OBJECTIVE:Although a multitude of techniques exist for the treatment of superficial venous reflux in symptomatic patients with chronic venous disease (CVD), metrics used to determine and quantify superficial reflux and thereby assess the need for intervention remain unclear. This study explores this topic by evaluating duplex ultrasound (DUS) and air plethysmography (APG) metrics in terms of their relation to clinical parameters in the setting of isolated lower extremity venous reflux. METHODS:Analysis of retrospectively collected data of patients who underwent successful endovenous laser ablation of superficial venous reflux with/without stab phlebectomies for symptomatic CVD from venous reflux was carried out to determine predictors of initial clinical presentation and outcomes after successful intervention. Characteristics evaluated included the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) clinical class, venous clinical severity score (VCSS), grade of swelling (GOS), and visual analog scale pain; DUS characteristics included superficial vein diameter, total reflux volume in the limb, and venous segmental disease score (VSDS). APG metrics included venous volume (VV) and venous filling index, in addition to calf pump function metrics (ejection fraction [EF] and residual volume fraction). Bivariate correlation analysis, paired/unpaired t tests, and regression analysis were used to evaluate the data. RESULTS:There were 131 patients (134 limbs) with a median age of 61 (25-87) years, of whom 96 were women and 35 men. The median body mass index was 28.3 (18-57). There were 44 limbs in the C2 class, 38 limbs in the C3 class, 42 limbs in the C4 class, 2 limbs in the C5 class, and 8 limbs in the C6 class. All limbs had superficial reflux, including 80 with superficial reflux in the great saphenous vein (GSV) alone, and 54 had reflux in both GSV and small saphenous vein (SSV). There were no limbs with isolated reflux in the SSV. A total of 57 limbs had additional reflux in the deep veins (30 axial deep venous reflux). There were 21 limbs with reflux in the perforator veins. All limbs underwent successful ablation of the GSV, whereas 120 underwent additional stab phlebectomies at the same time, 1 limb had additional sclerotherapy (also at the time of the index procedure), and 5 limbs underwent treatment of the SSV. The median follow-up was 188 days. The correlation between DUS metrics (GSV diameter and total reflux volume) and clinical parameters (CEAP clinical class, VCSS, GOS, and visual analog scale pain score) was weak (r = 0.1-0.3; P > .05), although VSDS had a moderate correlation (r = 0.4; P = .004) with VCSS. A weak correlation was also noted between the clinical parameters and APG metrics (venous filling index, EF, residual volume fraction), except VV, which had a moderate correlation (r = 0.4; P < .001). At baseline, while VSDS was found to be a significant predictor for CEAP clinical class (hazard ratio [HR] = 8.1; P = .005) and VCSS (HR = 5.3, P = .03), VV was noted to be a significant predictor for GOS (HR =17; P < .001). After successful superficial venous intervention, there was improvement in clinical, DUS (VSDS), and APG metrics. VSDS was again a significant predictor of improvement in VCSS (HR = 9.3; P = .003), whereas both VV (HR = 5.5, P = .02) and EF (HR = 6.2; P = .01) were significant predictors for improvement in GOS after intervention. CONCLUSIONS:In symptomatic patients with CVD from isolated venous reflux, initial clinical presentation and improvement after successful superficial venous intervention can be predicted by DUS (VSDS) and APG (VV and EF) metrics. After such intervention, there is improvement in clinical, DUS, and APG metrics.

