This study aimed to evaluate the safety and efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) and stenting for treating acute iliofemoral deep venous thrombosis (DVT) combined with iliac vein compression syndrome (IVCS), and to identify the predictors of stent restenosis. Patients with acute proximal DVT combined with IVCS underwent PCDT and stenting from January 2017 to December 2022 were enrolled. Primary and secondary patency were assessed by duplex ultrasound (DUS). The morbidity of postthrombotic syndrome (PTS) was assessed by the Villalta score. Risk factors for stent restenosis were assessed using univariate and multivariate Cox regression models. Total of 254 patients were included. The mean follow-up time was 36.06 ± 17.66 months. The primary patency rates at 1 year, 3 years, and 5 years were 92.5%±1.7%, 85.4%±2.4%, and 82.4%±2.9%, respectively. The incidence of stent restenosis was 14.2%. Discontinuation of anticoagulants within one year [hazard ratio (HR) = 5.03; P = .048] was the factor associated with acute in-stent thrombosis. Previous DVT history (HR =2.29; P = .037) and stent placement across the inguinal ligament (HR =6.70; P < .001) were identified as independent risk factors significantly associated with stent restenosis. The overall PTS rate was 19.3%. PCDT with stenting is safe and effective for patients with iliofemoral DVT secondary to IVCS, leading to low rates of PTS. Previous DVT history and stents placed across the inguinal ligament may be predictors of stent restenosis. Furthermore, stent restenosis typically occurs within one year and is mainly caused by acute thrombosis due to discontinuation of anticoagulants.

Background: Nutcracker syndrome (NCS) is defined as left renal vein (LRV) compression by the superior mesenteric artery. NCS diagnosis is rendered complex by confounding symptoms. The study objective was to perform a prospective observational analysis of the diagnostic and therapeutic criteria of the patients with suspected NCS. When NCS diagnosis was confirmed, transposition of the LRV was carried out by mini-invasive robotic surgery (MIRS). Method: All patients addressed to the vascular surgery department for suspicion of NCS between January 2022 and June 2023 were included in the study. Patients were subsequently assessed by means of a computed tomography scan, dynamic duplex ultrasound and phlebography associated with an occlusion test of the left gonadic vein (LGV). Diagnostic criteria included aorto-mesenteric angle, LGV diameter and reflux, velocity ratios and diameters and the reno-caval gradient. Result: Thirty two patients aged 37 ± 14 years had suspicion of NCS. Twenty presented an aorto-mesenteric angle below 20°, twenty three had a LGV diameter greater than 5 mm and twenty two of the latter patients also had LGV reflux. A significant reno-caval gradient greater than 5 mmHg was found in ten cases, thereby consolidating NCS diagnosis. Overall, thirteen patients neither presented NCS or pelvic varicosities; eight had pelvic congestion syndrome without NCS and were successfully treated by embolization. Eleven patients with confirmed NCS underwent LRV transposition in the inferior vena cava (IVC). Eight of the latter patients received a complementary pelvic varicosity embolization 2 days later. Two months post-operation 100% of transposed LRV were permeable as assessed by duplex ultrasound controls and all of these patients reported an improvement of symptoms. Conclusion: An innovative multidisciplinary decisional algorithm establishes certitude in NCS diagnosis which can subsequently be treated radically by MIRS.

May-Thurner syndrome (MTS) involves the chronic compression of the left common iliac vein (CIV) by the overlying right common iliac artery (CIA) against the lumbar vertebrae. This compression can result in signs and symptoms of deep vein thrombosis (DVT) affecting the left side. In this case report, we present the clinical details of a 19-year-old patient diagnosed with severe MTS, which manifested as DVT with symptoms of severe thigh pain, redness, and difficulty walking. Additionally, the patient experienced pleuritic chest pain, ultimately diagnosed as pulmonary embolism (PE). Her management involved surgical removal of the thrombus and endovascular stenting of the left CIV. Following her recovery, she progressed favorably, and her follow-up assessment yielded satisfactory results.

