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• W2507431036 abstract "Persistent pain after iliac vein stenting is rare. Surgical removal of two oversized (20-mm) iliac vein stents was performed in a 36-year-old woman because of severe back pain of 2½ years' duration. Clamping or venotomy were not required for stent removal, which was done by extraction of each wire of the stent through small puncture wounds in the vein wall. Duplex scanning confirmed residual pseudointima obstructing the orifice of the right common iliac vein. The pseudointima was surgically removed. The patient recovered without complications, and her pain completely resolved. Persistent pain after iliac vein stenting is rare. Surgical removal of two oversized (20-mm) iliac vein stents was performed in a 36-year-old woman because of severe back pain of 2½ years' duration. Clamping or venotomy were not required for stent removal, which was done by extraction of each wire of the stent through small puncture wounds in the vein wall. Duplex scanning confirmed residual pseudointima obstructing the orifice of the right common iliac vein. The pseudointima was surgically removed. The patient recovered without complications, and her pain completely resolved. Stenting of the obstructed iliac or iliofemoral veins has been performed with rapidly increasing frequency in recent years, with excellent patency rates and good clinical results. Adverse effects, such as significant back pain or contralateral iliac vein obstruction, have been rarely reported. We present a patient with persisting postprocedural pain and asymptomatic contralateral iliac vein obstruction that was treated with an open surgical procedure. A 36-year-old Caucasian woman presented with severe, persisting back, left hip, and left lower extremity pain. Her symptoms started 2½ years earlier, immediately after she underwent stenting of the left common iliac vein (CIV) for nonthrombotic left iliac vein obstruction (May-Thurner syndrome) at another institution. Indications for the procedure included left ankle swelling and bluish discoloration of her left foot. Two 20-mm × 4-cm Wallstents (Boston Scientific, Natick, Mass) were placed. Her left leg swelling and discoloration was cured, but she developed relentless back, left hip, and left lower extremity pain, rated 4 to 5 on a scale of 1 to 10. Imaging studies revealed widely patent iliac vein stents with excellent flow, with the proximal stent well extending into the inferior vena cava (IVC) completely over-riding the ostium of the right CIV. She was taking over-the-counter pain medications for pain control. Her symptoms impaired her quality of life. She was unable to engage in running and hiking that she enjoyed doing previously. During the past 2½ years she was advised at several institutions that the pain was caused by the two large stents stretching her veins and surrounding structures, and she wanted to have her stent removed. Her medical history was otherwise unremarkable. She had no history of deep vein thrombosis and had no cardiovascular risk factors. She had two previous uncomplicated pregnancies. On physical examination she was averagely built (body mass index, 22.1 kg/m2), with mild to moderate midabdominal tenderness on deep palpation. She had spider veins in her left leg, but no varicosity, leg swelling, or discoloration. Her arterial pulses were within normal reference ranges. The results of the neurology evaluation and electromyography were negative and did not reveal a cause for the pain. A computed tomography (CT) venogram (Fig 1) showed a widely patent left CIV and two 20-mm × 4-cm Wallstents that extended from the CIV into the IVC, with the tip of the proximal stent perforating the right IVC wall. The right CIV diameter was 12 to 14 mm. The common iliac arteries (CIAs) were markedly displaced anteriorly by the 20-mm stents. There was no lumbosacral plexus compression. The explanation of the pain was diffuse tissue tension in the vein wall and the surrounding structures caused by the oversized stents. The patient agreed to proceed with stent removal and provided consent for publication. The patient was placed under general anesthesia, a 9-cm midline laparotomy was made at the level of the umbilicus, and the left CIV and the confluence of the IVC with the overlying right CIA were exposed (Fig 2, A). The stent was easily seen through the transparent thin wall of the left CIV, and a pseudointima that had formed over the luminal surface of the stent was also apparent. A No. 1 phlebectomy hook was pushed through the wall of the