High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity

Abstract

Purpose: Nonthrombotic iliac vein lesions (NIVL), such as webs and spurs described by May and Thurner, are commonly found in the asymptomatic general population. However, the clinical syndrome, variously known as May-Thurner syndrome, Cockett syndrome, or iliac vein compression syndrome, is thought to be a relatively rare contributor of chronic venous disease (CVD), predominantly affecting the left lower extremity of young women. The present study describes the much broader disease profile that has emerged with the use of intravascular ultrasound (IVUS) scanning for diagnosis and analyzes stent placement outcome in two specific NIVL subsets that may offer clues to their pathogenic role.

Methods: Among 4026 patients with CVD symptoms spanning the range of CEAP clinical classes, IVUS examinations were selectively done in severely symptomatic patients for indications as described. Iliac vein obstructive lesions were found in 938 limbs of 879 patients; 53% of the limbs had NIVL, 40% were post-thrombotic, and 7% were a combination. Stents were placed in 332 limbs in 319 patients in two NIVL subsets. The subsets, one with and one without associated distal limb reflux, were compared. Reflux was left untreated in the first subset.

Results: The median age was 54 years (range, 18 to 90 years). The female-male ratio was 4:1 and the left-right ratio was 3:1. NIVL lesions in the iliac vein occurred at the iliac artery crossing (proximal lesion) and also at the hypogastric artery crossing (distal lesion), a new IVUS finding. Venography was only 66% sensitive, with 34% of venograms appearing "normal." IVUS had a diagnostic sensitivity of >90%. The cumulative results observed at 2.5 years after stent placement in the NIVL subsets with reflux and without reflux, respectively, were complete relief of pain 82% and 77%, complete relief of swelling 47% and 53%, complete stasis ulcer healing 67% and 76%, and overall clinical relief outcome 75% and 79%. These results are nearly identical between the two subsets even though distal reflux remained uncorrected in the NIVL plus reflux subset.

Conclusions: NIVL has high prevalence and a broad demographic spectrum in patients with CVD. Similar lesions in the asymptomatic general population may be permissive of future development of CVD. Stent placement alone, without correction of associated reflux, often provides relief.