Objective Iliofemoral venous stenting has become the standard of care for patients with quality-of-life-impairing manifestations of chronic iliac venous obstruction (CIVO). The initial diagnosis of CIVO is through the use of duplex ultrasound (DUS). Here, set diameters are used for each segment (common femoral [CFV], external iliac [EIV] and common iliac [CIV]) to determine if a patient has venous stenosis or not. However, there is concern that DUS measurements obtained in the supine position (standard approach) are different from those when the person is standing, thereby raising the question as to the appropriate positioning for such a study. This study evaluates this possibility through DUS examination of healthy adults. Methods Sixteen limbs (8 healthy volunteers) without any symptoms or signs of chronic venous disease underwent duplex ultrasound of their right and left CFV, EIV, and CIV segments in the supine and standing positions. Measurements included peak velocity (PV), time-averaged velocity (TAV), and the smallest vein diameter in each segment. Measurements were done for each person across 6 cohorts: CFV, EIV, CIV, CFV+EIV, EIV+CIV and CFV+EIV+CIV. Normality of paired differences was assessed using the Shapiro–Wilk test. Variables demonstrating non-normal distributions were analyzed using the Wilcoxon signed-rank test, whereas normally distributed variables were compared using paired t-tests. Effect size was quantified using Cohen's dz. P-value <0.05 was considered significant. Results In the CFV, the PV and TAV were both greater in the supine than in the standing position (p<0.05), while the diameter was smaller in the supine position (mean difference =1.1 mm, p=0.05). In the EIV, a similar finding was observed; however, statistical significance was noted only for PV (p=0.02) and TAV (p=0.02). In the CIV, no statistically significant change in PV, TAV, or diameter was noted when supine was compared to the standing position. When EIV and CIV segments were combined, a statistically significant decrease in the PV (0.07 cm/s, p=0.02) and TAV (0.02 cm/s, p=0.03) was noted in the standing compared to supine. An increase in diameter (mean difference =0.2 mm, p=0.39) was noted going from supine to standing position. Effect size analysis (Cohen’s dz) demonstrated a moderate to large effect size for PV and TAV and a small effect size for diameter. Conclusions Venous duplex-derived flow velocities in the iliac vein in healthy volunteers demonstrate a moderate to large, statistically significant decrease from supine to standing position without a significant change in the vein diameter. This raises the question about the relevance of any increase in vein diameter from supine to standing, which has become an important contemporary issue. Further study is warranted.

Objectives: Phlebolymphedema, the most common cause of secondary lymphedema in Western societies, seldom gets the attention it deserves. Diagnosis is often missed and when evaluated is through lymphoscintigraphy (LSG) which is cumbersome. This study aims to assess the role of computed tomography (CT) scanning in the diagnosis of phlebolymphedema of the lower extremities by comparing CT characteristics with the International Society of Lymphology (ISL) grading system and LSG. Methods: Patients presenting with chronic venous disease who underwent a CT scan and LSG of the lower extremities (diagnostic testing) formed the study cohort. Three assessors blinded to the patients' ISL stage and LSG results evaluated the CT for skin thickening (present/absent), subcutaneous interstitial edema (honeycombing; graded 0-2), and muscle compartment (MC) edema (graded 0-2), in the thigh (20 cm above apex of patella), leg (10 cm below apex of patella), and ankle (5 cm above lateral malleolus). Agreement from two of the three raters determined the value used for analysis. Additionally, the final score used for each variable for each limb was determined by taking the most severe value of the three levels. The three CT variables were then compared independently and together with ISL stage and LSG to determine their diagnostic potential for phlebolymphedema. Also assessed was the severity of each CT variable across each limb in addition to the evaluation of the extent of their inter-rater agreement. Results: Of the 35 patients (50 limbs), 28 were female, with left laterality noted in 22 limbs. Clinical, Etiological, Anatomical, and Pathophysiological clinical class for the cohort included C0 to 2, 4 limbs (8%); C3, 13 limbs (26%); C4, 17 limbs (34%); C5, 9 limbs (18%); and C6, 7 limbs (14%). Thirty-one limbs underwent stenting for chronic iliofemoral venous obstruction after having failed conservative therapy. Of the 50 limbs, 8 (16%) were ISL stage 0, 10 (20%) ISL stage 1, 2 (4%) ISL stage 2, and 30 (60%) ISL stage 3. With LSG, 6 (12%) had a normal study, 21(42%) mild disease, 0 (0%) moderate disease, and 23 (46%) severe disease. Correlation between LSG and ISL stage was poor (r = 0.18; P = .20). With ISL stage as a reference, the sensitivity, specificity, and accuracy of CT in diagnosing phlebolymphedema were as follows: skin thickening (95%/75%/92%), honeycombing (100%/0%/84%), MC edema (100%/0%/84%), any one CT variable (100%/0%/ 84%), any two CT variables (100%/0%/84%), and all three CT variables (93%/63%/88%). With LSG as a reference, the sensitivity, specificity, and accuracy of CT in diagnosing phlebolymphedema were as follows: skin thickening (82%/0%/ 72%), honeycombing (100%/0%/88%), MC edema (100%/0%/88%), any one CT variable (100%/0%/88%), any two CT variables (100%/0%/88%), and all three CT variables (82%/0%/72%). For CT variables, there was no significant difference between skin thickening in the thigh vs calf vs ankle (P = .5). MC edema, however, worsened from thigh to calf (P < .0001) without a difference between the calf and the ankle (P = .3). The severity of honeycombing was worst in the ankle and least in the thigh, with a significant difference between all 3 sites (P = .008). The inter-rater agreement (kappa statistic) varied from 0.2 for skin thickening to 0.7 for honeycombing. Conclusions: CT scanning can be used as a screening tool for phlebolymphedema in the lower extremities. However, such a diagnosis depends on the reference standard used, ISL stage vs lymphoscintigram. Although skin thickness offered the greatest sensitivity, specificity, and accuracy when the ISL stage was used, honeycombing or MC edema had high sensitivity and accuracy but low specificity when LSG was used as the reference. Factoring in inter-rater agreement as well, honeycombing was noted to be the best CT variable to diagnose phlebolymphedema. (J Vasc Surg Venous Lymphat Disord 2025;13:102166.)

