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Endovascular Treatment for Iliac Vein
Compression Syndrome: a Comparison
between the Presence and Absence of
Secondary Thrombosis
Objective: To evaluate the value of early identification and endovascular treat-
ment of iliac vein compression syndrome (IVCS), with or without deep vein throm- Materials and Methods: Three groups of patients, IVCS without DVT (group 1,
n = 39), IVCS with fresh thrombosis (group 2, n = 52) and IVCS with non-fresh thrombosis (group 3, n = 34) were detected by Doppler ultrasonography, magnetic resonance venography, computed tomography or venography. The fresh venous thrombosis were treated by aspiration and thrombectomy, whereas the iliac veincompression per se were treated with a self-expandable stent. In cases with freshthrombus, the inferior vena cava filter was inserted before the thrombosis suction,mechanical thrombus ablation, percutaneous transluminal angioplasty, stenting ortranscatheter thrombolysis. Results: Stenting was performed in 111 patients (38 of 39 group 1 patients and
73 of 86 group 2 or 3 patients). The stenting was tried in one of group 1 and inthree of group 2 or 3 patients only to fail. The initial patency rates were 95%(group 1), 89% (group 2) and 65% (group 3), respectively and were significantlydifferent (p = 0.001). Further, the six month patency rates were 93% (group 1), Index terms :
83% (group 2) and 50% (group 3), respectively, and were similarly significantly different (p = 0.001). Both the initial and six month patency rates in the IVCS patients (without thrombosis or with fresh thrombosis), were significantly greater than the patency rates of IVCS patients with non-fresh thrombosis.
Conclusion: From the cases examined, the study suggests that endovascular
treatment of IVCS, with or without thrombosis, is effective.
Korean J Radiol 2009;10:135-143
Received April 30, 2008; accepted
after revision July 28, 2008.
liac vein compression syndrome (IVCS) is a clinical syndrome which All authors: Department of Interventional causes lower extremity swelling, pain, varicosities and other symptoms (Affiliated to Nanjing Medical University) resulting from pelvic and lower extremity venous flow obstruction caused by the compression of the iliac vein by the overlying iliac artery. McMurrich Address reprint requests to :
Jian-Ping Gu, MD, Department of
first discovered that the left leg swelling is caused by the left iliac vein compression in 1908. In 1956, May and Thurner described, for the first time, the anatomical features Hospital Affiliated to Nanjing MedicalUniversity, No. 68 Chang Le Road, of this disease which was then named the May-Thurner syndrome (1, 2). In 1965, Cockett and Thomas reported the pathology and clinical features of this syndrome and named it the IVCS. Since then, many people have called this syndrome the Cockett syndrome. IVCS is not only the main cause of dysfunction in the deep venous valveand varicosities, but also the main cause of iliofemoral vein thrombosis and animportant factor contributing to the higher number of deep-vein thrombosis (DVT)cases in the left extremity (3). The surgical treatment of IVCS has been progressingover the last 40 years (4, 5). For instance, researchers have put the Fogarty balloon Lou et al.
embolectomy method into practice in subsequent thrombo- and 60 were of the mixed type (involving the entire lower sis cases. Furthermore, over the last 20 years, the rapid development of vascular imaging and intravascular Stenosis of the iliac vein was observed in 43 cases, interventional therapy enabled the improvement of whereas iliofemoral vein occlusion, which included diagnosis and microinvasive treatment of the IVCS and common iliac vein occlusion (33 cases) and occlusion of the secondary thrombosis (6, 7). We present our retrospective common and external iliac vein (49 cases), was observed in data from 125 patients to evaluate and compare the effects 82 cases (65.6%). Contrast stasis and emptying delay was of the endovascular treatment of IVCS, with or without observed in 122 cases (97.6%) by venography. Moreover, 124 cases (99.2%) had collateral circulation.