iliac vein and used to hook each wire at multiple sites in the midportion of the stent. The 30 steel wires of each Wallstent were gently teased out, one-by-one, through the venous wall, without clamping the vein or making a long venotomy (Fig 2, B-E). All 60 wires (30 per stent) were removed in single segment, with the exception of 2 to 3, for which each end was gently pulled using forceps. Minimal to no bleeding was encountered at the puncture sites because of the pseudointima that had formed on the luminal side of the stent. The vein wall was reinforced with 6.0 polypropylene interrupted sutures. Complete removal of wires took ∼15 to 20 minutes and was confirmed with an abdominal X-ray and ultrasound imaging. After removal of the stents, duplex ultrasound imaging showed an additional problem: a floating pseudointimal flap (likely related to pseudointimal layer/fibrin sheath formed around the sheath as a result of the incorporation of the stent) was noted in the left distal CIV and another large flap completely covered the right CIV ostium and part the IVC (Fig 3, A). Heparin (5000 units) was given intravenously, the IVC and both CIVs were cross-clamped through the same exposure, and the lumbar veins were controlled with vessel loops. Two venotomies were made, one in the left CIV and another in the IVC. The flaps had many small holes corresponding to the pores of the stent permitting blood flow across the wall of the stent (Fig 3, B and C). The portion of the flap covering the ostium of the right CIV, however, was covered by thrombus, and several holes were also obstructed by the pseudointima, decreasing venous flow from the right CIV (Fig 3, D and F). Two separate venotomies were made, one at the confluence of the left CIV and IVC and the second in the IVC. After all floating flaps were excised, the venotomies were closed with 5-0 running polypropylene sutures (Fig 3, G and H). Repeat duplex scanning confirmed excellent flow and widely patent CIVs and IVC, without residual flaps or wire. The laparotomy was closed in standard fashion. Blood loss was 50 mL. The patient recovered without complication, and her back, hip, and leg pain immediately resolved. She was discharged on the third postoperative day with full anticoagulation. A CT venogram at discharge showed patent CIVs and IVC (Fig 4), with moderate recurrent compression of the left CIV by the overriding right CIA. Because she had no leg symptoms, she elected not to proceed with repeat venous stenting. Treatment of symptomatic thrombotic or nonthrombotic iliac vein obstructions using venous stenting has been well established in the past decade. Society guidelines,1Meissner M.H. Gloviczki P. Comerota A.J. Dalsing M.C. Eklof B.G. Gillespie D.L. et al.Early thrombus removal strategies for acute deep venous thrombosis: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.J Vasc Surg. 2012; 55: 1449-1462Abstract Full Text Full Text PDF PubMed Scopus (309) Google Scholar large individual series,2Neglen P. Hollis K.C. Olivier J. Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result.J Vasc Surg. 2007; 46: 979-990Abstract Full Text Full Text PDF PubMed Scopus (507) Google Scholar, 3Raju S. Ward M. Utility of iliac vein stenting in elderly population older than 80 years.J Vasc Surg Venous Lymphat Disord. 2015; 3: 58-63Abstract Full Text Full Text PDF Scopus (14) Google Scholar, 4Raju S. Best management options for chronic iliac vein stenosis and occlusion.J Vasc Surg. 2013; 57: 1163-1169Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar and a recent systematic review5Seager M.J. Busuttil A. Dharmarajah B. Davies A.H. Editor's choice - A systematic review of endovenous stenting in chronic venous disease secondary to iliac vein obstruction.Eur J Vasc Endovasc Surg. 2016; 51: 100-120Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar recommended stenting of patients with venous outflow obstruction at the iliofemoral level. Neglen et al2Neglen P. Hollis K.C. Olivier J. Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result.J Vasc Surg. 2007; 46: 979-990Abstract Full Text Full Text PDF PubMed Scopus (507) Google Scholar reported 5-year results of 982 venous stenting procedures using Wallstents in 98% of the patients, with primary patency rates of 57% and 79% and secondary patency rates of 86% and 100% in thrombotic and nonthrombotic obstructions, respectively. In patients with chronic iliac vein obstruction, Raju4Raju S. Best management options for chronic iliac vein stenosis and occlusion.J Vasc Surg. 2013; 57: 1163-1169Abstract Full Text Full Text PDF PubMed Scopus (128) Google Scholar reported relief of pain in 86% to 94% and relief from swelling in 66% to 89% after stenting. The major complication rate has been low, between 0% and 8.7% in a recent systematic review.5Seager M.J. Busuttil A. Dharmarajah B. Davies A.H. Editor's choice - A systematic review of endovenous stenting in chronic venous disease secondary to iliac vein obstruction.Eur J Vasc Endovasc Surg. 2016; 51: 100-120Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar Postoperative back pain can be present in up to 25% of the patients, but the pain seldom lasts longer than a couple of weeks and usually can be treated well without narcotic medications.6Raju S. Neglen P. Percutaneous recanalization of total occlusions of the iliac vein.J Vasc Surg. 2009; 50: 360-368Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar Chronic persisting pain without direct compression of the sciatic or femoral nerve by the stent is either extremely rare or is under-reported. The immediate cessation of symptoms after removal of the stents in our patient is testimony that overextension of the vein and stretching the surrounding tissues were the causes of pain. In our practice, we usually place 14-mm to 16-mm stents in thrombotic patients and 16-mm stents with selective placement of 18-mm stents in nonthrombotic patients.7Kurklinsky A.K. Bjarnason H. Friese J.L. Wysokinski W.E. McBane R.D. Misselt A. et al.Outcomes of venoplasty with stent placement for chronic thrombosis of the iliac and femoral veins: single-center experience.J Vasc Interv Radiol. 2012; 23: 1009-1015Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar It is noteworthy that the center with the largest experience recommends mostly 18-mm and 20-mm stents for CIV reconstructions.8Raju S. Ward Jr., M. Kirk O. A modification of iliac vein stent technique.Ann Vasc Surg. 2014; 28: 1485-1492Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar A few case reports have described minimally invasive percutaneous removal of the Wallstent using endovascular snares.9Ghanem A. Tiemann K. Nickenig G. Gone with the flow: percutanous retrieval of a migrated wallstent trapped in the right ventricle.Eur Heart J. 2009; 30: 717Crossref PubMed Scopus (9) Google Scholar, 10Curran P.J. Currier J. Tobis J. Percutaneous snare retrieval of a partially embedded Wallstent.Catheter Cardiovasc Interv. 2004; 61: 400-402Crossref PubMed Scopus (9) Google Scholar These techniques are only applicable if the stent is removed very early, before any incorporation with the pseudointima. To our knowledge, removal of a venous stent without a venotomy using the technique we report here has not been reported before. Although our patient consented to an open venous reconstruction11Garg N. Gloviczki P. Karimi K.M. Duncan A.A. Bjarnason H. Kalra M. et al.Factors affecting outcome of open and hybrid reconstructions for nonmalignant obstruction of iliofemoral veins and inferior vena cava.J Vasc Surg. 2011; 53: 383-393Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar if needed, we were fortunate to be able to use a less invasive method to remove the stent by extracting each individual wire, one-by-one, through small puncture holes or tiny cuts over the wires. The technique can only be used with the Wallstent, which is put together using individual braided wires, without any interconnection between them. Less bleeding from the puncture sites is expected the longer the stent is in place because of the occlusive pseudointima that develops on the inner surface of the stent. The pin-hole bleeding, if encountered, can easily be controlled with digital compression, and the wall is closed with a single 6-0 polypropylene suture. A venotomy in our patient would not have been needed after stent removal had we not observed on duplex scanning the pseudointimal flaps that partially occluded the left CIV and completely covered the outflow from the right CIV. Concerns about the increasing possibility of partial jailing of the flow from the right CIV by a stent used for left CIV obstruction was raised by Raju et al.8Raju S. Ward Jr., M. Kirk O. A modification of iliac vein stent technique.Ann Vasc Surg. 2014; 28: 1485-1492Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar These authors now recommend a modified technique of iliac vein stenting by adding a Gianturco Z stent (Cook Medical, Bloomington, Ind) to the Wallstent for two reasons: first, to reinforce the Wallstent at the area of external compression by the right CIA and, second, to use a stent that has large gaps between the struts that extend