Endovascular management of chronic total occlusions of the inferior vena cava and iliac veins

Abstract

Objective: Percutaneous recanalization and stenting is currently the standard of care for symptomatic chronic total occlusions (CTOs) of the iliofemoral veins. CTO lesions involving the inferior vena cava (IVC) present a more complex patient subset. In this series we describe our single-center experience with endovascular recanalization of symptomatic occlusions of the IVC.

Methods: Patients were evaluated with duplex ultrasound imaging, venous function tests, and venography before intervention. Occluded segments were recanalized, balloon dilated, and stented. The basic stent technique modified over time to accommodate the iliocaval junction, presence of IVC filters, and lesions extending to the renal veins and atrium.

Results: Between November 2000 and August 2015, 71 patients (41 men [58%]) underwent IVC endovascular recanalization procedures for symptomatic chronic IVC occlusions. Patients were an average age of 51 years (range, 23-77 years). Underlying contributing factors for venous occlusion included IVC filter occlusion in 38 (54%), caval ligation/clipping in 4 (6%), and hypercoagulable disorder in 27 (38%). The technical success rate was 85% (n = 60). The proximal extent of the stents were infrarenal in 40 (67%), suprarenal in 11 (18%), or intrathoracic in 9 (15%). There was minimal perioperative morbidity (2 hematomas, 1 renal failure) and no postoperative mortality. Average follow-up was 48.0 ± 43.3 months (range, 6-172 months). Primary, primary assisted, and secondary patency rates at 60 months were 52%, 85%, and 93%, respectively. Significant improvement in pain and swelling was seen in 91% and 83%, respectively; and complete cumulative relief of pain and swelling was 66% and 41% respectively. Ulcers were present in 18 patients and healed completely without recurrence in 14 (78%) after recanalization. The Venous Clinical Severity Score was 8.4 ± 5.1 (range, 4-27) before the intervention and 3.9 ± 3.2 (range, 0-14) after the intervention (P < .001).

Conclusions: Endovascular recanalization of chronic total IVC occlusions can be performed with minimal morbidity and mortality. When successful, symptoms can be substantially improved, with excellent patency.