Left iliac venous thrombosis caused by venous spur: Treatment with thrombectomy and stent implantation

ORIGINAL ARTICLES

Left iliac venous thrombosis caused by venous spur: Treatment with thrombectomy and stent implantation Volker Mickley, MD, Robert Schwagierek, Norbert Rilinger, MD, Johannes Görich, MD, and Ludger Sunder-Plassmann, MD, PhD, Ulm, Germany Purpose: To determine the frequency of iliac venous spurs in left iliofemoral venous thrombosis and to report the results of interventional management of venous spurs after transfemoral venous thrombectomy. Methods: From 1990 through 1996, 77 patients with acute iliac venous thrombosis (61 left and 16 right) underwent surgical treatment. Patients with malignant disease were excluded from this series. All patients had transfemoral venous thrombectomy with construction of an inguinal arteriovenous fistula and perioperative anticoagulation with heparin with a switch to warfarin sodium for at least 12 postoperative months. Immediate results of thrombectomy were documented by means of intraoperative completion venography. Arteriovenous fistulas were ligated 3 months after control arteriovenography. Since 1995 venous spurs eventually detected during thrombectomy were treated immediately by means of stent implantation. Results: Among 61 patients with left-sided thrombosis, intraoperative phlebography revealed common iliac venous obstruction suggestive of venous spurs in 30 patients (49%). In 16 of 22 patients (73%) with untreated spurs, postoperative rethrombosis of the iliac vein was documented despite adequate anticoagulation. Only one of eight patients (13%) with stented spurs had reocclusion (χ2 test P < .01). Conclusion: Venous spurs are found among about half of patients with left-sided iliac venous thrombosis. As long as the underlying venous pathologic process is left untreated, thrombectomy will not restore patency. Stent implantation is a simple and safe means to correct central venous strictures and provides excellent long-term results. (J Vasc Surg 1998;28:492-7.)

Studies have shown that operative thrombectomy may provide long-term iliac venous patency rates of about 80%, especially when combined with construction of an inguinal arteriovenous fistula. 1-4 However, for a large number of patients thrombectomy is incomplete or impossible, or early rethrombosis occurs. Iliofemoral venous thrombosis occurs From the Departments of Thoracic and Vascular Surgery and Diagnostic Radiology (Drs. Rilinger and Görich), University of Ulm. Presented in part at the Mayo Vascular Symposium 1996, Rochester, Minn., Oct. 3-5, 1996. Reprint requests: Volker Mickley, MD, Department of General Surgery, Subdivision for Vascular Surgery, Johann Wolfgang Goethe-University, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany. Copyright © 1998 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/98/$5.00 + 0 24/1/91607

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much more frequently on the left side than on the right. The cause is believed to be lifelong pulsatile compression of the left common iliac vein between the overlying right common iliac artery and the promontory.5,6 By causing fibrous strictures and web- or spur-like stenoses of the left common iliac vein, this iliac compression syndrome7 might be responsible for the frequent difficulties in restoring venous patency by means of thrombectomy alone. The purpose of this study was to determine the frequency of iliac venous spurs in left iliofemoral venous thrombosis and to report the results of intervention in venous spurs after transfemoral venous thrombectomy. METHODS In 1995, we began a prospective study on intervention in venous spurs after transfemoral venous thrombectomy. Results were compared (χ2 test)

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Fig. 1. Intraoperative phlebogram of a 45-year-old woman. After transfemoral thrombectomy for iliofemoral venous thrombosis, persistent, complete occlusion of the left common iliac vein was caused by iliac compression syndrome. Huge presacral collateral blood vessel indicates chronic venous obstruction.

Fig. 2. Intraoperative phlebogram of a 45-year-old woman. A guide wire was manipulated through the occlusion. After implantation of a Wallstent endoprosthesis (12 × 40 mm), there is still high-grade stenosis of the left common iliac vein.

