New Hybrid Procedure Shows Improved Patency Of Iliofemoral Stenting In Patents With Compromised Infrainguinal Inflow Vessels In Post-Thrombotic Chronic Venous Obstruction
Vascular Surgeon Oslo University Hospital Tolvsroed, Vestfold, Norway
Objective: Iliac stenting of post-thrombotic chronic venous obstruction is an established form of treatment with good results, but iliofemoral stenting has had variable success, believed to be due to poor inflow and some have been deterred from stenting below the inguinal ligament all together due to these limitations. We have attempted to optimise inflow by surgically removing post-thrombotic septae in the common femoral vein before iliofemoral stenting before stenting flush at the femoral confluence.
Methods: In a retrospective analysis of our own previously published material (2018), where we performed iliofemoral obstruction stenting, we identified a subgroup of patients (group A) that had compromised infrainguinal inflow vessels. These patients were in that period treated with stenting of the dominant inflow vessel. The stent patency in this group was 58 % after 2 years. Revisiting the MRV pictures of this subgroup showed that choosing a single dominant vessel could exclude other sources of inflow due to post-thrombotic intravenous septae. Consequently, we have changed our approach by introducing a hybrid procedure. This includes an endophlebectomy of a 2 cm segment of the common femoral vein above the femoral confluence, resecting fibrotic tissue and collecting all possible sources of inflow. Then deploying the self-expanding stent flush to the confluence. Here we present a retrospective, preliminary analysis of the first 8 patients (group B) treated with this method during the period September 2018-October 2020. The patients in group B had the same compromised inflow vessels as group A, verified by comparison of all MRV. The patients in group B were 1:1 men and women, median age 51 years (range 28-74 years), and clinical status was categorized based on the CEAP and VCSS. Preoperative MRV was performed on all 8 patients. The post-operative median follow up was 29.5 months (range 17-42 months). Postoperative controls were assessed by duplex ultrasound, and for patients with severe obesity CTV was used.
Results: Endophlebectomy and stent placement was successful in all 8 patients. Early occlusion occurred in 3 patients and mechanical thrombectomy was performed in all of these. In one patient, adjunctive extension of infrainguinal stent was necessary. In another the occlusion was due to HIT, requiring the LMWH to be replaced by Fondaparinuks. One remained occluded. One patient required open surgery to evacuate a hematoma without any consequence for the stenting. Primary patency 3/8, primary assisted patency 4/8 and the secondary patency for this pilot group is 7 out of 8 after 2 years.
Conclusions: Stenting an endophlebectomized common femoral vein above the femoral confluence to secure adequate inflow may improve patency when stenting below the inguinal ligament.