MATERIALS AND METHODS
Interventional Treatment
We treated 39 IVCS patients without DVT as follows: we Patient Selection
accessed the femoral via local anesthesia and the One hundred twenty-five cases with IVCS (50 males, 75 subsequent insertion of a F4-F5 sheath. Next, we passed a females, age range 18-75 yrs, mean 52.5 yrs), with or H1 catheter (Cordis Corporation, Miami, FL), and guide without DVT, were enrolled in this study. The exclusion wire (Terumo Corporation, Tokyo, Japan) through the criteria included some other causes of DVT such as stenosis lesion and advanced them up to the inferior vena malignancy, recent limb trauma, recent surgery (except for cava. In addition, we exchanged the H1 catheter with a great saphenous vein stripping) and estrogen therapy.
multi-sidehole catheter (Cook, Bloomington, IN) followed IVCS is a condition defined by a greater than 50% stenosis by performing a venography of the iliac vein and inferior or occlusion of the common iliac vein, accompanied with vena cava to assess the location and severity of the iliac significant venous collateral vessels. We did not routinely vein stenosis or occlusion and ensure that the catheter was measure venous pressure at our institution as we consider positioned in the real lumen. A F6-F7 sheath was these measurements of lesser value for patients in the exchanged in an 8-12 mm diameter balloon catheter (C.R.
supine position. Contrast stasis and the predominant collat- Bard, Murray Hill, NJ) was inflated for 20-30 seconds at eral vein indicated that the hemodynamic significance of the usual 6-10 ATM, to treat the iliac vein stenosis or iliac vein stenosis or obstruction. The duration of patient occlusion. For patients with more than 30% residual symptoms, including leg swelling, pain and varicose veins, stenosis, a 10-16 mm diameter self-expandable stent ranged from one day to two months. The patient (Luminexx, C.R. Bard, Murray Hill, NJ) should be placed demographic data are itemized in Table 1. for patients with 3-4 mm of the cephalad end of the stent Iliac vein compression syndrome without DVT was placed into the inferior vena cava. We performed post- detected in 39 patients by means of venous duplex stenting dilatation for patients with intra-stent stenosis.
ultrasonography (n = 9), magnetic resonance venography Of the 125 cases of IVCS, 86 employed an alternative (n = 7), computed tomography (n = 19) or venography (n = strategy according to their course, features and position of 4), and confirmed by a femoral venogram. In total, we the DVT as well as the angiograms of the femoral popliteal diagnosed 12 patients before stripping the great saphenous veins. The definition of fresh thrombus consisted of the vein or endovascular closure, whereas nine cases were intraluminal-filling defect and double track sign in a diagnosed by a venography performed due to the aggrava- venography. In addition, the aspirated thrombus was soft tion of leg swelling after the stripping of the greatsaphenous vein. The remaining 18 diagnosed IVCS cases Table 1. Demographic Data of Patients (n = 125)
presented with isolated unilateral lower extremity edema.
In total, 32 cases occurred on the patient’s left side, whereas seven cases occurred on the right side (left : right Iliac vein compression syndrome was confirmed in 86 DVT patients by a venography after the aspiration or mechanical thrombectomy, in which, 71 cases occurred on the patient’s left side, whereas 15 cases occurred on the right side (left : right = 4.7 : 1). Of the 86 diagnosed cases of DVT, 26 were of the central type (involving the common iliac, external iliac and common femoral vein) Endovascular Treatment for Iliac Vein Compression Syndrome
and red, or less than 14 days of symptoms.
According to the DSA road map or ultrasound guidance, All patients were observed using a blood coagulation followed by other procedures described above, 11 central function monitor when practicing anticoagulation and type DVT cases (> 2 weeks, without fresh thrombosis) thrombolytic therapy. We injected the patients with low experienced a punctured popliteal vein. Next, a self- molecular heparin (Nadroparin, GlaxoSmithKline, Tianjin, expandable stent was implanted. The distal end of the stent China) twice a day for 3-5 days (4,100 IU abdominal subcutaneous injection) as well as Warfarin (1.25-5.00 mg In the 23 mixed DVT cases (> 2 weeks, without fresh orally) once per day for 1-6 months. We treated patients thrombosis), the femoral vein in the normal side or the implanted with a permanent filter with warfarin for a right internal jugular vein was accessed for the implanta- longer time than patients with temporary filters. For tion of the catheter into to iliofemoral vein, followed by a patients with fresh thrombus who were undergoing percutaneous transluminal angioplasty (PTA) in the lesion.
