Chapters Transcript Iliac Vein Stenting and management of May-Thurner Course: Venous Thrombosis Update 2024 I want to thank everybody for hanging in there for these um lectures, and I want to thank Doctor Sade and uh some of the other lectures because we're really starting to build on, on some of the ideas that are developing. We want to look at iliac main stenting specifically, and we want to look at the good, bad, and the ugly with the risks and benefits, um, because iliac main stenting right now, and at least in our um in our institution, is becoming the number one cause for ilofemoral thrombosis. I have no conflict of interest. So venous disease is, is, um, more common, 5 times more common as compared to arterial disease worldwide. It accounts for a large portion of the US healthcare costs and also um decreases quality of life. The major two pathophysiologies that are thought to result in venous diseases are reflux and obstruction, and we're gonna be focusing mostly on obstruction, but they may be related. This is just an example of a of a um a relatively new technology to image the iliac veins using intravascular ultrasound, and you can see as we pull the catheter down into the common iliac vein with a big large circle here becomes quite compressed, and this patient not only has a very tight compression of the left common iliac vein, but also the left external iliac vein. We go ahead and have the wire in there already, then we go and put in a stent to disobliterate this stenosis, and the goal of this is to, after you put the stent in, to allow the incremental veins to decompress the leg, help with the venous congestion, help the patient's symptoms, and help heal the wounds. Where's the data supporting this? Well, fortunately, as we discussed before, there is some data, um, with a prospective randomized study that was published in 2018 from Doctor Rossi down down in Brazil, um, where you randomized patients daily stenting as compared to medical therapy and did find that the wounds healed faster and that the patients had increased quality of life. This is just a venogram showing across pelvic collaterals over here where the arrow is, and you can also see the hyper dense area in the on the initial venogram on a patient with a non-thrombotic iliac vein stenosis, what we would call a target sign which we investigated a few years ago. While venograms are important and consider the gold standard, we actually would suggest that intravascular ultrasound should be used for all these patients to diagnose it because the resolution sensitivity and specificity is much better, according to the video trial. At the same time, while venous insufficiency is quite important and DVTs are quite important to, to contribute to these symptoms, we also see both these factors increased with elderly patients. Indeed, the World Health Organization expects within the next couple of years that we're gonna be doubling the number of elderly patients greater than 65, 60 years old, um, and, uh, in 2050. So this is a big concern because this not only contributes to um DVTs but venous insufficiency. Brooklyn is no exception to this. Um, we're actually seeing an increasing number of elderly patients. You can see the numbers here that, um, we have a large community of elderly patients, greater than 80 years old in Brooklyn, one of the largest in all the 5 boroughs, and we're expected to increase this, um, acceleration. So we want to look at the interaction between this elderly population and in and um iliac stenosis, and we decide to look at our experience with iliacine stenting in in the elderly and how do they do? Is it justified putting in iliacine stents in the elderly as compared to the younger patients? So patients, of course, had conservative therapy initially, and if they failed that, then we would offer them um iliac vein stenting as long as they had greater than C3 disease which is leg swelling, lipodermatosclerosis, healed ulcers or or healed or open ulcers, and over a 13 year period, we had about 4400 procedures performed in about 20,002,700 patients. The mean age is what you'd expect with 73 years old, which is significantly higher than the prior literature. Um, Doctor Raju's study looking in Jackson, Mississippi, where his average, average age of the patient is in the 40s. Most of our patients are actually males as compared to the prior data, and our average range, our range of our ages is quite broad. So again, is it worth fixing a 90 year old patient with an iliac stent when we know the complications that that we that Doctor Sade had talked about? Well, maybe it is in certain patients. If you've already tried conservative therapy, they have a recurrent ulcer or, or the ulcer is not getting better, um, despite infrareal procedures, maybe it's worth doing an office-based and a local anesthesia procedure, percutaneous procedure, and even in a 90 year old. So you can see our distribution. We had most of our patients were 60, 70, and 80 years old, but we did have a few non-engenarians and a handful of of of centaurians. Most of the stents indeed were placed in the common iliac vein, which is where Matherne originally described that these lesions would be. However, we did find that some of them were actually on the right side and some of them were in the external iliac vein, again, not what was originally described with the Maitherner papers. What were the distribution for the thrombosis? A lot of them were within 30 days of the procedure. However, if we look further out, even beyond a year, we still see a substantial number of thromboses occurring even after these procedures were performed. So really going back to what Doctor Se was saying that these interventions need to be followed for life because it's a prosthesis, it's a stent placed in the low flow system and these patients need to be continued to be surveilled and examined at least clinically for, for prolonged periods. We had 4630 day thrombosis, and you can see the age of distribution here. When we look at it, we can see that the um that the distribution is equally distributed across