In Reply to: Re: Case 1097_08 --External iliac vein occlusion: treatment with endovascular stents posted by Scott Trerotola on October 20, 1997 at 17:50:59:
In a young active adult with a venous outflow obstruction and competent infrainguinal venous valves, typical symptoms include exertional pain and swelling and fatigue-all indicative of venous claudication. Four strategies:1) do nothing but patient will remain symptomatic, 2)medical therapy with chronic anticoagulation - this will do nothing to open up that iliac vein, 3) surgical venous bypass of either a cross femoral saphenous vein bypass (Palma procedure) or using a reinforced PTFE conduit. Many surgeons, including the Stanford group (Fogarty et al) are really luke warm on operating on the veins in the pelvis of a young, active woman 4) endovascular approach. We would approach this patient typically from popliteal access to map out the inflow into the iliac veins and recanalize the vein in similar fashion to a chronic iliac arterial occlusion. No antecedent urokinase would be utilized. Predilate and place a Wallstent as large as feasible (minimum of 10 mm). For this type of patient (healthy, no cancer), our patency rate at one-year is 93%. Interestingly, all of our failures occurred in the first 6 - 8 weeks. So if you can get the patient to three months, I feel they will have good durability. Our current recommendation is coumadin (INR 2-3) for 6 months based on the American College of Chest Physicians.