Instent restenosis and stent compression following stenting for chronic iliofemoral venous obstruction

ABSTRACT Objectives

Instent restenosis (ISR) and stent compression (SC) are problems encountered following stenting for chronic iliofemoral venous obstruction (CIVO) that are responsible for a majority of reinterventions. However, characteristics of ISR and SC, in addition to outcomes following reintervention have not been explored in detail and represent the focus of this study.

Methods

A retrospective analysis of contemporaneously entered EMR data on 578 limbs/patients with initial unilateral iliofemoral venous stents placed from 2014 to 2018 was performed. ISR was estimated from stent and flow channel diameters measured using duplex ultrasound (DUS). SC was estimated from rated stent diameter and actual stent diameter on DUS. Characteristics evaluated included onset of ISR/SC post stent placement and progression over time. Analysis was performed to evaluate risk factors for the development of ISR and SC. Outcomes following reintervention for ISR/SC were also appraised.

Results

578 limbs underwent stenting for stenotic lesions (NIVL/PTS). ISR was noted in 27% of limbs on post-intervention day 1. The prevalence of ISR increased to 74% by 3 months and stabilized thereafter. SC was noted in 80% of limbs on day 1 and plateaued. Of the variables evaluated as potential risk factors for ISR, IVUS determined stent inflow luminal area and shear rate were found to be significant. For SC, asymmetric stent sizing was a significant risk factor. Over a median follow up of 24 months, 95/578 (16.4%) limbs underwent reintervention for ISR, SC or a combination. The median time to reintervention was 11 months. There was no statistically significant difference in the degree of ISR/SC among patients who underwent reintervention versus those who did not [p>0.05]. However, there was a statistically significant difference in the grade of swelling (p=0.006) and VAS pain scores (p<0.0001) between those who underwent reintervention and those who did not. Primary, primary assisted and secondary patencies at 60 months, following reintervention for ISR was 70%, 98% and 84% respectively, and for SC was 70%, 99% and 84%.

Conclusions

While ISR and SC are both common following stenting for CIVO, neither are relentlessly progressive. Indication for reintervention must be a recurrence of symptoms with impairment of quality of life and not the percentage of ISR or degree of SC. Post reintervention good outcomes can be expected both in terms of clinical improvement and stent patency. Further study of the impact of shear rate on stent flow is required to help reduce the incidence of ISR.

Article InfoPublication History

Accepted: June 6, 2021

Received: October 6, 2020

Publication stageIn Press Journal Pre-ProofFootnotes

This study was presented at the 31st annual American Venous Forum meeting in Rancho Mirage, February 19-22, 2019.

ARTICLE HIGHLIGHTS

Type of Research: Single center retrospective analysis of prospectively collected data

Key Findings: In patients undergoing stenting for CIVO, the overall incidence of instent restenosis (ISR) and stent compression (SC) is high. While ISR peaks at 3 months and plateaus, SC peaks on day 1 and steadies thereafter. Stent inflow channel luminal area and shear rate were risk factors for the development of ISR, while asymmetric stent sizing was a risk factor for stent compression

Take home Message: While ISR and SC are common following stenting for CIVO, neither is relentlessly progressive and overall, only 16% required reintervention. Indication for reintervention must be a recurrence of symptoms impairing quality of life and not the percentage of ISR or degree of SC.

In this single center retrospective analysis of prospectively collected data on 578 limbs that underwent stenting for symptomatic chronic iliofemoral venous obstruction, instent restenosis and stent compression were noted to be common. However, neither were found to be relentlessly progressive and overall, approximately 16%, required reintervention.

Identification

DOI: https://doi.org/10.1016/j.jvsv.2021.06.009

Copyright

© 2021 Published by Elsevier Inc. on behalf of the Society for Vascular Surgery.

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