thrombus aspiration or mechanical thrombectomy, we kept In 13 of the 23 cases, which experienced higher blood flow a multi-sidehole catheter for 3-5 days of thrombolysis in femoral or external iliac vein, a self-expandable stent and/or 5-7 days of antegrade thrombolysis. We adminis- was implanted. The remaining 10 cases with lower blood tered a daily urokinase dose of approximately 250,000- flow in the femoral vein, we only performed a PTA to 1,000,000 units. In addition, the patient took a 75-300 mg daily dose of Aspirin for 6-12 months. We also monitored If fresh thrombus was found in central DVT patients (15 for blood coagulation to provide evidence for adjustments case), a retrievable filter (n = 8) was inserted in patients with less than 14 days of symptoms or a permanent filter(n = 7) in patients with more than 14 days of symptoms via Assessment of Effect
the contralateral femoral vein, jugular vein or antecubital Seventy-eight cases had follow-up data. Each patient was vein. After accessing the popliteal vein, we advanced the followed by clinical symptom (edema and pain) at 1, 3, 6 H1 catheter and guide wire through the stenosis lesion, up and 12 months after discharge and annually thereafter. At to the inferior vena cava. In addition, we exchanged in a six months after discharge, we performed a venography.
long sheath or guiding catheter, through which we The average follow-up period was 10.2±0.3 months suctioned the thrombosis in the iliac and femoral veins.
(range: 0.5-3.0 yrs). We lost 47 cases to follow-up. Based When a relatively large quantity of thrombosis was on the comparison of the symptoms and the venography present, we performed a mechanical thrombectomy via a performed prior to and six months after discharge, the Clot Buster Thrombectomy Device (ev3, Plymouth, MN) clinical effect was graded into four classes as follows: or a Straub Rotarex system (SRS, Straub Medical AG, Excellent: disappearance of edema and pain; blood flow Switzerland). Next, we performed PTA and self-expand- completely restored on venography; disappearance of collateral vein; no contrast stasis; and the vessel wall was If fresh thrombus was found in the mixed DVT patients smooth. Good: edema and/or pain; blood flow completely (37 cases), a retrievable filter (n = 9) was inserted in restored on venography; no collateral vein remained; no patients with less than 14 days of symptoms, or a contrast stasis; and the vessel wall was smooth. Moderate: permanent filter (n = 28) in patients with more than 14 edema and/or pain; blood flow partially restored (greater days of symptoms via contralateral femoral vein. We used than 50% patency rate in stent) on venography; collateral a C3 catheter (Cordis Corporation, Miami, FL) through the vessels remained; contrast stasis or the vessel wall was not filter carrier sheath to find the mouth of the affected smooth. Poor: no improvement of symptoms; no recovery common iliac vein. Once the catheter attained the external of blood flow on venography; collateral vein was the main iliac vein, a H1 catheter was exchanged in and advanced down to the femoral-popliteal vein, followed by exchang- Group 1 included IVCS patients without thrombosis, ing in an 8 Fr long sheath (Arrow International Inc., whereas group 2 included IVCS patients with fresh Reading, PA), through which thrombosis suction was thrombus and group 3 included IVCS patients with non- performed in the popliteal, femoral and iliac vein using the fresh thrombus and the effect of the procedure was 8 Fr guiding catheter (Cordis Corporation, Miami, FL). If assessed for each group, respectively.
excessive residual thrombus was present, we performed amechanical thrombectomy (such as Clot Buster thrombec- Definition
tomy device or SRS). Next, we performed a PTA and self- We defined a technical success as the restoration of expandable stenting for the residual stenosis found in the continuous inline flow with the abolition of collaterals Lou et al.
through the femoral and iliac vein segment into the inferior (97.4%) had stenting in the iliac vein stenosis (n = 20) and vena cava. We defined an effective case as a complete or a occlusion (n = 18) (Fig. 1), either at pre-stent balloon greater than 50% patency rate for the stenting, and dilatation (n = 21) or post-stent dilatation (n = 6). In one included patients classified as excellent, good and case, the catheter and wire failed to pass the lesion, which moderate. Patency was defined as the inline flow through rendered PTA and stenting impossible. The clinical evalua- the implanted stent segment, into the inferior vena cava, tions before discharge were classified as: “Excellent” - 21 without contrast stasis and emptying delay, and including (53.8%), “Good” - 16 (41.0%), “Moderate” - one (2.6%), patients classified as “excellent” and “good”.
