Hemodynamic Consequences of Deep Venous Obstructive Disease

s from the 2015 American Venous Forum Annual Meeting Fig. Mean pressure in common femoral vein. Randomized Double-Blinded Study Comparing Clinical Versus Endovascular Treatment of Iliac Vein Obstruction F. H. Rossi, A. M. Kambara, N. M. Izukawa, P. B. Metzger, C. B. Betelli, B. L. Almeida, T. O. Rodrigues, I. P. Masciarelli, A. G. Sousa, C. B. O. Rossi. Instituto Dante Pazzanese, Sao Paulo, Brazil; Instituto Dante Pazzanese, Sao Paulo, Brazil Objectives: Post-thrombotic (PIVL) and nonthrombotic iliac vein lesions (NIVL) are frequently treated with endovascular methods. However, outcomes have never been studied by a randomized clinical trial before. The purpose of this study is to compare clinical and endovascular treatment outcomes in symptomatic chronic venous disease (CVD) patients with documented iliac vein obstruction. Methods: Patients with CVD (CEAP C3-6) and visual analog scale for pain (VAS pain) score >5 were considered eligible. We randomly assigned 50 iliac vein obstructions with >50% area reduction, per intravascular ultrasound, to undergo angioplasty and iliac vein stenting plus clinical treatment or clinical treatment alone (venoactive drug/aminaftone or warfarin [PIVL], plus compression therapy, and Unna boot for active venous ulcer). The patient and the clinical physician were blinded. Primary outcomes included (1) change from baseline in VAS pain and (2) venous ulcer healing rate at 6 months. Secondary outcomes included changes in Venous Clinical Severity Score (VCSS) and SF-36 Quality of Life Questionnaire as well as stent integrity, position, and patency at 6 months. Results: Between February 2013 andMarch 2014, 40 patients with 50 highly symptomatic iliac vein obstructions were studied. The median age was 57 years (range, 19-78 years). The female-to-male ratio was 4.7:1, and the leftright ratio was 3:1. CEAP classification was 3:36%, 4:22%, 5:12%, and 6:30%. Iliac vein stenting was 100% successful (PIVL, 42%; NIVL, 52%). The pain level on VAS scale declined from a median of 8.5 to 1.8 following stenting and from7.5 to7.0 after clinical treatment (P< .001).The rate of ulcer healing was higher after stenting (80%) vs clinical treatment group (33.3%) at 6months (95% confidence interval, 0.74-7.75; odds ratio, 2.4; P 1⁄4 .144). The VCSS scale (0-30) declined from a median of 19.2 to 11.6 after stenting and from 15.1 to 14.8 after clinical treatment (P < .001). The SF-36 Quality of Life Questionnaire (0-100) improved from a median of 53.9 to 85.0 with stenting and 48.3 to 59.8 after clinical treatment (P< .001). With a median follow-up of 10.2months, there was no stent fracture or migration. Primary and assisted primary stent patency rates were 96% and 100%, respectively. Conclusions: Angioplasty with stenting is a safe and effective treatment. The intervention promotes rapid relief of CVD symptoms and improves quality of life in highly symptomatic patients. Our results reproduce those achieved in numerous nonrandomized clinical studies. The data suggest clinical treatment alone should be limited to a very restricted number of patients who cannot undergo endovascular treatment. Author Disclosures: F. H. Rossi: FAPESP, Research Grant, Principal Investigator; A. M. Kambara: Nothing to disclose; N. M. Izukawa: Nothing to disclose; P. B. Metzger: Nothing to disclose; C. B. Betelli: Nothing to disclose; B. L. Almeida: Nothing to disclose; T. O. Rodrigues: Nothing to disclose; I. P. Masciarelli: Nothing to disclose; A. G. Sousa: Nothing to disclose; C. B. O. Rossi: Nothing to disclose. Hemodynamic Consequences of Deep Venous Obstructive Disease R. L. M. Kurstjens, M. A. F. de Wolf, I. M. Toonder, R. de Graaf, C. H. A. Wittens. Maastricht University Medical Centre, Maastricht, The Netherlands Objectives: Post-thrombotic iliofemoral venous obstruction can cause debilitating symptoms and can be treated by