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The Incidence of Contralateral Iliac Venous Thrombosis After Stenting Across the Iliocaval Confluence in Patients with Acute or Chronic Venous Outflow Obstruction
Xzabia A. Caliste, MD, Amanda L. Clark, BS, John P. Cullen, PhD, Craig Narins, MD, Ankur Chandra, MD, Jennifer Ellis, MD, Jason Kim, MD, Michael Singh, MD, David L. Gillespie, MD.
University of Rochester Medical Center, Division of Vascular Surgery, Rochester, NY, USA.
Objective: Percutaneous transluminal angioplasty and stenting of the iliac veins is becoming a more common method of treating patients with symptomatic lower extremity venous outflow obstruction. Several questions as to the conformation of these stents remain to be answered. One in particular is whether these venous stents should extend into the vena cava or stop short of this in fear of causing further harm to the patient’s contralateral leg.
Method: We retrospectively reviewed prospectively collected data from 2008-2012, in patients with symptomatic iliocaval venous thrombosis that underwent percutaneous angioplasty and stenting. Data was collected using the AVF venous stent database variables. Most patients were maintained on full anticoagulation using Warfarin (INR 2-3) or low molecular weight heparin (weight based daily or bid dosing). Patients with first time DVT were anti-coagulated for 6 months on average and those with repeat DVT were maintained on lifelong anticoagulation. Intra-operative anticoagulation was performed using intravenous Heparin. Contralateral thrombosis and patency rates were recorded.
Results: 183 iliocaval stents were placed in 66 patients (median age 43; range 15-80), of which 63 patients experienced thrombosis causing the venous outflow obstruction. 30 patients experienced acute venous thrombosis, 25 chronic, and 9 acute on chronic. 48/66 patients (72.7%) had patent stents noted on Duplex ultrasound at one year, 10 patients have no follow-up data (3 of whom surgery was recently completed, 7 of which were lost to follow up), and 8 patients experienced thrombosis. The majority of patients 45/66 (68%) had stents that extended into the IVC crossing the normal contralateral side. Seven of these patients (15%) suffered new thrombosis of the non-stented contralateral side. Of these 7 patients, 3 were totally noncompliant with their postoperative anticoagulation. Thus 8% of compliant patients had new contralateral thrombosis after stenting across a normal contralateral common iliac vein and into the vena caval wall.
Conclusion: To date there is no consensus whether to stent across the thrombosed common iliac vein into the cava or completely across and into the vena cava. From this data it appears that stenting across the iliocaval confluence can result in a small percentage of contralateral thrombosis despite chronic therapeutic anticoagulation. This data will help us move forward in the development of new technologies and in the treatment of these patients.
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