and “Poor” - one (2.6%). Overall, the effective rate was We performed all statistical calculations using the SPSS 97% (38 of 39 cases), and the patency rate was 95% (37 software package, version 13.0 (SPSS Software Inc, of 39 cases). In 27 of 39 cases (69.2%), patients were kept Chicago, IL). We used the 2 test to determine the presence for obtaining follow-up data. The assessment of the effect of a statistical difference. For the three groups, we used a at six months after discharge was as follows: 16 (59.3%) p-value of less than 0.05 as a threshold for statistical signif- patients were “Excellent”; nine (33.3%) patients were icance, and a p-value of less than 0.05 to indicate a statisti- “Good”; one (3.7%) patient was “moderate” and 1 (3.7%) cal difference between the two groups.
patient was “poor”. The effective rate was 96% (26 of 27cases) and the patency rate was 93% (25 of 27 cases).
Among the 86 IVCS cases with iliofemoral vein thrombosis, we performed a thrombosis aspiration or The overall technical success rate of the treatment was mechanical thrombectomy in 83 cases (96.5%). Further, 97% (121 of 125 cases). Moreover, the balloon diameter we performed PTA (n = 67) and stenting (n = 73) in cases ranged from 8 to 12 mm, with a length ranging from 20 to of stenosis or occlusion of the iliac vein (Fig. 2), both at 40 mm. The stent diameter ranged from 10 to 16 mm, with pre- and post-stent dilatation (post-stent performed in one patient). The catheter and wire failed to pass the occlusion Among the 39 IVCS cases belonging to group 1, 38 in three cases. This rendered the mechanical thrombec- Table 2. Effective Rate and Patency Rate Comparison at Discharge (n = 125)
Note.─ Group 1 = iliac vein compression syndrome without thrombosis, group 2 = iliac vein compression syndrome with fresh thrombosis, group 3 = iliac vein compression syndrome with non-fresh thrombosis. No significant difference in patency rates were observed between group 1 and group 2 ( 2 = 0.483,p = 0.487). Conversely, significant difference was observed for patency rate between group 1 and group 3 ( 2 = 10,664, p = 0.001) and between group 2and group 3 ( 2 = 7,010, p = 0.008).
Table 3. Effective Rate and Patency Rate Comparison at Six Months Follow-up (n = 78)
Note.─ Group 1 = iliac vein compression syndrome without thrombosis, group 2 = iliac vein compression syndrome with fresh thrombosis, group 3 = iliac vein compression syndrome with non-fresh thrombosis. No significant difference was observed for patency rates between group 1 and group 2 ( 2 = 0,501,p = 0.479). Conversely, significant difference was observed for patency rates between group 1 and group 3 ( 2 = 11,282, p = 0.001) and between group 2and group 3 ( 2 = 6,235, p = 0.013).
Endovascular Treatment for Iliac Vein Compression Syndrome
tomy, PTA and stenting impossible, and consequently, condition, five (22.7%) were in “good” condition; seven thrombus aspiration only was performed for these three (31.8%) were in “moderate” condition and four (18.2%) patients. Twelve of the 17 retrievable filters were retrieved were in “poor” condition. The effective rate was 82% and within 10 days of the procedure, whereas the other five the patency rate was 50%. A detailed assessment is filters were kept inside because the thrombus lot was The initial effective rate between the three groups Of the clinical evaluations of patients belonging to group revealed no significant difference (p = 0.573). However, 2 (n = 52) performed before discharge, 20 (38.5%) were in the difference in the initial patency rates between groups “excellent” condition, 26 (50.0%) were in “good” were found to be statistically significant (p = 0.001).
condition, five (9.6%) were in “moderate” condition, and Moreover, the initial patency rates of group 1 (94.9% vs.
one (1.9%) patient was in “poor” condition. The effective 64.7%, p = 0.001) or group 2 (88.5% vs. 64.7%, p = rate was 98% and the patency rate was 89%. Moreover, 0.008) was greater than the patency rate recorded in group 29 of the 52 (55.8%) patients belonging to group 2 were 3. No significant difference was found for the initial followed-up. At six months after being discharged, nine patency rate between group 1 and group 2 (94.9% vs.
