Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.
Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, NC.
J Vasc Surg Venous Lymphat Disord. 2021 Nov;9(6):1399-1407.e1. doi: 10.1016/j.jvsv.2021.02.012. Epub 2021 Mar 2.
Stenting of the iliac venous system is often performed for symptomatic obstruction, with high patency rates reported. However, patients with post-thrombotic disease and those with more extensive obstruction have experienced poorer outcomes, including a higher rate of early post-stent thrombosis. In the present study, we examined the outcomes of patients with complete venous outflow occlusion. We focused on the variables associated with early post-stenting thrombosis to identify opportunities to reduce its incidence.
From 2010 to 2020, the patients who had undergone stenting for chronic obstruction of the common femoral vein, iliac veins, and/or inferior vena cava were retrospectively reviewed. The pre- and intraoperative imaging studies were examined to identify those who had had total occlusion of one venous outflow segment (type III disease) or multiple venous outflow segments (type IV disease). The patient characteristics and procedural and post-stent variables were recorded. The post-procedure follow-up visits and imaging studies were reviewed to determine stent patency and thrombotic complications. Key variables were studied to determine their association with early stent reocclusion.
A total of 106 patients were identified, including 43 with type III (40.6%) and 63 with type IV (59.4%) disease. The mean patient age was 49.8 ± 13.7 years, and the mean stented length was 177.3 ± 63 mm. Stainless steel Wallstents were used solely in 44% of the cases, with a variety of nitinol stents used in the remainder. Femoral vein inflow was minimally diseased in 50% of the cases, moderately diseased in 26%, and severely diseased or occluded in 24%. Antiplatelet medications were prescribed after intervention for 52.8% and anticoagulation medication for 95.3% of the patients. Occlusion of the stented segment occurred within 3 months in 25.5%. Primary patency was 74.5% at 3 months, 63.9% at 12 months, and 58.5% at 3 years. Secondary patency was 93.4% at 3 months and 76.1% at 3 and 5 years. Univariate analysis of variables related to early stent thrombosis identified the presence of a hypercoagulable state, type IV obstruction, and the type of anticoagulation used after stenting were associated with early stent thrombosis. On multivariate analysis, each of these variables was independently associated with early stent thrombosis. The presence of type IV obstruction (odds ratio [OR], 4.596; 95% confidence interval [CI], 1.424-18.109) or a hypercoagulable state (OR, 3.835; 95% CI, 1.207-12.871) was associated with significantly greater odds of reocclusion than was class III obstruction and no hypercoagulable state. Treatment with low-molecular-weight heparin for >10 days was associated with significantly lower odds (OR, 0.012; 95% CI, 0.001-0.130) of reocclusion.
Patients who require recanalization of a completely occluded venous outflow tract before stenting have a high rate of early reocclusion. Patients with more extensive occlusion and a hypercoagulable state have greater odds of reocclusion. Treatment with low-molecular-weight heparin for >10 days reduced the odds of early reocclusion.
髂静脉系统支架置入术常用于治疗症状性阻塞，报告的通畅率较高。然而，患有血栓后疾病和更广泛阻塞的患者的预后较差，包括早期支架内血栓形成的发生率较高。在本研究中，我们检查了完全静脉流出道阻塞患者的结局。我们重点关注与早期支架内血栓形成相关的变量，以确定降低其发生率的机会。
回顾性分析 2010 年至 2020 年期间因股总静脉、髂静脉和/或下腔静脉慢性阻塞而行支架置入术的患者。检查术前和术中影像学研究，以确定是否存在一段静脉流出段完全阻塞（III 型疾病）或多段静脉流出段阻塞（IV 型疾病）。记录患者特征、手术和支架置入后变量。回顾术后随访和影像学检查，以确定支架通畅性和血栓并发症。研究关键变量，以确定其与早期支架再闭塞的关系。
共纳入 106 例患者，其中 43 例为 III 型（40.6%），63 例为 IV 型（59.4%）疾病。患者平均年龄为 49.8±13.7 岁，平均支架置入长度为 177.3±63mm。44%的病例仅使用不锈钢 Wallstents，其余病例使用各种镍钛合金支架。50%的股静脉流入段轻度病变，26%中度病变，24%严重病变或闭塞。52.8%的患者在介入治疗后使用抗血小板药物，95.3%使用抗凝药物。25.5%的患者支架置入段在 3 个月内闭塞。3 个月时的初始通畅率为 74.5%，12 个月时为 63.9%，3 年时为 58.5%。3 个月时的继发性通畅率为 93.4%，3 和 5 年时分别为 76.1%。对与早期支架血栓形成相关的变量进行单因素分析，发现存在高凝状态、IV 型阻塞以及支架置入后使用的抗凝类型与早期支架血栓形成有关。多因素分析显示，这些变量均与早期支架血栓形成独立相关。存在 IV 型阻塞（比值比[OR]，4.596；95%置信区间[CI]，1.424-18.109）或高凝状态（OR，3.835；95%CI，1.207-12.871）与 III 型阻塞和无高凝状态相比，支架再闭塞的可能性显著增加。使用低分子肝素治疗>10 天与支架再闭塞的可能性显著降低（OR，0.012；95%CI，0.001-0.130）有关。
需要在支架置入前重新开通完全闭塞的静脉流出道的患者，早期再闭塞的发生率较高。阻塞范围较广和存在高凝状态的患者支架再闭塞的可能性较大。使用低分子肝素治疗>10 天可降低早期再闭塞的可能性。
