From the American Venous Forum

Obstructive lesions of the inferior vena cava:

Clinical features and endovenous treatment
Seshadri Raju, MD, Kathryn Hollis, BA, and Peter Neglen, MD, PhD, Flowood, Miss

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 patency 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. ( J Vasc Surg 2006;44:820-7.)

Chronic obstructive lesions of the inferior vena cava 14 patients because symptoms were mild, transient, or
(IVC) are associated with many unusual features: many absent to begin with (n ⫽ 10) or abated (n ⫽ 4) after
have chronic symptoms, but some total occlusions may be successful catheter-directed lysis of acute distal thrombus
entirely silent.1-3 Some, having remained silent, present below the chronic IVC obstruction. Stent placement was
acutely with the onset of distal thrombosis.4-9 Renal and, recommended in the remaining 106 patients. Two patients
less often, hepatic impairment are usually absent. Obstruc- declined, and placement was successful in 97 patients (99
tive symptoms in the extremities may be surprisingly vari- limbs: 2 bilateral, 14 occlusions, and 85 stenoses) and
able in type and intensity, and often only one extremity is unsuccessful in 7 (all occlusions). IVC stent placement (n ⫽
affected. In this article, we describe the clinical features, 99) constituted 6% of all venous stent placements for
technique of stent placement, and mid-term results in a chronic venous disease during this period.
group of cases with IVC stenosis or occlusions seen over a The female-male ratio was 2:1, and the left-right ratio
10-year period. was also 2:1. The median age was 51 years (range, 14-80
years). Among patients treated with stent placement, limb
MATERIALS AND METHODS symptoms were bilateral in only 32 (33%) of 97 and were
A total of 120 patients with IVC obstructions were unilateral in the remaining 65 (67%). Among all four
encountered from 1997 to 2005, representing 2.8% of patients who developed acute symptoms with distal throm-
patients with chronic venous disease (n ⫽ 4217) seen bosis below a chronically occluded IVC, symptoms were
during the same period. Stent placement was not offered in unilateral. The CEAP clinical classification10 in stented
limbs (n ⫽ 99) was as follows: C1, 2%; C2, 9%; C3, 37%;
From the University of Mississippi Medical Center and River Oaks Hospital. C4, 26%; C5, 7%; and C6, 19%.
Competition of interest: none.
Presented at the Eighteenth Annual Meeting of the American Venous
Pathology
Forum, Miami, Fla, Feb 22-26, 2006.
Reprint requests: Seshadri Raju, MD, 1020 River Oaks Dr, Suite 420, Eighty-two percent (81/97) of the IVC lesions (n ⫽
Flowood, MS 39232 (e-mail: [email protected]). 97) were infrarenal, 14% (14/97) were suprarenal below
CME article
0741-5214/$32.00
the diaphragm, and 4% (4/97) extended further into the
Copyright © 2006 by The Society for Vascular Surgery. thoracic IVC segment. The disease was limited to the IVC
doi:10.1016/j.jvs.2006.05.054 proper only in 7% of patients. Distal extension into the
820
JOURNAL OF VASCULAR SURGERY
Volume 44, Number 4 Raju, Hollis, and Neglen 821

common iliac vein or beyond occurred in 93% of the limbs,

into the distal common iliac vein in 22%, into the external
iliac vein in 37%, into the common femoral vein in 31%, and
further distally in 3%. IVC lesions were partial (⬎60%
stenosis) in 86% and were total occlusions in 14%. Collat-
erals were uniformly present. In nine cases, an IVC filter
was present.
Reflux was present in 66 of 99 limbs, with axial reflux to
below the knee in 27 limbs. In 49 limbs, reflux involved two
or more venous segments. Among 19 limbs with ulcers,
reflux was present in 17, all involving both the superficial
and deep systems (axial in 10) except in one limb, for which
only the superficial system was involved.