(31.0%) patients were in “excellent” condition, 15 88.5%, p = 0.487). Consistently, the results from the six (51.7%) were in “good” condition, four (13.8%) were in month follow-up period were similar, with no significant “moderate” condition and one (3.4%) patient was in difference in the effective rate between the three groups (p “poor” condition. The effective rate was 97% and the = 0.093). Further, a more favorable patency was observed patency rate was 83%. The clinical evaluation of the in group 1 (92.6% vs. 50.0%, p = 0.001) and group 2 patients belonging to group 3 (n = 34) before discharge (82.8% vs. 50.0%, p = 0.013).
found that eight (23.5%) patients were in “excellent”, 14 No complications (i.e. bleeding and hematoma, stent (41.2%) were in “good” condition, 10 (29.4%) were in migration, acute thrombosis) occurred during the stenting “moderate” condition and two (5.9%) were in “poor” procedure. Moreover, no cases of pulmonary embolism condition. The effective rate was 94% and the patency rate (PE) were recorded for all 125 patients (in hospital) and was 65%. Of the 34 patients belonging to group 3, 22 the 78 patients from the procedure to the 6-month follow- (64.7%) possessed follow-up data. The six month follow- up period. We observed one case of inferior vena cava up indicated that six (27.3%) patients were in “excellent” obstruction from a patient with an inferior vena cava filter Fig. 1. Treatment of iliac vein compres-
sion syndrome without deep vein
thrombosis.
A. Venography showing compressed
left common iliac vein (black arrow) and
contralateral venous drainage via pelvic
venous collaterals (white arrow).
B. Venography after stenting showing
widely patent left common iliac vein.
Lou et al.
6-month post-treatment angiogram results). However, we Of the 12 patients with a confirmed IVCS during a restored the inferior vena cava blood flow following preoperative examination for the stripping or endovascular aspiration and a mechanical thrombectomy. In two IVCS closure of the great saphenous vein symptoms were patients with recurrent DVT present (3 and 6 months after relieved in four cases within 3-6 months. The other eight discharge follow-up evaluation showing the in-stent cases experienced no remarkable improvement. We obstruction), blood flow was successfully restored in one performed five laser and radiofrequency closures in the case by PTA and not in the other due to the inability to great saphenous. For the follow-up period, all 12 patients pass the catheter and wire beyond the obstruction. were free of the symptoms associated with DVT. Leg Fig. 2. Treatment of iliac vein compres-
sion syndrome with deep vein thrombo-
sis.
A. Venography showing thrombosis
(fresh thrombus and 8 days after onset)
and occlusion of left iliofemoral vein as
well as contralateral venous drainage
via pelvic venous collaterals.
B. Venography after thrombectomy and
stenting showing patent left femoral vein
and in-stent stenosis due to iliac vein
compression (black arrow).
C. Venography after intra-stent percuta-
neous transluminal angioplasty showing
widely patent left common iliac vein.
D. Venography one year after retrieval
of filter showing remaining patent inferior
vena cava and left iliofemoral vein.
Endovascular Treatment for Iliac Vein Compression Syndrome
swelling was diminished after PTA and stenting in nine and Neglen (9) proposed that the development is probably cases in which IVCS was found by venography because of a slow, progressive condition. Fluid balance in the limb is aggravation of symptoms after great saphenous vein on the edge during orthostasis; however, many patients surgery. The remaining 18 cases with isolated IVCS remain asymptomatic until the progressive hemodynamic showed an improvement in symptoms in 16 cases.
deterioration across a certain critical threshold includingsurgery as well as pregnancy and prolonged immobiliza- DISCUSSION
tion had been mentioned as contributory factors contribut-ing to patients with asymptomatic lesions and should be Iliac vein compression is a frequent anatomic variant.
