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PC184 Delayed Conversion to Kissing Stent Configuration in the Setting of Unilateral Iliac Vein Stenting
Journal of Vascular Surgery
Abstracts
189S
Volume 65, Number 6S prospective studies are necessary to elucidate the proper algorithm for patient selection in the endovascular management of this patient population. Author Disclosures: D. B. Alfson: Nothing to disclose; K. Inaba: Nothing to disclose; V. L. Rowe: Nothing to disclose; F. A. Weaver: Nothing to disclose.
PC182. The Impact of Different Treatment Modalities on Recalcitrant Venous Ulcer Healing Peter Lawrence,1 Eric Hager,2 Michael P. Harlander-Locke,3 Lowell Kabnick,4 Naveed Saqib,5 Kristofer M. Charlton-Ouw,5 Misaki Kiguchi,6 The Vascular Low-Frequency Disease Consortium. 1University of California Los Angeles School of Medicine, Los Angeles, Calif; 2University of Pittsburgh Medical Center, Pittsburgh, Pa; 3Lake Erie College of Osteopathic Medicine, Erie, Pa; 4New York University Langone Medical Center, New York, NY; 5University of Texas Health Science Center, Austin, Tex; 6MedStar Heart and Vascular Institute, Washington, D.C. Objectives: Refractory venous ulcers are a national health issue, despite advances in wound care and compression therapy. We examined the impact of compression, correction of incompetent superficial and perforator veins, and dilatation of iliac stenosis/occlusion. Methods: All patients with venous ulcers from eight institutions, treated between January 2013 and January 2016, were retrospectively evaluated for the impact of different treatment modalities. Results: A total of 406 patients with venous ulcers, accompanied by reflux in lower extremity deep veins (30%), superficial veins (92%), perforator veins (80%), and with iliac venous stenosis (4%) were treated, and 105 patients (26%) were managed conservatively with compression, for a mean of 3.8 months until ulcer healing. The remaining 301 patients (74%) underwent wound care for a mean of 9 months prior to surgical treatment. There were 276 patients (68%) who underwent ablation of an incompetent great saphenous vein 6.4 months after ulcer onset, 83 patients (20%) underwent ablation of an incompetent small saphenous vein after 11 months, and 288 patients (71%) underwent ablation of an incompetent perforator vein after 21 months. Patients undergoing perforator ablation had a mean of 1.7 perforator veins closed. Ulcer size at beginning of conservative treatment was smaller in those that healed with compression and wound care alone (7 vs 22 cm2, respectively; P < .05). Patients with concomitant deep venous reflux required more vein ablations (3.1 vs 1.4 veins, respectively; P < .05) to achieve ulcer healing. Time from onset to ulcer healing for patients requiring only superficial vein ablation was 9.1 months but was 13.8 months for patients requiring both superficial and perforator vein ablation (P < .05). Patients with deep vein incompetence took the longest time to heal, with a mean of 21 months. Stenosis >75% in the femoral or popliteal vein was a significant barrier to ulcer healing (P < .05). In patients with prior superficial vein ablation and iliac vein stenosis >50%, ulcer healing was achieved following iliac vein stenting in 76%. Absolute ulcer healing was achieved during the study period in 336 patients (83%). There were 35 ulcer recurrences (10%) during the study; new incompetent perforator veins were identified in 13 patients (37%). Conclusions: Patients with multilevel venous disease involving the deep system are at highest risk for developing venous ulcers that are refractory to compression therapy alone. Venous ulcer healing time and rate is improved with ablation of incompetent superficial and perforator veins. Correction of iliac venous stenosis/occlusion also facilitates ulcer healing. Author Disclosures: K. M. Charlton-Ouw: Medtronic and W. L. Gore and Associates Inc: consulting fees (eg, advisory boards); E. Hager: Nothing to disclose; M. P. Harlander-Locke: Nothing to disclose; L. Kabnick: Nothing to disclose; M. Kiguchi: Nothing to disclose; P. Lawrence: Nothing to disclose; The Vascular Low-Frequency Disease Consortium: Nothing to disclose; N. Saqib: Nothing to disclose.
