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Left common iliac vein diameter in patients referred for lower limb venous duplex ultrasound

Left common iliac vein diameter in patients referred for lower limb venous duplex ultrasound Introduction: Evidence regarding ultrasound assessment of left common iliac vein diameter (LCIV) is limited. Extensive work is currently being undertaken worldwide on non-thrombotic iliac vein lesions to identify patients who may benefit from intervention to alleviate symptoms of chronic venous obstruction. Interventions include long-term stent implantation to improve vein diameter stenosis. This study aimed to assess a cohort of symptomatic venous patients and the diameter of the LCIV in these patients. Methods: : Retrospective medical records review of all patients attending a tertiary vascular surgery centre who un- derwent a venous duplex ultrasound assessment between April 2017 and February 2018 were analysed for assessment of LCIV. Medical records of those patients with documented LCIV diameter were assessed over 18 months of follow-up. Results: : A total of 672 (271 males, 401 females) LCIV diameter measurements were collected. The age of the patients ranged from 21 to 95 years (mean = 56.38). Median LCIV diameter overall was 7.64 mm (IQR 5.80mm–9.00 mm). 40 patients (6%) were reported to have a LCIV diameter measurement of < 4 mm, 8 (20%) male and 32 female (80%). 17 of these 40 patients (47.5%) were treated conservatively. Median LCIV diameter was 3.4 mm (IQR 2.5–3.7). 21 of these 40 patients (52.5%) underwent superficial venous intervention only, with a median LCIV diameter of 3.5 mm (IQR 3.2–3.7) and 2 out of these 40 patients (5%) underwent deep venous stenting (2/2 female – 100%), with a median LCIV diameter of 2.9 (IQR 2.9–2.9). No patients underwent both superficial and deep venous treatment in this 40 patient cohort. In those undergoing superficial venous intervention, 4 (19%) underwent repeat treatment. The two deep venous stenting patients underwent magnetic resonance venogram and venogram with intravascular ultrasound to allow stent placement, which confirmed a narrowed left common iliac vein. Primary stent patency at 18 months was 100%. Conclusion: In this large study cohort of venous duplex assessments the median vein diameter was 7.64 mm and 40 patients out of 672 had a vein diameter smaller than 4 mm. 2 patients underwent deep venous stenting with primary patency of 100%. Keywords Venous, vascular, ultrasound well as those with lower limb venous insufficiency is still Introduction 6–9 evolving. Non-thrombotic iliac veins lesions (NIVL) such as iliac vein compression syndrome (formerly known as May–Thurner syndrome) or extrinsic compression from other sources can Department of Surgery and Cancer, Imperial College London, London, contribute to the pathophysiology of chronic venous disease UK 1–4 in the lower limbs. Endovascular interventions for the Cambridge Vascular Unit, Addenbrookes Hospital, Cambridge, UK management of NIVL have been increasing over recent Corresponding author: years; however, the evidence surrounding the criteria for Tristan Robert Alexander Lane, Cambridge Vascular Unit, Cambridge intervention remains limited. Furthermore, the evidence University Hospitals NHS Foundation Trust, Box 212, Addenbrookes around the prevalence of NIVL in the general population Hospital, Hills Road, Cambridge, CB2 0QQ, UK. and the clinical significance on asymptomatic patients as Email: tristan.lane@imperial.ac.uk 2 Vascular 0(0) Earlier studies have utilised indirect methods or com- transducer on a Phillips Epic 7, IU22 or GE logic 10,11 puter tomography venography to assess vein diameter. E9 ultrasound machine. The aim of this paper is to develop a better understanding of the left common iliac vein (LCIV) anatomy in patients with Statistics symptoms of venous insufficiency and contribute to the evidence base surrounding the diagnosis and management Data was assessed visually for normality and formally of patients with NIVL. assessed with the Shapiro-Wilk test. Parametric data is presented as mean and standard deviation, non-parametric data is presented as median and interquartile range. Sta- Methods tistical analysis of the sample was performed using STATA This study was a retrospective review of duplex ultrasound (version 