iliac; venous; stent; May-Thurner syndrome; catheter-directed thrombolysis (CDT)
Submitted Jan 03, 2023. Accepted for publication Mar 14, 2023. Published online Apr 14, 2023.
doi: 10.21037/qims-23-12
View this article at: https://dx.doi.org/10.21037/qims-23-12
3
^ ORCID: 0000-0003-4467-3090.
Saleem. Risk factors for stent occlusion
2
© Quantitative Imaging in Medicine and Surgery. All rights reserved. Quant Imaging Med Surg 2023 | https://dx.doi.org/10.21037/qims-23-12
thrombectomy without CDT in a single setting
that obviates the utilization of an ICU bed (5).
However, although some services do not adopt
thrombolysis as the first line of treatment in
these cases, we should be aware that it is still
the treatment of choice in most vascular surgery
centers.
(V) When available, the use of IVUS in the detection of
stent malfunction is highly preferred as multiplanar
venography can underdiagnose not only the
presence but also the severity of underlying
chronic iliac venous lesions (6,7). However, the
low availability of the exam in a large number of
vascular centers poses a potential problem. The use
of IVUS in all patients can potentially add to the
cost and reduce the sample size.
(VI) Venous stents such as the WallstentTM (Boston
Scientific, Marlborough, MA, USA) should be
slightly oversized rather than undersized due to two
primary reasons. Firstly, it reduces the risk of stent
embolization. Secondly, it allows for aggressive
hyperdilation in the future to accommodate for the
potential development of stent compression and in-
stent restenosis (ISR)—a ubiquitous problem with
venous stents (8).
(VII) Management of iliac-caval confluence remains a
technical challenge. On the one hand, there is a risk
of jailing the contralateral iliac vein orifice if the
stent is extended into the inferior vena cava (IVC).
On the other hand, there is risk of undertreatment
if the stent is placed distally near the iliac-caval
conuence. The iliac-caval conuence is a potential
choke point where potential venous lesions can
occur. Our modus operandi has been to use the
Zenith (Z) stent at the iliac-caval confluence.
This technique has several advantages—provision
of stronger radial force, allowance for easier
sequential bilateral stenting and avoidance of jailing
of the contralateral side due to larger interstices (9).
Another technique of dealing with the iliac-caval
conuence is the “skip stent technique” which has
been utilized by some authors without an adverse
impact on stent patency (Figure 1). It involves
leaving a skipped lesion at the level of iliocaval
conuence (10).
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was a standard
submission to the journal. The article has undergone
external peer review.
Conflicts of Interest: The author has completed the ICMJE
uniform disclosure form (available at https://qims.
amegroups.com/article/view/10.21037/qims-23-12/coif).
The author has no conicts of interest to declare.
Ethical Statement: The author is accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work are
appropriately investigated and resolved.
Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Attribution-NonCommercial-NoDerivs 4.0 International
License (CC BY-NC-ND 4.0), which permits the non-
commercial replication and distribution of the article with
the strict proviso that no changes or edits are made and the
original work is properly cited (including links to both the
formal publication through the relevant DOI and the license).
Figure 1 Skipped stent technique of dealing with iliac-caval
conuence. The asterisk represents the unstented “skipped” area
at the iliac-caval conuence. The technique has not been shown to
have any adverse effects on outcomes.
Quantitative Imaging in Medicine and Surgery, 2023 3
© Quantitative Imaging in Medicine and Surgery. All rights reserved. Quant Imaging Med Surg 2023 | https://dx.doi.org/10.21037/qims-23-12
See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
1. Kim MS, Park HS, Hong HP, Hyun D, Cho SK, Park
KB, Shin SW, Choo SW, Do YS. Risk factors for stent
occlusion after catheter-directed thrombolysis and iliac
vein stenting in the treatment of May-Thurner syndrome
with iliofemoral deep vein thrombosis: a retrospective
cohort study. Quant Imaging Med Surg 2022;12:5420-32.
2. Saleem T. Accurate and Appropriate Selection of Patients
for Endovenous Iliofemoral Intervention: Are We There
Yet? Eur J Vasc Endovasc Surg 2022;64:135-6.
3. Saleem T. The Stent's Gatekeeper: Inow Disease. Eur J
Vasc Endovasc Surg 2022;64:738-9.
4. Neglén P, Tackett TP Jr, Raju S. Venous stenting across
the inguinal ligament. J Vasc Surg 2008;48:1255-61.
5. Saleem T, Fuller R, Raju S. Aspiration mechanical
thrombectomy for treatment of acute iliofemoral and
central deep venous thrombosis. Ann Vasc Surg Brief Rep
Innov 2021;1:100012.