PC184. Delayed Conversion to Kissing Stent Configuration in the Setting of Unilateral Iliac Vein Stenting Chien Yi M. Png, Jacob Lurie, Sida Chen, Sneha Subramaniam, Rami O. Tadros, Peter Faries, Michael Marin, Windsor Ting. Icahn School of Medicine at Mount Sinai, New York, NY Objectives: Iliac vein stents are being increasingly used to treat chronic proximal venous outflow obstruction. Among patients with unilateral stenting in the proximal common iliac vein with extension into the inferior vena cava (IVC), a small number of patients presented with venous symptoms related to outflow obstruction of the contralateral common iliac vein. While the incidence of this complication of iliac vein stenting is unknown, this abstract presents one technical approach to this complication. Methods: We present 11 patients with outflow obstructive symptoms in the contralateral iliac vein after a prior IVC common iliac vein stent placement. Postanesthesia, ultrasound guidance is used to obtain access to the common femoral vein bilaterally. Inferior vena cavograms and venograms of the iliac veins are undertaken using contrast in digital subtraction mode. Intravascular ultrasound (IVUS) using a Volcano Visions PV .035 Digital IVUS catheter (Volcano Corporation, San Diego, Calif) is then used to evaluate the iliac veins and assess the degree of stenosis in each vein segment. The use of IVUS is critical to locate the narrow channel present between the contralateral stent and wall of the IVC, assist passage of the guidewire through this narrow channel, and ensure that the guidewire does not pass through the interstices of the stent (Fig 1). Balloon angioplasty is seldom necessary. The initial guidewire is then exchanged for a stiff 0.35-inch 180-cm guidewire. Next, a 16-mm or 18-mm stent is positioned alongside the existing stent in a kissing iliac stents configuration. After the newly placed stent is deployed, both stents are simultaneously dilated with either 16-mm or 18-mm balloons (Fig 2). Finally, a completion venogram and IVUS confirm fully expanded stents. Results: This procedure was performed in 11 patients (6 males, 5 females), with three performed on the right iliac vein and eight on the left iliac vein. The mean time to development of contralateral occlusive symptoms was 626 days from the initial stenting. Average follow-up time from the second stenting was 167 days, with no postoperative complications. Eight patients reported significant symptomatic improvement in their newly treated limb at 30 days postoperatively, while 10 patients
Fig 1.
190S
Journal of Vascular Surgery
Abstracts
June Supplement 2017 groups: no known history of DVT, known history of DVT, and intraoperative findings of DVT as demonstrated by venogram and intravascular ultrasound imaging. Preoperative demographic and comorbidity data were analyzed using independent t-tests and c2 tests. Focused hypercoagulation profiles consisting of 11 prominent indicators of hypercoagulation were extracted from the broader pool of 48 and used to perform a multiple logistic regression to identify potential predictors of DVT. Results: A total of 77 patients (50.7%) were positive for DVT, but only 26 (17.1%) had a known history of DVT, while 71 (46.7%) had intraoperative findings of a remote DVT. c2 Tests were significant for increased rates of intraoperative findings of remote DVT in patients with a history of DVT (81% vs 38%; P < .01). c2 Tests were additionally significant for increased rates of DVT findings in patients with one or more positive hypercoagulation markers (67% vs 42%; P < .01). The most significant predictor for DVT in the logistic regression was a positive result for one of the 11 select hypercoagulation markers (n ¼ 148; odds ratio, 2.41; P ¼ .022). Conclusions: PVOO in the iliac veins appears to be associated with DVT, with many of these DVT clinically silent to the patient. Several hypercoagulation markers were found to confer significant predictive value for DVT. This information may aid in management of DVT, PVOO, and patients undergoing vein stent placement for PVOO. Author Disclosures: S. Chen: Nothing to disclose; P. Faries: Nothing to disclose; J. Lurie: Nothing to disclose; M. Marin: Nothing to disclose; C. M. Png: Nothing to disclose; S. Subramaniam: Nothing to disclose; R. O. Tadros: Nothing to disclose; W. Ting: Janssen Pharmaceuticals: consulting fees (eg, advisory boards), speaker’s bureau. Fig 2.
