Treating Obstructive Lesions of the Inferior Vena Cava

BY KAREN M. DENTE

MIAMI -- Stenting of extensive iliocaval venous obstructions resulted in excellent midterm patency with subjective and objective symptom improvement, according to Dr. Seshadri Raju at the annual meeting of the American Venous Forum.

Dr. Raju presented his findings in a scientific session on management of venous obstruction. He drew from experience based on 120 limbs and 118 patients treated for obstructive lesions of the inferior vena cava between 1997 and 2005. Three groups of patients were involved: the asymptomatic group, usually discovered incidentally on imaging studies (8 patients); the acutely symptomatic group (4 patients); and the chronically symptomatic patients, which made up the largest group (108 patients).

The key to understanding inferior vena cava obstruction is the iliac vein, where the collaterals originate. DR. RAJU

The acutely symptomatic patients developed deep venous thrombosis symptoms below the lesion. The lesion was then lysed, and the patients became asymptomatic, said Dr. Raju of the University of Mississippi Medical Center, Jackson.

Of the remaining two groups, 14 patients were treated conservatively, and 99 patients underwent a procedure in which the stenotic or occluded segment was balloon dilated and stented.

Dr. Raju also presented the results of the recanalization procedures to treat totally occluded caval lesions. "This is a recanalization procedure," said Dr. Raju, indicating the opening of a totally occluded inferior vena cava. "In over close to a thousand stent experiences, we have not had a single case of clinical rupture of the vein. That is because the glide wire will stay within the venous channel even in recanalizations, if you are careful with your technique," said Dr. Raju.

Procedure success was 66% (14/21) for the recannalization procedure and 100% (all 85 patients) for stenoses, Dr. Raju reported. Symptom remission was excellent with 74% (cumulative) maintaining complete relief of pain at 31/2 years after stent placement.

"Swelling of venous origin is generally more difficult to deal with. Total relief of swelling at 31/2 years was a little above 50% (cumulative), which is pretty good for complete swelling relief," explained Dr. Raju.

Previous studies have shown that more than 60% of ulcers heal with stent placement. There were 19 ulcers in this study. "Many of the ulcers that healed at 24 months had deep reflux that was left untreated. So the ulcer heals just with a stent alone," said Dr. Raju.

"Inferior vena cava occlusion is a curious lesion. Symptoms are variable in intensity, because of variations in collateral flow which is usually excellent," Dr. Raju explained. Often only one limb is affected in symptomatic patients. When the inferior vena cava occludes or fails to develop properly during early development, symptoms may be totally absent. "The key to understanding inferior vena cava obstruction is the iliac vein. That is where the collaterals originate," Dr. Raju said. Thrombosis of the ipsilateral vein is usually productive of symptoms.