6. Saleem T, Raju S. Comparison of intravascular ultrasound
and multidimensional contrast imaging modalities for
characterization of chronic occlusive iliofemoral venous
disease: A systematic review. J Vasc Surg Venous Lymphat
Disord 2021;9:1545-1556.e2.
7. Saleem T, Knight A, Raju S. Diagnostic yield of
intravascular ultrasound in patients with clinical signs and
symptoms of lower extremity venous disease. J Vasc Surg
Venous Lymphat Disord 2020;8:634-9.
8. Saleem T, Raju S. An overview of in-stent restenosis in
iliofemoral venous stents. J Vasc Surg Venous Lymphat
Disord 2022;10:492-503.e2.
9. Saleem T, Raju S. Management of iatrogenic inferior
vena cava perforation with composite Wallstent-Z-stent
technique. J Vasc Surg Cases Innov Tech 2021;7:630-3.
10. Barbati ME, Gombert A, Toonder IM, Schleimer K,
Kotelis D, de Graaf R, Doganci S, Razavi MK, Jalaie H.
Iliocaval Skip Stent Reconstruction Technique for Chronic
Bilateral Iliocaval Venous Occlusion. J Vasc Interv Radiol
2020;31:2060-5.
Cite this article as: Saleem T. Risk factors for stent occlusion
in the treatment of May-Thurner syndrome with iliofemoral
deep venous thrombosis. Quant Imaging Med Surg 2023. doi:
10.21037/qims-23-12
ResearchGate has not been able to resolve any citations for this publication.
Risk factors for stent occlusion after catheter-directed thrombolysis and iliac vein stenting in the treatment of May-Thurner syndrome with iliofemoral deep vein thrombosis: a retrospective cohort study
Article
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Background: This study aimed to identify the risk factors for stent occlusion in patients with iliofemoral deep vein thrombosis (DVT) secondary to May-Thurner syndrome (MTS) who underwent catheter-directed thrombolysis (CDT) and iliac vein stenting. Methods: A retrospective analysis was performed on 44 patients who underwent CDT and iliac vein stenting for MTS with iliofemoral DVT between October 2001 and March 2018. MTS was diagnosed based on extrinsic compression of the left common iliac vein (CIV) by the overlying right common iliac artery (CIA) on computed tomography (CT). Clinical records of the study population were reviewed to collect baseline data, procedural characteristics, and outcomes. Final venograms showing diffuse and irregular wall thickening in the iliofemoral vein were considered to indicate a chronic post-thrombotic lesion. The stent position was categorized as follows: confluence coverage without touching the contralateral inferior vena cava (IVC) wall, IVC extension contacting the contralateral IVC wall, or distal to the iliocaval junction. Stent patency was assessed using duplex ultrasonography. Risk factors for stent occlusion were assessed using univariate and multivariate Cox proportional hazard models. Results: The median duplex ultrasound follow-up period was 25 months (range, 1-196 months). The overall cumulative patency rate at 12 months was 70.0%. In the univariate Cox regression, factors significantly associated with stent occlusion included symptom duration >2 weeks before CDT, partial thrombolysis (50-99% of thrombus removal), chronic post-thrombotic lesions, and stent position. Multivariate Cox regression showed that chronic post-thrombotic lesions [hazard ratio (HR) =7.15; 95% confidence interval (CI): 1.32-38.81; P=0.023] and a stent distal to the iliocaval junction (HR =5.59; 95% CI: 1.46-21.38; P=0.012) were significantly associated with stent occlusion. Conclusions: Chronic post-thrombotic lesion and a stent distal to the iliocaval junction were important risk factors for stent occlusion in patients who underwent CDT and iliac vein stenting.
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Management of iatrogenic inferior vena cava perforation with composite Wallstent-Z-stent technique
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Inferior vena cava (IVC) rupture is uncommon but can occur as a result of trauma, catheterization and in the course of venous interventions. Two instances of iatrogenic IVC perforation are described along with their successful management with bare metal stents (composite Wallstent – Z stent technique). This management strategy was possible due to the unique properties of the venous system.