16, STATACORP, College Station, Texas, USA), reports from April 2017 to February 2018 that documented a JMP Pro 15 (SAS, Cary, North Carolina, USA) and Wizard measurement (mm) of the LCIV diameter for patients re- 2 (Evan Miller, Chicago, Illinois, USA). ferred for assessment of lower limb venous insufficiency. Data was extracted from electronic patient records in Au- Results gust 2020 providing 18 months minimum clinical follow- up. Between April 2017 and February 2018 (11 months), a total of 1249 lower limb venous duplex ultrasound scans were performed, and then reviewed for this study. This number Institutional approval comprises a range of venous examinations and only those The study was classed as service evaluation according to the patients referred for assessment of venous insufficiency NHS Research Ethics Service – analysis of routinely col- were included in the results. A total of 672 (271 males, lected data and therefore formal ethical review and informed 401 females) LCIV diameter measurements were collected. patient consent was not necessary. The age of the patients ranged from 21 to 95 years (mean = 56.38). A summary of the findings is detailed in Table 1 below. LCIV diameter was significantly greater in males Patients (p < 0.001). Figure 1 shows the entire distribution and All patients were referred to the Vascular surgery depart- Figure 2 shows the male and female distribution. ment at Imperial College Healthcare NHS Trust and un- derwent lower limb venous duplex to investigate symptoms Left common iliac vein diameter <4 mm: of lower limb venous insufficiency in either lower limb (CEAP 2–6). Of the 672 patients scanned, 40 patients (6%) were reported to have an LCIV diameter measurement of < 4 mm, 8 (20%) male and 32 female (80%). All patients presented with Duplex Ultrasound Protocol symptoms of leg swelling or symptomatic varicose veins. The department’s venous insufficiency protocol was Three patients had a previous history of DVT with evidence adapted to include the assessment of the ilio-caval vessels on duplex ultrasound and 2 patients were found to have an and measurement of the LCIV. At the completion of a acute DVT at the time of scanning. standing lower limb venous insufficiency venous duplex Of these 40 patients, 17 patients (47.5%) were treated patients were asked to lie supine and a check of ilio-caval conservatively (4/17 male – 24%), with 3 advised to wear venous patency was performed in addition to a transverse compression hosiery long-term. Median LCIV diameter was diameter measurement (mm) of the LCIV as the right 3.4 mm (IQR 2.5–3.7, Min 1.4 Max 3.9). 21 patients common iliac artery crosses the LCIV. The results were (52.5%) underwent superficial venous intervention only (4/ reported on the standard lower limb venous duplex report. 21 male – 19%), with a median LCIV diameter of 3.5 mm The research protocol was discussed at length at Vascular (IQR 3.2–3.7, Min 0.8 Max 3.8). scientist education meetings and initial measurements were Two patients (5%) underwent deep venous stenting (2/ recorded with two scientists in the room to ensure a 2 female – 100%), with a median LCIV diameter of 2.9 standardised measurement and minimise inter-operator (IQR 2.9–2.9, Min 2.9 Max 2.9). There was no history of variation. DVT in the stenting patients. No patients underwent both superficial and deep venous treatment in this cohort. In those undergoing superficial venous intervention, 4 Ultrasound machine (19%) underwent repeat treatment – 2 cases of repeat foam Duplex ultrasound was performed by the Trust`s experi- sclerotherapy, 1 case of foam sclerotherapy after radio- enced vascular scientists using a C 1–5 MHz curved array frequency ablation to residual varicosities and 1 case of redo Judges et al. 3 Table 1. Min, Max, Mean, standard deviation, Median and Interquartile Range. Mean Standard deviation Median Interquartile range Min (mm) Max (mm) n = Total 7.64 2.92 7.10 5.80–9.00 0.80 31.00 672 Males 8.42 3.16 8.00 6.40–10.00 1.40 31.00 271 Females 7.12 2.63 6.90 5.30–8.70 0.80 19.00 401 Figure 1. Distribution of Left Common Iliac Vein diameter (mm). Figure 2. Distribution of Left Common Iliac Vein diameter (mm) stratified by sex (M - Male – Red, F - Female – Blue). 