PC188.
did at 90 days postoperatively. No patients reported any worsening symptoms in either limb. Conclusions: Delayed conversion to a kissing stent configuration can be considered for treatment of contralateral iliac vein outflow obstruction in the setting of previous unilateral iliac vein stenting. Author Disclosures: S. Chen: Nothing to disclose; P. Faries: Nothing to disclose; J. Lurie: Nothing to disclose; M. Marin: Nothing to disclose; C. M. Png: Nothing to disclose; S. Subramaniam: Nothing to disclose; R. O. Tadros: Nothing to disclose; W. Ting: Janssen Pharmaceuticals: consulting fees (eg, advisory boards), speaker’s bureau.
PC186. Silent Deep Venous Thrombosis: Associations With Proximal Venous Outflow Obstruction and Hypercoagulation Markers Jacob Lurie, Chien Yi M. Png, Sneha Subramaniam, Sida Chen, Rami O. Tadros, Michael Marin, Peter Faries, Windsor Ting. Icahn School of Medicine at Mount Sinai, New York, NY Objectives: The presence of a proximal venous outflow obstruction (PVOO) in the iliac vein has been observed during catheter-based interventions for acute deep venous thrombosis (DVT). It is not clear whether the proximal obstruction and the more distal DVT are causally related, even though stasis is a commonly known contributor to DVT. Stent placement in the iliac vein, an emerging intervention for chronic PVOO, has provided an unexpected opportunity to evaluate the relationship between PVOO in the iliac vein and DVT. Methods: In order to evaluate a possible PVOO and DVT association, we retrospectively reviewed the medical records of 180 consecutive patients (mean age, 59 years; 57% females), with 90% presenting with edema and 10% presenting with active ulceration, who underwent iliac vein stent placement for chronic PVOO from October 2013 to March 2015. Of these, 152 had partial or complete panels for 48 separate markers of hypercoagulation. We divided the study patients into three
Outcomes of Iliac Vein Stenting in Proximal Venous Outflow Obstruction Sida Chen, Chien Yi M. Png, Jacob Lurie, Sneha Subramaniam, Charles Sanky, Michael Marin, Peter Faries, Windsor Ting. Icahn School of Medicine at Mount Sinai, New York, NY Objectives: This study evaluated the outcome of vein stent placement for chronic proximal venous outflow obstruction (PVOO) in order to improve patient selection, enhance technical approach, and better define quality measurements for these cases. Methods: A total of 484 consecutive patients who underwent iliac vein stenting for PVOO from October 2013 to July 2016 were reviewed. Postoperative outcomes at 30 days, 60 days, 6 months, 1 year, and 1.5 years were analyzed. Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were run for demographic/operative variables. Additionally, ordered logistic regressions were run for the outcomes at each time point. Results: Follow-up was maintained in 90% of patients, with a mean follow-up time of 320 days. Mean patient age was 60 years, with 57% female. Edema was a symptom in 90.5% of patients and active ulceration in 10.7%. Kruskal-Wallis tests were significant for improvement in patients of all CEAP classes at 30 days (P ¼ .041), 90 days (P ¼ .045), 6 months (P ¼ .041), and 1 year (P ¼ .011). Ordered logistic regressions found the presence of edema (95% confidence interval [CI], 0.43-2.62; P ¼ .006), active ulceration (95% CI, 0.083-3.50; P ¼ .040), and decreased number of stents placed (95% CI, e1.07 to e 0.035; P ¼ .036) predicted increased improvement at 30 days, and a history of deep vein thrombosis (DVT; 95% CI, e1.79 to e 0.096; P ¼ .029) predicted decreased improvement at 1 year postoperatively (Table). Bilateral vein stents comprised 59% of patients. Wilcoxon-Mann-Whitney tests were significant for more improvement in patients who had unilateral vs bilateral stents placed at 30 days (P ¼ .013) and 6 months (P ¼ .039). A total of 7.6% of patients underwent major postoperative reinterventions (61.7% for recurrent symptoms, 17.6% for persistent symptoms, 15% for new symptoms, and 6% for DVT). Mean time to reintervention was 191 days. The reintervention population was disproportionately composed of patients with a history of DVT (29.4%) and intraoperative DVT findings (47.1%) compared to the total patient population (13.8% and 21.5%, respectively). Conclusions: Vein stent placement for PVOO is associated with beneficial outcomes >1 year after the procedure. While unilateral stents are
Abstracts
189S
Volume 65, Number 6S prospective studies are necessary to elucidate the proper algorithm for patient selection in the endovascular management of this patient population. Author Disclosures: D. B. Alfson: Nothing to disclose; K. Inaba: Nothing to disclose; V. L. Rowe: Nothing to disclose; F. A. Weaver: Nothing to disclose.