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An overview of in-stent restenosis in iliofemoral venous stents
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Background While endovenous stents are associated with overall low morbidity, they may require re-interventions to correct stent malfunction due to in-stent restenosis (ISR). ISR is commonly seen in iliofemoral venous stents but is not well described. It may develop in over 70% of patients who undergo iliofemoral venous stenting. The aim of this article is to provide an overview of ISR in iliofemoral venous stents, including pathologic, diagnostic and management considerations along with identification of several areas of potential research in the future. Methods A review of the published English language literature was performed in PubMed and The Cochrane Library. “Instent restenosis”, “vein”, “venous”, “iliac” and “iliofemoral” were utilized as keywords. Pertinent publications included in the review addressed the pathology, diagnosis and current management options for ISR. Results ISR refers to the narrowing of the luminal caliber of the stent due to the development of stenosis inside the stent itself. It should be differentiated from stent compression. Two main types of ISR have been described: a soft lesion and a hard lesion. These lesions respond differently to angioplasty. Stent inflow and shear stress are important factors in the development of ISR. Currently available treatment options include balloon angioplasty (hyperdilation or isodilation), laser ablation, atherectomy and Z-stent placement. Conclusion Re-intervention for ISR should be based on the presence of residual or recurrent symptoms and not simply on a numeric value obtained from an imaging study. Overall stent occlusions are rare from ISR and there is no role for prophylactic angioplasty of asymptomatic ISR. Current treatment options for ISR are mostly durable and effective but more research is needed on ways to prevent the development of ISR. The role of antiplatelet agents and anticoagulants in the prevention of ISR requires further investigation with particular attention to unique subset of patients (post-thrombotic versus NIVLs). In high risk, post-thrombotic patients, anticoagulation may be considered to prevent ISR. The role of triple therapy (anticoagulation and dual antiplatelet therapy) in the prevention of ISR remains unclear.
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Aspiration mechanical thrombectomy for treatment of acute iliofemoral and central deep venous thrombosis
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We describe our experience with the Indigo CATTM aspiration mechanical thrombectomy (AMT) system in 20 patients. A modification of the AMT technique was done in 7 patients (35%) whereby a snare was used instead of a separator. Technical success by intravascular ultrasound (IVUS) was noted in 8 patients (40%) while symptom improvement was noted in all patients prior to discharge. In 4 patients (20%), occlusion was noted on first post-operative day ultrasound; remainder demonstrated venous patency. Snare use was associated with higher technical success (85.7% versus 15.4%, p = 0.004) and less procedural blood loss (235 ± 40 cc versus 300 ± 55 cc, p = 0.04) compared to the separator.
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Comparison of IVUS and multi-dimensional contrast imaging modalities for characterization of chronic occlusive iliofemoral venous disease: a systematic review
Article
  • May 2021
Background Techniques to diagnose and treat chronic iliofemoral venous obstruction (CIVO) continue to evolve. Intravascular ultrasound (IVUS) displays real-time cross-sectional venous anatomy and can be used to guide venous interventions. However, being invasive, it is not a suitable initial screening tool. The comparison of IVUS with other three dimensional contrast imaging modalities is less well documented. This article provides a systematic analysis of the performance of IVUS and other three dimensional contrast imaging modalities in CIVO. Methods A search of various databases including MEDLINE, Embase, EBSCOhost, Cochrane Library, CINAHL PLUS and Web of Science was conducted to identify studies that compared IVUS and at least one other multidimensional contrast imaging modality including multiplanar venography (MPV), computed tomography venography (CTV)/computed tomography angiography (CTA) or magnetic resonance venography (MRV) in CIVO. Results 2,117 articles were screened. Of these, 8 publications met the inclusion criteria. Additionally, twelve other studies were identified that compared IVUS to single plane venography. A meaningful meta-analysis could not be conducted due to data heterogeneity. The quality of evidence varied from very low to low. IVUS identified stenotic lesions in 0 – 30% more patients than MPV. CTV and IVUS measurements correlated well with each other. The sensitivity of the two segment CTV technique approached 97%. Specificity of CTV was 57 – 86%; varying with the venous segment. The sensitivity and specificity of MRV compared to IVUS was 100% and 22.7% respectively. Conclusion Given the fact that IVUS is considered the gold standard used to guide venous interventions in CIVO, the use of venography, despite utilizing multiple projection views underestimates the severity and presence of venous stenosis and should not be used as the only diagnostic modality. 3D-CTV is non-invasive with a high sensitivity. It may be used to screen patients who may benefit from more invasive investigation with IVUS. It can also be considered in the preoperative planning of venous interventions in CIVO patients.
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Iliocaval Skip Stent Reconstruction Technique for Chronic Bilateral Iliocaval Venous Occlusion
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  • Dec 2020
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Purpose To report safety and efficacy of a skip stent technique using nitinol stents in patients with chronic bilateral iliocaval venous occlusions. Materials and Methods A retrospective analysis of 48 consecutive patients (32 men; mean age, 40.7 years; age range, 18–68 years) with chronic bilateral iliocaval obstructions treated using a nonoverlapping stent technique was conducted at a single center. None of the patients had May-Thurner syndrome. Iliocaval confluence was treated by deploying a nitinol stent in inferior vena cava (IVC) and a nitinol stent in each common iliac vein close to the caval stent. Patency of stents was assessed by duplex US at 2 weeks, 3 months, and 6 months and yearly thereafter. Results Recanalization and stent reconstruction was technically successful in 47 (98%) patients. The sinus-XL venous stent was used to treat IVC (95 [100%]). Common iliac and external iliac veins were treated with sinus-Venous and VENOVO stents (80 [83%] and 16 [17%] limbs, respectively). External iliac and common femoral veins were treated with sinus-Venous and VENOVO stents (83 [92%] and 7 [18%] limbs, respectively). Early thrombosis (< 30 days) of the iliac vein with stent occurred in 2 limbs. Cumulative primary, assisted primary, and secondary patency rates at 30 months were 74%, 83%, and 97%. Conclusions Findings of this study suggest that leaving a skipped lesion at the level of iliocaval confluence may not adversely affect stent patency. Patency rates were comparable with other reported techniques of stent reconstruction at the level of iliocaval confluence.