4 Vascular 0(0) saphenofemoral ligation and multiple phlebectomies after pathology, and other studies found significant differences 18,19 initial phlebectomies only. in diameter in the standing and lying positions. These Thirteen patients (33%) underwent further imaging; 3 results emphasise the need for a detailed understanding of (17.6%) of the conservatively managed patients underwent population characteristics relating to NIVL and the im- further imaging, and 8 (38%) of the patients undergoing portance of detailed clinical examination and evaluation of superficial intervention underwent further imaging, though these patients. 7 patients underwent repeat confirmatory duplex ultra- However, work by Arendt et al., assessing vein seg- sound prior to treatment. The eighth patient underwent a ments using centreline adjusted CT venography, found magnetic resonance venogram prior to multiple significantly larger vein diameters in the region of the LCIV. phlebectomies. Their findings, in a different modality with post-processing The two deep venous stenting patients underwent of the imaging, showed a mean LCIVof 12.2 mm, compared magnetic resonance venogram and venogram with intra- to this study’s 7.64 mm. This difference may be due to vascular ultrasound to allow stent placement, which con- different modalities, demographics or the fact that Arendt firmed a narrowed left common iliac vein. Primary stent et al’s study only included post-thrombotic patients (albeit patency at 18 months was 100% (2/2). only healthy segments were assessed). Duplex ultrasound is widely recognised as not having the sensitivity to enable diagnosis of NIVL as a single imaging Discussion 4,6,20 modality. However, the role of duplex ultrasound (with This single centre study assessed 672 patients and found the a well-trained operator) in the diagnosis, treatment and post- mean LCIV diameter was 7.64 mm; this was larger in males operative surveillance of NIVL in conjunction with (8.42 mm) than females (7.12 mm). There is a limited body venography, computer tomography venography and of evidence with which to compare this study’s mean LCIV intravascular ultrasound should not be underestimated. diameters. A previous study compared LCIV diameters of female patients with lower limb DVT (n = 21) and an age Limitations matched control group (n = 26) who reported to Emergency Departments with abdominal pain and reported mean LCIV The actual number of lower limb venous duplex scans during diameters of 4.0 mm and 6.5 mm, respectively. Another April 2017–February 2018 was 1249, this included pre-op study reported on patients with DVT caused by iliac vein vein mapping, post op varicose vein ablation/patency, post op compression with mean LCIV diameters of 3.5 mm (DVT iliac stent, ad-hoc DVT scans for other research projects and group, n = 10 (5 males, 5 females)) and 11.5 mm (control other miscellaneous venous scans. There was no way to group, n = 14). retrospectively differentiate these scans to quantify the However, in this study, only 5 patients had an acute or success rate of obtaining a LCIV diameter measurement, chronic DVT and 2 other patients underwent deep venous however all vascular scientists in the department reported stenting intervention. In addition, the reported severity of high confidence in obtaining a LCIV measurement according symptoms and duplex results varied drastically between to the scan protocol in the vast majority of patients sent for patients (not quantitatively analysed in this cohort). lower limb venous insufficiency assessment. It is hoped This study shows that, as found in the disparate literature, future studies will help confirm this. vein diameter is not always associated with treatment The small number of patients in this study with <4.0 mm 14–17 necessity. Only 6% of patients in this cohort had a < LCIV limits the generalisability of the findings in the study. 