By: William Marston, M.D. Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.

1. Disclosure
William Marston, M.D.
I disclose the following financial relationship(s):
•Consultant/Advisory Board: Advanced
BioHealing, BSN Jobst

2. Diagnosis of Ilio-caval venous
obstruction
Bill Marston MD
Professor and Chief,
Division of Vasc Surg
Univ of N. Carolina

3. Causes of venous obstruction
• May-Thurner
• Post-phlebitic
• External compression from tumor
• Iatrogenic/surgical ligation
• Central venous catheterization/dialysis
• Other

5. • 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

6. Iliac stent outcome: symptoms
Symptom Pre-
intervention
Post-
intervention
P value
Severe leg
pain
54% 11% < .001
Leg swelling 44% 18% < .001

7. Distribution of iliac vein compression
in asymptomatic controls
Kibbe et al J Vasc Surg 2004;39:937

8. 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?

9. Ilio-caval obstruction
• Unlikely that
compression < 50%
leads to symptoms
• 60%, 80%?
• Not currently well
defined

10. • 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

11. Thin cut 3D
CT
venography
•1 mm cuts
•Examined in
multiple planes
•Max % of
narrowing of
iliac or IVC
recorded

12. Duplex of CFV
• Common femoral vein waveforms studied
for evidence of iliac obstruction
– Lack of respiratory variation
– No change in velocity with augmentation
maneuvers

13. 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%

14. 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%

15. 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

16. 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%

17. Diagnostic modalities for
ICVO: Developing a
diagnostic strategy
• Ultrasound/duplex
• CT/MR
• Venography
• IVUS

18. Chronic Venous Obstruction – Diagnostic Evaluation
Duplex US
RIA
LIA
VB

19. Ilio-caval venography
• May reveal obstruction
if in correct plane
• Degree of collateral
development is useful
• Low sensitivity

20. Elimination of collaterals

21. 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”

22. 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

23. How much compression should
we require to intervene?
• Need some
method of non-
invasive diagnosis
of hemodynamic
significance of
compression

24. 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