Obstructive lesions of the inferior vena cava: Clinical features and endovenous treatment

Objective: Chronic obstructions of the inferior vena cava (IVC) are associated with many odd features. Even total occlusions may remain entirely silent or present late with acute symptoms. Renal dysfunction is rare. Many have chronic symptoms, but often only one limb is affected. We describe the clinical features in a series of 120 patients seen over a 10-year period and the results of successful stent placement in 99 limbs. Methods: Patients with acute onset of symptoms due to distal thromboses underwent catheter-directed thrombolysis. Patients with significant chronic symptoms were investigated by duplex, venous function tests, transfemoral venography and finally intravascular ultrasound (IVUS). Stenotic segments were balloon dilated and occluded segments were recannalized when feasible; stents were placed under IVUS control. Results: In the asymptomatic group, 10 patients with total occlusions had transient or no occlusive symptoms. In the acute symptom group, four patients with chronic IVC occlusions presented with acute onset of deep venous thrombosis distal to the occlusion but became asymptomatic when the clot was lysed. In the chronic symptom group, 97 patients (99 limbs) had symptoms of chronic venous disease of variable distribution and intensity. In two-thirds, limb symptoms were unilateral. Pathology was total occlusion in 14%, and the rest were stenoses. The lesion extended above the renal vein in 18%. Common iliac obstruction was concurrent in 93%. Distal reflux was present in 66%. Modifications of the basic stent technique were required in recanalization of total occlusions (four extending up to the atrium), two bilateral stent deployments, and nine IVC filter cases. Stent deployment across the renal and hepatic veins or the contralateral iliac vein had no adverse sequelae. Stent patency (cumulative) at 2 years was 82%. Complete relief (cumulative) of pain and swelling at 3.5 years was 74% and 51%, respectively. The cumulative rate of complete ulcer healing at 2 years was 63%. Overall clinical outcome was rated as good or excellent in 70%. Conclusions: The unusual clinical features of IVC obstructions seem related to the rich collateralization, which has an embryonic basis. Common iliac vein potency seems to be a crucial link in collateral function, and its concurrent occlusion produces symptoms. Percutaneous stent placement has an emerging role in the treatment of IVC obstructive lesions, with good mid-term stent patency and clinical results.