Stenting has unexpected major role in venous reflux disease


Investigators say research presented at the 63rd Annual Meeting of the Society for Vascular Surgery, Denver, USA, is the basis for a new paradigm in the treatment of chronic venous insufficiency.

Seshadri Raju, principal investigator, and other researchers from the University of Mississippi and River Oaks Hospital, Jackson, USA, have found that stenting in iliac veins can significantly alleviate the symptoms of chronic venous insufficiency (CVI) by addressing the underlying obstructive deep vein lesions found in many of the patients with the condition.

“ Iliac vein obstructions should be considered and investigated in chronic venous disease, and our study demonstrates a new paradigm of treating venous disease replacing traditional open techniques with minimally invasive procedures,” says Raju.

Researchers said intravascular ultrasound has shown that obstructive deep vein lesions are found in more than 90% of CVI patients with severe symptoms. In about half of the cases, obstruction is caused by prior blood clots. In the other half, non-thrombotic mechanisms previously thought to be relatively rare, were the cause of blocking. Deep valve reflux is commonly present as well in both types of obstruction.

Combined obstruction/reflux is often present in CVI of post-thrombotic or primary aetiologies. Substantial symptom relief is obtained by percutaneous stenting alone. CVI responds to partial correction of combined pathology with stent and the residual reflux is well-tolerated, said Raju.

Raju and team presented on how patients with severe symptoms of CVI can be treated with newer, minimally invasive stent treatment technology alone. This outpatient procedure incorporates stent placement in iliac veins which are major venous drainage pathways from the lower limbs and are important sources of deep venous obstruction.

Investigators reviewed 513 intravascular iliac stenting procedures performed from 1997 to 2008, at their institution in CVI patients with associated deep vein reflux.

Using intravascular ultrasound, the researchers determined that patients limbs had either primary non-thrombotic (42%) or post-thrombotic (58%) reflux, with 58% of cases classified as severe (reflux segment = 3 and/or axial reflux).

Cumulative stent patency was 100% for non-thrombotic iliac vein lesions at six years, and 87% for post-thrombotic vein lesions. Complete pain relief occurred in 83% (cumulative) of the patients, with complete relief of swelling in 46% (cumulative). Also, complete healing of leg ulcers/freedom from recurrence was 63% (cumulative) at five years. Clinical outcomes were similar between non-thrombotic and post-thrombotic limbs, as well as severe and lesser reflux subgroups.

“Clinical results were impressive after stent placement alone and symptoms were so greatly relieved that further correction of the refluxing valves was not found to be necessary. Complete relief of pain was noticed in 83% of patients which was sustained long-term. Also, at six years, swelling disappeared in 46%t of patients and was improved significantly in an additional 25% of patients. A total of 63 percent of leg ulcers remained healed at five years after the procedure and quality of life measures also were improved.”

Raju explained that deep vein reflux is usually treated with complex open surgery, which is only available at a few specialty centers. On the other hand, stenting, which is a much simpler procedure, is more widely available.

“This research is a basis for a new paradigm in the treatment of CVI, he said. “Clinical results were impressive after stent placement alone and symptoms were so greatly relieved that further correction of the refluxing valves was not found to be necessary.”