BACKGROUND:Nutcracker syndrome (NCS) describes the symptomatic compression of the left renal vein between the aorta and superior mesenteric artery. Whereas asymptomatic compression is a common radiological finding, patients with NCS can report a range of symptoms. There are no specific diagnostic criteria and interventions include a range of open surgical and endovascular procedures. Therefore, we wished to develop an international consensus document covering aspects of diagnosis, management, and follow-up for patients with NCS. METHODS:A three-stage modified Delphi consensus was performed. A steering committee developed 37 statements covering 3 categories for patients with NCS: diagnosis, management, and follow-up. These statements were reported individually by 20 international experts in the management of venous disease, using a 5-point Likert scale. Consensus was defined if ≥70% of respondents rated the statement between 1 and 2 (agreement) and between 4 and 5 (disagreement). Those statements without consensus were recirculated in a second round of voting. A third round of the questionnaire was performed with 14 additional statements to clarify diagnostic values of NCS. RESULTS:Responses were returned by 20 of 20 experts (100%) in round one and 17 of 20 (85%) in round two. Initial consensus was reached in 24 of 37 statements (65%) spread over all categories. Round two achieved a further consensus on 5 out of 10 statements (50%). No categories reported consensus on all statements. In round two consensus was reached in the category of follow-up (4/5 statements [80%]). The final round reached consensus on 5 out of 14 statements (36%). Experts agreed that imaging is obligated to confirm NCS. Experts did not agree on specific diagnostic cut-off values. There was a consensus that the first choice of operative treatment is left renal vein transposition and that the risk of stent migration outweighs the advantages of a percutaneous procedure. CONCLUSIONS:Consensus was achieved on most statements concerning the assessment and management of NCS. This Delphi consensus identified those areas in which further research is needed, such as antiplatelet therapy, endovascular treatment, and renal autotransplantation. A rare disease registry to improve data and reports of patient outcomes is warranted.

Reinterventions after stenting for chronic iliofemoral venous obstruction have an incidence of approximately 20% to 40% in the literature. The most common reason for this tends to be in-stent restenosis (ISR). Although angioplasty historically has been the modality used to treat this problem, at times ISR can be robust and associated with calcium deposits, leading to an inadequate outcome. Although newer debulking devices like the RevCore can be helpful, sometimes even these devices are not adequate given their inability to secure a foothold on the fibrotic tissue to enable its removal. Using an intravascular lithotripsy catheter (12 mm) helps to soften the fibrotic tissue and fracture the calcium deposits, thus enabling angioplasty or a debulking device (if needed) to be successful. This case series outlines the author’s experience with three patients with recalcitrant ISR who benefited from using an intravascular lithotripsy catheter that enabled prolonged symptom improvement and stent patency over a follow-up of 19 months. However, the use of such a catheter for the treatment of venous ISR represents an off-label use of the device.