Clinical features
Patients in this series fell into three clinical groups:
(1) asymptomatic, (2) acutely symptomatic, and (3) chron- Fig 1. The stenosis/occlusion should be dilated to accommodate
ically symptomatic. a stent of approximately the same size as normal anatomy for
Asymptomatic group. Ten patients in this series were proper function (left). In rigid lesions and occlusions, overdilation
either totally asymptomatic or had only transient or cos- by 1 or 2 mm will allow for recoil. The Glidewire seldom strays
metic symptoms with little functional impairment of the outside the occluded vein, and this can be confirmed by intrave-
limb. Several (n ⫽ 7) sought clinical advice because of nous ultrasonography after predilation (right). Dilation of up to 24
limb, scrotal, or abdominal varices. Superficial thrombo- mm in the inferior vena cava has not resulted in clinical hemor-
rhage.
sis of the abdominal varix was the presenting complaint
in two of these cases. Mild transient leg swelling, tran-
sient groin pain, and a transient ulcer were the mode of Stent placement
presentation in one patient each. All were treated conser- Stent placement was offered to patients according to
vatively for fear of producing overt limb pain and edema by symptom severity. Most belonged to CEAP class 3 or
unwarranted surgical trauma in the context of trivial or higher. Five patients in class C1 and 2 received a stent
absent symptoms. because of severe associated pain and six others to relieve
Acute symptom group. Four patients initially pre- recurrent cellulitis (4) or recurrent superficial phlebitis (2).
sented with acute deep venous thrombosis of the lower Nineteen patients received stents because of active ulcer-
extremity without prior leg symptoms. All four underwent ation. In two patients, bilateral iliac vein stents were re-
catheter-directed thrombolysis during which a chronically quired in addition to IVC stenting.
occluded vena cava was discovered. After successful lysis of Technique. Venous stent placement and recanalization
the acute thrombus below the occluded IVC, all four pa- procedures have been described in detail elsewhere.14,15
tients became asymptomatic again. Three remained asymp- Some modifications for special situations in IVC were
tomatic, and the fourth patient developed limb symptoms required.
after recurrent distal thrombosis 5 years later. Access was obtained through the femoral vein at the
Chronic symptom group. Symptoms were chronic in midthigh level under ultrasound guidance with the patient
99 limbs of 97 patients. in the supine position. Sheaths ranging from 9F to 14F
were used as necessary. Traversing stenotic lesions is
Assessment straightforward. For recanalizations, Glidewires (Terumo
The degree of swelling was assessed by physical exami- Medical Corporation, Somerset, NJ) of varying sizes, tip
nation (grade 0, none; grade 1, pitting, not obvious; grade angles, and stiffnesses were used in conjunction with sup-
2, ankle edema; and grade 3, obvious swelling involving the porting catheters (angled or straight tips) as necessary to
limb). The level of pain was measured by using the visual traverse the occlusions. Because the Glidewire tip is floppy,
analogue scale.11 it invariably remains within the occluded venous structure.
The tough adventitia and perivenous fibrosis seem to pro-
vide natural resistance against perforations. Limited ex-
Investigations travasations of contrast can be safely ignored. Larger dye
Patients underwent venous laboratory tests including extravasations (rare with experience) call for cessation of
duplex scan, ambulatory venous pressure measurement the procedure, which can be reattempted a few weeks later.
(percentage decrease; venous filling time), arm/foot pres- After the lesion is crossed, further easy passage of the
sure test,12 air plethysmography (VFI90),13 and contrast Glidewire signifies proper IVC re-entry, which should be
studies. A valve closure time of longer than 0.5 seconds on confirmed by venography/intravenous ultrasonography
duplex scan was defined as reflux. (IVUS). Predilation up to 6 to 8 atm is generally adequate
 JOURNAL OF VASCULAR SURGERY
822 Raju, Hollis, and Neglen October 2006

Fig 2. A case in which there was segmental occlusion of the

Fig 3. A case in which an inferior vena cava filter was pushed aside
inferior vena cava (IVC) at the renal level with additional diffuse
and a stent was placed past the compacted stent. Nine filters of
stenotic lesions involving infrarenal IVC and both iliofemoral veins
various makes in common use, including types with prongs, were
(left). The stents were extended into the thoracic IVC and distally
successfully stented across (despite balloon punctures).
into the femoral veins bilaterally (right).

