Management of Chronic Iliofemoral Venous Obstruction with Endovascular Placement of Metallic Stents
Publication Date: June 15, 2023
Last Updated: October 31, 2023
Summary of Recommendations
Clinical Suspicion
In patients with symptoms or signs of advanced chronic venous disease, the possibility that iliofemoral venous obstruction could be a contributing factor should be considered and evaluated when supported by the medical history, symptoms, physical examination, and prior imaging studies. (E, S)
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Clinical Evaluation
A thorough clinical evaluation of the patient’s self-reported symptoms, objective clinical signs of venous disease, and their impact on life activities should be performed and documented before undertaking any endovascular treatment for chronic iliofemoral venous obstruction. (E, S)
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Conservative Therapy
In patients with chronic iliofemoral venous obstruction, efforts to alleviate symptoms and optimize limb function using conservative means should be made before placing stents. (E, S)
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Venous Ulcers
Patients with venous ulcers should receive compression therapy and close active follow-up, ideally in a specialized wound care facility that follows published clinical practice guidelines. (A, S)
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Patient Selection for Stent Placement
Venous stent placement may be appropriate in highly selected symptomatic patients with chronic iliac vein obstruction but should be avoided in most patients who do not have the following: (a) life interference (symptoms or functional disability) of at least moderate severity, with a high probability that it is attributable to the venous disease; (b) anatomic evidence of significant venous obstruction in the IVC, iliac vein, or common femoral vein; (c) good inflow to the common femoral vein from a patent femoral and/or deep femoral vein; and (d), for patients with an individualized risk profile that portends a substantial risk of stent thrombosis, the ability to receive long-term anticoagulation. (C, W)
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Intravascular US
The addition of intravascular US is encouraged when catheter venography is performed to evaluate for chronic iliac venous obstruction. (C, M)
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Clinical Trial Enrollment
Enrollment of study-eligible patients with chronic iliofemoral venous obstruction in rigorous randomized controlled clinical trials that evaluate the effectiveness and safety of endovascular therapies including stent placement is strongly recommended. (E, S)
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Patients with Cancer
In patients with malignant iliofemoral venous obstruction, application of a palliative care framework is suggested to ensure that patient selection for stent placement is appropriate, considering the multifactorial etiology of symptoms, cancer treatment goals, and palliative goals. (E, M)
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Pregnant Women
For most pregnant women with chronic iliofemoral venous obstruction, deferral of consideration of stent placement to the postpartum period is suggested. (D, M)
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Children and Younger Adolescents
For children and younger adolescents with chronic iliofemoral venous obstruction, stent placement should not be routinely performed. (D, M)
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Choice of Stent Device
For iliac vein placement, the use of self-expandable, noncovered stents with longitudinal flexibility and high radial strength is suggested; however, the optimal device to use is uncertain. (C, M)
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Stent Sizing and Deployment
When iliac vein stent placement is performed, careful attention should be given to ensuring appropriate stent sizing to enable durable venous patency, freedom from chronic pain, and freedom from stent migration. (C, S)
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Anticoagulant Therapy after Stent Placement
After iliac vein stent placement, anticoagulant therapy is recommended for at least several months in most patients with a history of DVT/PTS but may not be needed for most patients with nonthrombotic disease. (D, M)
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Antiplatelet Therapy after Stent Placement
After iliac vein stent placement, the addition of antiplatelet therapy to anticoagulation for at least several months is appropriate for most patients being treated for PTS who have a low projected risk of bleeding. It is uncertain whether patients receiving stents for NIVLs should receive antiplatelet therapy. (D, W)
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Follow-up
After iliac vein stent placement, close clinical follow-up should be performed to ensure that the patient is compliant with antithrombotic therapy and anticoagulation is fully therapeutic, to monitor for bleeding and symptom response, to enable timely reintervention to restore patency in patients who develop recurrent symptoms, and to monitor for late stent complications. (C, S)
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Management of Chronic Iliofemoral Venous Obstruction with Endovascular Placement of Metallic Stents
Authoring Organization
Society of Interventional Radiology
Publication Month/Year
June 15, 2023
Last Updated Month/Year
November 6, 2023
Document Type
Consensus
Country of Publication
US
Document Objectives
To state the position of the Society of Interventional Radiology (SIR) on the endovascular management of chronic iliofemoral venous obstruction with metallic stents.
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Hospital, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D015607 - Stents, D000069322 - Self Expandable Metallic Stents
Keywords
Chronic Iliofemoral Venous Obstruction, Iliofemoral Venous Obstruction, endovascular stents, metallic stents
Source Citation
Vedantham S, Weinberg I, Desai KR, Winokur R, Kolli KP, Patel S, Nelson K, Marston W, Azene E. Society of Interventional Radiology Position Statement on the Management of Chronic Iliofemoral Venous Obstruction with Endovascular Placement of Metallic Stents. J Vasc Interv Radiol. 2023 Oct;34(10):1643-1657.e6. doi: 10.1016/j.jvir.2023.06.013. Epub 2023 Jun 16. PMID: 37330211.