Best practices in diagnosis and treatment of chronic iliac vein obstruction

Iliac vein obstruction occurs in 20-30% of the general population. In patients with severe chronic venous insufficiency, this prevalence can be even higher, reaching 50-90% when the obstruction is investigated using intravascular ultrasound. Less invasive methods, such as venous Duplex Scanning, and even invasive ones such as venography may fail to diagnose the condition. Endovascular treatment of these obstructions is effective, safe, and associated with excellent clinical outcomes and stent patency rates, provided that fundamental anatomical and technical principles are considered and applied.

Keywords:
May-Thurner Syndrome; Cockett Syndrome; iliac vein; venous thrombosis; angioplasty; stenosis; stent

Authorship

Fabio Henrique Rossi

Instituto Dante Pazzanese de Cardiologia de São Paulo – IDPC-SP, São Paulo, SP, Brasil.Instituto Dante Pazzanese de Cardiologia de São PauloBrasilSão Paulo, SP, BrasilInstituto Dante Pazzanese de Cardiologia de São Paulo – IDPC-SP, São Paulo, SP, Brasil.

http://orcid.org/0000-0001-9423-3638

Thiago Osawa Rodrigues

Nilo Mitsuru Izukawa

Centro de Intervenções Endovasculares – CIEV-IDPC, São Paulo, SP, Brasil.Centro de Intervenções EndovascularesBrasilSão Paulo, SP, BrasilCentro de Intervenções Endovasculares – CIEV-IDPC, São Paulo, SP, Brasil.

Antônio Massamitsu Kambara

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

Correspondence Fabio Henrique Rossi Instituto Dante Pazzanese de Cardiologia de São Paulo – IDPC-SP Av. Dr. Amâncio de Carvalho, 182 - Vila Mariana CEP 04012-080 – São Paulo (SP), Brazil Tel.: + 55 (11) 4227-6658 E-mail: vascular369@hotmail.com

Author information FHR - MD, PhD, FMUSP/IDPC; Staff, Cirurgia Vascular Endovascular, Instituto Dante Pazzanese de Cardiologia; Coordinator, Disciplina de Pós-Graduação (IDPC/FMUSP), Tecnologia em Cirurgia Cardiovascular e Endovascular Extracardíaca. TOR – MD, Vascular and Endovascular Surgeon, Doctorate- Fellow, IDPC/USP. NMI – MD, PhD, Faculdade de Medicina, Universidade de São Paulo (FMUSP), Chief, Serviço de Cirurgia Vascular do IDPC. AMK – MD, PhD, Universidade Federal de São Paulo (UNIFESP), Chief, Serviço de Radiologia do IDPC.

Author contributions Conception and design: FHR Analysis and interpretation: FHR, TOR, NMI, AMK Data collection: FHR, TOR, NMI, AMK Writing the article: FHR Critical revision of the article: FHR, TOR, NMI, AMK Final approval of the article*: FHR, TOR, NMI, AMK Statistical analysis: N/A. Overall responsibility: FHR, TOR, NMI, AMK *All authors have read and approved of the final version of the article submitted to J Vasc Bras.

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Figures

Figures (6)

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Figure 1
Digital subtraction phlebographic images of patients with iliac obstructions: (A) Pancaking and compression in a proximal segment of the left common iliac vein; (B) Severe compression of a proximal segment of the left common iliac vein and presence of a paravertebral collateral; (C) Presence of central rarefaction of contrast in a proximal segment of the left common iliac vein (bull's-eye sign); (D) Bilateral compression of the proximal common iliac veins; (E) Presence of intraluminal membranes in the left common iliac vein; (F) Severe obstruction of the left iliac vein with formation of a network of paravertebral and transpelvic collaterals.

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Figure 2
Multiplanar reconstruction of venous angiotomography to identify the point of maximum compression or obstruction.

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Figure 3
Calculation of the degree of obstruction at the point of maximum compression in limbs with chronic venous insufficiency with clinical, etiological, anatomic, and pathophysiological (CEAP) classification grades C3-6.

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Figure 4
Venography and intravascular ultrasound for determination of degree of obstruction and segment obstructed: (A) Right limb; (B) Venography; (C) Left limb; *Confluence of the internal and external iliac veins; b- Common iliac vein; c- Confluence of the external and internal iliac veins.

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Figure 5
Angioplasty with bilateral stenting in a patient with clinical, etiological, anatomic, and pathophysiological classification (CEAP) classification grade C6, with a severe obstruction compromising the iliac veins bilaterally: (A) Unilateral venous ulcer (chronic venous insufficiency, CEAP C6S); Presence of severe bilateral iliac compression: (B, C) Angiotomography; (D) intravascular ultrasound, confirming severe bilateral obstruction (>50%); (E) Satisfactory result with stent deployment using the double-barrel technique.

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Figure 6
Final control intravascular ultrasound (IVUS). In (A), initial phlebography demonstrating direct and indirect signs of obstruction of the left iliac vein, confirmed by IVUS (area at the point of greatest compression is 53.5 mm²). In (B), control phlebography apparently demonstrating a satisfactory result, but not confirmed by IVUS (area at the point of greatest compression is 54.1 mm²). In (C), final result after angioplasty with low complacency, high pressure balloon.

Figure 1 Digital subtraction phlebographic images of patients with iliac obstructions: (A) Pancaking and compression in a proximal segment of the left common iliac vein; (B) Severe compression of a proximal segment of the left common iliac vein and presence of a paravertebral collateral; (C) Presence of central rarefaction of contrast in a proximal segment of the left common iliac vein (bull's-eye sign); (D) Bilateral compression of the proximal common iliac veins; (E) Presence of intraluminal membranes in the left common iliac vein; (F) Severe obstruction of the left iliac vein with formation of a network of paravertebral and transpelvic collaterals.

Figure 2 Multiplanar reconstruction of venous angiotomography to identify the point of maximum compression or obstruction.

Figure 3 Calculation of the degree of obstruction at the point of maximum compression in limbs with chronic venous insufficiency with clinical, etiological, anatomic, and pathophysiological (CEAP) classification grades C3-6.

Figure 4 Venography and intravascular ultrasound for determination of degree of obstruction and segment obstructed: (A) Right limb; (B) Venography; (C) Left limb; *Confluence of the internal and external iliac veins; b- Common iliac vein; c- Confluence of the external and internal iliac veins.

Figure 5 Angioplasty with bilateral stenting in a patient with clinical, etiological, anatomic, and pathophysiological classification (CEAP) classification grade C6, with a severe obstruction compromising the iliac veins bilaterally: (A) Unilateral venous ulcer (chronic venous insufficiency, CEAP C6S); Presence of severe bilateral iliac compression: (B, C) Angiotomography; (D) intravascular ultrasound, confirming severe bilateral obstruction (>50%); (E) Satisfactory result with stent deployment using the double-barrel technique.

Figure 6 Final control intravascular ultrasound (IVUS). In (A), initial phlebography demonstrating direct and indirect signs of obstruction of the left iliac vein, confirmed by IVUS (area at the point of greatest compression is 53.5 mm²). In (B), control phlebography apparently demonstrating a satisfactory result, but not confirmed by IVUS (area at the point of greatest compression is 54.1 mm²). In (C), final result after angioplasty with low complacency, high pressure balloon.

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[1] Conflicts of interest: No conflicts of interest declared concerning the publication of this article.