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ProgrammeTopic highlightsVenous nightmares

Venous nightmares

We spoke to Dr. Andrew Wigham to learn more about his presentation at CIRSE 2022.

Watch his lecture in the case-based discussion “Venous nightmares.”

The treatment of both chronic and acute venous disease continues to expand rapidly with the development of multiple new exciting technologies. New thrombectomy devices and dedicated venous stents mean patients can be treated more efficiently with lower procedural risks and potentially improved long-term outcomes. However, the key to successful long-term results remains decision-making including patient selection, accurate assessment of thrombus clearance, in-flow assessment, and knowing when to stent and when not to stent.

 

This case in the ‘Venous nightmares’ session will demonstrate the importance of correct decision-making at each stage of the treatment process. The patient had suffered a left ilio-femoral DVT several years previously which had been managed conservatively. The patient had not been referred or considered for endovascular intervention. He subsequently developed severe PTS with leg ulceration. MRV confirmed occlusion of the left iliac veins and catheter venography was performed to assess the in-flow vessels prior to iliac recanalization and stenting (Fig. 1). This was thought to be adequate to support iliac vein stenting.

 

The patient underwent iliac recanalization and stenting of the iliac veins down to the femoral / profunda confluence (Fig. 2). The stents occluded early requiring CDT to clear. Subsequently, there were three more episodes of stent occlusion. Adequate anti-coagulation was confirmed, and no stent compromise was identified – with poor in-flow deemed the cause for the repeated occlusions. At this stage, the decision was made to extend the stent into the profunda vein (Fig. 3). This started a cycle of symptom improvement, followed by stent fracture or stenosis (Fig. 4) resulting in stent extension more inferiorly into the profunda (Fig. 5), ultimately leading to profunda occlusion which was not salvageable (Fig. 6). The patient’s symptoms returned with recurrent ulceration and limited further endovascular options.

 

Whilst this case does not illustrate an acute, dramatic complication of venous intervention, it does demonstrate how important the combination of sound technique, decision-making, and robust follow-up are in achieving good long-term outcomes. There are several points in this patient’s treatment where different decisions may have improved outcomes, although it should be remembered that techniques and historical treatment algorithms do not necessarily reflect contemporary best practise.

 

The first point to address is the initial decision not to treat this patient acutely with thrombectomy and stenting. At that time, they were not referred for consideration of intervention and even now many patients do not see a doctor with expertise in venous intervention. Up to 50% of patients with proximal DVT will develop PTS [1] and this patient was one of the 10% of iliofemoral DVT patients [2] who go on to develop severe post-thrombotic syndrome (PTS) with ulceration. PTS prediction remains more art than science. Predictive factors for PTS include proximal DVT, increasing age, obesity, recurrent DVT, sub-therapeutic anti-coagulation, and residual thrombus and symptoms beyond 4 weeks [3]. The difficulty with a number of these factors is that by the time they are apparent, the effective window for endovascular treatment has passed. Of note, several of the new thrombectomy devices can effectively remove thrombus beyond the traditional two-week window and this allows patients who present late to be treated effectively. Additionally, in equivocal cases a short period of conservative management can be trialled, safe in the knowledge that effective treatment is possible out to 4 and possibly 6 weeks if required [4].

 

The next decision which can be questioned is the adequacy of the in-flow prior to iliac recanalization and stenting. The initial diagnostic venogram was thought to demonstrate adequate in-flow. (Fig. 1). A classification system proposed by Jalaie’s group [5]. defines the extent of veno-occlusive disease; grade 1 representing focal compression such as May-Thurner, through to grade 5 with post-thrombotic / occlusive changes involving the entire iliac segment, extending into the common femoral, profunda, and femoral veins. It is proposed that patients with grade 5 disease are not suitable for endovascular reconstruction, and grade 4 patients need in-flow optimisation whether endovascular or surgical. Our patient’s disease severity was at least grade 4. Sub-optimal in-flow in chronic venous disease is known to be predictive of stent failure [6].

 

Accurate assessment is challenging and comes with experience. The quandary that we often find ourselves in is that patients with the most severe in-flow disease have the most severe symptoms. In patients with impaired in-flow and severe symptoms, we have now moved to using endovascular techniques to optimise in-flow, such as the ‘ACCESS PTS’ technique [7], utilising a combination of thrombolysis infusion and venoplasty. If adequate in-flow is obtained, we then proceed to recanalization and stenting. It is vital that the patients are invested in the process and understand the need for follow-up and possible re-interventions. If the in-flow is very poor, then we will turn patients down. Another key point is that in-flow damage occurs as a result of the acute event, and whilst waiting to see if patients develop PTS before treating may seem a sensible option, often by the time intervention is considered, the in-flow damage has occurred.