Objective: May–Thurner syndrome typically refers to symptoms and signs arising from the compression of the left common iliac vein by the right common iliac artery. However, such clinical manifestations can occur in the setting of compression of the right common iliac vein and/or either external iliac vein. Given this scenario, the more appropriate term for the condition would be non-thrombotic iliac vein lesion(s) [NIVL]. The goal of this review of large sample size studies is to evaluate outcomes following stenting for chronic iliofemoral venous obstruction (CIVO) due to NIVL, including clinical, quality-of-life, and stent-related outcomes. Additionally, where evidence gaps or controversies exist, expert opinion has been offered for guidance. Methods: A review of the literature was undertaken to determine the role of stenting for NIVL. Appropriate search terms were used to search PubMed, Cochrane Central Register of Controlled Trials, and EMBASE. Studies were only included if they had a sample size of at least 100 limbs that underwent stenting for NIVL and had at least 12 months of follow-up. Additionally, every study needed to have at least one metric of objective clinical evaluation [Venous clinical severity score (VCSS)] and/or a quality-of-life (QoL) measure (generic or venous disease-specific). Results: A total of six studies met the eligibility criteria and included 1404 limbs that underwent stenting for NIVL. All except three studies had a combination of PTS and NIVL limbs, with all six studies having at least 100 limbs that underwent stenting for NIVL. Follow-up varied from 12 to 50 months post-stenting. Improvements in VCSS and quality-of-life measures were noted post-stenting. Additional outcome measures, like grade of swelling or visual analog scale pain score, when utilized, also demonstrated improvement. Recurrence-free ulcer healing rates of 63% to 82% were observed. Good long-term stent primary stent patencies (74–98%) were also reported, irrespective of stent type. Conclusions: This review notes that good outcomes can be expected following stenting for CIVO due to NIVL. Gaps, however, exist with regard to patient selection, peri/post-procedural antithrombotic strategies, and long-term follow-up in this context. A CEAP clinical class-based algorithm is provided to help with patient selection in addition to guidance on antithrombotic therapy and follow-up. Further study of these areas is merited.

OBJECTIVE:Venous stenting has become the standard of care for patients with iliofemoral venous stenosis who have failed conservative therapy. Although outcome data following such stenting exist for Wallstents and Wallstent-Zenith (Z) stent combination, such data for dedicated stents is sparse outside of industry-sponsored trials. This study aims to address this gap by comparing the outcomes of matched cohorts of limbs that underwent stenting with either the Medtronic Abre stent (Medtronic Inc), the Bard Venovo stent (Becton, Dickinson, and Co), or Wallstent-Z stent combination (Boston Scientific; Cook Medical Inc). METHODS:Contemporaneously entered data on matched cohorts of patients who underwent stenting from 2016 to 2022 for quality of life (QoL)-impairing iliofemoral venous stenosis (not occlusion) after failing conservative therapy were analyzed. The venous clinical severity score (VCSS, 0-27), grade of swelling (GOS, 0-4), visual analog scale pain score (VAS pain score, 0-10), and CIVIQ-20 QoL scores were evaluated initially and post stenting to assess the effects of stenting. Analysis of variance and paired t-tests were used to compare clinical and QoL variables, whereas Kaplan-Meier analysis was used to examine primary, primary-assisted, and secondary stent patencies, with log-rank test used to discriminate between different curves. RESULTS:There were a total of 198 limbs that had undergone stenting, including 68 in the Abre, 60 in the Venovo and 70 in the Wallstent-Z stent groups. The median age for the entire cohort was 65 years (range, 21-101 years). The cohort included 141 women and 57 men. Left laterality (112 limbs) was more common than right laterality (86 limbs). Post-thrombotic syndrome was seen in 146 limbs and nonthrombotic iliac vein lesions/May-Thurner syndrome in 52 limbs. The median body mass index was 35 kg/m2. Median follow-up was 20 months. For the entire cohort, post stenting, VCSS improved from 6 to 4.5 at 3 months (P < .0001), further improved to 4 at 6 months (P < .0001), and remained at 4 at 12 months (P < .0001) and 24 months (P < .0001). GOS for the entire cohort improved from 3 to 1 at 3 months (P < .0001) and remained at 1 at 6 months, (P < .0001), 12 months (P < .0001), and 24 months (P < .0001). VAS pain score for the entire cohort improved from 8 to 2 at 3 months (P < .0001), increased to 3 at 6 months (P < .0001) before dropping to 2 at 12 months (P < .0001), and remained at 2 at 24 months (P < .0001). The CIVIQ-20 score for the entire cohort improved from 61 to 38 (P < .0001) over the duration of follow-up. The primary patencies for the Abre, Bard, and Wallstent-Z stent groups at 32 months were 93%, 86%, and 92%, respectively (P = .37). Primary assisted patencies for all three groups at 32 months was 100% (P = .08). There were no stent occlusions in any of the groups. Reintervention was pursued for QoL-impairing recurrent clinical manifestations in 13 limbs (7%), without a significant difference between groups (P = .46). CONCLUSIONS:For patients undergoing stenting for QoL-impairing symptoms of iliofemoral venous stenosis after failing conservative therapy, Abre, Venovo, and Wallstent-Z stent combination all appear to provide similar clinical and QoL improvement. A significant difference between stent patencies for the three stent types was also not detected. Stent selection for treatment of stenotic lesions of the iliofemoral venous territory can be based on stent availability and the preference/expertise of the interventionalist.

