Secret Revealed: The % of iliac vein compression needed to justify a stent?

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Venous disease is complex. MTS, CVI, NCS, PCS…the list of abbreviations seems endless and will make your head spin. To make things even more confusing, many patients are told that the treatment for their venous disease is placement of a stent. This results in patients turning to social media and Dr. Google, trying to find information about the stent procedure. Is it safe? What is the recovery like? Do I have to take blood thinners?

While patients from all over the world will share both their positive and negative experiences of getting a stent, there is one question that no one can answer. It’s the most common question that patients ask, and the question that has the least consensus among vascular specialists.

What % of iliac vein compression is needed to justify a stent?

Typically, many vascular specialists will place a stent if there is greater than 50% stenosis (narrowing) of the vein. How did the vascular community come up with 50% as the number to justify a stent?

Fig 1. Peripheral artery disease treated with balloon angioplasty and stent.

In peripheral arterial disease, a 50% narrowing of a leg artery can lead to pain when walking — a condition known as claudication. While conservative therapy such as exercise and smoking cessation is tried first, a stent may be placed if symptoms do not improve and the artery is narrowed more than 50%. However, venous disease is completely different than arterial disease (even though they are both blood vessels) and applying the same principles to veins that are used for arteries does not work! Therefore…

The % of iliac vein compression at which a stent is needed is….(drum roll please)

The % of iliac vein compression does NOT matter!

The % of iliac vein compression does NOT matter!

And one more time….

The % of iliac vein compression does NOT matter!

You’re probably really confused now, so let me explain…

If someone came to me for a 2nd opinion after being told by another physician that they had 99% compression of their iliac vein, I would not place a stent in that patient. Why? Because it is the patient and their symptoms that should be treated, NOT a number.

All of us on the planet have some degree of compression. Some of us have 10%, some have 15%, some have 30%, and yes some have 90%. So why don’t we place a stent in every single person on earth? It’s the same reason why we don’t preemptively take everyone’s appendix out in case they were to develop appendicitis at some point in their lifetime. Likewise, with iliac vein compression, we do not stent patients who are asymptomatic (do not have symptoms). Remember, you can’t make asymptomatic better! Therefore, I’m really confused when a patient has been recommended a stent and they have no DVT, swelling, pelvic pain…nothing. It makes me wonder, why are they seeing a physician in the first place if they didn’t have symptoms? Why are they seeing me?

Remember, you can’t make asymptomatic better?

The problem is that many vascular specialists do NOT have a good understanding of both superficial vein disease — aka chronic venous insufficiency (CVI) — and deep venous disease. These two types of venous disease are closely related and yet they are quite different. CVI will affect 1 in 4 adults in their lifetime. In fact, more than 90% of the population will develop CVI in their lifetime when pregnancy, obesity, family history, occupation, and other factors are taken into account. For a condition that affects so many people and is statistically more common than deep venous disease, one would think that a physician would evaluate a patient for CVI first before considering deep venous disease. Unfortunately, this is often not the case.

CVI will affect 1 in 4 adults in their lifetime.

If a patient with a history of severe pelvic pain, pain with intercourse, left leg pain and swelling, and back pain undergoes a venogram and is found to have 80% compression of the iliac vein on intravascular ultrasound (IVUS), a stent may very well be needed. However, if they have 80% compression and no symptoms, then why is a venogram being done in the first place? Whatever the reason is for doing the venogram, if there are no symptoms, I do not believe a stent is needed no matter how severe the compression is.

Similarly, if another patient with the same symptoms has 40% compression (which is less than the 50% threshold used by many physicians to justify a stent) than that patient may very well get a stent from me. So I treat the patient not the % compression. Now if someone has symptoms and IVUS shows that they have 10-20% compression, then I will not place a stent and iliac vein compression is likely not their problem. This means that I have more work to do in finding out the cause of their symptoms.

So will science ever determine what % compression is needed to justify a stent? I don’t know. What I do know is that there is both a science and an art to medicine. Performing a thorough history and physical exam is the cornerstone of how a physician determines the treatment to offer a patient. If that exam is not done well or with a poor knowledge of venous disease, then that physician is more likely to steer the patient in the wrong direction of treatment.

Performing a thorough history and physical exam is the cornerstone of how a physician determines the treatment to offer a patient.

Before getting a stent, do your homework! Read The Patient’s Guide to May Thurner Syndrome: Questions To Ask Your Physician Before Getting A Stent. Get a 2nd and perhaps a 3rd opinion. Since many vascular specialists specialize in treating arterial disease only, ask your physician how much venous disease he/she treats. Remember that in most cases, venous disease is not life threatening and does not require an emergent procedure. Take the time to educate yourself and your family about venous disease so that you can optimize your chances of a successful outcome.

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1 Comment

  1. Carol Derstine

    Great information in your article. Thank You

    Reply

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