Endovascular recanalization for nonmalignant obstruction of the inferior vena cava

Abstract

Objective: The aim of this study was to evaluate outcomes of endovascular recanalization of the inferior vena cava (IVC) and iliac veins with long-standing chronic venous obstruction caused by nonmalignant disease.

Methods: Medical records for 66 patients who underwent endovascular recanalization of the IVC with or without iliac veins from January 2001 to December 2014 at our medical center were retrospectively reviewed. Primary outcomes included morbidity and mortality; secondary outcomes included primary, primary assisted, and secondary patency and resolution of symptoms.

Results: Forty-five (68%) patients were male; the mean age was 43 years (range, 17-83 years). All but one patient had chronic symptoms (mean duration, 8 ± 9 years). Clinical, Etiology, Anatomy, and Pathophysiology classes included 3, 4a, 4b, 5, and 6 in 41, 2, 1, 2, and 20 patients, respectively. Mean Venous Clinical Severity Score was 12.4 ± 6.5. Fifty-nine patients (89%) had history of deep venous thrombosis, and 13 also had pulmonary embolism. Twenty-five patients (38%) had an IVC filter; 20 (30%) had thrombophilia. The obstruction involved the infrarenal IVC in 44 patients and both the infrarenal and suprarenal IVC in 22 patients. All recanalizations were performed under conscious sedation and local anesthesia and involved sequential angioplasty and stent placement into the IVC, with or without iliac vein stenting. Venous access included bilateral femoral veins and right internal jugular vein. Stents used were Wallstents (Boston Scientific, Marlborough, Mass; n = 70), Protegé stents (ev3, Plymouth, Minn; n = 49), Gianturco (Cook Medical, Bloomington, Ind; n = 44), and Luminexx (Bard, Tempe, Ariz; n = 1). Pressure gradients were 6.7 ± 4.0 mm Hg before and 0.9 ± 1.1 mm Hg after stenting (P < .001). Procedural success was 90% and 100% at first and second attempt at recanalization, respectively. There was no mortality or clinically significant pulmonary embolism. Four patients had five complications: two developed an arteriovenous fistula, one patient developed groin hematoma that required open evacuation, and one had peri-IVC hematoma and femoral vein thrombosis that required repeated angioplasty and stenting; 93% of patients received long-term anticoagulation. Follow-up was 42 ± 36 months. Four patients were lost to follow-up. Primary patency, primary assisted patency, and secondary patency at 36 months were 78%, 87%, and 91%, respectively. Symptoms resolved in 83% of patients. On multivariable regression analysis, hypercoagulable state was the only predictor of reocclusion of the recanalized veins.

Conclusions: Endovascular recanalization for nonmalignant symptomatic IVC and associated iliofemoral venous obstruction with balloon angioplasty and self-expanding stents is technically challenging; however, it is safe and durable. In our retrospective study, estimated patency rates at 36 months were >85%, and clinical outcomes were excellent. Venous stenting should be attempted for chronic nonmalignant IVC and associated iliac or iliofemoral venous obstructions before open surgical reconstruction is contemplated.