to dilate stenoses, but up to 16 atm can be used to relieve

rigid lesions and total occlusions. Progressive dilation is
recommended in the latter case (Fig 1).
Wallstents (Boston Scientific, Natick, Mass) ranging
from 14 mm in the external iliac vein to 24 mm in the IVC
were used as appropriate to match the normal lumen size.
Generous overlap of at least 3 to 4 cm is necessary to avoid
“shelving” of the stent ends at curvature points and the
pelvic brim and to allow for stent shortening with postde-
ployment dilation. Intravenous ultrasonography is essential to
select the optimal proximal and distal landing sites for the
stent because disease often extends beyond that visible on
venography.16,17 All diseased segments should be covered by
the stent to ensure adequate inflow into and outflow from the
Fig 4. Stent placement at the inferior vena cava (IVC) bifurca-
stent (Fig 2).
tion: after the IVC stent is extended into one of the iliac veins, a
Filters, when present, were treated like rigid lesions and
fenestrum is created by balloon dilation over a guidewire. The
pushed aside by balloon dilation up to 16 atm (Fig 3). guidewire is introduced through the opposite side and manipu-
When both limbs are symptomatic with bilateral iliac vein/ lated through the stent. A generous overlap of 5 cm between the
IVC disease, Wallstents can be configured in the form of an stents is recommended to prevent the second stent from shrinking
inverted Y (Fig 4). back through the fenestrum during postdilation. No restriction of
A completion venogram and intravenous ultrasonogra- either iliac flow has been observed when this technique has been
phy are performed to assess proper positioning of the stents used.
and to ensure the absence of intrastent stenoses, thrombi,
or uncorrected proximal and distal lesions, all of which
should be corrected without hesitation. Prompt deploy- (Vasoseal, Datascope Corp, Montvale, NJ) because of the
ment of the stents and establishment of flow, once the mid-thigh access and the large sheath size needed.
recanalized channel is predilated, is the key to avoid signif- The procedure was performed with patients under gen-
icant channel or intrastent thrombus formation. When eral anesthesia on an outpatient basis (23-hour admission).
encountered, the thrombus can usually be squeezed out by Patients were administered 5000 U of dalteparin before
postdeployment balloon dilation. Rapid clearance of con- surgery. The procedure was performed under intermittent
trast through the stent and disappearance of collaterals is a minimal heparin (1000-2000 U every 90 minutes). More
reliable indication of adequate stent function. Poor inflow, recently, bivalirudin (75-mg intravenous single dose) has
when encountered, should be reassessed with a smaller (6F been satisfactorily substituted for heparin to further mini-
or 7F) sheath, because larger sheaths can impede inflow. mize platelet activation. After surgery, patients received
Adjunctive A-V fistulas to increase inflow were not used. dalteparin 5000 U subcutaneously every 12 hours for a
We have routinely used sealing devices at the access site maximum of three doses or longer (4 days) if follow-up
JOURNAL OF VASCULAR SURGERY
Volume 44, Number 4 Raju, Hollis, and Neglen 823