PC182. The Impact of Different Treatment Modalities on Recalcitrant Venous Ulcer Healing Peter Lawrence,1 Eric Hager,2 Michael P. Harlander-Locke,3 Lowell Kabnick,4 Naveed Saqib,5 Kristofer M. Charlton-Ouw,5 Misaki Kiguchi,6 The Vascular Low-Frequency Disease Consortium. 1University of California Los Angeles School of Medicine, Los Angeles, Calif; 2University of Pittsburgh Medical Center, Pittsburgh, Pa; 3Lake Erie College of Osteopathic Medicine, Erie, Pa; 4New York University Langone Medical Center, New York, NY; 5University of Texas Health Science Center, Austin, Tex; 6MedStar Heart and Vascular Institute, Washington, D.C. Objectives: Refractory venous ulcers are a national health issue, despite advances in wound care and compression therapy. We examined the impact of compression, correction of incompetent superficial and perforator veins, and dilatation of iliac stenosis/occlusion. Methods: All patients with venous ulcers from eight institutions, treated between January 2013 and January 2016, were retrospectively evaluated for the impact of different treatment modalities. Results: A total of 406 patients with venous ulcers, accompanied by reflux in lower extremity deep veins (30%), superficial veins (92%), perforator veins (80%), and with iliac venous stenosis (4%) were treated, and 105 patients (26%) were managed conservatively with compression, for a mean of 3.8 months until ulcer healing. The remaining 301 patients (74%) underwent wound care for a mean of 9 months prior to surgical treatment. There were 276 patients (68%) who underwent ablation of an incompetent great saphenous vein 6.4 months after ulcer onset, 83 patients (20%) underwent ablation of an incompetent small saphenous vein after 11 months, and 288 patients (71%) underwent ablation of an incompetent perforator vein after 21 months. Patients undergoing perforator ablation had a mean of 1.7 perforator veins closed. Ulcer size at beginning of conservative treatment was smaller in those that healed with compression and wound care alone (7 vs 22 cm2, respectively; P < .05). Patients with concomitant deep venous reflux required more vein ablations (3.1 vs 1.4 veins, respectively; P < .05) to achieve ulcer healing. Time from onset to ulcer healing for patients requiring only superficial vein ablation was 9.1 months but was 13.8 months for patients requiring both superficial and perforator vein ablation (P < .05). Patients with deep vein incompetence took the longest time to heal, with a mean of 21 months. Stenosis >75% in the femoral or popliteal vein was a significant barrier to ulcer healing (P < .05). In patients with prior superficial vein ablation and iliac vein stenosis >50%, ulcer healing was achieved following iliac vein stenting in 76%. Absolute ulcer healing was achieved during the study period in 336 patients (83%). There were 35 ulcer recurrences (10%) during the study; new incompetent perforator veins were identified in 13 patients (37%). Conclusions: Patients with multilevel venous disease involving the deep system are at highest risk for developing venous ulcers that are refractory to compression therapy alone. Venous ulcer healing time and rate is improved with ablation of incompetent superficial and perforator veins. Correction of iliac venous stenosis/occlusion also facilitates ulcer healing. Author Disclosures: K. M. Charlton-Ouw: Medtronic and W. L. Gore and Associates Inc: consulting fees (eg, advisory boards); E. Hager: Nothing to disclose; M. P. Harlander-Locke: Nothing to disclose; L. Kabnick: Nothing to disclose; M. Kiguchi: Nothing to disclose; P. Lawrence: Nothing to disclose; The Vascular Low-Frequency Disease Consortium: Nothing to disclose; N. Saqib: Nothing to disclose.
