Diagnosis of Llio-caval Venous Obstruction: Causes of Venous Obstruction

Disclosure William Marston, M.D.

I disclose the following financial relationship(s):

•Consultant/Advisory Board: Advanced BioHealing, BSN Jobst

Diagnosis of Ilio-caval venous

obstruction

Bill Marston MD

Professor and Chief,

Division of Vasc Surg

Univ of N. Carolina

Causes of venous obstruction

• May-Thurner

• Post-phlebitic

• External compression from tumor

• Iatrogenic/surgical ligation

• Central venous catheterization/dialysis

• Other

• 982 iliac lesions treated 1997-2005

• Characteristics – Median age 54

– Female:male 2.6:1

– CEAP clinical class

• 2 7%

• 3 47%

• 4 24%

• 5 5%

• 6 17%

J Vasc Surg 2007;46:979

Iliac stent outcome: symptoms

Symptom Pre-

intervention

Post-

intervention

P value

Severe leg

pain

54% 11% < .001

Leg swelling 44% 18% < .001

Distribution of iliac vein compression

in asymptomatic controls

Kibbe et al J Vasc Surg 2004;39:937

2 key questions

• When is ilio-caval compression

hemodynamically significant?

– When is it responsible for symptoms

• What is best non-invasive method of

studying patients for this problem?

Ilio-caval obstruction

• Unlikely that compression < 50% leads to symptoms

• 60%, 80%?

• Not currently well defined

• Patients with CEAP clinical class 5 or 6 CVI identified at a multispecialty wound healing center

• All tested with CT or MR venography to determine incidence of ilio-caval obstruction

JVS 2011;53:1303-8

Thin cut 3D

CT

venography

•1 mm cuts

•Examined in

multiple planes

•Max % of

narrowing of

iliac or IVC

recorded

Duplex of CFV

• Common femoral vein waveforms studied

for evidence of iliac obstruction

– Lack of respiratory variation

– No change in velocity with augmentation

maneuvers

Results

• 78 limbs in 64

patients with CEAP

clinical class 5 or 6

CVI identified

Patient Demographics

• Average Age 59.3 ± 12.8

• Male gender 55.6%

• % Caucasian 72.5%

• % African-Amer 21.0%

• Diabetes 28.1%

• Average BMI 32.3 ± 9.0

• History of DVT 49.1%

• Affected limb Left 48.3% right 51.7%

Incidence of ilio-caval

obstruction on CT/MR Iliocaval stenosis % of total cases

100% 8.8%

80-99% 14.0%

50-79% 14.0%

30 - 49% 5.3%

10-29% 17.5%

0-10% 42.1%

≥80% 23%

≥50% 37%

Risk factors associated with

increased incidence of ICVO

Risk Factor ICVO with ICVO w/out p Val

risk factor risk factor

Age > 60 22.2% 21.2% .89

Diabetes mellitus 29.4% 20.9% .43

African American 31.2% 20.5% .37

Left limb ulcer 30.8% 16.1% .16

BMI > 30 30.3% 12.0% .09

Female gender 33.3% 12.9% .06

History of DVT 37.9% 7.1% .005

Deep venous reflux 39.8% 0% .002

Utility of CFV duplex as a

screening test % iliac stenosis

on CT/MR

% of duplex

exams negative

for ICVO

% of duplex

exams positive

for ICVO

< 50% 100% 0%

50-79% 100% 0%

≥ 80% 23% 77%

Sensitivity - 77% Specificity - 100%

Diagnostic modalities for

ICVO: Developing a

diagnostic strategy

• Ultrasound/duplex

• CT/MR

• Venography

• IVUS

Chronic Venous Obstruction – Diagnostic Evaluation

Duplex US

RIA LIA

VB

Ilio-caval venography

• May reveal obstruction if in correct plane

• Degree of collateral development is useful

• Low sensitivity

Elimination of collaterals

Neglen P, Raju S. J Vasc Surg 2002;35:694-700

IVUS is superior to

phlebography

for the diagnosis

of iliac venous outflow

obstruction.

The median stenosis on

phlebographic

results was 50% on IVUS

80%.

Chronic Venous Obstruction – “The standard”

Protocol for diagnosis of ICVO in

CEAP clinical class 5 and 6 patients

+ for ICVO - for ICVO

Venography with IVUS

and intervention

Common femoral vein waveforms

suggest outflow obstruction

17%

CT or MR venography

Deep venous disease on duplex

or history of DVT

45%

No further evaluation

Superficial venous disease only

38%

Common femoral waveforms

negative for outflow obstruction

83%

Duplex ultrasound exam

CEAP class 5/6 limb

How much compression should

we require to intervene?

• Need some

method of non-

invasive diagnosis

of hemodynamic

significance of

compression

Summary

• ICVO is common in pts with advanced venous disease

• Major need for noninvasive test to determine hemodynamic significance of anatomic obstruction

• Protocol for diagnosis using duplex, CT or MR, and venography with IVUS can reduce need for invasive testing