Purpose: Iliac vein stenting is the primary treatment for patients with iliac vein compression syndrome (IVCS). However, post-stent placement, patients often experience in-stent restenosis and thrombosis. Despite this, the role of lower limb movements in the functioning of stents and veins in IVCS patients remains unclear. This study aimed to address this knowledge gap by developing a computational model using medical imaging techniques to simulate IVCS after stent placement. Methods: This research used a patient-specific model to analyze the effects of lower extremity exercises on hemodynamics post-stent placement. We conducted a comprehensive analysis to evaluate the impact of specific lower limb movements, including hip flexion, ankle movement and pneumatic compression on the hemo-dynamic characteristics within the treated vein. The analysis assessed parameters such as wall shear stress (WSS), oscillatory shear index (OSI), and residence time (RRT). Results: The results demonstrated that hip flexion significantly disrupts blood flow dynamics at the iliac vein bifurcation after stenting. Bilateral and left hip flexion were associated with pronounced regions of low WSS and high OSI at the iliac-vena junction and the stent segment. Additionally, active ankle exercise (AAE) and intermittent pump compression (IPC) therapy were found to enhance the occurrence of low WSS regions along the venous wall, potentially reducing the risk of thrombosis post-stent placement. Consequently, both active joint movements (hip and ankle) and passive movements have the potential to influence the local blood flow environment within the iliac vein after stenting. Conclusions: The exploration of the impact of lower limb movements on hemodynamics provides valuable insights for mitigating adverse effects associated with lower limb movements post iliac-stenting. Bilateral and left hip flexions negatively impacted blood flow, increasing thrombosis risk. However, active ankle exercise and intermittent pump compression therapies effectively improve the patency.

Venous compressive disorders are a heterogenous group of vascular syndromes characterized by extrinsic venous compression that can lead to complications of venous hypertension or venous thrombosis. Endovascular damage secondary to deep venous thrombosis (DVT) can result in post-thrombotic syndrome (PTS), a potentially debilitating condition that can be associated with significant morbidity in the pediatric population. Here we discuss 4 venous compressive disorders: iliac vein compression (May-Thurner syndrome [MTS]); subclavian vein compression at the venous thoracic inlet (Paget-Schroetter syndrome); left renal vein compression (nutcracker syndrome); and popliteal vein compression (popliteal entrapment syndrome) with a focus on clinical evaluation and diagnostic methods. Where endovascular therapy is appropriate, specific procedural considerations including procedure indications, equipment, procedural steps, technical challenges, complications, clinical follow-up and expected outcomes are discussed.

Chronic venous disease is a common disease, the prevalence of which increases with age, and can cause debilitating symptoms that adversely affect the quality of life. The risk factors include family history, female sex, obesity, pregnancy, parity, and history of deep vein thrombosis. Moreover, it is associated with venous obstruction, reflux, or both, which, in turn, leads to ambulatory venous hypertension. Chronic venous disease is the leading cause of leg ulcers, which place a significant cost burden on the health care system. Compression therapy remains the cornerstone of treatment, particularly for more advanced disease. Superficial saphenous vein reflux can be associated with significant symptoms. Catheter techniques, both thermal and nonthermal, have demonstrated efficacy and safety in successful closure and symptom improvement. Deep vein obstruction can be broadly divided into thrombotic and nonthrombotic and can lead to symptomatic chronic venous disease. Recanalization using balloons and stents has been increasingly used and studied in such patients. It is critical to develop training opportunities and guidelines to improve evidence-based and appropriate care for cardiologists treating chronic venous disease.