Table. Venous function tests before and after stent

placement in inferior vena cava obstruction

Before surgery, After surgery,

Variable median (range) median (range)*

Ambulatory venous pressure

Pressure drop (%) n ⫽ 58 n ⫽ 16
62.5 (1-100) 51.5 (28-90)†
Venous filling time (s) n ⫽ 58 n ⫽ 15
19 (3-120) 33 (6-160)†
Air plethysmography
VFI90 (mL/s) n ⫽ 73 n ⫽ 37
1.9 (0.1-11.9) 1.3 (0.2-5.4)†
Hand/foot—venous
pressure test
Hand/foot pressure n ⫽ 54 n ⫽ 20
differential (mm Hg) 1 (0-15) 0 (0-7)†
Reactive hyperemia n ⫽ 58 n ⫽ 21
pressure elevation 7 (0-29) 5 (2-23)†
Fig 5. Cumulative inferior vena cava (IVC) stent patency (pri- (mm Hg)
mary assisted) confirmed by venography.
*Latest available test.
†
P ⱕ .0008.
warfarin (started the same day after stenting) was required.
Warfarin was instituted in cases of thrombophilia and su-
prarenal stent extension and if patients were taking chronic Kaplan-Meier method. Nonparametric Wilcoxon rank tests
anticoagulation before surgery. Otherwise, patients were for unpaired data and ␹2 analysis were used to compare
placed on daily aspirin (81 mg). groups as appropriate. A P value of less than .05 was
considered significant.
Concurrent procedures
Twelve patients underwent saphenous ablation (radio- RESULTS
frequency or laser) concurrent with the stent procedure. Procedure success was 100% in stenotic lesions and 66%
Saphenous reflux in five patients was ignored either because (14/21) in occlusions; the latter includes 2 patients in
the vein was small (⬍5 mm) in caliber or for technical whom recanalization was successful only on the second
reasons (prolonged or complex stent procedure). attempt. In five of seven patients in whom the procedure
failed, a minimum of two attempts were made before stent
Reinterventions placement was abandoned.
There were 15 primary assisted (patent stent with re- Periprocedure (30-day) mortality and late stent-related
sidual symptoms) interventions in the follow-up period. mortality during the follow-up period were nil. There were
Nine patients underwent balloon dilation to relieve focal no pulmonary emboli. There was a transient postprocedure
stenoses compressing the stent; these seemed to be the creatinine increase (probably contrast related) in one pa-
result of inadequate predilation during the original proce- tient, in whom recanalization had failed. There was no
dure. In six others, extension of the stent proximally or instance of clinically apparent hemorrhage that necessitated
distally was required to correct missed lesions during the transfusions or volume replacement. There was no detect-
original procedure. able renal or hepatic dysfunction in cases of suprarenal or
thoracic stent extensions, respectively. There were no ac-
Follow-up and outcome assessment cess site complications in this series. There were no malse-
Patients were examined at 6 weeks and 3, 6, and 9 quelae in patients in whom the procedure was unsuccessful
months after stent placement and at yearly intervals there- or aborted as a result of major contrast extravasations.
after. Venography and venous laboratory tests were per- Postoperative mild to moderate back pain was a common
formed during the first 6 months after stent placement and complaint in many patients (approximately 20%) and was
then annually. Outcome was graded as recommended by easily controlled by nonsteroidal analgesics; none necessi-
reporting standards.18 tated admission.
Follow-up was available in 92% (91/99) after stent
Data analysis placement. The median follow-up was 11 months (range,
Clinical data were entered prospectively into a time- 3-59 months).
stamped electronic medical records program for retrospec- Cumulative primary and primary assisted stent patency
tive analysis. A commercially available statistical program were 58% and 82%, respectively, at 2 years (Fig 5). Four
(GraphPad Prism for Windows, version 3.0; GraphPad stents had become occluded during the follow-up period:
Software, San Diego, Calif) was used for statistical analysis. two for correction of stenoses and two others for recanaliz-
Actuarial survival curves were constructed according to the ing totally occluded segments. There was no worsening in
 JOURNAL OF VASCULAR SURGERY
824 Raju, Hollis, and Neglen October 2006

Fig 7. Cumulative complete relief of swelling after inferior vena

Fig 6. Cumulative complete relief of pain after inferior vena cava cava (IVC) stent placement; partial swelling relief was marked as
(IVC) stent placement; partial pain relief was marked as failure and failure and censored. Only those who had preoperative swelling
censored. Only those who had preoperative pain were included. were included.