PC184. Delayed Conversion to Kissing Stent Configuration in the Setting of Unilateral Iliac Vein Stenting Chien Yi M. Png, Jacob Lurie, Sida Chen, Sneha Subramaniam, Rami O. Tadros, Peter Faries, Michael Marin, Windsor Ting. Icahn School of Medicine at Mount Sinai, New York, NY Objectives: Iliac vein stents are being increasingly used to treat chronic proximal venous outflow obstruction. Among patients with unilateral stenting in the proximal common iliac vein with extension into the inferior vena cava (IVC), a small number of patients presented with venous symptoms related to outflow obstruction of the contralateral common iliac vein. While the incidence of this complication of iliac vein stenting is unknown, this abstract presents one technical approach to this complication. Methods: We present 11 patients with outflow obstructive symptoms in the contralateral iliac vein after a prior IVC common iliac vein stent placement. Postanesthesia, ultrasound guidance is used to obtain access to the common femoral vein bilaterally. Inferior vena cavograms and venograms of the iliac veins are undertaken using contrast in digital subtraction mode. Intravascular ultrasound (IVUS) using a Volcano Visions PV .035 Digital IVUS catheter (Volcano Corporation, San Diego, Calif) is then used to evaluate the iliac veins and assess the degree of stenosis in each vein segment. The use of IVUS is critical to locate the narrow channel present between the contralateral stent and wall of the IVC, assist passage of the guidewire through this narrow channel, and ensure that the guidewire does not pass through the interstices of the stent (Fig 1). Balloon angioplasty is seldom necessary. The initial guidewire is then exchanged for a stiff 0.35-inch 180-cm guidewire. Next, a 16-mm or 18-mm stent is positioned alongside the existing stent in a kissing iliac stents configuration. After the newly placed stent is deployed, both stents are simultaneously dilated with either 16-mm or 18-mm balloons (Fig 2). Finally, a completion venogram and IVUS confirm fully expanded stents. Results: This procedure was performed in 11 patients (6 males, 5 females), with three performed on the right iliac vein and eight on the left iliac vein. The mean time to development of contralateral occlusive symptoms was 626 days from the initial stenting. Average follow-up time from the second stenting was 167 days, with no postoperative complications. Eight patients reported significant symptomatic improvement in their newly treated limb at 30 days postoperatively, while 10 patients
Fig 1.
190S
Journal of Vascular Surgery
Abstracts
June Supplement 2017 groups: no known history of DVT, known history of DVT, and intraoperative findings of DVT as demonstrated by venogram and intravascular ultrasound imaging. Preoperative demographic and comorbidity data were analyzed using independent t-tests and c2 tests. Focused hypercoagulation profiles consisting of 11 prominent indicators of hypercoagulation were extracted from the broader pool of 48 and used to perform a multiple logistic regression to identify potential predictors of DVT. Results: A total of 77 patients (50.7%) were positive for DVT, but only 26 (17.1%) had a known history of DVT, while 71 (46.7%) had intraoperative findings of a remote DVT. c2 Tests were significant for increased rates of intraoperative findings of remote DVT in patients with a history of DVT (81% vs 38%; P < .01). c2 Tests were additionally significant for increased rates of DVT findings in patients with one or more positive hypercoagulation markers (67% vs 42%; P < .01). The most significant predictor for DVT in the logistic regression was a positive result for one of the 11 select hypercoagulation markers (n ¼ 148; odds ratio, 2.41; P ¼ .022). Conclusions: PVOO in the iliac veins appears to be associated with DVT, with many of these DVT clinically silent to the patient. Several hypercoagulation markers were found to confer significant predictive value for DVT. This information may aid in management of DVT, PVOO, and patients undergoing vein stent placement for PVOO. Author Disclosures: S. Chen: Nothing to disclose; P. Faries: Nothing to disclose; J. Lurie: Nothing to disclose; M. Marin: Nothing to disclose; C. M. Png: Nothing to disclose; S. Subramaniam: Nothing to disclose; R. O. Tadros: Nothing to disclose; W. Ting: Janssen Pharmaceuticals: consulting fees (eg, advisory boards), speaker’s bureau. Fig 2.
