Venous Stenting for Post Thrombotic Syndrome (PTS)

Deep venous disease occurs as a result of venous valve incompetence leading to venous reflux or intrinsic obstruction (deep venous thrombosis) or extrinsic venous obstruction (also called non-thrombotic iliac vein lesions (NIVL)). Iliofemoral DVT accounts for 25% of all DVTs. Post thrombotic syndrome is a complication of iliofemoral DVTs affecting half of the patients despite being on anticoagulation¹. Patients with post thrombotic syndrome can present symptoms of leg swelling, skin pigmentation, venous claudication (leg pain on standing or walking) and leg ulceration. Venous ulcers are a common and debilitating condition with an estimated prevalence of active venous ulcers is between 0.8 to 1.0 per 1000population². A thorough history and examination are very important to identify management plan. Some patients with May-Thurner syndrome may also present late with symptoms and signs of venous insufficiency or post thrombotic syndrome. Duplex ultrasound scan of the leg provides information about the patency of the vein, clot in the vein and any reflux within the vein. In order to identify involvement of iliac veins CT venogram is useful. CT venogram also helps in planning intervention/ thrombolysis/ stenting. MR venogram is an alternative to CT and has the advantage of carrying no radiation. Percutaneous venogram is performed to support in diagnosis and at the same time performing treatment. Intravenous ultrasound (IVUS) is used to evaluate the inside of the vein wall and has high sensitivity for identifying stenosis or occlusion in the IVC or iliac venous obstruction. IVUS also accurately measures the diameter of the vein and hence is useful in measuring the correct stent size. IVUS guided stenting also assists in identifying the appropriate landing zone for the stents¹.

Endovascular treatment, by use of percutaneous transluminal angioplasty (PTA) and stenting of post-thrombotic obstructions and venous compression syndromes, such as May-Thurner syndrome (MTS), has become standard care in a large number of specialized centers worldwide^4-7.

There are a wide range of stents available now for venous disease. For example, the Veniti Vici (VENITI inc., St. Louis, MO, USA), Zilver Vena (Cook, Bloomington, IN, USA), and sinus Venous (OptiMed, Ettlingen, Germany) are some of the common ones. For common iliac lesions the cranial end of the stent is extended well into the IVC. In the case of bilateral disease, the stents are deployed by a kissing technique with the creation of a double barrel of stents in the IVC. In some cases the externaliliac stent is extended across the inguinal ligament to reach a healthy inflow segment.