Stent occlusion after stenting for chronic iliofemoral venous disease has an incidence of around 3% to 12% in the literature. The reasons for such occlusion vary, with patient and stent-related factors playing a role. One stent-related issue leading to stent occlusion is the use of undersized stents. Although undersized nitinol stents can be fractured and relined, this is not an option with a woven stent (eg, Wallstent). With an undersized, occluded woven stent, an option would be to bypass the occluded stent. This case report outlines the author's experience in such a setting where a patient presented with an undersized, occluded iliofemoral venous stent with severe quality-of-life impairing symptoms, and an endovenous bypass was created around the occluded stent column using Wallstent-Z stent combination. Nine months on, the patient remains significantly better with a patent stent.

Objective: Venous stenting has become the first line of treatment for patients with symptomatic chronic iliofemoral venous obstruction (CIVO) in whom conservative therapy has failed. Intravascular ultrasound (IVUS) interrogation with the use of normal minimal luminal diameters or areas has become the standard to confirm the diagnosis and determine the adequacy of stenting. However, the aspect ratio (ratio between the maximal and minimal luminal diameters) has also been put forth as a possible metric for determining stent adequacy. This study explores the utility of the native iliac vein and stent aspect ratios in determining the initial presentation and outcomes after stenting. Methods: A retrospective analysis of contemporaneously entered data from patients who underwent stenting for quality of life (QoL)-impairing clinical manifestations of CIVO for whom conservative therapy had failed formed the study cohort. The limbs were grouped into three at the time of intervention using the IVUS-determined native vein aspect ratio: group I, those with a ratio of <= 1.4; group II, those with a ratio of 1.41 to 1.99; and group III, those with a ratio of >= 2. The characteristics appraised initially and after stenting included the venous clinical severity score, grade of swelling (GOS), visual analog scale (VAS) for pain score, and the CIVIQ-20 QoL score. Analysis of variance and paired and unpaired t tests were used for comparison of clinical and QoL variables, and Kaplan-Meier analysis was used to evaluate stent patency, with the log-rank test used to discriminate between different curves. Results: There were a total of 236 limbs (236 patients). The median age for the entire cohort was 62 years (range, 16-92 years). There were 161 women in the study, and left laterality was more common (137 limbs). Post-thrombotic obstruction was noted in 201 limbs (86%). The median body mass index was 36 kg/m(2). There were 54 (23%), 64 (27%), and 118 (50%) limbs in groups I, II, and III, respectively. The median follow-up was 65 months. For the entire cohort, after stenting, the venous clinical severity score improved from 6 to 4 (P < .0001) at 3 months and remained at 4 at 6 months (P < .0001), 12 months (P < .0001), and 24 months (P < .0001). The GOS for the entire cohort improved from 3 to 1 (P < .0001) at 3 months and remained at 1 at 6 months (P < .0001), 12 months (P < .0001), and 24 months (P < .0001). The VAS for pain score for the entire cohort improved from 7 to 0 (P < .0001) at 3 months, increased to 2 (P < .0001) at 6 months, and remained at 2 (P < .0001) at 12 months. At 24 months, the VAS for pain score worsened to 3 (P < .0001). For the entire cohort, the CIVIQ-20 score improved from 62 to 40 (P < .0001). There was no difference in the GOS, VAS for pain score, or CIVIQ-20 score between the groups at baseline or at 6, 12, and 24 months after intervention. At 60 months, the primary stent patency was 89% for group I, 80% for group II, and 75% for group III (P = .85). The primary assisted stent patency was 100% for group I, 98% for group II, and 98% for group III (P = .5). Secondary patency was 100% for groups II and III (P > .5). Reintervention was pursued for QoL-impairing clinical manifestations in 53 limbs (22%) without a significant difference between the three groups (P = .13). Conclusions: The native vein aspect ratio does not appear to determine the initial clinical presentation or QoL or impact the clinical or QoL outcomes after stenting for CIVO. Following stenting, no patient had an aspect ratio >2, with 97% of patients having an aspect ratio <= 1.4 and the remaining 3% having an aspect ratio of 1.41 to 1.99. IVUS-determined minimal cross-sectional luminal area and not the aspect ratios should be used for confirmation of the diagnosis of CIVO and to assess the adequacy of stenting.

