Michał Molski presented on his experience with 36 patients who underwent stenting to treat chronic proximal venous outflow obstruction between 2016-2019 at a hospital in Poland. The majority of patients had post-thrombotic lesions or non-thrombotic iliac vein lesions. Technical success was achieved in 77.7% of cases. Follow-up showed patency rates remained high at 87.5-90.9% at 1-3 years. Symptoms significantly improved and were maintained at follow-up of up to 3 years. Complications were infrequent. Molski concluded cPVOO stenting significantly improves symptoms long-term and has good patency rates.

1. 3 years experience
with venous stenting
Michał Molski MD PhD
Stanisław Molski MD PhD DSc Prof.
Vascular Surgery Department,
Szpital ESKULAP Osielsko, Poland

2. Herewith, the speaker has disclosed
that there is no relevant relationship
with any commercial interests related
to the content of the following
presentation.
Michal Molski 17.08.2019

3. Symptoms
• Pain, heaviness, cramps, venous claudication
• Varicose veins
• Oedema
• Discoloration
• Lipodermatosclerosis
Complications
• Deep Venous Thrombosis
• Ulceration
Michal Molski 17.08.2019
Chronic Proximal Venous Outflow Obstruction (cPVOO)

4. Chronic Proximal Venous Outflow Obstruction (cPVOO)
Post-thrombotic
• Segmental / Multisegmental
• Wall fibrosis and trabeculations
Non-thrombotic Iliac Vein Lesion ( NIVL)
• Subsegmental
• Vein compression
• May-Thurner, etc.
Mixed lesions
Michal Molski 17.08.2019

5. Diagnosis
• Clinical examination
• 15% shows abdominal / groin varicosieties
• USG doppler
• Stenosis / occlusion of veins
• Lack / diminishment of respiratory flow phasicity
• Groin / pubic / abdominal varicosities
• Inversed flow in internal illiac vein
• MR / CT
• Flebography
• Pletysmography
Michal Molski 17.08.2019
Chronic Proximal Venous Outflow Obstruction (cPVOO)

6. Guidelines for cPVOO stenting – AVF 2009
Michal Molski 17.08.2019

7. Guidelines for cPVOO stenting – ESVS 2015
Michal Molski 17.08.2019

8. Material
Since 2013 we have screened potential patients for cPVOO
• Pubic / abdominal / groin varicosities
• Venous ulceration unsusceptible for treatment
• Unilateral symptoms of CVI with „normal USG”
• cPVOO on USG / CT/ MR
Michal Molski 17.08.2019

9. Material
Between 2013 and 2019.06
• 54 patients were qualified for cPVOO stenting
Between 2016.03 and 2019.06
• 36 patients were admitted for the cPVOO stenting
• 18 patients remain in a queue
• Limitations from polish health provider
• Patient rejections / reschedules
• 1 patient was qualified for endophlebectomy + stenting
Michal Molski 17.08.2019

10. Michal Molski 17.08.2019
Procedure is performed on hybrid OR
• In local anesthesia and analgosedation
• USG guided venous acsess belof CFV confluence

11. Venous Access
Venous acces site puncture under USG guidance
• Superficial Femoral Vein – 28 cases ( 77% )
• Greater Saphenous Vein – 4 cases ( 11% )
• Popliteal Vein – 1 case ( 2,8% )
• Small Saphenous Vein – 1 case ( 2,8% )
• Common Femoral Vein – 1 case ( 2,8% )
• External Iliac Vein – 1 case ( 2,8% )
• Additional Internal Iugular Vein – 3 cases ( 8,4% )
Michal Molski 17.08.2019

12. Post procedure protocol
• LMWH & Pneumatic compression overnight
• USG next morning
• Ambulation and hospital discharge next day
• Compresion hosiery
• LMWH @ therapeutic doses for 14 days
• NOAC for at least 6 months
• Follow up visit @ 14 days / 3 months / 6 months / 12 months
• Discontinuation of anticoagulation if
• No residual stenosis
• No significant lesions in inflow segment
• D-dimers in normal range
Michal Molski 17.08.2019

13. Result of ascending phlebography
PTS Total
occlusion, 10, 28%
PTS Stenosis, 16,
45%
May-Thurner, 3,
8%
No problem, 7,
19%
Michal Molski 17.08.2019
36 patients

14. Phlebographical cPVOO
Michal Molski 17.08.2019
Left, 21, 73%
Right, 5, 17%
Bilateral, 3,
10%
29 patients

15. Anatomical involvement
6
( 20,6% )
12
( 41,2% )
7
( 24% )
3
( 10,2% )
1
( 3,4% )
Michal Molski 17.08.2019
2 / 29 ( 6,9% ) cases were disqualified from stenting due to inadequate inflow

16. Technical sucess
Primum non nocere
Technical sucess in 20 /27 cases ( 77,7% )
• 5 failures to cross the lesion
• 3 cases involved IVC + bilateral illiac veins
• 2 cases unilateral lesions
• 2 failures to dilate EIV stenosis
Michal Molski 17.08.2019

17. Complications
Inhospital
• No clinically significant hematomas
• No periprocedural DVT
• No Pulmonary Embolism
• No A-V fistulas
After discharge
• 1 readmission @ day 3 post-op due to back pain
• Resoluted after bed rest and NSAIDs
• 1 anemia due to menorhagia on NOAC
( hgb 7g/dl ) @ 3 months post-op
• 1 adverse reaction to rywaroxaban  dabigatran
Michal Molski 17.08.2019

18. Patency
20 patients follow-up 2-39 months ( average 20 months )
Reooclusions
• 2 thrombosis @ 2 weeks
• 1 thrombosis @ 3 years
Patency
• at 2 weeks 18 / 20 ( 90,0% )
• at 3 months 14 / 16 ( 87,5% )
• at 1 year 10 / 11 ( 90,9% )
• at 2 years 8 / 9 ( 88,8% )
• at 3 years 6 / 7 ( 87,5% )
Michal Molski 17.08.2019

19. Results
Michal Molski 17.08.2019
Improvement in Villalta score ( average )
• Before 10,8  After 3,88
Improvement in clinical symptoms
• Oedema
• Pain
• Cramps
• Venous claudication
• Varicosities reduction
• Ulceration healing

20. Conclusions
Michal Molski 17.08.2019
cPVOO stenting
• Significantly improves symptoms
• in postthrombotic lesions
• in nonthrombotic iliac vein lesion ( NIVL )
• Gives good longterm patency up to 3 years
• Gives longterm symptom improvement up to 3 years
• Complications are unfrequent
• Sucess rate is high

21. Future
Continuation of cPVOO stenting program
• IVUS
• Endophlebectomy

22. Thank you
Form Daugava river
in Riga