with those for a group of patients who underwent consecutive operations between 1990 and 1994 without immediate management of spurs. Primary and secondary patency rates of implanted stents were calculated according to the life-table method.8 Indications for venous thrombectomy were standardized throughout the period. Patients older than 60 years underwent operations only if they suffered from phlegmasia cerulea dolens. Clinical thrombus age had to be less than 10 days, unless unsuccessful thrombolytic therapy (3 patients) or recurrent pulmonary embolism (6 patients) preceded presentation. All patients had iliac thrombi at phlebography. Tumor compression of the iliac veins was ruled out by means of preoperative sonography or computed tomography. All patients underwent transfemoral venous thrombectomy with construction of an inguinal prosthetic (5 mm expanded polytetrafluoroethyelene) arteriovenous fistula. Additional transperitoneal caval thrombectomy was performed on patients with floating caval thrombi. In all patients, the morphologic features of the iliac vein after transfemoral Fogarty thrombectomy were documented by means of intraoperative phlebography. Between 1990 and 1994, venous spurs detected during thrombectomy were left untreated. Since 1995, angioplasty and stenting of venous spurs have been added to our routine procedure. For

the first three patients, Palmaz stents (Cordis Corp, Miami, Fl) were implanted on the first postoperative day through a transjugular approach. The method and immediate results have been reported elsewhere.9 The other patients underwent intraoperative implantation of self-expandable stents. Depending on the surgeons’ preferences, a Wallstent endoprosthesis (Schneider, Minneapolis, Minn) or nitinol stent was used. After thrombectomy and intraoperative phlebography (Fig 1), a 10F sheath was introduced through the inguinal venotomy. Stents were implanted under road-mapping control with a mobile digital subtraction angiography unit. Great care was taken to avoid bridging of the left internal iliac vein and stent protrusion into the inferior vena cava (Fig 2). All stents were dilated to achieve complete opening within the fibrous strictures of the common iliac veins (Fig 3). All patients underwent perioperative full-dose heparin anticoagulation (partial thromboplastin time 60 to 90 seconds), and the medication was switched to vitamin K antagonists for at least 1 year. Arteriovenous fistulas were routinely closed after arteriovenography 3 months after the operation. (Most of the patients underwent surgical ligation of the fistula, and interventional embolization recently has been performed successfully on six patients.) Thereafter all patients were seen every 3 months for clinical follow-up examinations and duplex sonogra-

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Fig. 3. Intraoperative phlebogram of a 45-year-old woman. Complete restoration of venous patency was achieved by means of high-pressure balloon dilation of the stented segment.

phy. During March and April 1997, and after giving informed consent, patients with iliac venous stents underwent ascending phlebography or computed tomography with three-dimensional reconstruction for exact delineation of stent configuration and eventual restenosis. RESULTS During the study period, four nonfatal pulmonary embolisms were encountered (5%). One occurred during the operation at wound closure. Despite acute severe right heart failure, the patient was successfully resuscitated and later left the hospital without adverse sequelae. Minor pulmonary embolism was diagnosed among three patients on postoperative days 1 to 3. They had acute dyspnea and inspiratory pain without signs of cardiac shock. The diagnosis was confirmed by means of pulmonary perfusion scintigraphy. None of the pulmonary embolisms occurred among patients with stents.

From 1990 through 1994, 50 consecutive transfemoral venous thrombectomies with construction of an arteriovenous fistula were performed. Fortyone patients had left iliofemoral venous thrombosis. Among 22 patients (54% of those with left-sided thrombosis) an iliac venous spur was diagnosed during thrombectomy and left untreated. Sixteen (72%) of these iliac veins (39% of all instances of left-sided thrombosis) reoccluded during the follow-up period. There was one reocclusion of a right iliac vein and none of a left vein without spur. All rethromboses occurred before scheduled closure of the arteriovenous fistula 3 months after the operation. From 1995 through 1996, 27 consecutive transfemoral venous thrombectomies with construction of an arteriovenous fistula were performed. Venous spurs were found among 8 (40%) of 20 instances of left iliofemoral thrombosis. All spurs were managed by means of immediate stent implantation. A total of 12 stents were implanted. Palmaz stents were used to treat 3 patients (6 stents), nitinol stents to treat 3

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Table I. Surgical options for the treatment of venous spurs. Author

Fig. 4. Cumulative primary (open boxes) and secondary (closed boxes) patency rates of implanted stents.