4 mm LCIV, and of those only 2 (0.3% of total cohort) As this study was a retrospective review of duplex ul- required deep venous intervention. This suggests that in an trasound scan results, there was no gold standard diagnostic unselected cohort, the prevalence of clinically significant comparator such as venography performed to compare the LCIV stenosis is low. measurements with. Comparison with other studies as- Additionally, those patients with small LCIV who un- sessing NIVL with venography and IVUS was also limited derwent intervention responded well out to 18 month due to the majority of studies reporting in percentage of 4,6–9 follow-up, with 1 only one true treatment failure (6%) – compression rather than diameter of the vessel. following superficial venous intervention. However, the numbers in this study preclude any firm judgements re- Conclusion garding longevity of intervention. These findings are complementary to a recent study that This study provides one of the largest samples to date, to found a high percentage of asymptomatic healthy volun- describe the LCIV diameter characteristics of patients with teers showed signs of significant iliac vein compression on symptoms of venous insufficiency as assessed by duplex venography. Previous studies have even suggested left iliac ultrasound. In 672 patients, median LCIV was 7.64 mm vein compression as an anatomical variant instead of with 40 patients having an LCIV <4 mm. Judges et al. 5 Acknowledgements 8. Oguzkurt L, Ozkan U, Ulusan S, et al. Compression of the left common iliac vein in asymptomatic subjects and patients with The research was supported by the National Institute for Health left iliofemoral deep vein thrombosis. J Vasc Interv Radiol Research (NIHR) Biomedical Research Centre based at Imperial 2008; 19: 366–370; quiz 371. College Healthcare NHS Trust and Imperial College London. The 9. Nazzal M, El-Fedaly M, Kazan V, et al. Incidence and clinical views expressed are those of the authors and not necessarily those significance of iliac vein compression. Vascular 2015; 23: of the NHS, NIHR or the Department of Health. 337–343. 10. Arendt VA, Mabud TS, Jeon GS, et al. Analysis of patent, Declaration of conflicting interests unstented lower extremity vein segment diameters in The author(s) declared no potential conflicts of interest with re- 266 patients with venous disease. J Vasc Surg Venous Lym- spect to the research, authorship, and/or publication of this article. phat Disord 2020; 8: 841–850. 11. Raju S, Buck WJ, Crim W, et al. Optimal sizing of iliac vein Funding stents. Phlebology 2018; 33: 451–457. The author(s) received no financial support for the research, au- 12. Carr S, Chan K, Rosenberg J, et al. Correlation of the diameter thorship, and/or publication of this article. of the left common iliac vein with the risk of lower-extremity deep venous thrombosis. J Vasc Interv Radiol 2012; 23: ORCID iDs 1467–1472. 13. Oguzkurt L, Tercan F, Pourbagher MA, et al. Computed Sarah Onida https://orcid.org/0000-0001-5926-4578 tomography findings in 10 cases of iliac vein compression Tristan Robert Alexander Lane https://orcid.org/0000-0002- (May-Thurner) syndrome. Eur J Radiol 2005; 55: 8681-7075 421–425. Alun Huw Davies  https://orcid.org/0000-0001-5261-6913 14. Lane TRA, Varatharajan L, Fiorentino F, et al. Truncal var- icose vein diameter and patient-reported outcome measures. References Br J Surg 2017; 104: 1648–1655. 1. May R and Thurner J. The cause of the predominantly si- 15. Navarro TP. Clinical and hemodynamic significance of the nistral occurrence of thrombosis of the pelvic veins. Angi- greater saphenous vein diameter in chronic venous insuffi- ology 1957; 8: 419–427. ciency. Arch Surg 2002; 137: 1233. 2. Cockett FB and Thomas ML. The iliac compression syn- 16. Tan MKH, Sutanto SA, Onida S, et al.. The relationship drome. Br J Surg 1965; 52: 816–821. between vein diameters, clinical severity, and quality of life: a 3. Milinis K, Thapar A, Shalhoub J, et al. Antithrombotic systematic review. Eur J Vasc Endovasc Surg 2019; 57: therapy following venous stenting: international delphi 851–857. consensus. Eur J Vasc Endovasc Surg 2018; 55: 537–544. 17. Aurshina A, Huber S, Deng Y, et al. Correlation of venous 4. Dzieciuchowicz Ł, Krzyza ˙ nski ´ R, Kruszyna Ł, et al. Prev- symptoms with iliac vein stenosis on magnetic resonance alence of non-thrombotic iliac vein lesions in patients with imaging. J Vasc Surg Venous Lymphat Disord 2020; 9: unilateral primary varicose veins. Eur J Vasc Endovasc Surg 1291–1296.e1. 2016; 51: 429–433. 18. Krzanowski M, Partyka L, Drelicharz L, et al. Posture 5. Seager MJ, Busuttil A, Dharmarajah B, et al. A systematic commonly and considerably modifies stenosis of left common review of endovenous stenting in chronic venous disease iliac and left renal veins in women diagnosed with pelvic secondary to iliac vein obstruction. Eur J Vasc Endovasc Surg venous disorder. J Vasc Surg Venous Lymphat Disord 2019; 7: 2016; 51: 100–120. 