reflux or global venous function parameters after stent such as webs and strictures. Parts of the formative venous
placement (Table); reflux and obstructive indices actually network disappear or remain as embryonic rudiments;
showed a slight improvement after surgery. other parts are recognizable in the adult as named struc-
Preoperative pain was present in only 61 (61%) of 99 tures, such as the azygos, hemiazygos, accessory hemiazy-
limbs, and the remainder were pain-free. Among limbs that gos, and thoracolumbar veins. All interconnect with each
had limb pain before, 74% (cumulative) were completely other to freely form a potentially rich collateral network.
pain-free at 3.5 years after stent placement (Fig 6). The thoracolumbar vein receives drainage directly from the
Preoperative swelling was present in 75 of 99 patients common iliac vein through a large connection that is prom-
and absent in the remainder. Among the limbs that had inent in cases of IVC obstruction (Fig 8). As embryonic
swelling before, 51% (cumulative) were completely free of alternates to the IVC, growth of the retained named and
swelling at 3.5 years after stent placement (Fig 7). unnamed putative collateral veins can be expected to be
Among 19 with active ulcers, 12 (63%; cumulative) vigorous if the IVC failed to develop properly before birth
healed and remained healed with complete epithelialization or occluded even later during the growth period. The
at 2 years. Among the 12 healed ulcers, only 2 had concur- normal flow direction in these veins is the same as potential
rent saphenous ablation, meaning that ulcer healing in the collateral flow. These attributes probably provide for very
rest could be directly attributed to the stent procedure, efficient collateral function, and the collaterals can be ap-
because the associated reflux remained uncorrected. Nine propriately termed natural collaterals. These may be so
limbs with ulcers that healed after stent placement had dilated as to appear as a left-sided vena cava or double venae
untreated residual deep reflux (4/9 axial). All seven limbs cavae on venograms (Fig 9). Given the fact that the collat-
with unhealed ulcers had residual untreated reflux (six eral network in IVC obstructions receives drainage directly
axial). or indirectly from the common iliac veins, the patency of
The overall clinical outcome was graded as follows the latter vein seems to be crucial for the collateral network
according to the reporting standards (⫹3, excellent; ⫹2, to function effectively. Natural collaterals elsewhere with an
good; ⫹1, mild improvement; 0, no improvement; and embryonic basis and natural flow direction also seem to
⫺1, worse): ⫹3, 43%; ⫹2, 27%; ⫹1, 16%; 0, 13%; and ⫺1, function efficiently.21 Tributary collaterals—main alternate
1%. Thus, 70% of the limbs had an excellent or good clinical pathways in isolated iliac vein obstructions—seem to func-
outcome at the end of their follow-up period. tion less efficiently; collateral flow direction is opposite
normal. Many or most iliac vein occlusions seem to remain
DISCUSSION symptomatic despite the presence of tributary collaterals on
The fully developed IVC is a complex structure derived venography.12 In cases of combined iliac/IVC obstruction,
from different segments of an array of multiple paired collateral compensation is likely to be poor.
longitudinal embryonic veins (at least four pairs) and the Many curious features of IVC obstructions/occlusions
interconnections between them.19,20 The development of can be explained on the basis of the aforementioned collat-
the IVC near the liver and diaphragm is particularly com- eral development. Approximately 10% in this series had no,
plex, because new outgrowths from the hepatic veins and mild, or only transient symptoms. With widespread use of
the infrarenal IVC have to meet and establish a connection. imaging studies, the lesion is being detected in asymptom-
This area seems to be prone to developmental anomalies atic patients as an incidental finding during examination for
JOURNAL OF VASCULAR SURGERY
Volume 44, Number 4 Raju, Hollis, and Neglen 825

Fig 8. Collaterals in a case of inferior vena cava obstruction. Note the large connection between the thoracolumbar
vein and the common iliac vein (left). Higher up, the thoracolumbar vein feeds into the azygos network (center) to
drain into the right atrium (right).