into the IVC and decrease the chances of any pseudointima formation. Contralateral stenting at the bifurcation is also made easier.8Raju S. Ward Jr., M. Kirk O. A modification of iliac vein stent technique.Ann Vasc Surg. 2014; 28: 1485-1492Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar Our patient eminently displayed the secondary changes that may develop after a stent with small pores is extended across the lumen of the IVC. She, however, did not have any signs or symptoms of right CIV obstruction and also did not have any extra collaterals on the CT imaging. The technique to extend the iliac vein stent into the IVC has been widely used in this country and abroad after the initial report of Neglen et al,2Neglen P. Hollis K.C. Olivier J. Raju S. Stenting of the venous outflow in chronic venous disease: long-term stent-related outcome, clinical, and hemodynamic result.J Vasc Surg. 2007; 46: 979-990Abstract Full Text Full Text PDF PubMed Scopus (507) Google Scholar who recommended that stenting of a stenosis adjacent to the confluence of the CIVs “required that the stent be placed well into the IVC to avoid early restenosis.” Although jailing of the flow in the contralateral CIV has been mentioned more frequently in the recent literature,8Raju S. Ward Jr., M. Kirk O. A modification of iliac vein stent technique.Ann Vasc Surg. 2014; 28: 1485-1492Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar we have not seen previous publications of nor have we directly observed formation of a perforated pseudointima that completely covered the ostium of the contralateral CIV as we report here. We presume this happens with time in most patients in whom a stent is placed across the IVC, because we have observed it now in two additional patients who were operated on since this case report. It is noteworthy that in this patient at 2 years and 6 months after stenting, many pores were already covered by pseudointima and a thrombus had formed on the surface, decreasing the amount of blood that could flow through the stent. The rare, 1.1% to 2.2% clinical occurrence of reported contralateral thromboses suggests that flow through the pores of the pseudointima can be maintained for a long period of time even after complete coverage of the contralateral CIV with the stent.5Seager M.J. Busuttil A. Dharmarajah B. Davies A.H. Editor's choice - A systematic review of endovenous stenting in chronic venous disease secondary to iliac vein obstruction.Eur J Vasc Endovasc Surg. 2016; 51: 100-120Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar The observation in our patient, however, raises a concern in this frequently young patient population and urges using different techniques and stents in the future for treatment of iliac vein obstructions close to the iliocaval junction. One option is to use a Gianturco Z stent, with large distances between the struts that decrease the chances of an occlusive pseudointima formation and also serve as reinforcement of the Wallstent at the critical area of compression, as recommended recently by Raju et al.8Raju S. Ward Jr., M. Kirk O. A modification of iliac vein stent technique.Ann Vasc Surg. 2014; 28: 1485-1492Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar The other option is to introduce new dedicated venous stent cut at an angle proximally to avoid protrusion into the IVC, similar to the new Sinus Obliquus stent, manufactured by Optimed (Ettlingen, Germany).12Sinus Obliquus stent. 2016http://www.opti-med.de/Google Scholar A third option is to develop a new bifurcated iliocaval stent system. An oversized venous stent occasionally can cause persistent postoperative pain that requires removal of the stent. We recommend that stents >18 mm in diameter be used rarely, especially in young and thin patients. The minimally invasive technique we describe here is suitable to remove a Wallstent from a vein without clamping and need for venotomy, unless intimal flaps need to be removed after stent removal, as was the case in our patient. Formation of an occlusive pseudointima on the surface of a stents with small pores placed across the IVC is a concern and warrants re-evaluation of techniques and stents used for endovascular reconstructions of the iliocaval bifurcation. Development of dedicated new venous stents is urgently needed." @default.
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• W2507431036 title "Open surgical removal of iliac vein Wallstents with excision of pseudointima obstructing the contralateral iliac vein" @default.
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