1. Epidemiology and Natural history of Venous Obstruction/Compression
Antonios P Gasparis, MD
Professor of Surgery
Director, Center for Vein Care
Stony Brook Medicine

2. Chronic Venous Disease
Secondary Disease
Primary Disease
Deep vein thrombosis
Vein/Valvular damage
Venous reflux
Venous reflux
Venous Hypertension
Obstruction
Skin damage

3. Clinical Etiology Anatomy Pathology
Labropoulos N. CEAP in clinical practice. Vasc Surg 1997; 31:

4. Prevalence of Venous Obstruction
Isolated Obstruction – 2% Reflux+ Obstruction – 16.8%
Reflux plus obstruction most severe morbidity!
Labropoulos N. CEAP in clinical practice. Vasc Surg 1997; 31:

5. Venous Obstruction Infra-inguinal
Non-thrombotic
Post-thrombotic
Images courtesy of Antonios P Gasparis

6. Venous Outflow Obstruction Supra-inguinal
Non-thrombotic
Post-thrombotic

7. Venous Obstruction Supra-inguinal veins Infra-inguinal - PTS Acute
- Deep vein thrombosis
Chronic
- PTS
- Pelvic reflux
Acute
- Deep vein thrombosis
Chronic
- PTS

8. Labropoulos N et al. Arch Surg 1997;132:46-51
The role of venous outflow obstruction in patients
with chronic venous dysfunction

9. Iliac Vein Compression

10. Iliac Vein Compression
Observed valve-like strictures of the left iliac vein causing iliofemoral venous thrombosis.
McMurrich JP. The valves of the iliac vein. Br Med J 1906;2:
McMurrich JP. The occurrence of congenital adhesions in the common iliac veins, and their relation to thrombosis of the femoral and iliac veins. Am J Med Sci 1908;135:342-3

11. Iliac Vein Compression
Pulsation of the right common iliac artery can induce reactive proliferation of venous wall cells and give rise to web- or spur-like stenosis. They reported that venous spurs occurred in 22% of healthy adults.
May R, Thurner J. Ein Gefäßsporn in der Vena iliaca communis sinistra als Ursache der überwiegend linksseitigen Beckenvenenthrombosen. Z Kreislaufforschung 1956;45:
May R, Thurner J. The cause of the predominantly sinistral occurrence of thrombosis of the pelvic veins. Angiology :

12. Iliac Vein Compression
The iliac compression syndrome may be the cause for the fibrous strictures and web- or spur-like stenoses of the left common iliac vein. Therefore it could be responsible for the difficulty in restoring patency by thrombectomy alone.
Cockett FB, Thomas ML. The iliac compression syndrome. Br J Surg 1965;52:816-21
Cockett FB. Venous causes of swollen leg. Br J Surg 1967;54:

13. Incidence in Asymptomatic
50 patients with abdominal pain
Mean age 40
CT scan – measure AP diameter
24% had >50% compression
Compression of the LIV is a frequent anatomic variant in asymptomatic individuals - may represent a normal anatomic pattern
Kibbe MR, Ujiki M, Goodwin AL, Eskandari M, Yao J, Matsumura J. Iliac vein compression in an asymptomatic patient population. J Vasc Surg May;39(5):

14. Incidence in population
300 patients - reviewed CT scans
The mean age was 52 years
Patients with >70% vs <70% stenosis showed similar risk factors
Diameter stenosis more than 70% in 30.6% with higher incidence in females
The presence of stenosis was not associated with the presence of clinical symptoms
Nazzal M, El-Fedaly M, Kazan V, Qu W, Renno AW, Al-Natour M, Abbas J. Incidence and clinical significance of iliac vein compression. Vascular Aug;23(4):

15. Incidence in C5 and C6 Incidence of ICVO in CEAP class 5 and 6
78 patients evaluated with CT or MR venogram
37% had obstruction of at least 50%
23% had obstruction of >80%
Risk factors associated with >80% ICVO include:
female gender, history of DVT, and deep reflux
Marston W1, Fish D, Unger J, Keagy B. Incidence of and risk factors for iliocaval venous obstruction in patients with active or healed venous leg ulcers. J Vasc Surg May;53(5):

16. Natural History Iliac vein Compression
There is no data on the natural history of iliac vein compression
However, a number of patients could develop CVI but what triggers the development of these signs and symptoms, when it starts and how long it takes to reach this point is unknown

17. Compression and DVT 230 patients with CT prior to unilateral DVT
Patients with right DVT were more likely to have a PE
29.7% had greater than 50% compression
7.2% had greater than 70% compression
>70% compression associated with left DVT
Narayan A, Eng J, Carmi L, McGrane S, Ahmed M, Sharrett AR, Streiff M, Coresh J, Powe N, Hong K.Iliac vein compression as risk factor for left- versus right-sided deep venous thrombosis: case-control study. Radiology Dec;265(3):949-57

18. Compression and DVT
Females < 45 with DVT (21) and age-matched control (26)
Presented with abdominal pain, had CT and CIV diameters
were measured, reviewed risk factors for DVT
LCIV stenosis was a strong independent risk factor for DVT
Identical LCIV diameters were associated with a higher
probability of developing DVT if the risk factor score was higher
Carr S, Chan K, Rosenberg J, Kuo WT, Kothary N, Hovsepian DM, Sze DY, Hofmann LV. Correlation of the diameter of the left common iliac vein with the risk of lower-extremity deep venous thrombosis. J Vasc Interv Radiol Nov;23(11):

19. Post-thrombotic Iliac Vein Obstruction

20. Prevalence of Post-thrombotic Ilio-caval Venous Obstruction
In patients with acute DVT: % prevalence of iliofemoral thrombosis
Given that small number of these patients receives aggressive treatment a large number of patients should have iliocaval obstruction.
Therefore, those with signs and symptoms
of venous insufficiency may be treated
Douketis JD, Crowther MA, Foster GA, et al. “Does the location of thrombosis determine the risk of disease recurrence in patients with proximal deep vein thrombosis? “ Am J Med 2001;110:515-9.
Crisostomo PR, Cho J, Feliciano B, et al. “Period frequency of iliofemoral venous occlusive disease by Doppler ultrasound and corresponding treatment in a tertiary care facility” J Vasc Surg 2010;52:

21. Prevalence of Post-thrombotic Ilio-caval Venous Obstruction
Annual incidence of DVT – 700,000
5% ilio-femoral – 35,000
>90% anticoagulation – 31,500
15% develop PTS – 4,725

22. Natural History of Post-thrombotic Venous Obstruction
Recurrence
Pot-thrombotic Syndrome

23. Recurrence Months VTE (N) Cum Incid 6 85 10% 32 4.2% 12 39 15% 17 6.6%
Predictors of recurrent VTE
Unprovoked VTE
Location
Cancer
Shorter anticoagulation
Age
Months
VTE (N)
Cum Incid 6 85
10% 32
4.2% 12 39
15% 17
6.6% 60
130
40.8% 48
16.1%
120 14
52.6% 8
22.5%
Prandoni et al, Hematologica 2007

24. Recurrence 1,149 Symptomatic DVT Rx’ed with Anticoagulation Results
Overall 3 mos – 5.1% Femoral vein thrombosis – 5.3% Iliofemoral DVT – 11.8%
Risk for Recurrence
Factor
Odds Ratio
Iliofemoral DVT Cancer 2.6
Douketis JD et al
Am J Med 2001;110:515

25. Natural History of Deep Vein Thrombosis
Early Results (6 months) of Thrombolysis vs Anticoagulation in Iliofemoral Venous Thrombosis
35 patients were randomized
Anticoagulation alone (17)
Thrombolysis (18)
Obstruction % %
Reflux % %
Elsharawy M, Elzayat E. early results of thrombolysis vs anticoagulation in iliofemoral venous thrombosis: a randomised clinical trial. Eur J Vasc Endovasc Surg. 2002; 24:

26. PTS 355 consecutive patients with first DVT
Cumulative incidence of PTS
All - 28% at 5 years
Severe - 9.3% at 5 years
Prandoni et al, Ann Intern Med 1996

27. Effect of Venous Thrombus Location and Extent on Developing PTS
CEAP classification in patients with isolated vein thrombosis
Mean – 3.4 yrs
15% advanced to C4
REFERENCE: Labropoulos N, et al. The effect of venous thrombus location and extent on the development of post-thrombotic signs and symptoms. J Vasc Surg. 2008;48: [pg 409, col 1, Table IV]
Labropoulos N, et al. J Vasc Surg. 2008;48:407-12

28. Effect of Venous Thrombus Location and Extent on Developing PTS
CEAP classification in patients with vein thrombosis in multiple segments
Mean – 3.4 yrs
37% advanced to C4-6
REFERENCE: Labropoulos N, et al. The effect of venous thrombus location and extent on the development of post-thrombotic signs and symptoms. J Vasc Surg. 2008;48: [pg 409, col 2, Table V]
10% developed ulcer
Labropoulos N, et al. 2008;48:407-12

29. Observations at 5 Years after iliofemoral DVT
Venous ulceration 15%
Venous claudication developed in almost 50%
Limited ambulation in 15%
Significant hemodynamic impairment
Markedly reduced QOL
Labropoulos N et al. J Vasc Surg 2009;49:704-10
Labropoulos N, et al. J Vasc Surg 2008;48:407-12
Delis KT et al. Ann Surg 2004;239:118-26
Akesson H. Eur J Vasc Surg 1990;4:483-9

30. Evaluate iliofemoral DVT and HRQOL
Retrospective study of 68 patients treated
w/ CDT vs. 30 w/ anticoagulation
16 mo f/u
Lower incidence of PTS (p=0.006)
Better HRQOL (p=0.038)
Results
Comerota et. al, J Vasc Surg. 2000;32(1):130-7

31. Summary
Venous outflow obstruction can lead to significant venous hypertension
Diagnosis is often under-estimated
Natural history of compression is unknown but post-thrombotic obstruction is a significant risk factor for recurrent DVT and progression to CVI