845–852.e2. 6. van Vuuren TMAJ, Kurstjens RLM, Wittens CHA, et al. 19. Lattimer CR and Mendoza E. Reappraisal of the utility of the Illusory Angiographic Signs of Significant Iliac Vein Com- tilt-table in the investigation of venous disease. Eur J Vasc pression in Healthy Volunteers. Eur J Vasc Endovasc Surg Endovasc Surg 2016; 52: 854–861. 2018; 56: 874–879. 20. Brinegar KN, Sheth RA, Khademhosseini A, et al. Iliac vein 7. Kibbe MR, Ujiki M, Goodwin AL, et al. Iliac vein com- compression syndrome: clinical, imaging and pathologic pression in an asymptomatic patient population. J Vasc Surg findings. World J Radiol 2015; 7: 375–381. 2004; 39: 937–943. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Vascular SAGE

Left common iliac vein diameter in patients referred for lower limb venous duplex ultrasound

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SAGE
Copyright
© The Author(s) 2023
ISSN
1708-5381
eISSN
1708-539X
DOI
10.1177/17085381231153540
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Abstract

Introduction: Evidence regarding ultrasound assessment of left common iliac vein diameter (LCIV) is limited. Extensive work is currently being undertaken worldwide on non-thrombotic iliac vein lesions to identify patients who may benefit from intervention to alleviate symptoms of chronic venous obstruction. Interventions include long-term stent implantation to improve vein diameter stenosis. This study aimed to assess a cohort of symptomatic venous patients and the diameter of the LCIV in these patients. Methods: : Retrospective medical records review of all patients attending a tertiary vascular surgery centre who un- derwent a venous duplex ultrasound assessment between April 2017 and February 2018 were analysed for assessment of LCIV. Medical records of those patients with documented LCIV diameter were assessed over 18 months of follow-up. Results: : A total of 672 (271 males, 401 females) LCIV diameter measurements were collected. The age of the patients ranged from 21 to 95 years (mean = 56.38). Median LCIV diameter overall was 7.64 mm (IQR 5.80mm–9.00 mm). 40 patients (6%) were reported to have a LCIV diameter measurement of < 4 mm, 8 (20%) male and 32 female (80%). 17 of these 40 patients (47.5%) were treated conservatively. Median LCIV diameter was 3.4 mm (IQR 2.5–3.7). 21 of these 40 patients (52.5%) underwent superficial venous intervention only, with a median LCIV diameter of 3.5 mm (IQR 3.2–3.7) and 2 out of these 40 patients (5%) underwent deep venous stenting (2/2 female – 100%), with a median LCIV diameter of 2.9 (IQR 2.9–2.9). No patients underwent both superficial and deep venous treatment in this 40 patient cohort. In those undergoing superficial venous intervention, 4 (19%) underwent repeat treatment. The two deep venous stenting patients underwent magnetic resonance venogram and venogram with intravascular ultrasound to allow stent placement, which confirmed a narrowed left common iliac vein. Primary stent patency at 18 months was 100%. Conclusion: In this large study cohort of venous duplex assessments the median vein diameter was 7.64 mm and 40 patients out of 672 had a vein diameter smaller than 4 mm. 2 patients underwent deep venous stenting with primary patency of 100%. Keywords Venous, vascular, ultrasound well as those with lower limb venous insufficiency is still Introduction 6–9 evolving. Non-thrombotic iliac veins lesions (NIVL) such as iliac vein compression syndrome (formerly known as May–Thurner syndrome) or extrinsic compression from other sources can Department of Surgery and Cancer, Imperial College London, London, contribute to the pathophysiology of chronic venous disease UK 1–4 in the lower limbs. Endovascular interventions for the Cambridge Vascular Unit, Addenbrookes Hospital, Cambridge, UK management of NIVL have been increasing over recent Corresponding author: years; however, the evidence surrounding the criteria for Tristan Robert Alexander Lane, Cambridge Vascular Unit, Cambridge intervention remains limited. Furthermore, the evidence University Hospitals NHS Foundation Trust, Box 212, Addenbrookes around the prevalence of NIVL in the general population Hospital, Hills Road, Cambridge, CB2 0QQ, UK. and the clinical significance on asymptomatic patients