OBJECTIVE: Left renal vein compression syndrome (LRVCS) remains a challenging diagnosis. This study aimed to correlate imaging and hemodynamic findings with clinical outcomes for patients with LRVCS.
METHODS: A retrospective review of 66 renal venography procedures with or without intravascular ultrasound (IVUS) was performed from 2017 to 2023 at a single institution. Patients with prior LRVCS treatment or other indications were excluded (n = 11). Primary outcome measure was correlation of catheter-based endovascular (CBE) findings with clinical outcomes (n = 55). Secondary outcome measures included correlation of CBE findings and LRV (i.e., beak) angle > 32°, beak sign, aortomesenteric angle (AMA < 41°), and hilar-to-aortomesenteric ratio (HTAMR ≥ 4.9) on cross sectional imaging. Descriptive statistics, chi-square testing, and ROC analyses were used.
RESULTS: Of the 55 patients, 52 (94.5%) were females (median age 31, range 14-72) and 56.4% (n = 31) had a diagnosis of LRVCS on CBE evaluation. A renocaval pressure gradient of ≥ 3 mmHg, presence of collaterals, and > 50% area stenosis on IVUS were significantly associated with CBE diagnosis of LRVCS (p < 0.001). Surgical treatment (renal autotransplantation or LRV transposition) was recommended to all patients with CBE diagnosis of LRVCS (n = 31). 81.2% (18/22) of patients who underwent surgery reported symptom resolution or improvement. When the cross sectional imaging measurements were compared with CBE evaluation, AMA was the most sensitive (100%), HTAMR and beak sign were highly specific (93.3%), and beak angle was the most predictive (77.4% sensitivity; 86.7% specificity).
CONCLUSIONS: CBE diagnosis of LRVCS was highly predictive of surgical candidacy and post-surgical symptom resolution. The presence of collaterals, > 50% area stenosis on IVUS, or a renocaval pressure gradient ≥ 3 mmHg had a significant association with a CBE diagnosis of LRVCS.

May-Thurner syndrome (MTS) is a rare condition that increases the risk of left-sided iliofemoral venous thrombosis due to compression of the left common iliac vein by the right common iliac artery. Treatment for symptomatic MTS typically includes combined anticoagulation and endovascular therapy. This patient presented to the emergency department with acute left lower extremity pain and swelling. After imaging confirmed MTS, the patient was discharged from the ED and expeditiously treated in an office-based lab (OBL) setting with venous thrombectomy, angioplasty, and stenting. The setting where endovascular therapy is performed may significantly impact access to care for patients. Additionally, cost-effectiveness is a factor that should be considered when deciding the treatment site of service. We demonstrate the safety and cost-viability of performing venous thrombectomy, angioplasty, and stenting in an outpatient setting for the treatment of acute iliofemoral venous thrombosis.

May-Thurner syndrome (MTS) is a rare cause of deep venous thrombosis (DVT), characterized by the external compression of the left common iliac vein by the right common iliac artery against bony structures. Risk factors for MTS include female sex (postpartum, multiparous, and using oral contraceptive pills), spinal abnormalities like scoliosis, prior aortoiliac vascular stent placement, dehydration, and hypercoagulability. MTS patients with partial obstruction can be asymptomatic, but progression to extensive symptomatic DVT and/or chronic venous insufficiency can occur. MTS can be diagnosed by non-invasive imaging studies including ultrasound (US), computed tomography (CT) scan, magnetic resonance imaging (MRI), venogram, catheter-based venogram, and intravascular US. For MTS patients with moderate to severe symptoms, we suggest thrombectomy, angioplasty, and stenting of the affected segment. In this case report, we highlight a 44-year-old male with a recent diagnosis of left-sided DVT on apixaban who presented with worsening leg swelling. DVT, pulmonary embolism (PE), and MTS were diagnosed with a lower extremity US, chest CT angiography, and abdominal/pelvic CT scan and venography, respectively. The patient underwent interventional radiology-guided local thrombolysis, thrombectomy, and venoplasty along with stent placement in the left common iliac vein. Subsequently, the patient was discharged on rivaroxaban.

Scrotal edema and positional priapism are uncommon chief complaints with a scant differential. May-Thurner syndrome as well as inferior vena cava thrombosis are not often associated with these symptoms. This report outlines the case of a 50-year-old male who has undergone pulmonary artery thrombectomy and inferior vena cava filter placement. He presents with a chief complaint of scrotal swelling and positional priapism, likely low-flow priapism. Upon further work up, in-filter thrombosis was identified, likely attributed to a lack of anticoagulation and May-Thurner syndrome was diagnosed. The patient subsequently underwent thrombolysis and thrombectomy and was found to have May-Thurner syndrome which was treated with left iliac vein stenting.