M.A.F. de Wolf

Short-Term Clinical Experience with a Dedicated Venous Nitinol Stent: Initial Results with the Sinus-Venous Stent.

OBJECTIVE Deep venous stenting has become the primary treatment option for chronic venous obstructive disease, both for iliac vein compression and post-thrombotic venous lesions. Until recently, only stents aimed at arterial pathology were used, because no dedicated venous stents were available. However, three such stents have now become available. These venous stents are characterized by increased length, diameter, flexibility, and radial force. This study reports an early experience with one of these devices; the sinus Venous stent (OptiMed GmbH, Ettlingen, Germany). METHODS Between March 2012 and July 2014, 75 patients were treated with the sinus Venous stent: 35 cases of iliac vein compression syndrome and 40 cases of unilateral chronic obstruction in post-thrombotic syndrome (PTS). Diagnosis of relevant obstruction was made using clinical evaluation, duplex ultrasound, and magnetic resonance venography. Patency during follow up was assessed with duplex ultrasound. Clinical improvement was assessed by VCSS, Villalta score, rate of ulcer healing, and improvement of venous claudication. RESULTS The cumulative patency rates at 3, 6, and 12 months were 99%, 96%, and 92%, respectively. The cumulative assisted primary patency rates were 99% at 3, 6, and 12 months. The cumulative secondary patency rate at 12 months was 100%. Differences exist in patency rate between the subgroups of non-thrombotic and post-thrombotic, with the first showing no re-occlusions. All re-thromboses in the PTS group were treated by ancillary treatment modalities. VCSS and Villalta score decreased significantly after stenting, as did venous claudication. Morbidity was low without clinically relevant pulmonary embolism, and mortality was nil. Although two out of seven ulcers healed temporarily, no ulcer remained healed at 12 months follow up. CONCLUSION Short-term clinical results using the sinus Venous stent are excellent, with significant symptom reduction, low morbidity rates, and no mortality. Loss of stent patency is seen less often compared with arterial stents described in the literature.

What predicts outcome after recanalization of chronic venous obstruction: hemodynamic factors, stent geometry, patient selection, anticoagulation or other factors?

In this review we evaluated the effect of different suggested factors associate with the outcome after recanalization of chronic venous obstruction (CVO). Hemodynamic factors: Based upon literature no clear suggestions can be made to identify the risk of stent occlusion in association with the hemodynamic effects. However it is evident that ensuring optimal in- and outflow of the stented tract is key in maintaining the patency. Patient selection: Noninvasive imaging modalities are used to divide patients in three subgroups based on the place and extension of post-thrombotic changes. Moreover it should be noted that AV fistula in selected patients can reduce the risk of thrombosis or re-occlusion. Geometry: Excessive oversizing of the stent and stent compression from outside are considered to be associated with stent occlusion. Additionally, overlapping rigid stents, unnatural angel between stents and in-stent kinking are other geometrical factors related to worse outcome after venous recanalization. Anticoagulation: Adequate peri-and postoperative anticoagulation has a crutial role in stent patency. There is no data regarding the duration of anticoagulation therapy and recommendations vary between 6 weeks to 6 months. Result: impaired inflow or outflow, presence of a hypercoagulability, total number of treated segments and use of stents designed for implantation in arterial system are associated with decreased stent patency.

Indications for endophlebectomy and/or arteriovenous fistula after stenting

Endovenous recanalization with percutaneous transluminal angioplasty and stenting in post-thrombotic syndrome patients with iliocaval obstruction is a treatment modality quickly gaining popularity. Studies show good patency and clinical success rates. If the obstruction extends distally, below the inguinal ligament, stenting remains controversial. Without adequate inflow, the patency of stented iliocaval segments drops dramatically. This suggests that treatment of diseased common femoral, femoral and profunda femoral veins is required to ensure adequate inflow. Endophlebectomy, the removal of synechiae and septae from the common femoral vein, is a viable option in these cases. Another option, which can be done concurrently with the endophlebectomy, is the creation of an arteriovenous fistula. Selecting patients for these interventions however remains difficult, as precise preoperative prediction of inflow into the stented segments is difficult. In this paper we describe our experience in using duplex ultrasonography, magnetic resonance venography and conventional venography to assess the patency of the inflow trajectory. We believe this approach is essential in dealing with cases of complex post-thrombotic disease extending below the inguinal ligament. There is a great need to establish criteria to accurately assess pre- and postinterventional flow through treated vein segments.

