High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: A permissive role in pathogenicity Seshadri Raju, MD, Peter Neglen, MD,

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Presentation transcript:

High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: A permissive role in pathogenicity Seshadri Raju, MD, Peter Neglen, MD, PhD Journal of Vascular Surgery Volume 44, Issue 1, Pages 136-144 (July 2006) DOI: 10.1016/j.jvs.2006.02.065 Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 1 Age distribution of 319 patients with nonthrombotic iliac vein lesions. The median age was 54. Journal of Vascular Surgery 2006 44, 136-144DOI: (10.1016/j.jvs.2006.02.065) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 2 Variable venographic appearance of nonthrombotic iliac vein lesions (NIVLs). Left, “Classic” appearance with contrast translucency appearing as a filling defect (arrow). Middle, Broadening (pancaking) of the vein with collaterals (arrow). Right, the venogram appears entirely normal in about a third of cases. Note the absence of collaterals. However, an intravascular ultrasound (IVUS) scan showed a tight lesion (inset) with the lumen not larger than the 6F IVUS catheter (arrow); “a” denotes adjacent artery. The arrow in the venogram points to the general area where the IVUS found the NIVL. Journal of Vascular Surgery 2006 44, 136-144DOI: (10.1016/j.jvs.2006.02.065) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 3 Pain relief after stent placement alone in nonthrombotic iliac vein lesion (NIVL) subsets with and without reflux. The cumulative curves represent limbs (%) with complete relief of pain. Only limbs that had preoperative pain are shown. At 2.5 years, 82% and 77% of limbs in the two subsets, respectively, were totally free of pain. There is no statistical difference between the curves. Limbs at risk at various time intervals for each subset are shown at the bottom of the graph (all SEM <10%). Journal of Vascular Surgery 2006 44, 136-144DOI: (10.1016/j.jvs.2006.02.065) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 4 Swelling relief following stent placement alone in nonthrombotic iliac vein lesion (NIVL) subsets with and without reflux. Only limbs with preoperative swelling are shown. The cumulative curves represent limbs (%) with complete relief of swelling. At 2.5 years, 47% and 53% of limbs in the two subsets, respectively, were totally free of swelling. There is no statistical difference between the curves. Limbs at risk at various time intervals for each subset are shown at the bottom of the graph (all SEM <10%). Journal of Vascular Surgery 2006 44, 136-144DOI: (10.1016/j.jvs.2006.02.065) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 5 Cumulative complete ulcer healing following stent placement in nonthrombotic iliac vein lesion (NIVL) subsets with and without reflux. Reflux was not corrected in the latter subset, yet 67% of ulcers remained completely healed at 2.5 years. Ulcer healing was 76% in the subset without reflux at 2.5 years. There is no statistical difference between the curves. Limbs at risk at various time intervals for each subset are shown at the bottom of the graph (SEM <10% solid line; SEM >10% hashed line). Journal of Vascular Surgery 2006 44, 136-144DOI: (10.1016/j.jvs.2006.02.065) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 6 Overall symptom relief following stent placement in nonthrombotic iliac vein lesion (NIVL) subsets with and without reflux. Each curve (cumulative) represents limbs with grade 3 or 2 (excellent or good) outcomes for the specific subset. The curves are nearly identical. Limbs at risk for each subset at various time intervals are shown at the bottom of the graph (all SEM <10%). Journal of Vascular Surgery 2006 44, 136-144DOI: (10.1016/j.jvs.2006.02.065) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 7 The pathologic anatomy of a nonthrombotic iliac vein lesion (NIVL). The classic left-sided proximal lesion is related to abrupt crossing of the left iliac vein by the right iliac artery. The subsequent course of the right iliac artery is variable (see text). The minority pattern (22%) is shown in the large drawing. Coursing lazily across the vein, the right iliac artery may be related to the proximal or distal NIVL, or both. In the majority pattern (prevalent in 75%, shown in the inset), the right iliac artery crosses the right common iliac vein more abruptly, but lower down at or near the external iliac vein level, inducing distal right NIVL but will not be a factor in proximal right NIVL. The left hypogastric artery crossing may be related to left distal NIVL. The hypogastric veins have been omitted to reduce clutter. Journal of Vascular Surgery 2006 44, 136-144DOI: (10.1016/j.jvs.2006.02.065) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 8 The proximal lesion is coronal and the distal lesion is often sagittal as the hypogastric artery crosses the vein from anterior to the posterior rather than transversely. Note the differential appearance and disappearance of the lesions as the tube is rotated from midline to lateral in the coronal plane: 0° (Left), 45° (Middle), and 60° (Right). The proximal lesion is spiral, often giving a corkscrew appearance. Journal of Vascular Surgery 2006 44, 136-144DOI: (10.1016/j.jvs.2006.02.065) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions