Defining the utility of anteroposterior venography in the diagnosis of venous iliofemoral obstruction

Background: Intravascular ultrasound (IVUS) is the current standard for the diagnosis of obstruction in the iliac and femoral veins. However, multiple venographic findings including collaterals, pancaking, and contrast thinning have been suggested to improve the sensitivity of venography. The objective of our study was to further elucidate where and how anteroposterior venography may successfully guide the diagnosis of venous obstruction.

Methods: A retrospective review of patients with chronic venous insufficiency who received iliofemoral stenting by a single practitioner at a tertiary medical center between January 2014 and August 2016 was performed. Patients who had records of anteroposterior venography and IVUS were included. Patients who underwent reoperation, did not have complete records of venography and IVUS, or had preoperative acute deep vein thrombosis were excluded. All patients with a greater than 50% luminal area reduction by IVUS underwent balloon angioplasty and stent placement. The locations of stenosis, collaterals, pancaking, and contrast thinning with venography, the locations of stenosis with IVUS, and the location of each stent placed were recorded.

Results: There were 107 patients who underwent venous stenting guided by venography and IVUS in this study. Six patients who underwent reoperation, 1 patient who had an acute preoperative deep vein thrombosis, and 14 patients who had incomplete records were excluded. Thus, 86 patients with 77 left lower extremity and 68 right lower extremity studies were available for analysis. The sensitivity by stenosis on venography was 4% in the left common iliac vein (CIV), 44% in the left external iliac vein (EIV), and 44% in the common femoral vein (CFV). The sensitivity by stenosis on venography in the right CIV, EIV, and CFV was 21%, 46%, and 40%, respectively. Combined, pancaking and collaterals had a sensitivity of 97% in the left CIV. IVUS resulted in a change in plan in 2%, 32%, and 48% of patients in the left CIV, EIV, and CFV, and in 26%, 35%, and 48% of patients in the right CIV, EIV, and CFV, respectively.

Conclusions: Anteroposterior venography can indirectly diagnose obstruction of the left CIV through the identification of collaterals and pancaking. The combination of low sensitivity and a high rate of change of plan owing to IVUS precludes complete reliance on anteroposterior venography for the diagnosis of lesions in the left EIV and CFV and the right CIV, EIV, and CFV. IVUS must be used to comprehensively identify all venous iliofemoral lesions.