 

Finally; stenting into the in-flow vessels. Whilst there are small cohorts demonstrating reasonable results [8], it is not a durable solution and should only be performed as a last resort.  Importantly, profunda occlusion may precipitate symptom deterioration. Our case highlights the common course of stenting into in-flow vessels; a reasonable venographic result and short-term clinical improvement followed by stent stenosis, occlusion or fracture and symptom recurrence.

 

As our experience and understanding of venous disease have progressed, our approach to this patient would be different now. We have established a centralised electronic referral pathway within our vascular network to ensure all acute iliofemoral DVTs are referred and reviewed for consideration of intervention. Given the diseased in-flow, we would now use endovascular techniques to improve this before potentially proceeding to stenting. Finally, we would probably have avoided stenting into the profunda vein.

 

In summary, this case highlights the continued evolution of our understanding of venous disease. It highlights the importance of decision-making and the need to provide ongoing follow-up and care to these often-complex patients. Talks such as the venous nightmares session enable frank and honest discussions with colleagues from across Europe to learn from each other mistakes, exchange new ideas and continue to improve the quality of care we provide to our venous patients.

Figure 1: Initial diagnostic venogram demonstrating severe post-thrombotic change affecting the iliac segment extending into the CFV. The upper femoral vein is occluded with stenosis of the upper profunda vein.

Figure 2: Venogram following venous recanalization and stenting down to the femoral/profunda confluence.

Figure 3: Stent extension into the profunda vein.

Figure 4: Venogram showing in-stent stenosis of the iliac and profunda stents with a tight stenosis at the lower aspect of the profunda stent.

Figure 5: Stent extended further into the profunda vein.

Figure 6: Venogram demonstrating occluded iliac and profunda stents.

 

Andrew Wigham

 

Oxford University Hospitals, Oxford/GB

 

Dr. Andrew Wigham is an Interventional Radiologist at Oxford University Hospitals NHS Trust. He trained in IR at the Royal Free Hospital in London before being appointed in Oxford. His main interest is in the treatment of deep and superficial venous disease, and he established the deep venous programme in Oxford shortly after his appointment. He was involved in the design of the BSIR National Registry for acute DVT and is currently centre PI for several venous stent trials.

 

References

  1. Vedantham S, Goldhaber SZ, Julian JA, Kahn SR et al ATTRACT Trial Investigators. Pharmacomechanical Catheter-Directed Thrombolysis for Deep-Vein Thrombosis. N Engl J Med. 2017 Dec 7;377(23):2240-2252.
  2. Kahn SR, Comerota AJ, Cushman M, et al; American Heart Association Council on Peripheral Vascular Disease, Council on Clinical Cardiology, and Council on Cardiovascular and Stroke Nursing. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation. 2014;130(18):1636-1661.
  3. Kahn SR, Shrier I, Julian JA, et al. Determinants and time course of the post-thrombotic syndrome after acute deep venous thrombosis. Ann Intern Med. 2008;149(10):698-707.
  4. Dexter D, Kado H, Schor J, Annambhotla S et al. Interim outcomes of mechanical thrombectomy for deep vein thrombosis from the All-Comer CLOUT Registry, Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2022, Vol 10 (4) 832-840.e2,
  5. Jalaie H, Barbati M, Gombert A, Kotelis D et al. Endovenous Treatment of Chronic Venous Obstruction. Phlebologie 2021; 50(03): 215-221
  6. Criteria to predict mid-term outcome after stenting of chronic iliac vein obstructions (PROMISE trial) Hügel U, Khatami F, Muka T, Koeckerling D et al. Journal of Vascular Surgery: Venous & Lymphatic Disorders (Published online Aug 2022) doi.org/10.1016/j.jvsv.2022.05.018)
  7. Garcia M, Sterling K, Kahn S Comerota A et al. Ultrasound-Accelerated Thrombolysis and Venoplasty for the Treatment of the Postthrombotic Syndrome: Results of the ACCESS PTS Study. Journal of the American Heart Association. 2020 9. e013398. 10.1161
  8. Raju S, Cooper L, Powell T, Saleem T et al. Extension of iliac vein stent into the profunda femoral vein for salvage.  Journal of Vascular Surgery: Venous and Lymphatic Disorders, (Published on-line May 2022) org/10.1016/j.jvsv.2022.03.016