educated and followed-up on closely for the early identifi- The right common iliac artery crosses over the left cation of acute occlusion. From the accounts above, we common iliac vein and then reaches the outside of right emphasize that the evaluation of the iliac vein in the iliac vein, where it continues to the right external iliac patients presenting with unilateral lower extremity edema artery, which is parallel to the right external iliac vein, and/or varicose veins, especially in the preoperative behind the left iliac vein there are sacral promontory or the examination of the great saphenous stripping and early fifth lumbar vertebra. The causes of IVCS include the recognition of iliac vein compression, which may prevent a combination of compression and vibratory pressure in the right iliac artery on the iliac vein, which results in the The successful treatment of IVCS would involve a pinching of the iliac vein between the artery and the pelvic combination of several interventional techniques to bone. The two walls of the vein rub against each other, remove as much of the iliofemoral vein thrombosis as which lead to irritation of the endothelium. Moreover, this possible. Thus, deep vein blood flow can be restored and irritation led to the proliferation of the endothelium, the course can be shortened. Also, it can prevent or reduce synechiae or spurs and the formation of a partition in the the valve dysfunction of the popliteal and calf vein, as well lumen. Further, it may cause chronic symptoms of left-side as reduce the incidence of post thrombosis syndrome. A venous hypertension including edema, leg heaviness, skin clot Buster thrombectomy device and SRS work well with discoloration, pain, varicose veins or ulceration. In the acute thrombus present in iliofemoral vein (10-14).
addition, it may frequently lead to thrombosis when the SRS is also effective in dealing with subacute iliofemoral stenosis of the iliac vein is greater than 50%. IVCS and thrombosis. An endovascular mechanical thrombectomy, subsequent thrombosis occurs more commonly on the left combined with guiding catheter suction, can substitute side. In our study, IVCS occurred 4.6 times more most of the surgical embolectomy. However, neither the frequently on the left side than the right side, whereas Clot Buster thrombectomy device nor the SRS can be used IVCS with thrombosis occurred 4.7 times more frequently to deal with DVT bellow popliteal vein, which needs on the left side than the right, This difference in frequency embolectomy from posterior tibial vein incision.
suggests that the results are consistent with the published The use of an inferior vena cava filter to prevent fatal PEs is still controversial, Decousus et al. (15) published the It is difficult to find isolated iliac vein compression only randomized study for vena cava filters in 1998. The without thrombosis in a clinical setting, but it does not results indicated that a significant decrease in the incidence indicate the low incidence of iliac vein compression.
of PE compared with anticoagulation alone (1.1% vs.
Recent imaging reports have demonstrated that at least a 4.8%, p = 0.03) at 8 to 12 days of follow-up. After two 25% compression of the left iliac vein at the arterial years, this difference was no longer statistically significant crossover point may be present in 66% of the asympto- (3.4% vs. 6.3%, p = 0.16). In contrast, vena caval filters matic patient population (8). This correlates with nearly a were associated with significantly more recurrent DVT 50% reduction in the total cross-sectional areas of the vein.
than anticoagulation alone (20.8% vs. 11.6%, p = 0.02). If Previous reports have suggested that this anatomic variant there are large amounts of fresh thrombus in the may predispose the formation of deep venous thrombosis.
iliofemoral vein before PTA, an inferior vena cava filter Virchow’s Triad describes an increased risk of venous should be inserted to prevent of thrombus shedding, which thrombosis with stasis, hypercoagulability and vessel may lead to a fatal PE (16-18). There are many different intimal injury, the first of which is present with any venous types of inferior vena cava filters; the retrievable filter may obstruction disease including IVCS. There is evidence to be the best choice for acute thrombosis since it can be suggest that intimal injury may also take place in the form retrieved after thrombolysis or a thrombectomy to prevent of a spur when the compression occurs over time. These will increase the risk for the development of DVT. Raju Recent reports have shown that stenting of the iliac vein Lou et al.