patients (4 stents), and a Wallstent endoprosthesis to treat 2 patients. There was only one instance of single acute rethrombosis among this group of patients, and it was caused by intraoperative misplacement of the stent. Patency could not be restored despite implantation of a second stent. No other procedure-related complications were recorded. Three months after the operation, symptomatic restenosis (leg swelling) was detected in another stent. After successful percutaneous dilation, the patient had no symptoms for 18 months. Both complications occurred in nitinol stents. All other stents remained widely open throughout the study period (4.5 to 30 months). There was no reocclusion of a right iliac vein, but there were two instances of reocclusion in left iliac veins without spur. The primary 2-year patency rate (Fig 4) of implanted stents was 73%. The secondary patency rate was 82%. Iliofemoral rethrombosis was significantly less frequent after stent implantation for iliac venous spurs than when spurs were left untreated (72% versus 13%; χ2 test P < .01). Rethrombosis in the right iliac veins and in the left iliac veins without documented spurs occurred in 6% of instances, which was not significantly different from the reocclusion rate after stent implantation (χ2 test P = .68). DISCUSSION As early as 1906, McMurrich10 observed valvelike strictures of the left iliac vein causing iliofemoral venous thrombosis.11 He suggested a congenital origin of the lesion. May and Thurner5 in 1956 assumed that permanent pulsation of the overlying right common iliac artery might induce reactive proliferation of venous wall cells and give rise to web- or spur-like stenosis. They reported that venous spurs (as they called them) occurred in about 20% of healthy adults. This frequency was later confirmed by Salomonowitz and Gottlob6 in another autopsy

Year

Palma and Esperon13

1960

Calnan et al14

1964

Cockett and Thomas7 Rigas et al15 Trimble et al16 Pokrovsky and Klioner17 Vollmar and Hutschenreiter12

1965 1970 1972 1977 1989

Method Saphenofemoral crossover Arterial retropositioning Peritoneal flap Fascia lata sling Prosthetic bridging Aortic elevation Ilioiliac crossover bypass

study. Little is known, however, about frequency and importance of this phenomenon in acute venous thrombosis and chronic venous insufficiency. Having in mind the great number of asymptomatic venous spurs among healthy adults without a history of venous disease, we were not surprised to find iliac compression syndromes present in 49% of instances of left-sided thrombosis. By means of venous endoscopy after thrombectomy, Vollmar and Hutschenreiter12 detected venous spurs in 50% of all instances of left-sided thrombosis. Juhan et al4 by means of completion venography found a 62% prevalence of iliac spurs in a series of 50 left iliofemoral thrombectomies. Today there are several surgical options to cope with these lesions7,13-18 (Table I). Some authors prefer the direct approach by patch venoplasty combined with retropositioning of the artery or tissue slings or flaps that elevate the artery. These operations necessitate median laparotomy and extensive dissection of blood vessels or even division and reanastomosis. Venovenous crossover bypasses are less invasive. With a crossover bypass, however, the surgeon has to operate on at least one as yet undiseased vein, which could lead to the well-known sequelae and complications of venous operations. The great diversity of methods recommended for correction of the iliac compression syndrome indicates therapeutic insecurity rather than a generally satisfactory outcome. Only a few long-term studies have been performed and these have small numbers of surgical patients. Depending on authors and procedures, patency rates between 0% and 70% are given. The better rates are for the more invasive options, that is, arterial retropositioning and prosthetic bypass.19-23 The simple structure of most venous spurs and the great potential of modern endovascular treatment make it appealing to look for less invasive alter-

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natives to surgical procedures. Successful percutaneous transluminal angioplasty (PTA) of venous spurs diagnosed after thrombectomy or thrombolysis have been described in case reports24 and small series25,26 since 1991. After we27 and other authors25 showed that PTA of central venous stenosis had an unacceptably high recurrence rate, we combined PTA with stent implantation. In 1995 we began routinely to stent venous spurs immediately after transfemoral venous thrombectomy. Our first three patients were treated on the first postoperative day by means of a transjugular approach.9 With a mobile digital subtraction angiography unit, we performed intraoperative stent implantation thus sparing the patients another invasive procedure. Misplacement of a nitinol stent in one patient caused acute reocclusion of the common iliac vein despite immediate implantation of a second stent. Misplacement was caused by insufficient stent visualization in this adipose patient. No other intraoperative complications were encountered. Three months after thrombectomy, restenosis within stent caused recurrent leg swelling in another patient. Transfemoral PTA was performed by means of a crossover technique; after 18 months there was no recurrent stenosis. When restenosis is classified as stent failure, the cumulative primary patency rate for all 12 implanted stents was 73% at 1 and 2 years. When successful redilation at 3 months was included, the secondary patency rate was 82% at 1 and 2 years. Our results compared favorably with those of the surgical series cited earlier.19-23 To our knowledge, this is the first study on perioperative stent implantation for the management of iliac compression syndrome causing iliofemoral venous thrombosis. Some authors, however, have reported on stenting of venous spurs eventually detected during fibrinolytic therapy. The largest series is that of Buelens et al,28 who reported successful treatment of six patients with Wallstent endoprostheses. Semba and Dake,29 in their collective series of 27 limbs with acute or chronic iliofemoral thrombosis, mention two patients with MayThurner syndrome. Both had chronic occlusion of the common iliac veins. In one of them, the occlusion could be passed with a guide wire, and after catheter-directed thrombolysis, a Palmaz stent was implanted. In a later publication on 41 limbs, the same authors30 presented phlebograms of a 33-yearold female patient with successful thrombolysis of acute thrombosis of the left external iliac vein and persistent high-grade common iliac venous stenosis suggestive of venous spur. By means of implantation

