Unexpected major role for venous stenting in deep reflux

A forum to discuss Chronic Cerebrospinal Venous Insufficiency and its relationship to Multiple Sclerosis.

Unexpected major role for venous stenting in deep reflux

Postby Sharon » Tue Dec 15, 2009 6:42 pm

This research is not about CCSVI in the CNS, but I thought it was interesting for some of the conclusions which were reached and especially because there has been discussion on the forum about the patency of stents and because of the results shown - quality of life improved significantly.
Unexpected major role for venous stenting in deep reflux disease
Presented at the 2009 Vascular Annual Meeting, Denver, Colo.
Seshadri Raju, MDa, Rikki Darcey, BSb, Peter Neglén, MD, PhDb

Received 8 June 2009; accepted 14 August 2009. published online 14 December 2009.
Corrected Proof

Background
Treatment of chronic venous insufficiency (CVI) has largely focused on reflux. Minimally-invasive techniques to address superficial and perforator reflux have evolved, but correction of deep reflux continues to be challenging. The advent of intravascular ultrasound (IVUS) scan and minimally invasive venous stent technology have renewed interest in the obstructive component in CVI pathophysiology. The aim of this study is to assess stent-related and clinical outcomes following treatment by iliac venous stenting alone in limbs with a combination of iliac vein obstruction and deep venous reflux.

Methods
A total of 528 limbs in 504 patients, ranging in age from 15 to 87, underwent IVUS-guided iliac vein stent placement to correct obstruction over an 11-year period. The etiology of obstruction was nonthrombotic in 196 (37%), post-thrombotic in 285 (54%) limbs, and combined in 47 (9%). Clinical severity class of CEAP was C3 in 44%, C4,5 in 27%, and C6 in 25% of stented limbs. Deep venous reflux was present in all limbs, associated with superficial and/or perforator reflux in 69%. Reflux was severe in 309/528 (59%) limbs (reflux multisegment score ≥3) and 224/528 (42%) limbs had axial reflux. Venography and other functional tests had poor diagnostic sensitivity to detect obstruction, which was ultimately diagnosed by IVUS. The IVUS-guided iliac vein stenting was the only procedure performed and the associated reflux was left uncorrected.

Results
There was no mortality; morbidity was minor. Cumulative secondary stent patency was 88% at 5 years; no stent occlusions occurred in nonthrombotic limbs. Cumulative rates of limbs with healed active ulcers, freedom of ulcer recurrence in legs with healed ulcers (C5), and freedom from leg dermatitis at 5 years were 54%, 88%, and 81%, respectively. Cumulative rate of substantial improvement of pain and swelling at 5 years was 78% and 55%, respectively. Quality of life improved significantly. Reflux parameters did not deteriorate after stenting.

Conclusion
Iliac venous stenting alone is sufficient to control symptoms in the majority of patients with combined outflow obstruction and deep reflux. Partial correction of the pathophysiology in limbs with multisystem or multilevel disease can provide substantial symptom relief. Percutaneous stent technology in concert with other minimally-invasive techniques to address superficial and/or perforator reflux offers such partial correction in limbs with advanced CVI and complex venous pathology. Open correction of obstruction or reflux is now required only infrequently as a “last resort”.

http://www.jvascsurg.org/article/S0741-5214(09)01675-9/abstract

Sharon
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Postby CureIous » Tue Dec 15, 2009 8:48 pm

I like the "intravascular ultrasound" part. What the heck is that? Sounds intriguing! Thanks for digging this up. I know we use iliac and arterial stenting as a platform to peer into the future of vein stenting the jugulars. Not sure if stenting is the answer, or the future for CCSVI, but it sure doesn't hurt to get all the info we can on it either... Thanks again.

Mark.
RRMS Dx'd 2007, first episode 2004. Bilateral stent placement, 3 on left, 1 stent on right, at Stanford August 2009. Watch my operation video: http://www.youtube.com/watch?v=cwc6QlLVtko, Virtually symptom free since, no relap
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Postby cah » Tue Dec 15, 2009 9:37 pm

To me, the important sentence is

no stent occlusions occurred in nonthrombotic limbs"
"There is only one good, knowledge, and one evil, ignorance." Socrates
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Postby Sharon » Wed Dec 16, 2009 6:36 am

Mark - you asked about intravascular ultrasound -- here you go:
Intravascular ultrasound (IVUS) is a medical imaging methodology using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter. The proximal end of the catheter is attached to computerized ultrasound equipment. It allows the application of ultrasound technology to see from inside blood vessels out through the surrounding blood column, visualizing the endothelium (inner wall) of blood vessels in living individuals.

http://en.wikipedia.org/wiki/Intravascular_ultrasound
The IVUS is routinely used to look at the arteries in the heart - the study was using it in the veins.

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