unrelated problems.1-4,9,22,23 Many are assumed to be identified. The critical lesion in the collateral in all three
congenital agenesis or atresias, even though early occlu- cases was at or near the diaphragm, which could not be
sions could present a similar picture. The lack of symptoms, traversed with a guidewire (Fig 10).
including the nearly universal absence of renal or hepatic IVC lesions, particularly occlusions, are lengthy, and
dysfunction, in this subset is undoubtedly related to excel- there is an intuitive tendency to limit the length of stented
lent collateral development and function. Symptomatic segments to minimize thrombosis from stent exposure.
Budd-Chiari syndrome related to segmental IVC obstruc- Counterintuitively, our experience indicates otherwise.
tions seems to behave differently in this respect; this may in Thrombosis of treated segments has been less related to the
part be related to the concurrent involvement of hepatic metal load of the stents per se than to the violation of
veins.24,25 established principles of vascular surgery: ensuring proper
There are scores of reports in the literature of previously inflow and outflow (correcting all lesions) and avoiding
silent IVC obstructions presenting with symptomatic acute technical defects related to the conduit (stent). In pursuit of
distal deep venous thrombosis. For this reason, chronic these principles, we have extended the stent above patent
anticoagulation has been suggested when such silent le- renal veins, across contralateral iliac veins, and below the
sions are found.2 There were four patients in this series with inguinal ligament when necessary.14-16 There were no
such a presentation. All four became symptom-free with thromboses of either the stent or the major tributary out-
lysis of the acute thrombus. This clinical pattern under- flow in this series. The Wallstent seems to allow free flow of
scores the importance of the common iliac vein as the the tributaries across the interstices of the stent. Crossing
primary outflow source for the collateral network in IVC the inguinal crease has not resulted in fracture or increased
obstructions. Ninety-two of 99 symptomatic limbs that re- stent thrombosis. Stent fracture in arteries at flexion points
ceived stent placement also had common iliac vein stenosis/ may be related to metal fatigue from movement related to
obstruction on the stented side. Ipsilateral common iliac arterial pulsations. There may be hesitation to dilate the
vein involvement also may explain why two-thirds of pa- obstructive vein to the size recommended, but fears of
tients in this series had only unilateral symptoms in IVC hemorrhage with rupture have not borne out in more than
occlusions. In seven cases in this series, there was no com- 1000 stent deployments (unpublished data). This is prob-
mon iliac vein involvement, and the lesion was entirely ably related to the comparatively low prevailing venous
confined to the IVC. In some of these cases, severe coex- pressure and the constraining influence of perivenous fascia
isting reflux could be responsible for symptom production. and retroperitoneal cover if rupture indeed occurs in some
In 3 of 7 cases, stenotic lesions in the major collateral were cases. Imaging studies in the cases of common postopera-
 JOURNAL OF VASCULAR SURGERY
826 Raju, Hollis, and Neglen October 2006

Fig 9. A case of a double vena cava with each channel receiving

direct drainage from the ipsilateral iliac vein. Anomalous inferior
vena cava (IVC) development or later occlusion can give rise to a
similar picture. The potentially rich collateral development in IVC
occlusions is dependent on the patency of the common iliac vein
for proper function.

tive back pain in our early experience ruled out vein rupture
as an unlikely etiologic factor. They are no longer per-
formed on a routine basis. Compromising dilation to the
required size is likely to result in residual stenosis in the
Fig 10. A case of inferior vena cava (IVC) occlusion without iliac
stented segment, stent malfunction, or thrombosis.
involvement. The IVC lesion could not be recanalized. The prom-
We have learned that success or failure in recanalizing
inent thoracolumbar collateral appeared to harbor multiple steno-
total occlusions cannot be predicted by the extent of the ses in the lumbar region and also a nonpassable lesion near the
lesion or by its venographic appearance. One or more diaphragm where it interconnected with the azygos system. The
attempts at reopening the occlusion are warranted in all lumbar portion of the collateral was stented, but this failed to
cases. We have been astonished at how even extensive relieve the symptoms.
lesions can be traversed with some persistence and pa-
tience. Percutaneous stent placement is emerging as an
alternative to open surgery26 to correct IVC obstruc-
Data collection: SR, KH
tions.27,28 Many of the technical challenges are solvable.
Writing the article: SR, PN
Mid-term stent patency with symptom relief is excellent.
Critical revision of the article: SR, PN
The healing of stasis ulceration by stent placement alone,
Final approval of the article: SR, PN, KH
even in the presence of significant untreated residual
Statistical analysis: PN, KH
reflux, has been previously reported.29 Stent placement
Overall responsibility: SR
is an attractive option in treating IVC lesions because it is
minimally invasive and safe and seems to be effective at
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Analysis and interpretation: SR, KH, PN bined with hyperhomocysteinemia. Ann Vasc Surg 2004;18:124-9.
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