percutaneous angioplasty and stenting with good clinical results. However, little is known about the hemodynamic effects of iliofemoral post-thrombotic obstruction. The aim of this study was to demonstrate the hemodynamic changes in iliofemoral venous obstructive disease in the common femoral vein (CFV), compared to the dorsal foot vein, during ambulation. Methods: Sixteen patients with post-thrombotic unilateral iliofemoral deep venous obstruction were included. The dorsal foot vein and CFV were cannulated bilaterally, and patients were instructed to walk on a treadmill until a maximum walking distance was reached (3.2 km/h, slope increasing 2% every 2 minutes to a maximum of 26 minutes). Results: All patients suffered from venous claudication. Mean age was 426 14 years; 13 patients were female, and two had right-sided complaints. Pressure in the CFVwas significantly higher in diseased limbs in erect position (58.8 6 12.5 compared with 42.1 6 16.8; P 1⁄4 .008, Wilcoxon signed rank test), but this difference was not found in the dorsal foot vein (84.96 11.8 vs 87.5 6 10.5; P 1⁄4 .386). During walking, pressure significantly increased by 25.66 17.0 mm Hg in the CFV of diseased limbs compared with 1.9 6 6.4 mmHg in control limbs (P 1⁄4 .001; Fig). Pressure decreased by 36.46 21.0 mm Hg in the dorsal foot vein of diseased limbs, which was not significant compared with 40.7 6 19.5 in controls (P 1⁄4 .508). Only four patients were able to finish the treadmill test, although all patients developed pain during the test. In the supine position, no significant differences were found. Conclusions: This is thefirst study showing a significantpressure increase at the level of theCFV in erect position and during ambulation in patients with a post-thrombotic deep venous obstruction. This could explain the occurrence of venous claudication in patients with iliofemoral venous obstruction. Author Disclosures: R. L. M. Kurstjens:Nothing to disclose;M. A. F. de Wolf: Nothing to disclose; I. M. Toonder: Nothing to disclose; R. de Graaf: Nothing to disclose; C. H. A. Wittens: Nothing to disclose. Nonthrombotic Venous Obstructions Cause Pelvic Congestion Syndrome S. F. Daugherty. Veincare Centers of Tennessee, Clarksville, Tenn Objectives: Pelvic congestion syndrome (PCS) usually is attributed to ovarian or internal iliac vein reflux. Until recently, nonthrombotic iliac vein obstruction and left renal vein obstruction rarely have been reported as causes of PCS. Methods: A total of 3730 new patients were evaluated in a vein center by a single physician from 2008 through August 2014. Records were reviewed for the patients who underwent treatment for PCS. After a history and physical examination suggested the clinical diagnosis of PCS, the patients were studied with transabdominal venous duplex ultrasound and either computed tomography or magnetic resonance venography. Subsequent venograms with intravascular ultrasound were used to confirm the diagnosis and to direct angioplasty/stenting of the left common iliac vein. Follow-up was performed with clinical examination and transabdominal ultrasound. Results: Twenty-nine patients were treated with angioplasty/stenting of the left common iliac vein for PCS. Only 12 of these patients presented to the center for pelvic symptoms. The other 17 presented for lower extremity complaints, but it quickly became apparent that their dominant symptoms affecting quality of life were pelvic symptoms. Fifty-six other patients whose primary symptoms were leg symptoms with variable degrees of pelvic symptoms were treated as well for nonthrombotic iliac vein obstruction. Three patients were treated for left ovarian vein reflux with coil embolization techniques. One patient was identified with severe aortomesenteric compression of the left renal vein with extensive left ovarian vein reflux causing pelvic congestion symptoms judged severe enough to recommend venous bypass.