Mid-term results of endovascular treatment for symptomatic chronic nonmalignant iliocaval venous occlusive disease

Background. The goal of this article is to present clinical and patency results of endovascular treatment of nonmalignant, iliocaval venous obstructive disease and to discuss the evolution of technical details. Methods. From November 1995 to June 2004, 44 patients (female-male ratio, 3.9:1; left-right lower limb ratio, 8.6: 1; median age, 42 years; range, 21-80 years) had treatment for chronic disabling obstructive venous insufficiency with iliocaval stenosis or occlusion. The clinical class of CEAP was 2 in 11 limbs, 3 in 31, 4 in 4, 5 in 1, and 6 in 1; etiology was primary in 32 patients, secondary in 10, and congenital in 2. Anatomic involvement included superficial veins in 16 patients and perforator veins in 11. Obstruction was associated with superficial reflux in 4 patients, deep reflux in 13, and both in 13. Ten patients had occlusion. All procedures were performed in the operating room with perioperative angiography and angioplasty with or without self-expanding stent implantation. Venous clinical severity and disability scores were obtained before and after treatment. Patency and restenosis were evaluated by duplex Doppler ultrasonography. Results: No perioperative death or pulmonary embolism occurred. The technical success rate was 95.5% (two recanalization failures), and two (4.5%) perioperative stent migrations occurred. One early thrombosis (2.4%) was treated by thrombectomy and creation of an arteriovenous fistula. One late death and one thrombosis occurred. Restenoses were found in five patients and were all treated successfully (four needed iterative stenting). Median follow-up was 27 months (range, 2-103 months). Median venous clinical severity score improved from 8.5 to 2, and median venous disability score improved from 2 to 0. Cumulative primary, assisted primary, and secondary patency rates of the venous segments at 36 months were 73%, 88%, and 90%, respectively, in intention to treat. The survival rate was 100% at 12 months and 97.3% at 60 months. Conclusions. Endovascular treatment of benign iliocaval occlusive disease is a safe and efficient minimally invasive technique with good mid-term patency rates. Moreover, it improves cases with obstruction only, as well as cases with associated reflux and obstruction. Primary stenting should always be performed by using self-expanding stents deployed under general anesthesia to avoid lumbar pain. In case of failure, the endovascular procedure does not preclude further surgical reconstruction.