Systematic Review and Meta-Analysis of Iliofemoral Stenting for Post-thrombotic Syndrome

Abstract

WHAT THIS PAPER ADDS Endovascular stenting is relevant to the management of post-thrombotic syndrome with chronic obstruction in iliofemoral venous segment. Although this systematic review demonstrates that the quality of evidence for iliofemoral stents is weak, venous stenting has the potential to be effective, with extremely rare occurrences of peri-operative complications. This review may assist in clinical decision making and guide future research. Objective: Stent placements are considered as a treatment for post-thrombotic syndrome (PTS) with iliofemoral obstruction, but the application of these iliofemoral venous stents has also caused a lot of controversy. The purpose of this systematic review and meta-analysis was to summarise the efficacy and safety of venous stents in PTS with obstruction in iliofemoral venous segments. Methods: MEDLINE, EMBASE, and the Cochrane Central Register for Controlled Trials databases and key references were searched up to 15 January 2018. The main relevant outcomes included technical success, perioperative complications, symptom resolution, a change of symptom scores, and long-term patency of the stents. Results: Overall, 504 limbs of 489 patients from seven studies were included in this study. A GRADE assessment showed the quality of the evidence was "very low" for 11 relevant outcomes. The technical success rate was 95%. The pooled rate of complications including 30 day thrombotic event, per-operative venous injury, and back pain was 3.4%, 18.14%, and 52%, respectively. The rates of ulcer healing, pain and oedema relief were 75.66%, 52%, and 42%, respectively. The primary, assisted primary and secondary patency rates were 83.36%, 90.59%, and 94.32%, respectively, at 12 months and 67.98%, 82.26%, and 86.10%, respectively, at 36 months. Conclusions: Endovenous stenting has the potential to be effective and has a low risk of peri-operative complications. The quality of evidence to support this treatment is very low. Endovenous iliofemoral stenting should be considered a treatment option for PTS with iliofemoral obstruction.

Medicine and Phlebolymphology: Time to Change?

“…In fact, a reappraisal of invasive treatments in PTS has been recently highlighted [89]. In view of the contrasting evidence for venoplasty ± stenting in PTS patients [90][91][92], this procedure is being reserved to selected cases where other treatments have failed and the main risk factors (e.g., obesity, pump dysfunction, thrombophilia) have been already addressed, with little benefit.…”

Endovascular Deep Vein Stenting of Symptomatic Post-Thrombotic and Non-Thrombotic Iliac Vein Stenotic Lesions: A Multicentre Cohort Experience from Singapore

“…42 While there are innumerable studies reporting excellent patency rates and clinical outcomes following deep vein stenting for IFVO, the quality of evidence is low. [43][44][45] Most available studies are small, retrospective, single-site evaluations. 46 A systematic review conducted by Seager et al identified no randomised controlled trials, cohort studies or case-control studies.…”

“…A GRADE assessment 47 demonstrated the quality of the evidence to be "low" for ulcer healing and "very low" for other outcomes. 44 Despite the weak quality of evidence, deep vein stenting is relatively effective and safe with low incidence of peri-operative complications and high patency rates, 9,[43][44][45][46] and should be considered as a treatment option while the evidence base improves. 44 Post-operative anticoagulation decreases complication rates such as in-stent thrombosis.…”

Aiming for the Bottom Corner: How to Score a Field Goal When Landing Venous Stents in May–Thurner Syndrome

“…Recent systematic reviews and meta-analyses have demonstrated the majority of operators have followed the Neglan and Raju technique (5) by landing their stents a variable distance into the IVC (1,21). Reasons for this include difficulty identifying the confluence, ensuring lesion crossing, and overcoming shortcomings in available stent technology (4).…”