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Diagnostic yield of intravascular ultrasound in patients with clinical signs and symptoms of lower extremity venous disease
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  • Dec 2019
Background: Intravascular ultrasound (IVUS) examination has a higher sensitivity compared with venography in the assessment of obstructive venous disease. However, at most venous centers, both modalities continue to be used concomitantly. This study evaluated the diagnostic clinical yield of IVUS examination as a singular intraoperative investigative modality in patients in whom clinical signs and symptoms of venous disease were severe enough to merit such an examination and in whom a venogram was not performed simultaneously. Methods: From January, 2013, to December, 2018, there were 31 limbs (29 patients) who only had IVUS planimetry without concomitant venogram. Clinical parameters such as pain, swelling and Venous Clinical Severity Score were measured preoperatively and postoperatively. The degree of stenosis noted on intraoperative IVUS was compared with the preoperative duplex. Incidence of complications, technical success, and clinical yield of IVUS examination were noted. Results: The etiology of venous lesion was post thrombotic in the majority of patients (74%). All patients (100%) were either in Clinical, Etiologic, Anatomic, and Pathologic class C3 or higher. In all patients (100%) taken to the operating room, IVUS examination identified stenosis in at least one of the following three veins: common iliac vein, external iliac vein, and common femoral vein. Intervention was in the form of angioplasty with endovenous stenting. There was significant improvement in pain, swelling and Venous Clinical Severity Score after the intervention. Conclusions: IVUS is an effective diagnostic tool that displays high quality, real-time cross-sectional anatomy during venous interventions. When used as the sole intraoperative diagnostic modality, it seems to have a high clinical yield in patients in whom signs and symptoms of venous disease are severe enough to merit intervention.
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Venous stenting across the inguinal ligament
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  • Sep 2008
Arterial stenting across joints is not recommended because of increased risk of in-stent focal neointimal hyperplasia and compression or fracture of the stent by joint motion with decreased long-term patency. The aim of this study was to assess the risk of placing stents in the venous system across the inguinal ligament. From 1997 to 2006, 177 limbs with chronic non-malignant obstructive lesions had stents placed in the iliofemoral venous outflow across the inguinal ligament into the common femoral vein. Transfemoral venograms and duplex ultrasound scans to assess cumulative patency rates, cumulative rates, site of in-stent restenosis (ISR), and structural integrity of the stents were performed during follow-up. The results were compared to the findings in 316 limbs with stents terminating cephalad to the inguinal ligament. Overall cumulative secondary patency (CSP) rate at 54 months was greater in the limbs with cephalad than in those caudad stent termination in relation to the inguinal ligament (95% and 86%, respectively; P = .0001). Although CSP of limbs with non-thrombotic obstruction was 100% regardless of the site of stent termination, that of the limbs stented for thrombotic obstruction was greater for stents terminating cephalad than for those caudad to the ligament (90% and 84%, respectively; P = .0378). However, a comparison of CSP rates between limbs treated for thrombotic occlusion and those with thrombotic non-occlusive obstruction at 32 months revealed no difference whether or not the stent was placed across the inguinal ligament (occlusion 77% and 77%, P = .7540, non-occlusive obstruction 96% and 95%, P = .7437). Severe ISR (> or =50%) were rare, 5%. The cumulative rate was, however, not significantly different in limbs stented cephalad and caudad to the inguinal ligament (7% and 11%, respectively, P = .6393). Focal in-stent recurrent stenosis at the site of the inguinal ligament occurred in only 7% of limbs (all <50%). None of the braided stainless steel stents were compressed or fractured. Contrary to arterial stenting, braided stainless stents can be safely placed in the venous system across the inguinal crease with no risk of stent fractures, narrowing due to external compression, focal development of severe in-stent restenosis, and no effect on long-term patency. The patency rate is not related to the length of stented area or the placement of the stent across the inguinal ligament, but is dependent upon the etiology and whether the treated postthrombotic obstruction is occlusive or non-occlusive.
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