obstruction and venous spur is feasible and safe, and may thrombosis caused by May-Thurner syndrome. J Vasc Interv improve the long-term outcome of patients after a 3. Bulger CM, Jacobs C, Patel NH. Epidemiology of acute deep thrombectomy or thrombolysis of left-side acute DVT (19- vein thrombosis. Tech Vasc Interv Radiol 2004;7:50-54 23). In this series, both the initial and six month patency 4. Juhan C, Miltgen G, Barthe′le′my P, Ayuso D. Treatment of ilio- rates in IVCS patients, without thrombus or with fresh femoral venous thromboses with surgical thrombectomy. Bull thrombus, had significantly greater patency rates than IVCS patients with non-fresh thrombus. This demonstrates thrombectomy for iliofemoral vein thrombosis-10-year results that the early recognition and management of iliac vein of a prospective randomized study. Eur J Vasc Endovasc Surg compression would achieve a more favorable outcome. In addition, we mentioned that some patients did not experi- 6. Grossman C, McPherson S. Safety and efficacy of catheter- ence complete symptomatic relief, even though the patient directed thrombolysis for iliofemoral venous thrombosis. AJR achieved complete patency for the iliofemoral vein. We 7. Mewissen MW, Seabrook GR, Meissner MH, Cynamon J, believe that this may be attributed to an increase in venous Labropoulos N, Haughton SH. Caterter-directed thrombolysis reflux after iliofemoral stenting (24, 25). Delis et al. (24) for lower extremity deep venous thrombosis: report of a reported successful patency results after stenting, despite national multicenter registry. Radiology 1999;211:39-49 the deterioration of reflux and improved venous claudica- 8. Kibbe MR, Ujiki M, Goodwin AL, Eskandari M, Yao J, tion associated with successful stent recanalization in the Matsumura J. Iliac vein compression in an asymptomatic patientpopulation. J Vasc Surg 2004;39:937-943 limbs, which normalizes venous outflow, enhances the calf 9. Raju S, Neglen P. High prevalence of nonthrombotic iliac vein muscle pump function and leads to a significant improve- lesions in chronic venous disease: a permissive role in ment in clinical outcome. We suggest that the enhanced pathogenicity. J Vasc Surg 2006;44:136-144 postoperative stocking is pivotal in preventing disease 10. Sharafuddin MJ, Gu X, Han YM, Urness M, Gunther R, progression and outcome improvement.
Amplatz K. Injury potential to venous valves from the Amplatzthrombectomy device. J Vasc Interv Radiol 1999;10:64-69 The limitations of this study involve its retrospective 11. Delomez M, Beregi JP, Willoteaux S, Bauchart JJ, Janne d’Othe′e nature, the limited number of isolated iliac vein compres- B, Asseman P, et al. Mechanical thrombectomy in patients with sion patients evaluated, and the relatively short follow-up deep venous thrombosis. Cardiovasc Intervent Radiol period. These lower the relevance among iliac vein compression, incidence of deep venous thrombosis due to 12. Vedantham S, Vesely TM, Parti N, Darcy M, Hovsepian DM, Picus D. Lower extremity venous thrombolysis with adjunctive iliac vein compression, and the success of early treatment mechanical thrombectomy. J Vasc Interv Radiol 2002;13:1001- in relation to the longer-term outcome. Thus, we need to perform a prospective control study with a large sample 13. Frisoli JK, Sze D. Mechanical thrombectomy for the treatment of lower extremity deep vein thrombosis. Tech Vasc Interv In conclusion, the data obtained from the evaluated 14. Sharafuddin MJ, Sun S, Hoballah JJ, Youness FM, Sharp WJ, patients suggest that endovascular treatment for IVCS, Roh BS. Endovascular management of venous thrombotic and with or without thrombosis, is safe and effective. This occlusive disease of the lower extremities. J Vasc Interv Radiol study shows a superior patency rate in IVCS patients without thrombosis and with fresh thrombosis when 15. Decousus H, Leizorovicz A, Parent F, Page Y, Tardy B, Girard compared to IVCS patients with non-fresh thrombosis. We P, et al. A clinical trial of vena caval filters in the prevention ofpulmonary embolism in patients with proximal deep-vein suggest the reconstruction of the evaluation for the thrombosis. N Engl J Med 1998;338:409-415 occurrence of iliac vein compression in patients with unilat- 16. Yamagami T, Kato T, Iida S, Hirota T, Nishimura T. Gunther eral lower extremity edema and preoperative examina- tulip inferior vena cava filter placement for deep venous tions indicating the presence of varicose veins. Early thrombosis of the lower extremity. Cardiovasc Intervent Radiol recognition and endovascular treatment of iliac vein 17. Rosenthal D, Wellons ED, Lai KM, Bikk A, Henderson VJ.
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