Endophlebectomy of the common femoral vein and arteriovenous fistula creation as adjuncts to venous stenting for post-thrombotic syndrome

Good results have been reported for angioplasty and stenting of post‐thrombotic lesions of the iliac and proximal femoral veins. If lesions at the origin of the superficial femoral and profunda veins are stented, the intraluminal synechiae can be pushed against the orifices of inflow vessels, potentially decreasing stent inflow. Surgical disobliteration of the common femoral vein (endophlebectomy) has been suggested to mitigate this problem. Because of a temporary increase in thrombogenicity, this procedure may be accompanied by arteriovenous fistula creation.

Intravenous pressure changes in patients with postthrombotic deep venous obstruction: results using a treadmill stress test

Essentials Little is known about the hemodynamic consequences of deep venous obstructive disease. We investigated pressure changes in 22 patients with unilateral postthrombotic obstruction. Common femoral vein pressure significantly increased after walking, compared to control limbs. Common femoral vein hypertension could explain the debilitating effect of venous claudication.

Catheter-directed thrombolysis in deep vein thrombosis: Which procedural measurement predicts outcome?

The post-thrombotic syndrome (PTS) as a long-term consequence of deep vein thrombosis (DVT) is caused by a venous obstruction and/or chronic insufficiency of the deep venous system. New endovascular therapies enable early recanalization of the deep veins aiming reduced incidence and severity of PTS. Extended CDT is associated with an increased risk of bleeding and stenting of residual venous obstruction is indispensable to avoid early rethrombosis. Therefore, this article focuses on measurements during or after thrombolysis indicating post procedural outcome.

Editor's Choice – Reconstruction of the femoro-ilio-caval outflow by percutaneous and hybrid interventions in symptomatic deep venous obstruction

OBJECTIVE/BACKGROUND Deep venous obstruction is relatively prevalent in patients with chronic venous disease. Endovascular treatments and hybrid interventions can be used to relieve venous outflow obstructions. This paper assesses mid-term clinical outcomes and patency rates in a large cohort after percutaneous and hybrid interventions. METHODS This was a prospectively analysed cohort study. Patients with symptomatic deep venous obstruction who presented at a tertiary referral hospital were divided into three groups: patients who underwent percutaneous stenting for non-thrombotic iliac vein compression syndrome (IVCS group); patients with post-thrombotic syndrome (PTS) treated by percutaneous stent placement (P-PTS group); and PTS patients with obstruction involving the veins below the saphenofemoral junction in which a hybrid procedure was performed, combining stenting with open surgical disobliteration (H-PTS group). Patency rates, complications, and clinical outcomes were analysed. RESULTS A total of 425 lower extremities in 369 patients were treated. At 60 months, primary patency, assisted primary patency, and secondary patency rates were 90%, 100%, and 100% for IVCS, and 64%, 81%, and 89% for the P-PTS group, respectively. The H-PTS group, showed patency rates of 37%, 62%, and 72%, respectively, at 36 months. Venous claudication subsided in 90%, 82%, and 83%, respectively. At the 24 month follow-up, mean Venous Clinical Severity Score decreased for all patients and improvement in Villalta score was seen in post-thrombotic patients. The number of complications was related to the extent of deep venous obstruction in which patients in the H-PTS group showed the highest complication rates (81%) and re-interventions (59%). CONCLUSION Percutaneous stent placement to treat non-thrombotic iliac vein lesions, and post-thrombotic ilio-femoral obstructions are safe, effective, and showed patency rates comparable with previous research. Patients with advanced disease needing a hybrid procedure showed a lower patency rate and more complications. However, when successful, the clinical outcome was favourable at mid-term follow-up and the procedure may be offered to selected patients.