Stenting has become the first line of treatment for symptomatic chronic iliofemoral venous obstruction in patients with quality-of-life impairing clinical manifestations who have failed conservative therapy. Patient selection for such intervention is however dependant on clear identification of relevant clinical manifestations and subsequent testing to confirm the diagnosis. In this regard the physician engaged in management of such patients need to be well aware of symptoms and signs of chronic iliofemoral venous obstruction (CIVO), instruments used to grade chronic venous insufficiency (CVI) and determine quality of life in addition to diagnostic tests available and their individual roles. This review serves to provide an overview of the diagnosis of CIVO and patient selection for stenting.

Background Column interruption duration (CID) is a non-invasive surrogate for venous refill time (VFT), a parameter used in ambulatory venous pressure measurement. CID is more accurate than invasive VFT measurement because it avoids errors involved with indirect access of the deep system through the dorsal foot vein. The aim of this retrospective single center study is to analyze the clinical usefulness of CID in assessment of chronic venous disease (CVD).Methods Patients & subjects A total of 1551 limbs (777 patients) were referred with CVD symptoms over a 5-year period (2018-2023); CID, Air plethysmography (APG) and duplex reflux data were analyzed. 679 of these limbs had supine venous pressure data as well.The pathology was categorized as obstruction if supine peripheral venous pressure was >11 mm Hg. and as reflux if Duplex reflux time in superficial or deep veins was >1sec. CID was measured via doppler monitoring of flow in the great saphenous vein (GSV) and one of the paired posterior tibial veins (PT) near the ankle in the erect posture. The calf is emptied by rapid inflation cuff. CID is the time interval in seconds when cephalad venous flow in GSV and PT reappear after calf ejection. A CID <20 sec. in either vein is abnormal similar to the threshold used in VFT measurement. Results 32% of the limbs had obstruction, 17% had reflux and 37% had a combination; 14% had neither. Higher CEAP clinical classes (C4-6) were prevalent in 44% of pure reflux, significantly less (p<0.0001) than in pure obstruction (73%) or obstruction plus reflux subsets (72%), partly reflecting distribution of pathology. There is a progressive increase in supine venous pressure and abnormal CID (p<0.0001and p<0.0001respectively) in successive CEAP clinical class. No such correlation between CEAP and any of the reflux severity grading methods (reflux segment score, VFI90 and Kistner axial grading) was observed. Abnormal CID (55%) was more prevalent in higher CEAP classes (>4) (p<0.0001) than in lesser clinical classes (0-2) or limbs with neither obstruction nor reflux (p=0.0093). Conclusion Obstruction appears to be a more dominant pathology in clinical progression among CEAP clinical classes than reflux. CID is abnormal in both obstructive and refluxive pathologies and may represent a common end pathway for similar clinical manifestations (eg. Ulcer). These data suggest a useful role for CID measurement in clinical assessment of CVD limbs.

Objective: Phlebolymphedema has been noted to be one of the most common causes of lymphedema in the lower extremity in western societies. Although complex decongestive therapy (CDT) represents the mainstay of lymphedema treatment, its role for phlebolymphedema arising from chronic iliofemoral venous obstruction (CIVO) merits further exploration. We evaluated this through the use of a protocol of CDT first for limbs with CEAP (clinical, etiologic, anatomic, pathophysiologic) clinical C3 disease and stent correction of obstruction before CDT for those with more advanced disease (CEAP C4-C6). In the present study, we analyzed the outcomes after the use of such a protocol.Methods: We analyzed prospectively collected data for 192 limbs (166 patients) that underwent treatment of quality-of -life (QoL) impairing symptoms from CIVO due to lymphoscintigraphically determined phlebolymphedema between 2017 and 2022. The characteristics evaluated included CEAP clinical class, venous clinical severity score (VCSS), grade of swelling (GOS), visual analog scale (VAS) pain score, QoL (CIVIQ-20 [20-item chronic venous disease quality of life questionnaire]), stenting for CIVO, and outcomes related to CDT and stenting. For the limbs undergoing CDT or stenting followed by CDT, the outcomes were evaluated at 6 weeks and 3, 6, and 12 months after completion of CDT. Paired and unpaired t tests, c2 tests, and analysis of variance were used for comparisons of clinical variables. Kaplan-Meier analysis was used to evaluate stent patency, with the log-rank test used to discriminate between different