What is Iliofemoral vein stenosis?
ILFVS is narrowing of the major veins that drain the legs, from a variety of causes. The causes can be:
- Post-surgical, especially after spinal, hip, or pelvic surgery, such as hysterectomy or bladder surgery
- Congenital, such as May Thurner Syndrome
- After blood clots (DVT) with incomplete reopening of the veins after the clot
- Due to chemotherapy or radiation
What are the signs and symptoms of ILFVS?
The symptoms of ILFVS are due to two major issues, the lack of blood draining from the legs, as well as pooling of blood in the legs and pelvis, which can cause compression of other structures. This is much easier to understand, with an anatomical diagram. In addition to compression, patients may develop what is called “chronic compartment syndrome” which is the buildup of waste products such as lactic acid in the muscles of the leg and pelvis, causing pain, numbness, and tightness in the leg and very often the buttock area. What makes this pain separate from neurological causes, is it is always worse with prolonged standing and sitting, and worse at the end of the day, when blood has had time to pool in the leg and pelvis. If you have had diagnostic studies for neurologic causes, such as MRI or CT scan, and there has been no significant neurologic cause identified, often the cause is vascular in nature. Other common signs and symptoms include:
- Sciatica from compression of the sciatic nerve
- Leg pain, numbness, and cramps
- Buttock pain, and tight muscles in the buttock and hip area
- Hip pain
- Calf pain and tightness, especially behind the knee
How do you diagnose ILFVS?
ILFVS is screened for starting with a vascular ultrasound, but often we cannot see this structure well due to overlying organs hiding the vessels from view. In this case, a venogram is the next step which is a test done through an IV under local anesthesia. In a venogram, a small amount of dye is injected at specific locations where a problem is suspected, which shows both the absence or presence of any narrowing, as well as blood pooling in any specific areas. If the venogram is positive, we check the degree of narrowing with a small catheter, also done through the IV called IVUS, or intravascular ultrasound. IVUS is able to very specifically give us information on exactly how narrow the blood vessel is. Why is this important? Because there are specific, evidence based guidelines on at what level of narrowing blood vessels should be corrected. Veins that are narrowed to a degree of > 50% are defined as “critical” stenosis, and in general, evidence shows that correction is warranted. There are other criteria that determine your level of aggressiveness in terms of correction. If the level is > 50% and very symptomatic, meaning causing any of the symptoms listed, it should be corrected aggressively.
Also, if the vein narrowing is causing blood clots, even if there is no pain, correction is recommended, as the narrowing is causing clots due to blood pooling. In our practice, when we perform major abdominal surgery, and patients have significant narrowing, we typically recommend correction, as it is now known that ILFVS is one of the major contributors to blood clots, and major surgery is a risk factor for these clots. In our practice, since we have started correcting these lesions pre-operatively, we have had ZERO major blood clots after abdominal surgery, even the most high-risk cases.
How is iliofemoral vein stenosis treated?
The treatment, in most cases for ILFVS is stenting, which is the placement of a tiny, but permanent metal tube in the vein that holds the vein open. This is typically made out of a platinum alloy, and is similar in nature to the material a fly screen is made out of. A stent is permanent, and in most cases, is a very safe procedure, with almost no side effects. In some cases, we advise delayed stenting, or no stenting at all, and use angioplasty instead, for a variety of reasons, but in most patients, it is the optimal approach.
What are the risks of stenting?
Overall, stenting is a very safe procedure with a <1% risk profile. The exception to this rule is patients that have already had blood clots due to ILFVS, because when blood clots have already occurred, there is always a higher chance of clots in the future, as well as scar tissue due to clots around the vein. In patients who have had clots in the past, the risk of future clots is approximately 10% even in the best hands.
Another risk of stenting, which has never happened in our practice, but is described in the literature, is stent migration, or the stent moving. We believe this is largely due to surgeon error in stent sizing or placement, and we have not experienced this complication.
A minority of cases need what is called “re-intervention.” Most often this is due to scar around the stent that gets narrower with time, or a vein that was incompletely treated by a smaller stent. In these cases, typically what is needed is angioplasty or re-stenting, which is done as an outpatient procedure. In any surgical procedure, even a very low risk one, such as stenting, you should have an objective reason for the procedure, and discuss all options with your surgeon before having it done. At NYC Surgical, we always offer an open line of communication with all surgical staff.
What are the risks of doing nothing?
In every non-emergency surgical issue, such as ILFVS, the non-surgical option always remains doing nothing, or medical management. The medical treatment is wearing very high level compression
garments. In general, for structural problems, like ILFVS, which is more or less a “plumbing” problem in the body, there is not really an effective medical solution. Most patients also find these garments very arduous and uncomfortable, and we have not found they offer much relief. In general, the major reason to treat ILFVS is to minimize clot risk, or for pain/swelling relief, and the consequences of doing nothing are related to those things.
We hope that this informational packet helped explain the most common questions about ILFVS, and options for treatment. If more questions arise, please feel free to contact your surgeon, and we can help alleviate your concerns. At NYC Surgical, we believe our role is to gather information, present it in a format you can understand, and help you make the right decision for yourself, as we would do for our own family