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Clinical improvement after iliac vein stenting stratified by CEAP class

  • Taimur Saleem
    Correspondence
    Corresponding author. The Rane Center for Venous and Lymphatic Diseases, 971 Lakeland Drive, Suite 401, Jackson, MS 39216, Phone: 601-939-4230 Fax: 601-724-5298
    Affiliations
    The Rane Center for Venous and Lymphatic Diseases, 971 Lakeland Drive, Suite 401, Jackson, MS 39216
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Published:August 01, 2022DOI:https://doi.org/10.1016/j.avsg.2022.07.006
      I read with great interest the recent study by Cook PV et al
      • Cooke P.V.
      • Bai H.
      • Cho L.D.
      • Gonzalez C.
      • Vasan V.
      • Dionne E.
      • et al.
      Symptom Relief and Reintervention After Iliac Vein Stenting Stratified by CEAP Clinical Classification.
      published in the Annals of Vascular Surgery which detailed their comprehensive experience with iliac vein stenting (IVS) in patients with advanced Clinical, etiological, anatomical and pathophysiological (CEAP) categories. A few queries and comments of interest are listed below:
      • 1.
        The authors mentioned bilateral access in all cases followed by placement of bilateral access sheaths and diagnostic imaging. How many patients in this cohort had placement of bilateral iliac vein stents (simultaneous and sequential)? In our experience, patients with bilateral symptomatic iliac venous lesions often also experience improvement of the contralateral unstented limb symptoms (95%) after stenting of the worse ipsilateral limb. Therefore, bilateral stenting appears to be very infrequently required.
        • Jayaraj A.
        • Noel C.
        • Raju S.
        Contralateral limb improvement after unilateral iliac vein stenting argues against simultaneous bilateral stenting.
      • 2.
        The criterion of ≥ 50% reduction in cross-sectional area compared to the neighboring vein should be utilized with caution with regards to IVS and is likely extrapolated from arterial literature. Iliac veins demonstrate unique lesions known as Rokitansky lesions which are diffuse lesions. The venographic appearance of such lesions is deceivingly normal. In such cases, the neighboring vein is actually not normal. This can result in undertreatment of the lesion and subsequent placement of undersized stents. This, in turn, creates an iatrogenic stenosis that is often difficult to correct. The stent itself may remain patent but there is often inadequate decompression of peripheral venous hypertension, resulting in little to no improvement in symptoms.
        • Saleem T.
        • Knight A.
        • Raju S.
        Diagnostic yield of intravascular ultrasound in patients with clinical signs and symptoms of lower extremity venous disease.

        Raju S. Ten lessons learned in iliac venous stenting. Endovascular Today. https://evtoday.com/articles/2016-july/ten-lessons-learned-in-iliac-venous-stenting. Accessed on June 30, 2022.

        • Saleem T.
        • Raju S.
        Comparison of intravascular ultrasound and multidimensional contrast imaging modalities for characterization of chronic occlusive iliofemoral venous disease: a systematic review.
      • 3.
        Were patients with iliac vein compression syndrome, such as May-Thurner syndrome, also placed on anticoagulation after stenting? In our experience, anticoagulation is only selectively utilized after stenting for post-thrombotic limbs with a history of recurrent deep venous thrombosis (DVT), cases with poor inflow or outflow, certain thrombophilia conditions and after recanalization of chronic total occlusions.
        • Saleem T.
        • Burr B.
        • Robinson J.
        • Degelman K.
        • Stokes J.
        • Noel C.
        • Fuller R.
        Elevated plasma factor VIII levels in a mixed patient population on anticoagulation and past venous thrombosis.
        • Saleem T.
        Re: comparison of anticoagulation regimens following stent placement for nonthrombotic lower extremity venous disease.
        • Saleem T.
        Re: clinical outcomes and overview of dedicated venous stents for management of chronic iliocaval and femoral deep venous disease.
      • 4.
        How many patients had thermal ablation of superficial veins and IVS performed concurrently?
      • 5.
        How was the need for reintervention determined? Reinterventions for stent compression or in-stent restenosis should be guided by symptoms in addition to imaging findings indicative of stent malfunction. ISR rarely ever progresses to complete stent occlusion (∼10%). Therefore, there is no role for prophylactic angioplasty to correct ISR or stent compression in asymptomatic patients.
        • Saleem T.
        • Raju S.
        An overview of in-stent restenosis in iliofemoral venous stents.
        ,
        • Saleem T.
        In-stent restenosis and stent compression in iliofemoral venous stents.

      Key words

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      References

        • Cooke P.V.
        • Bai H.
        • Cho L.D.
        • Gonzalez C.
        • Vasan V.
        • Dionne E.
        • et al.
        Symptom Relief and Reintervention After Iliac Vein Stenting Stratified by CEAP Clinical Classification.
        Annals of Vascular Surgery. 2022; https://doi.org/10.1016/j.avsg.2022.05.035
        • Jayaraj A.
        • Noel C.
        • Raju S.
        Contralateral limb improvement after unilateral iliac vein stenting argues against simultaneous bilateral stenting.
        J Vasc Surg Venous Lymphat Disord. 2020; 8: 565-571
        • Saleem T.
        • Knight A.
        • Raju S.
        Diagnostic yield of intravascular ultrasound in patients with clinical signs and symptoms of lower extremity venous disease.
        J Vasc Surg Venous Lymphat Disord. 2020; 8: 634-639
      1. Raju S. Ten lessons learned in iliac venous stenting. Endovascular Today. https://evtoday.com/articles/2016-july/ten-lessons-learned-in-iliac-venous-stenting. Accessed on June 30, 2022.

        • Saleem T.
        • Raju S.
        Comparison of intravascular ultrasound and multidimensional contrast imaging modalities for characterization of chronic occlusive iliofemoral venous disease: a systematic review.
        J Vasc Surg Venous Lymphat Disord. 2021; 9: 1545-1556.e2
        • Saleem T.
        • Burr B.
        • Robinson J.
        • Degelman K.
        • Stokes J.
        • Noel C.
        • Fuller R.
        Elevated plasma factor VIII levels in a mixed patient population on anticoagulation and past venous thrombosis.
        J Vasc Surg Venous Lymphat Disord. 2021; 9: 1119-1127
        • Saleem T.
        Re: comparison of anticoagulation regimens following stent placement for nonthrombotic lower extremity venous disease.
        J Vasc Interv Radiol. 2022; 33: 341
        • Saleem T.
        Re: clinical outcomes and overview of dedicated venous stents for management of chronic iliocaval and femoral deep venous disease.
        Vascular. 2022; (17085381221097306)https://doi.org/10.1177/17085381221097306
        • Saleem T.
        • Raju S.
        An overview of in-stent restenosis in iliofemoral venous stents.
        J Vasc Surg Venous Lymphat Disord. 2022; 10: 492-503.e2
        • Saleem T.
        In-stent restenosis and stent compression in iliofemoral venous stents.
        Quant Imaging Med Surg. 2022; 12: 1658-1659