as Email: tristan.lane@imperial.ac.uk 2 Vascular 0(0) Earlier studies have utilised indirect methods or com- transducer on a Phillips Epic 7, IU22 or GE logic 10,11 puter tomography venography to assess vein diameter. E9 ultrasound machine. The aim of this paper is to develop a better understanding of the left common iliac vein (LCIV) anatomy in patients with Statistics symptoms of venous insufficiency and contribute to the evidence base surrounding the diagnosis and management Data was assessed visually for normality and formally of patients with NIVL. assessed with the Shapiro-Wilk test. Parametric data is presented as mean and standard deviation, non-parametric data is presented as median and interquartile range. Sta- Methods tistical analysis of the sample was performed using STATA This study was a retrospective review of duplex ultrasound (version 16, STATACORP, College Station, Texas, USA), reports from April 2017 to February 2018 that documented a JMP Pro 15 (SAS, Cary, North Carolina, USA) and Wizard measurement (mm) of the LCIV diameter for patients re- 2 (Evan Miller, Chicago, Illinois, USA). ferred for assessment of lower limb venous insufficiency. Data was extracted from electronic patient records in Au- Results gust 2020 providing 18 months minimum clinical follow- up. Between April 2017 and February 2018 (11 months), a total of 1249 lower limb venous duplex ultrasound scans were performed, and then reviewed for this study. This number Institutional approval comprises a range of venous examinations and only those The study was classed as service evaluation according to the patients referred for assessment of venous insufficiency NHS Research Ethics Service – analysis of routinely col- were included in the results. A total of 672 (271 males, lected data and therefore formal ethical review and informed 401 females) LCIV diameter measurements were collected. patient consent was not necessary. The age of the patients ranged from 21 to 95 years (mean = 56.38). A summary of the findings is detailed in Table 1 below. LCIV diameter was significantly greater in males Patients (p < 0.001). Figure 1 shows the entire distribution and All patients were referred to the Vascular surgery depart- Figure 2 shows the male and female distribution. ment at Imperial College Healthcare NHS Trust and un- derwent lower limb venous duplex to investigate symptoms Left common iliac vein diameter <4 mm: of lower limb venous insufficiency in either lower limb (CEAP 2–6). Of the 672 patients scanned, 40 patients (6%) were reported to have an LCIV diameter measurement of < 4 mm, 8 (20%) male and 32 female (80%). All patients presented with Duplex Ultrasound Protocol symptoms of leg swelling or symptomatic varicose veins. The department’s venous insufficiency protocol was Three patients had a previous history of DVT with evidence adapted to include the assessment of the ilio-caval vessels on duplex ultrasound and 2 patients were found to have an and measurement of the LCIV. At the completion of a acute DVT at the time of scanning. standing lower limb venous insufficiency venous duplex Of these 40 patients, 17 patients (47.5%) were treated patients were asked to lie supine and a check of ilio-caval conservatively (4/17 male – 24%), with 3 advised to wear venous patency was performed in addition to a transverse compression hosiery long-term. Median LCIV diameter was diameter measurement (mm) of the LCIV as the right 3.4 mm (IQR 2.5–3.7, Min 1.4 Max 3.9). 21 patients common iliac artery crosses the LCIV. The results were (52.5%) underwent superficial venous intervention only (4/ reported on the standard lower limb venous duplex report. 21 male – 19%), with a median LCIV diameter of 3.5 mm The research protocol was discussed at length at Vascular (IQR 3.2–3.7, Min 0.8 Max 3.8). scientist education meetings and initial measurements were Two patients (5%) underwent deep venous stenting (2/ recorded with two scientists in the room to ensure a 2 female – 100%), with a median LCIV diameter of 2.9 standardised measurement and minimise inter-operator (IQR 2.9–2.9, Min 2.9 Max 2.9). There was no history of variation. DVT in the stenting patients. No patients underwent both superficial and deep venous treatment in this cohort. In those undergoing superficial venous intervention, 4 Ultrasound machine (19%) underwent repeat