PC188.
did at 90 days postoperatively. No patients reported any worsening symptoms in either limb. Conclusions: Delayed conversion to a kissing stent configuration can be considered for treatment of contralateral iliac vein outflow obstruction in the setting of previous unilateral iliac vein stenting. Author Disclosures: S. Chen: Nothing to disclose; P. Faries: Nothing to disclose; J. Lurie: Nothing to disclose; M. Marin: Nothing to disclose; C. M. Png: Nothing to disclose; S. Subramaniam: Nothing to disclose; R. O. Tadros: Nothing to disclose; W. Ting: Janssen Pharmaceuticals: consulting fees (eg, advisory boards), speaker’s bureau.
PC186. Silent Deep Venous Thrombosis: Associations With Proximal Venous Outflow Obstruction and Hypercoagulation Markers Jacob Lurie, Chien Yi M. Png, Sneha Subramaniam, Sida Chen, Rami O. Tadros, Michael Marin, Peter Faries, Windsor Ting. Icahn School of Medicine at Mount Sinai, New York, NY Objectives: The presence of a proximal venous outflow obstruction (PVOO) in the iliac vein has been observed during catheter-based interventions for acute deep venous thrombosis (DVT). It is not clear whether the proximal obstruction and the more distal DVT are causally related, even though stasis is a commonly known contributor to DVT. Stent placement in the iliac vein, an emerging intervention for chronic PVOO, has provided an unexpected opportunity to evaluate the relationship between PVOO in the iliac vein and DVT. Methods: In order to evaluate a possible PVOO and DVT association, we retrospectively reviewed the medical records of 180 consecutive patients (mean age, 59 years; 57% females), with 90% presenting with edema and 10% presenting with active ulceration, who underwent iliac vein stent placement for chronic PVOO from October 2013 to March 2015. Of these, 152 had partial or complete panels for 48 separate markers of hypercoagulation. We divided the study patients into three
Outcomes of Iliac Vein Stenting in Proximal Venous Outflow Obstruction Sida Chen, Chien Yi M. Png, Jacob Lurie, Sneha Subramaniam, Charles Sanky, Michael Marin, Peter Faries, Windsor Ting. Icahn School of Medicine at Mount Sinai, New York, NY Objectives: This study evaluated the outcome of vein stent placement for chronic proximal venous outflow obstruction (PVOO) in order to improve patient selection, enhance technical approach, and better define quality measurements for these cases. Methods: A total of 484 consecutive patients who underwent iliac vein stenting for PVOO from October 2013 to July 2016 were reviewed. Postoperative outcomes at 30 days, 60 days, 6 months, 1 year, and 1.5 years were analyzed. Wilcoxon-Mann-Whitney and Kruskal-Wallis tests were run for demographic/operative variables. Additionally, ordered logistic regressions were run for the outcomes at each time point. Results: Follow-up was maintained in 90% of patients, with a mean follow-up time of 320 days. Mean patient age was 60 years, with 57% female. Edema was a symptom in 90.5% of patients and active ulceration in 10.7%. Kruskal-Wallis tests were significant for improvement in patients of all CEAP classes at 30 days (P ¼ .041), 90 days (P ¼ .045), 6 months (P ¼ .041), and 1 year (P ¼ .011). Ordered logistic regressions found the presence of edema (95% confidence interval [CI], 0.43-2.62; P ¼ .006), active ulceration (95% CI, 0.083-3.50; P ¼ .040), and decreased number of stents placed (95% CI, e1.07 to e 0.035; P ¼ .036) predicted increased improvement at 30 days, and a history of deep vein thrombosis (DVT; 95% CI, e1.79 to e 0.096; P ¼ .029) predicted decreased improvement at 1 year postoperatively (Table). Bilateral vein stents comprised 59% of patients. Wilcoxon-Mann-Whitney tests were significant for more improvement in patients who had unilateral vs bilateral stents placed at 30 days (P ¼ .013) and 6 months (P ¼ .039). A total of 7.6% of patients underwent major postoperative reinterventions (61.7% for recurrent symptoms, 17.6% for persistent symptoms, 15% for new symptoms, and 6% for DVT). Mean time to reintervention was 191 days. The reintervention population was disproportionately composed of patients with a history of DVT (29.4%) and intraoperative DVT findings (47.1%) compared to the total patient population (13.8% and 21.5%, respectively). Conclusions: Vein stent placement for PVOO is associated with beneficial outcomes >1 year after the procedure. While unilateral stents are