Venous In-stent Thrombosis Treated by Ultrasound Accelerated Catheter Directed Thrombolysis

OBJECTIVE/BACKGROUND Stent placement in the venous system is an increasingly used treatment modality in chronic venous obstruction and as additional treatment after thrombolytic therapy in ilio-femoral deep vein thrombosis (DVT). Experience in treating in-stent thrombosis with ultrasound accelerated catheter directed thrombolysis (UACDT) is reported. METHODS A retrospective analysis of patients treated for venous stent occlusion, after percutaneous transluminal angioplasty (PTA) and stent placement for either chronic venous occlusive disease or persistent vein compression in patients with acute DVT was performed. Duration of occlusion and suspected clot age were assessed using patient complaints and typical findings on duplex ultrasonography (DUS). DUS and venography were used to assess patency and to determine the cause of re-occlusion. Acute treatment of occlusion was by UACDT. Additional procedures included PTA, stent placement, and creation of an arteriovenous (AV) fistula. RESULTS Eighteen patients (median age 43 years; 67% male), treated for occluded stent tracts with UACDT between January 2009 and July 2014, were identified. Indications for initial stenting were treatment of chronic venous obstructive disease (12 patients) and treatment of underlying obstruction after initial thrombolysis in acute DVT (six patients). Technical success was achieved in 11/18 (61%) patients. Primary patency in 8/11 patients was 73% at last follow up (median follow up 14 months [range 0-41 months]). Additional treatments after successful lysis were re-stenting (seven patients) and creation of an AV fistula (six patients). CONCLUSION Treatment with UACDT of recently occluded stent tracts is feasible and effective. Recanalization of the stent tract can be achieved in most cases. Additional interventions were frequently used after successful UACDT treatment. Suboptimal stent positioning caused the majority of the stent occlusions.

Interventional treatment of postthrombotic syndrome.

BackgroundPostthrombotic syndrome (PTS) is the development of symptoms and signs of chronic venous insufficiency following deep vein thrombosis (DVT) and has a significant negative effect on the quality of life. The current understanding is that the clinical manifestation of PTS is related more to venous obstruction than it is to venous reflux. The use of interventional techniques for the treatment of venous obstruction and/or venous occlusion has rapidly increased in recent years.ObjectiveThis article summarizes the current concept of endovenous and hybrid interventions and presents the optimized treatment of choice in patients with chronic symptomatic venous obstruction.MethodsWe performed a systematic literature search in the Medline database to identify relevant studies on the treatment of patients with PTS.ResultsA meta-analysis of the relevant studies showed that this minimally invasive procedure is an effective treatment option with low morbidity and no mortality. Use of the newly developed dedicated venous stents showed promising results with good mid-term patency rates and a significant decrease in related symptoms.ConclusionInterventional therapy for the treatment of symptomatic chronic venous obstruction has become the method of choice in recent years. More studies are needed to evaluate the long-term success rate of dedicated venous stents.ZusammenfassungHintergrundDas postthrombotische Syndrom (PTS) als Langzeitfolge der tiefen Beinvenenthrombose (TVT) kann zu einer erheblichen Beeinträchtigung der Lebensqualität führen. Nach neuerem Erkenntnisstand trägt die obstruktive Komponente mehr zur Entstehung der Symptomatik bei als die refluxive. Interventionelle Verfahren zur Beseitigung der venösen Obstruktion/Okklusion haben im letzten Jahrzehnt rasant an Bedeutung zugenommen.ZielsetzungIn diesem Beitrag wird die endovaskuläre bzw. Hybridbehandlung der symptomatischen chronisch-venösen Obstruktion und unser Konzept zur Optimierung derselben dargestellt.MethodenDie elektronische Datenbank „medline“ wurde systematisch nach Artikeln in deutscher oder englischer Sprache durchsucht, welche die Behandlung des PTS thematisieren.ErgebnisseAlle zugrundeliegenden Studien zeigen, dass es sich bei dieser wenig invasiven Operation um eine effektive Behandlungsmethode ohne Mortalität mit wenig Morbidität handelt. Die Offenheitsraten sind gut. Es lässt sich ein signifikanter Rückgang der Beschwerden erzielen. Unsere Kurzzeitergebnisse mit speziellen venösen Stents sind erfolgversprechend.SchlussfolgerungDie interventionelle Therapie zur Behandlung der symptomatischen chronisch-venösen Obstruktion hat sich in den letzten Jahren zur Therapie der Wahl entwickelt. Die im Kurzzeitverlauf nachgewiesenen Vorteile der speziellen venösen Stents sollten anhand von kontrollierten Vergleichsstudien evaluiert werden.