curves.Results: Of the 192 limbs (166 patients) in the entire cohort, 74 were in the C3 group and 118 were in the C4-C6 group. The median patient age was 63 years; 57 were men and 109 were women. In the C3 group, after CDT, improvement had occurred in the VCSS and VAS pain score at 6 weeks (P < .0001) and at 3 (P < .0001), 6 (P < .0001), and 12 (P < .0001) months. Improvement in the GOS was noted at 6 (P < .0001) and 12 (P = .0005) months. The CIVIQ-20 score improved from 63 to 38 (P = .009). Nine limbs (12%) in the C3 group required stenting after CDT. In the C4-C6 group, of the 118 limbs, 75 (64%) underwent stenting only and 43 (36%) underwent stenting followed by CDT for persistent QoL impairing symptoms. For this latter group, after CDT, improvement occurred in the VCSS, GOS, and VAS pain score at 6 weeks (P < .0001) and 3 (P < .0001), 6 (P < .0001), and 12 (P < .0001) months. The CIVIQ-20 score improved from 61 to 34 (P < .0001). The primary, primary assisted, and secondary patency in the C4-C6 group at 36 months was 92%, 100%, and 100%, respectively.Conclusions: For CEAP C3 patients with phlebolymphedema due to CIVO, CDT should be a part of the first line of treatment. Stenting should be reserved for those with QoL impairing symptoms despite the use of CDT. Additionally, CDT helps provide symptom relief for patients with more advanced CEAP C4-C6 disease with persistent or residual edema after stenting. Further study is warranted. (J Vasc Surg Venous Lymphat Disord 2024;12:101686.)

The Society for Vascular Surgery, the American Venous Forum, and the American Vein and Lymphatic Society recently published Part I of the 2022 clinical practice guidelines on varicose veins. Recommendations were based on the latest scientific evidence researched following an independent systematic review and meta-analysis of five critical issues affecting the management of patients with lower extremity varicose veins, using the patients, interventions, comparators, and outcome system to answer critical questions. Part I discussed the role of duplex ultrasound scanning in the evaluation of varicose veins and treatment of superficial truncal reflux. Part II focuses on evidence supporting the prevention and management of varicose vein patients with compression, on treatment with drugs and nutritional supplements, on evaluation and treatment of varicose tributaries, on superficial venous aneurysms, and on the management of complications of varicose veins and their treatment. All guidelines were based on systematic reviews, and they were graded according to the level of evidence and the strength of recommendations, using the GRADE method. All ungraded Consensus Statements were supported by an extensive literature review and the unanimous agreement of an expert, multidisciplinary panel. Ungraded Good Practice Statements are recommendations that are supported only by indirect evidence. The topic, however, is usually noncontroversial and agreed upon by most stakeholders. The Implementation Remarks contain technical information that supports the implementation of specific recommendations. This comprehensive document includes a list of all recommendations (Parts I-II), ungraded consensus statements, implementation remarks, and best practice statements to aid practitioners with appropriate, up-to-date management of patients with lower extremity varicose veins.

Objective: Dedicated venous stents have not been used in the management of symptomatic chronic iliofemoral venous obstruction (CIVO) until recently. The Bard Venovo stent (Becton, Dickinson, and Co, Franklin Lakes, NJ) is one such stent noted to have an increased chronic outward force and radial resistive force compared with the Wallstent (Boston Scientific, Marlborough, MA). In the present study, we evaluated the outcomes following the use of the Bard Venovo stent vs a matched cohort of limbs that had undergone stenting with the Wallstent-Zenith (Z) stent (Cook Medical Inc, Bloomington, IN) composite configuration. Methods: A review of contemporaneously entered electronic medical record data for 167 patients (167 limbs) with initial iliofemoral stents placed from 2019 to 2020 for quality of life (QOL)-impairing CIVO that had failed conservative therapy was performed. The visual analog scale for pain score (score, 0-10), grade of swelling (score, 0-4), venous clinical severity score (score, 0-27), and the 20-item chronic venous insufficiency quality of life questionnaire instrument for QOL were evaluated before and after intervention to assess the effects of stenting. A Kaplan-Meier analysis was used to examine primary, primary-assisted and secondary stent patency, and analysis of variance with repeated measures was used to compare clinical outcomes. Results: A total of 167 limbs had undergone Bard Venovo stenting (56 men and 111 women). Their