treatment – 2 cases of repeat foam Duplex ultrasound was performed by the Trust`s experi- sclerotherapy, 1 case of foam sclerotherapy after radio- enced vascular scientists using a C 1–5 MHz curved array frequency ablation to residual varicosities and 1 case of redo Judges et al. 3 Table 1. Min, Max, Mean, standard deviation, Median and Interquartile Range. Mean Standard deviation Median Interquartile range Min (mm) Max (mm) n = Total 7.64 2.92 7.10 5.80–9.00 0.80 31.00 672 Males 8.42 3.16 8.00 6.40–10.00 1.40 31.00 271 Females 7.12 2.63 6.90 5.30–8.70 0.80 19.00 401 Figure 1. Distribution of Left Common Iliac Vein diameter (mm). Figure 2. Distribution of Left Common Iliac Vein diameter (mm) stratified by sex (M - Male – Red, F - Female – Blue). 4 Vascular 0(0) saphenofemoral ligation and multiple phlebectomies after pathology, and other studies found significant differences 18,19 initial phlebectomies only. in diameter in the standing and lying positions. These Thirteen patients (33%) underwent further imaging; 3 results emphasise the need for a detailed understanding of (17.6%) of the conservatively managed patients underwent population characteristics relating to NIVL and the im- further imaging, and 8 (38%) of the patients undergoing portance of detailed clinical examination and evaluation of superficial intervention underwent further imaging, though these patients. 7 patients underwent repeat confirmatory duplex ultra- However, work by Arendt et al., assessing vein seg- sound prior to treatment. The eighth patient underwent a ments using centreline adjusted CT venography, found magnetic resonance venogram prior to multiple significantly larger vein diameters in the region of the LCIV. phlebectomies. Their findings, in a different modality with post-processing The two deep venous stenting patients underwent of the imaging, showed a mean LCIVof 12.2 mm, compared magnetic resonance venogram and venogram with intra- to this study’s 7.64 mm. This difference may be due to vascular ultrasound to allow stent placement, which con- different modalities, demographics or the fact that Arendt firmed a narrowed left common iliac vein. Primary stent et al’s study only included post-thrombotic patients (albeit patency at 18 months was 100% (2/2). only healthy segments were assessed). Duplex ultrasound is widely recognised as not having the sensitivity to enable diagnosis of NIVL as a single imaging Discussion 4,6,20 modality. However, the role of duplex ultrasound (with This single centre study assessed 672 patients and found the a well-trained operator) in the diagnosis, treatment and post- mean LCIV diameter was 7.64 mm; this was larger in males operative surveillance of NIVL in conjunction with (8.42 mm) than females (7.12 mm). There is a limited body venography, computer tomography venography and of evidence with which to compare this study’s mean LCIV intravascular ultrasound should not be underestimated. diameters. A previous study compared LCIV diameters of female patients with lower limb DVT (n = 21) and an age Limitations matched control group (n = 26) who reported to Emergency Departments with abdominal pain and reported mean LCIV The actual number of lower limb venous duplex scans during diameters of 4.0 mm and 6.5 mm, respectively. Another April 2017–February 2018 was 1249, this included pre-op study reported on patients with DVT caused by iliac vein vein mapping, post op varicose vein ablation/patency, post op compression with mean LCIV diameters of 3.5 mm (DVT iliac stent, ad-hoc DVT scans for other research projects and group, n = 10 (5 males, 5 females)) and 11.5 mm (control other miscellaneous venous scans. There was no way to group, n = 14). retrospectively differentiate these scans to quantify the However, in this study, only 5 patients had an acute or success rate of obtaining a LCIV diameter measurement, chronic DVT and 2 other patients underwent deep venous however all vascular scientists in the department reported stenting intervention. In addition, the reported severity of high confidence in obtaining a LCIV measurement according symptoms and duplex results varied drastically between to the scan protocol in the vast majority of patients sent for patients (not quantitatively analysed in this cohort). lower limb venous insufficiency assessment. It is hoped This study shows that, as found in the disparate literature, future studies will help confirm this. vein diameter is not always associated with treatment The small number of patients in this study with <4.0 mm 14–17 necessity. Only 6% of patients in this cohort had a < LCIV limits the generalisability of the findings in the study. 