Authors
Shevchenko Yu.L., Litvinov A.A., Stoyko Yu.M., Marchak D.I., Ermakov D.Yu.
St. George thoracic and cardiovascular surgery clinic Pirogov National Medical and Surgical Center, Moscow
Abstract
Deep vein thrombosis (DVT) and its associated post-thrombotic syndrome (PTS) represent a significant medical and social challenge, particularly in cases involving the iliofemoral venous segment. Approximately 70% of patients with proximal venous thrombosis experience complete occlusion or partial recanalization, leading to persistent venous outflow obstruction and progression of PTS. Current treatment methods, including endovascular desobstruction and venous stenting, show mixed clinical results, highlighting the need to study the risk factors affecting the efficacy of these interventions.
Objective: To evaluate the effectiveness and safety of endovascular treatment in patients with post-thrombotic proximal obstruction of the iliofemoral venous segment of varying lengths.
Materials and Methods: This retrospective study included 99 patients with PTS complicated by post-thrombotic obstruction of the iliofemoral venous segment who underwent venous stenting between 2016 and 2024. Patients were divided into two groups based on the length of the iliofemoral segment occlusion. Clinical assessment was conducted using the international CEAP classification and clinical questionnaires such as Villalta, VCSS, and CIVIQ-20. The primary outcomes of treatment effectiveness were reductions in scores on the Villalta, VCSS, and CIVIQ-20 scales, as well as confirmation of patency of the stented iliofemoral segment via ultrasound duplex scanning three months post-discharge.
Results: Technical success of stenting was achieved in all patients across both groups. Both groups showed statistically significant improvements in clinical scores (Villalta, VCSS, CIVIQ-20; p<0.001). In the early postoperative period, stent patency was 93.2% in Group I (localized occlusion) and 83.3% in Group II (extensive occlusion). Key risk factors for stent thrombosis in the early postoperative period were identified: occlusion involving more than one venous segment and peak blood flow velocity below 13 cm/s.
Conclusion: Endovascular stenting of the iliofemoral segment is an effective and safe treatment for patients with obstructive lesions and severe PTS. However, the risk of postoperative thrombosis remains high, particularly in cases of extensive obstructive lesions. Peak blood flow velocity within the stent zone is a significant prognostic factor for thrombosis, emphasizing the need for a personalized approach to patient management.
Keywords: рost-thrombotic disease, venous obstruction, venous stenting, endovascular recanalization.
References
1. Shevchenko JuL., Stojko JuM. Klinicheskaja flebologija. Moscow: DPK Press, 2016 (In Russ.)
2. Heit JA, Spencer FA, White RH. The epidemiology of venous thromboembolism. J Thromb Thrombolysis. 2016; 41(1): 3-14. doi: 10.1007/ s11239-015-1311-6.
3. Khanna AK, Singh S. Postthrombotic syndrome: surgical possibilities. Thrombosis. 2012; 2012: 520604. doi: 10.1155/2012/520604.
4. Vedenskij AN. Posttromboticheskaja bolezn’. L.: Medicina, 1986. (In Russ.)
5. 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. doi: 10.1161/CIR.0000000000000130.
6. Zollikofer CL, Largiader I, Bruhlmann WF, Uhlschmid GK, Marty AH. Endovascular stenting of veins and grafts: preliminary clinical experience. Radiology. 1988; 167(3): 707-712. doi: 10.1148/radiology.167.3.2966417.
7. Elson JD, Becker GJ, Wholey MH, Ehrman KO. Vena caval and central venous stenoses: management with Palmaz balloon-expandable intraluminal stents. J Vasc Interv Radiol. 1991; 2(2): 215-223. doi: 10.1016/ s1051-0443(91)72285-9.
8. Savel’ev BC. Sovremennye napravlenija v hirurgicheskom lechenii hronicheskoj venoznoj nedostatochnosti. Flebolimfologija 1996; 1: 5-7. (In Russ.)
9. Palma EC, Esperon R. Vein transplants and grafts in the surgical treatment of the postphlebitic syndrome. J Cardiovasc Surg (Torino). 1960; 1: 94-107.
10. Dale WA. Reconstructive venous surgery. Archives of surgery (Chicago, Ill.:1960). 1979; 114(11), 1312-1318. doi: 10.1001/archsurg.1979.01370350114013.
11. May R, Weber J. Pelvic and abdominal veins: progress in diagnosis and therapy. Excerpta Medica. Amsterdam. 1981. Р.192-197.
12. Halliday P, Harris J, May J, Bergan J, et al. Surgery of the veins. Femoro-femoral cross over grafts (Palma operation): a long-term follow-up study. Orlando: Grune & Statton. 1985.
13. Gloviczki P, Oderich GS. Open surgical reconstructions for non-malignant occlusion of the inferior vena cava and iliofemoral veins. In: Gloviczki P, ed. Handbook of Venous Disorders. Third edition. London: Hodder Arnold. 2009. Р.514-522.
14. Vedenskij AN, Stojko JuM, Sabel’nikov VV. Perekrestnoe autovenoznoe shuntirovanie pri odnostoronnih okkljuzijah podvzdoshnyh ven. 1997; 4: 11-26. (In Russ.)
15. Raju S. Best management options for chronic iliac vein stenosis and occlusion. J Vasc Surg. 2013; 57(4): 1163-1169. doi: 10.1016/j.jvs.2012.11.084.
16. Litvinov АА Comparative characteristics of venous stents. Bulletin of Pirogov National Medical & Surgical Center. 2021; 16(2): 98-104. (In Russ.) doi: 10.25881/20728255_2021_16_2_98.
17. Razavi MK, Jaff MR, Miller LE. Safety and Effectiveness of Stent Placement for Iliofemoral Venous Outflow Obstruction: Systematic Review and Meta-Analysis. Circ Cardiovasc Interv. 2015; 8(10): e002772. doi: 10.1161/ CIRCINTERVENTIONS.115.002772.
18. Seager MJ, Busuttil A, Dharmarajah B, Davies AH. Editor’s Choice. A Systematic Review of Endovenous Stenting in Chronic Venous Disease Secondary to Iliac Vein Obstruction. Eur J Vasc Endovasc Surg. 2016; 51(1): 100-120. doi: 10.1016/j.ejvs.2015.09.002.
19. Qiu P, Zha B, Xu A, et al. Systematic Review and Meta-Analysis of Iliofemoral Stenting for Post-thrombotic Syndrome. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery. 2019; 57(3), 407-416. doi: 10.1016/j.ejvs.2018.09.022.