median age was 61 years. The laterality was right and left in 70 and 97 limbs, respectively. Post-thrombotic syndrome was seen in 84 limbs and nonthrombotic iliac vein lesions/May-Thurner syndrome in 83 limbs. At 6 months, the venous clinical severity score had improved from 7 to 4 in the limbs with a unilateral Venovo (UV) stent and from 5 to 4 in the composite Wallstent-Z stent group (P = .9). The grade of swelling had improved from 3 to 1 in the UV group and from 3 to 1 in the composite group (P = .6), and the visual analog scale for pain score had improved from 7 to 2 in the UV group and from 5 to 0 in the composite group (P = .007). At 12 months, ulcers had healed in 53% (8 of 15) of the UV group and 56% (5 of 9) of the composite group (P = .7). The global 20-item chronic venous insufficiency quality of life questionnaire scores had improved from 58 to 28 in the UV group and from 59 to 40 in the composite group (P = .6). The cumulative primary, primary-assisted, and secondary patency at 18 months was 81%, 97%, and 98% in the UV group and 87%, 98%, and 100% in the composite group, respectively (P > .4). No difference in the reintervention rates was noted between the two groups (P = .5). Conclusions: For patients who had undergone stenting for QOL-impairing CIVO, the results with the Bard Venovo venous stent were comparable to those with the composite Wallstent-Z stent configuration for clinical outcomes, QOL improvement, and stent patency. Further study is, however, required to confirm this improvement in the long term.

Objective Recent studies have emphasized the important role lymphatics play in the drainage of interstitial fluid and edema prevention. Although the infrainguinal lymphatics have been studied in some depth, with patterns of pathology identified, such data above the groin are sparse, especially for patients with phlebolymphedema. The present study attempts to evaluate the status of lymphatic flow above the inguinal ligament in patients presenting with edema and undergoing stenting for symptomatic chronic iliofemoral venous obstruction (CIVO). Methods A total of 31 lower limbs that underwent pedal lymphoscintigraphy for leg edema and subsequent stenting for symptomatic CIVO formed the study cohort. Each limb underwent intranodal lymphangiography of an ipsilateral inferior inguinal lymph node (10 mL of lipiodol) at the time of stenting. Fluoroscopic visualization of lipiodol transit was performed at 20, 40, and 60 minutes and 3 hours after injection. Enumeration of the lymph nodes and lymphatic collector vessels from above the inguinal ligament to L1, visualization of the thoracic duct, the time delay to visualization of the thoracic duct, and pathologic changes to the thoracic duct when present were all evaluated. These anomalies were independently scored, with the scores combined to generate a total suprainguinal score (range, 0-3). This score was then compared to the limb's lymphoscintigraphically derived infrainguinal score (total infrainguinal score range, 0-3) using the t test and Spearman correlation. The clinical outcomes (grade of swelling, venous clinical severity score) after stenting were appraised. Results Of the 30 patients (31 limbs), 18 were women, with left laterality noted in 23 limbs. A nonthrombotic iliac vein lesion occurred in 9 limbs and post-thrombotic syndrome in 22 limbs. Of the 31 limbs, 24 (77%) had suprainguinal lymphatic disease (SLD), with 22 of the 24 limbs having severe SLD and 2, mild SLD. When SLD was compared with infrainguinal lymphatic disease, 6 limbs (19%) had the same degree of involvement above and below the groin (1 with normal and 5 with severe disease), 17 limbs (55%) had more severe SLD, and 8 limbs (26%) had more severe infrainguinal lymphatic disease. Three limbs with normal pedal lymphoscintigraphic findings had severe SLD. The Spearman correlation coefficient for the comparison of SLD and infrainguinal disease in the same limb was 0.1 (P = .69). At baseline, the limbs with severe SLD had the same degree of leg swelling and venous clinical severity score as the limbs with absent to mild SLD (P > .1) with similar improvements after stenting (P > .4). Seven limbs underwent complex decongestive therapy (all with severe SLD and concomitant severe infrainguinal disease in one) to treat significant residual leg edema, with improvement. Conclusions SLD appears to be common in patients with leg edema undergoing stenting for symptomatic CIVO. Such disease appears to affect the thoracic duct more commonly. Although patients with persistent or residual leg edema after stenting can benefit from complex decongestive therapy, further workup in the form of inguinal intranodal lymphangiography and targeted intervention might need to be considered for those who do not benefit from such therapy. Further study is warranted.