4 mm LCIV, and of those only 2 (0.3% of total cohort) As this study was a retrospective review of duplex ul- required deep venous intervention. This suggests that in an trasound scan results, there was no gold standard diagnostic unselected cohort, the prevalence of clinically significant comparator such as venography performed to compare the LCIV stenosis is low. measurements with. Comparison with other studies as- Additionally, those patients with small LCIV who un- sessing NIVL with venography and IVUS was also limited derwent intervention responded well out to 18 month due to the majority of studies reporting in percentage of 4,6–9 follow-up, with 1 only one true treatment failure (6%) – compression rather than diameter of the vessel. following superficial venous intervention. However, the numbers in this study preclude any firm judgements re- Conclusion garding longevity of intervention. These findings are complementary to a recent study that This study provides one of the largest samples to date, to found a high percentage of asymptomatic healthy volun- describe the LCIV diameter characteristics of patients with teers showed signs of significant iliac vein compression on symptoms of venous insufficiency as assessed by duplex venography. Previous studies have even suggested left iliac ultrasound. In 672 patients, median LCIV was 7.64 mm vein compression as an anatomical variant instead of with 40 patients having an LCIV <4 mm. Judges et al. 5 Acknowledgements 8. Oguzkurt L, Ozkan U, Ulusan S, et al. Compression of the left common iliac vein in asymptomatic subjects and patients with The research was supported by the National Institute for Health left iliofemoral deep vein thrombosis. J Vasc Interv Radiol Research (NIHR) Biomedical Research Centre based at Imperial 2008; 19: 366–370; quiz 371. College Healthcare NHS Trust and Imperial College London. The 9. Nazzal M, El-Fedaly M, Kazan V, et al. Incidence and clinical views expressed are those of the authors and not necessarily those significance of iliac vein compression. Vascular 2015; 23: of the NHS, NIHR or the Department of Health. 337–343. 10. Arendt VA, Mabud TS, Jeon GS, et al. Analysis of patent, Declaration of conflicting interests unstented lower extremity vein segment diameters in The author(s) declared no potential conflicts of interest with re- 266 patients with venous disease. J Vasc Surg Venous Lym- spect to the research, authorship, and/or publication of this article. phat Disord 2020; 8: 841–850. 11. Raju S, Buck WJ, Crim W, et al. Optimal sizing of iliac vein Funding stents. Phlebology 2018; 33: 451–457. The author(s) received no financial support for the research, au- 12. Carr S, Chan K, Rosenberg J, et al. Correlation of the diameter thorship, and/or publication of this article. of the left common iliac vein with the risk of lower-extremity deep venous thrombosis. J Vasc Interv Radiol 2012; 23: ORCID iDs 1467–1472. 13. Oguzkurt L, Tercan F, Pourbagher MA, et al. Computed Sarah Onida https://orcid.org/0000-0001-5926-4578 tomography findings in 10 cases of iliac vein compression Tristan Robert Alexander Lane https://orcid.org/0000-0002- (May-Thurner) syndrome. Eur J Radiol 2005; 55: 8681-7075 421–425. Alun Huw Davies  https://orcid.org/0000-0001-5261-6913 14. Lane TRA, Varatharajan L, Fiorentino F, et al. Truncal var- icose vein diameter and patient-reported outcome measures. References Br J Surg 2017; 104: 1648–1655. 1. May R and Thurner J. The cause of the predominantly si- 15. Navarro TP. Clinical and hemodynamic significance of the nistral occurrence of thrombosis of the pelvic veins. Angi- greater saphenous vein diameter in chronic venous insuffi- ology 1957; 8: 419–427. ciency. Arch Surg 2002; 137: 1233. 2. Cockett FB and Thomas ML. The iliac compression syn- 16. Tan MKH, Sutanto SA, Onida S, et al.. The relationship drome. 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Journal

VascularSAGE

Published: Jan 1, 2023

Keywords: Venous; vascular; ultrasound

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