Experience with Vein Stent Placement for Proximal Venous Outflow Obstruction at One Center
Windsor Ting, MD, Sida Chen, Sneha Subramaniam, Jacob Lurie, Chien Yi M. Png, Ageliki Vouyouka, MD, Rami O. Tadros, MD, Michael L. Marin, MD, Peter L. Faries, MD.
Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Objective: Venous stenting in patients with chronic proximal venous outflow obstruction (PVOO) has recently emerged as a valuable therapeutic strategy. This report summarizes our experience, focusing on patient selection, technical approaches, and outcomes. Methods: This clinical experience comprised of 484 consecutive patients who underwent vein stent placement for chronic PVOO in the iliac veins from October 2013 to July 2016 at one facility. Postoperative outcomes were analyzed with logistic regressions, Wilcoxon-Mann-Whitney and Kruskall-Wallis tests. Results: Mean age of patients was 60 years (SD 13.4 years) and 57% female. Preoperatively, edema was present in 90.5%, active ulceration 10.7%, and history of DVT in 13.8%. During the procedure, 21.5% of patients without any known history of DVT had intraoperative findings (diffuse stenosis, vessel occlusion, intraluminal thrombus) suggestive of a remote DVT on their venogram/IVUS. Bilateral vein stents were performed in 59%. Follow-up was maintained in 90% of patients with a mean follow-up 320 days. Kruskall-Wallis tests were significant for improvement quantified by symptoms, CEAP class, & physical exam in patients at thirty days (p=0.041), ninety days (p=0.045), six months (p=0.041) and one year (p=0.011). Ordered logistic regressions found the presence of edema (95% CI [0.43, 2.62], p=0.006), active ulceration (95% CI [0.083, 3.50], p=0.040) and decreased number of stents placed (9 5% CI [-1.07, -0.035], p=0.036) to predict increased improvement at thirty days, and a history of DVT (95% CI [-1.79, -.096], p=0. 029) to predict decreased improvement at one year post-operatively. Wilcoxon-Mann-Whitney tests were significant for more improvement in patients who had unilateral vs. bilateral stents placed at thirty days (p=0.013) and six months (p=0.039). Major re-interventions (61.7% for recurrent symptoms, 17.6% for persistent symptoms, 6% for DVT) were performed in 37 patients (7.6%). Mean time to re-intervention 191 days. Re-interventions were more prevalent (29. 4%) among patients with a history of DVT. Conclusions: Vein stenting for chronic PVOO has a satisfactory outcome at one year. Eight percents of patients require a major reintervention. DVT provided by history or suggested by intraoperative findings is common among chronic PVOO patients undergoing vein stent placement. Patient selection and procedural indications warrant further investigation and discussion.
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