of two Wallstent endoprostheses, complete restoration of the venous lumen was achieved. The stents remained widely open until the last follow-up examination, at 6 months. In the treatment of an 18-yearold male patient, Åkesson et al,31 after reopening a chronic occlusion of a left external iliac vein by means of Wallstent implantation and after additional local fibrinolysis, detected a venous spur and managed it with a Palmaz stent. Nineteen months after the procedure, phlebography showed complete patency of the stented veins. Berger et al32 diagnosed iliac compression syndrome on computed tomographic scans obtained for acute iliac venous occlusion in a 51-year-old man. Two Palmaz stents were implanted after successful catheter-directed thrombolysis. Patency was demonstrated at a 6month follow-up phlebographic examination. Wallstent endoprostheses seem to have considerable advantages over the other stent models we used. Unlike Palmaz stents, they are flexible and allow nontraumatic manipulation within curved vessel segments. In comparison with commercially available nitinol stents, their greater radiodensity guarantees easy visualization in adipose patients, even with mobile digital subtraction angiography in the intraoperative setting. Although Wallstent endoprostheses shorten about 20% to 30% during expansion, the end of the stent distal to the surgeon can be positioned accurately. Stent protrusion into the inferior vena cava can be safely avoided as long as the stent is implanted from the groin. Venous spurs that cause marked luminal narrowing of the common iliac vein are found among about 20% of adults without symptoms and about 50% of adults with left iliac venous thrombosis. Intraoperative PTA and stent implantation of venous spurs is safe and easy. Our preliminary results were promising. Two-year iliac venous patency has been enhanced considerably since introduction of the method, almost reaching the patency rates after thrombectomy of right iliac veins and of left iliac veins without spurs. Although we consider the Wallstent endoprosthesis to be superior to others, long-term studies with different stent designs should be undertaken to define the model best suited for this indication. REFERENCES 1. Eklof B, Kistner RL. Is there a role for thrombectomy in iliofemoral venous thrombosis? Semin Vasc Surg 1996;9:34-45. 2. Rollo HA, Maffei FHA, Yoshida WB, Lastória S, Curi PR, Mattar L. Heparin, heparin plus ASA and dipyridamole, and arteriovenous fistula as adjuvant methods to prevent rethrombosis after venous thrombectomy: experimental study in rabbits. Int Angiol 1991;10:88-94.