Interventionelle Therapie des postthrombotischen Syndroms

ZusammenfassungHintergrundDas postthrombotische Syndrom (PTS) als Langzeitfolge der tiefen Beinvenenthrombose (TVT) kann zu einer erheblichen Beeinträchtigung der Lebensqualität führen. Nach neuerem Erkenntnisstand trägt die obstruktive Komponente mehr zur Entstehung der Symptomatik bei als die refluxive. Interventionelle Verfahren zur Beseitigung der venösen Obstruktion/Okklusion haben im letzten Jahrzehnt rasant an Bedeutung zugenommen.ZielsetzungIn diesem Beitrag wollen wir die endovaskuläre, bzw. Hybridbehandlung der symptomatischen chronisch-venösen Obstruktion und unser Konzept zur Optimierung derselben darstellen.MethodenDie elektronische Datenbank „medline“ wurde systematisch nach Artikeln in deutscher oder englischer Sprache durchsucht, die die Behandlung des PTS thematisieren.ErgebnisseAlle zugrundeliegenden Studien zeigen, dass es sich bei dieser wenig invasiven Operation um eine effektive Behandlungsmethode ohne Mortalität mit wenig Morbidität handelt. Die Offenheitsraten sind gut. Es lässt sich ein signifikanter Rückgang der Beschwerden erzielen. Unsere Kurzzeitergebnisse mit speziellen venösen Stents sind erfolgversprechend.SchlussfolgerungDie interventionelle Therapie zur Behandlung der symptomatischen chronisch-venösen Obstruktion hat sich in den letzten Jahren zur Therapie der Wahl entwickelt. Die im Kurzzeitverlauf nachgewiesenen Vorteile der speziellen venösen Stents sollten anhand von kontrollierten Vergleichsstudien evaluiert werden.AbstractBackgroundPostthrombotic syndrome (PTS) is the development of symptoms and signs of chronic venous insufficiency following deep vein thrombosis (DVT), which has a significant negative effect on the quality of life. The current understanding is that the clinical manifestation of PTS is more related to venous obstruction than to venous reflux. In the last decade the use of interventional techniques for the treatment of venous obstructions and occlusions has drastically increased.ObjectiveThis article summarizes the current concept of endovenous and hybrid interventions and presents our concept for optimization of the treatment in patients with symptomatic chronic venous obstruction.MethodA systematic literature search in the medline library was performed to identify relevant studies on the treatment of patients with PTS.ResultsA meta-analysis of the relevant studies showed that this minimally invasive operation is an effective treatment option with a low rate of morbidity and no mortality. Use of the newly developed dedicated venous stents showed promising results with good short-term patency rates, as well as a significant decrease of related symptoms.ConclusionEndovenous interventions have become the method of choice in the treatment of symptomatic chronic venous obstruction. More studies are needed to evaluate the long-term success rate of dedicated venous stents.