ages with p values that were not significant. Maybe it's because we didn't have enough patients that found books within 36, uh, within 30 days, but the bottom line is even in the 90 year olds and the 100 year olds and the 80-year-olds, they actually did fairly well within 30 days of the procedures. When we look at the CP distribution, we can see that most of the patients were C3 and 4, but see if 17% were uh were C6 is with open ulcers. Factors that were not associated with iliac mainsto process within 30 days of race, ethnicity, balloon angioplasty, the stenting, sight of the puncture, number of stents, even with full metal jackets, laterality, um, and wherever you put the stent in the common iliac external iliac didn't seem to make any difference. Based upon these data, we do suggest that there's no significant effect on 30 day thrombosis rate associated with these iliac main stents based upon age, and this even elderly patients preselected non-randomized retrospective data suggests that age did not seem to matter and see didn't seem to matter either. Another point of controversy, however, is looking at the 22 technologies with iliac vein stenting versus venous ablations, and we want to talk a little bit about this because this does offer some opportunity to talk about some of the complications of these venous um procedures that we're doing nowadays. Of course, conservative therapy is the gold standard, compression, compression, compression is the gold standard for these patients. However, the success rates for these patients is only around 20 to 40% in the literature, so some patients do need some intervention. Prior data from the Wall study confirmed and set off the um endovenous revolution worldwide. This is a study done at Morristown 21 years ago by um Doctor Kabnick, who was here for many years, and he randomized patients to radio frequency ablation to, um, and surgery, which was back then the goal of standard, and indeed found that the quality of life early and up to 2 years was improved with the radio frequency ablation. Subsequent data also looked at the laser and again confirmed that endovenous ablation using laser for infraangal veins did very well as compared to surgery also, and these two technologies have become the gold standard for endothermal ablations. Now there are lots of other technologies that have come up also. So we're talking a little bit about endovenous procedures, there's stenting, there's endovenous ablations, which one's better? Now we're starting to get two different camps. We have the stenters who say, you can stent these patients. You stent them, the infrareal reflex goes away. You don't need to do anything else. We have the we have the physicians who are saying, no, no, no, you don't need to fix those iliac vein lesions, you just ablate the veins, fix the reflex, the symptoms go away, the ulcers heal. You don't need to fix the iliac veins. We want to look and to see which one is better. So we looked at our retrospective data in our patients. Over 10, 7 year period, we had 700 patients who failed to improve with their leg swelling. We only limited to leg swelling in this particular data set, and all these patients had both iliac vein stenting and venous ablations, and all of these patients again were non-thrombotic lesions. We asked the patients two questions after they'd completed the procedures. Did your leg swelling get better? 1, and 2, if your leg swelling got better, which procedure helped you more, the stenting or the venous ablations? Very simple, very subjective. The main subjective part is actually what's important because that's what we're talking about with these patients. We want to know how their symptoms go. So the average age was 7 years old again, representative of our patient population in this particular data set, most of the patients were females. It was taken from a data set from 14,000 endomenous ablations performed during this procedure and around 4000 iliac vein stents. The annual um number of patients that we have is around 14,000 annual patient visits at our office, which is open seven days a week and has multiple sites. So the hypothesis is that one procedure is gonna do better. We don't know which one, but we're gonna find out from these patients. So we looked at the data and about 83% of the patients said that their leg swelling got better. 16% said no, our leg swelling didn't get better. 18% of the patients said that both procedures helped them. 23% said the iliac stent had had better improvement with their leg swelling. 24% said the endovenous ablations were better, and 19% said, we're not really sure, doc. So we decided to develop this a little bit more and did a multivariate analysis, and we found that the older patients were more often likely to respond that they were not certain which procedure helped them more. OK, that might be expected. Maybe the 90 year old patient may not be able to pick them, that's fine. But we also found that the younger patients tended to say the endovenous ablation helped with the swelling more, and the older patients suggested that the iliac main lesions, when they were stented resulted in better relief of their swelling. We found no significant differences between gender, laterality, presenting symptoms, and which procedure was performed first, and the average duration between these two procedures was about 5.7 months. So these data probably suggests it may not be black or white as our hypothesis suggested in the beginning, that there may be a comparative role for these two technologies, and the data is fairly broadly distributed and neither procedure may be superior in all patients. However, the age of the patient may play a role in terms of how much better they're going to get, and this may have a, a not only a role in terms of um how better they do in terms of the leg swelling, but in terms of complications. Thank you. Looking forward to the discussion afterwards and questions. Published April 19, 2024 Created by Related Presenters Anil Hingorani, MD View full profile
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