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3. Menawat SS, Gloviczki R, Mozes G, Whitley D, Anding WJ, Serry RD. Effect of a femoral arteriovenous fistula on lower extremity venous hemodynamics after femorocaval reconstruction. J Vasc Surg 1996;24:793-9. 4. Juhan MC, Alimi YS, Barthelemy PJ, Fabre DF, Riviere CS. Late results of iliofemoral venous thrombectomy. J Vasc Surg 1997;25:417-22. 5. May R, Thurner J. Ein Gefäßsporn in der Vena iliaca communis sinistra als Ursache der überwiegend linksseitigen Beckenvenenthrombosen. Z Kreislaufforschung 1956;45: 912-22. 6. Salomonowitz E, Gottlob R. Untersuchungen am Endothel der Vena iliaca communis sinistra als Beitrag zur Pathogenese des Venenspornes. Vasa 1981;10:194-8. 7. Cockett FB, Thomas ML. The iliac compression syndrome. Br J Surg 1965;52:816-21. 8. Peto R, Pike MC, Armitage P, Breslow NE, Cox DR, Howard SV, et al. Design and analysis of randomised clinical trials requiring prolonged observation of each patient. Br J Cancer 1977;35:1-39. 9. Rilinger N, Görich J, Mickley V, Vogel J, Scharrer-Pamler R, Sokiranski R, et al. Endovascular stenting in patients with iliac compression syndrome: experience in three cases. Invest Radiol 1996;11:729-33. 10. McMurrich JP. The valves of the iliac vein. Br Med J 1906;2:1699-700. 11. McMurrich JP. The occurrence of congenital adhesions in the common iliac veins, and their relation to thrombosis of the femoral and iliac veins. Am J Med Sci 1908;135:342-3. 12. Vollmar JF, Hutschenreiter S. Vascular endoscopy for venous thrombectomy. In: Moore WS, Alin SS, editors. Endovascular surgery. Philadelphia: WB Saunders; 1989. p. 65-73. 13. Palma E, Esperon R. Vein transplants and grafts in the surgical treatment of postphlebitic syndrome. J Cardiovasc Surg 1960;1:94-107. 14. Calnan JS, Kountz S, Pentecoast BL, Shillingford JP, Steiner RR. Venous obstruction in the aetiology of lymphoedema praecox. Br Med J 1964;2:221-6. 15. Rigas A, Vomvoyannis A, Tsardakas E. Iliac compression syndrome: report of ten cases. J Cardiovasc Surg 1970;11:389-92. 16. Trimble C, Bernstein EF, Pomerantz M, Eiseman B. A prosthetic bridging device to relieve iliac venous compression. Surg Forum 1972;23:249-51. 17. Pokrovsky AV, Klioner LI. Reconstructive surgery for occlusions of the major deep veins. In: Hobbs JT, editor. The treatment of venous disorders. Philadelphia: JB Lippincott, 1977:308-28.

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18. Vollmar J, Hutschenreiter S. Der quere Beckenvenenbypass (“hoher Palma”). Vasa 1980;9:62-6. 19. Jaszczak P, Mathiesen FR. The iliac compression syndrome. Acta Chir Scand 1978;144:133-6. 20. Dale WA. Reconstructive venous surgery. Arch Surg 1979; 114:1312-8. 21. Taheri SA, Williams J, Powell S, Cullen J, Peer R, Nowakowski P, et al. Iliocaval compression syndrome. Am J Surg 1987;154:169-72. 22. De Syo D, Despot I, Georgijevic. Chirurgische Therapie des Kompressionssyndroms der linken Vena iliaca communis. Angio 1989;11:275-83. 23. Gloviczki P, Pairolero PC, Toomey BJ, Bower TC, Rooke TW, Stanson AW, et al. Reconstruction of large veins for nonmalignant venous occlusive disease. J Vasc Surg 1992; 16:750-61. 24. Okrent D, Messersmith R, Buckman J. Transcatheter fibrinolytic therapy and angioplasty for left iliofemoral venous thrombosis. J Vasc Interv Radiol 1991;2:195-200. 25. Neglén P, Al-Hassan HK, Endrys J, Nazzal MMS, Christenson JT, Eklof B. Iliofemoral venous thrombectomy followed by percutaneous closure of the temporary arteriovenous fistula. Surgery 1991;110:493-9. 26. Molina JE, Hunter DW, Yedlicka JW. Thrombolytic therapy for iliofemoral venous thrombosis. Vasc Surg 1992;26:630-7. 27. Mickley V, Friedrich JM, Rilinger N, Storck M, Abendroth D. PTA plus stent implantation versus PTA alone for central venous stenoses. Vasc Surg 1994;28:505-12. 28. Buelens C, Vandenbosch G, Stockx L, Raat H, Lacroix R, Verhaege R, et al. Cockett’s syndrome: initial experience with percutaneous treatment in 6 patients. J Belge Radiol 1996;79:132-5. 29. Semba CP, Dake MD. Iliofemoral deep venous thrombosis: aggressive therapy with catheter-directed thrombolysis. Radiology 1994;191:487-94. 30. Semba CP, Dake MD. Catheter-directed thrombolysis for iliofemoral venous thrombosis. Semin Vasc Surg 1996;9: 26-33. 31. Åkesson H, Lindh M, Ivancev K, Risberg B. Venous stents in chronic iliac vein occlusions. Eur J Vasc Endovasc Surg 1997;13:334-6. 32. Berger A, Jaffe JW, York TN. Iliac compression syndrome treated with stent placement. J Vasc Surg 1995;21:510-4.

Submitted Jan 30, 1998; accepted May 8, 1998.