1. CHRONIC ILIAC VEIN/IVC OBSTRUCTION Stephen F. Daugherty, MD, FACS, RVT, RPhS Clarksville, Tennessee

2. ETIOLOGY CHRONIC POST-THROMBOTIC Complete Occlusion, High-grade Stenosis Long Stenosis due to Fibrosis Webs/Synechiae 80% of iliofemoral DVT have an underlying extrinsic iliac vein compression. Chang, et al. JVIR, 2004;15:249-256.

3. ARTERIAL COMPRESSION May-Thurner Aneurysms, tortuous iliac arteries, arterial grafts TUMORS, CYSTS - benign or malignant RADIATION OR RETROPERITONEAL FIBROSIS SURGICAL INJURY HYPOPLASTIC - Klippel-Trenaunay OBESITY, ASCITES NON-THROMBOTIC

4. CLINICAL PRESENTATION - May be subtle until the right questions are asked - Often multiple physician visits, multiple “normal” LE venous color duplex US studies Often misdiagnosed with: FibromyalgiaNeuropathy Statin MyopathyPlantar Fasciitis Lumbar Spine DiseaseStatin Myopathy

5. LOWER EXTREMITY PAIN At rest, worse with standing or ambulation Athletes - pain and tight leg limit running Waitress - unable to work Truck driver - unable to walk around his truck EDEMA Dependent, often worse with ambulation SUPRAPUBIC OR LABIAL VARICOSITIES BACK PAIN - Unusual blood loss during lumbar surgery

6. PELVIC PAIN/DYSPAREUNIA PELVIC CONGESTION SYNDROME Ovarian vein reflux and pelvic varicosities may co-exist with iliac vein obstruction and treatment of the iliac vein obstruction alone may resolve the pelvic symptoms.

7. CLINICAL EXAM - LE findings may be out of proportion to symptoms - Iliac vein obstruction often coexists with reflux or chronic LE post-thrombotic obstruction - Tenderness is quite variable - Edema may be minimal at rest - Varicosities may be absent or minimal

8. VARICOSE VEINS - esp. medial proximal thighs, infragluteal, hip, suprapubic, labial, anterior abdominal or chest wall EDEMA - unilateral or bilateral C4 - hyperpigmentation, stasis dermatitis C5,6 - stasis ulcers, healed or active

9. WORK-UP Physiologic Tests - Global, Limited Value LE Venous CDU - Reflux Obstruction CFV Doppler Flow Continuous Asymmetry Femoral Vein Collaterals to Pelvis

14. ABDOMINAL/PELVIC COLOR DUPLEX FLOW AND ANATOMY STENOSIS decreased diameter increased peak venous velocity FLOW REVERSAL Internal iliac vein or pelvic tributaries to iliac veins Exercise may reveal IIV flow reversal GONADAL OR ASCENDING LUMBAR VEIN PELVIC VARICOSITIES

27. CT/MR VENOGRAMS Help with anatomic detail Do not evaluate flow Variably useful depending on facility and radiologist experience/interest. CT-Timing of contrast injection/flow issues affect quality of imaging.

28. INTENT TO TREAT SYMPTOMS CONSISTENT WITH ILIAC VEIN OBSTRUCTION HEMODYNAMICALLY SIGNIFICANT LESION PATIENT WILLING AND ABLE TO PARTICIPATE IN CLOSE FOLLOW-UP AND ANTI-COAGULATION (IF NECESSARY)

29. PROTHROMBOTIC PROFILE PT, PTT PROTEIN S AND C ANTITHROMBIN III FACTOR II 2021A MUTATION FACTOR V LEIDEN MUTATION ANA LUPUS ANTICOAGULANT CARDIOLIPIN ANTIBODIES HOMOCYSTEINE

30. DEFINITIVE DIAGNOSTIC/THERAPEUTIC VENOGRAMS CFV OR FV INJECTIONS - FLOW, PELVIC COLLATERALS - FILLING DEFECTS - WILL MISS SOME STENOSES, WEBS IVUS - THE ANATOMICAL GOLD STANDARD - USUALLY BILATERAL ILIOFEMORAL AND IVC - CHOOSE DIAMETER/LENTH OF BALLOON AND STENT - STENT PLACEMENT - POST-STENTING EVALUATION

34. ANTICOAGULATION Lovenox, 1 mg/kg preprocedure and q 12 h x2 Aspirin, 325 mg daily lifelong Plavix, 150 mg po in PACU and 75 mg daily x 30d OR Long-term warfarin with Lovenox bridge for post- thrombotic patients or those testing positive for prothrombotic disorders

35. FOLLOW-UP <1 weekOffice visit 3-4 weeksAbd/pelvic venous CDU/OV 3, 6, 9, 12, 18,Abd/pelvic venous CDU/OV 24 months Then annuallyAbd/pelvic venous CDU/OV For early US finding of homogeneous density in stent, anticoagulate for at least 6 months. Repeat CDU 1-2 weeks after stopping anticoagulation.

39. SECONDARY PROCEDURES Flow-limiting in stent stenosisPTBA New stenosis outside stentPTBA/stent ThrombosisConsider thrombolysis Evaluate inflow and outflowand adequacy of anticoagulation

40. RESOURCES Handbook of Venous Disorders: Guidelines of the American Venous Forum, 3rd Ed, 2009. The Care of Patients with Varicose Veins and Associated Chronic Venous Disorders, Clinical Practice Guidelines of the Society for Vascular Surgery and the American Venous Forum. JVS.2011; Vol 53, Number 16S. Seshadri Raju and Peter Neglen, JVS, 2002-present.