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BackTable / VI / Article
Iliofemoral Venous Disease Diagnosis & Patient Management
Manisha Naganatanahalli • Jan 12, 2024 • 49 hits
Iliofemoral venous disease uniquely impacts a wide age range, distinguishing it from other vascular conditions. This complexity is further accentuated by the shift from off-label devices to on-label thrombectomy devices and stents, enhancing treatment efficacy and heralding a promising future in venous disease management. Variability in patient referral pathways necessitates a nuanced approach to early diagnosis and intervention. Emphasis on collaborative efforts with referring physicians is vital to address the long-term impacts of untreated deep vein thrombosis (DVT), such as venous hypertension and wound development.
In the clinic, a thorough diagnostic workup using scales like the Villalta and venous clinical severity score is crucial. Imaging, typically involving CT venography and duplex ultrasound, guides the assessment of iliofemoral segments. Establishing a clear partnership with patients ensures compliance with conservative treatments like anticoagulation and compression therapy, critical in managing complex venous diseases effectively.
This article features transcripts for the BackTable Podcast. We’ve provided the highlight reel here, and you can listen to the full podcast below.
The BackTable Brief
• Iliofemoral venous disease affects a broad age range, starting as early as in teenagers.
• The field has evolved from using off-label to on-label thrombectomy devices and stents.
• Patient referral patterns vary, often involving primary care or urgent care settings.
• Early and accurate diagnosis is crucial to manage the long-term impacts of iliofemoral DVT.
• Symptom severity assessment employs the Villalta and venous clinical severity score.
• Imaging strategies typically include CT venography and duplex ultrasound.
• Emphasis on patient education and compliance with treatment plans, including anticoagulation and compression therapy, is essential
• Differentiating symptoms of lymphedema from venous hypertension is essential in clinical evaluation.
Table of Contents
(1) The Significance of Iliofemoral Venous Disease
(2) Referral Dynamics in Iliofemoral Venous Disease Management
(3) Pre-procedure Workup for Iliofemoral Disease
The Significance of Iliofemoral Venous Disease
Iliofemoral venous disease has a significant impact across a broad range of age groups, which separates it from other vascular diseases. This early onset extends the symptom impact over a longer period compared to other vascular diseases. This conversation highlights the crucial role of randomized controlled trial (RCT) data in shaping current approaches, particularly emphasizing procedural interventions for patients with acute iliofemoral deep vein thrombosis (DVT) experiencing moderate to severe symptoms. A notable evolution in the field is the transition from off-label device usage to the adoption of on-label thrombectomy devices and stents, which has significantly enhanced treatment efficiency and outcomes. This shift not only demonstrates the dynamic growth and potential of the field but also points towards a promising future in the management of venous diseases, backed by ongoing clinical trials and emerging data.
[Dr. Christopher Beck]
Let's just jump into it. Iliofemoral venous disease, why do we care? Is this really that big of a problem? We have anticoagulation. Kush, start with you.
[Dr. Kush Desai]
Yes. We actually have level-one evidence, so to speak. We have RCT data that shows that we should care about iliofemoral venous obstructive disease because those are the patients that are going to have pretty significant quality of life impact. Unlike other vascular diseases, this is a disease that affects pretty much all cross-sections of society... With this disease process, we're starting even in teenagers, but more commonly third, fourth, and fifth decade of life. The time horizon for the symptoms to really impact patients is highly significant... We have RCT data to show on the acute DVT side that patients that are appropriate procedural candidates should be treated when they have iliofemoral DVT with at least moderate to severe symptoms…
[Dr. Christopher Beck]
Even in your career, Kush, since you started, how much have you seen how we approach and think about venous disease change? Even just a couple of years ago, it seems like this is a really exciting area to be as far as venous treatment.
[Dr. Kush Desai]
When I came into practice in 2013, it was all off-label devices. Everything was off-label. Now, not only do we have on-label thrombectomy devices... but we have on-label stents. We have currently, I believe, four on the market, and then one in clinical trial, and one that's just finished clinical trial for which we're awaiting the data. It's an exciting time...
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Referral Dynamics in Iliofemoral Venous Disease Management
While it may seem that most cases would originate in the emergency room, there is significant variability based on the patient's first point of contact with the health care system. Due to the variability in patient journeys, early and accurate diagnosis is critical. Educating and collaborating with referring physicians about the benefits of early intervention is also essential. A key point is the significant long-term impact of untreated iliofemoral DVT, which can lead to chronic issues like venous hypertension, pain, edema, and even severe complications like wound development. Dr. Desai and Dr. Abramowitz both emphasize the importance of conveying to the medical community the risks of post-thrombotic syndrome and the advantages of early, aggressive treatment, including the use of new technologies like single-session thrombectomy.
[Dr. Steven Abramowitz]
It started off thinking that most patients were going to come through the ER, but the reality is most patients aren't being diagnosed in the ER... Even more and more, we're seeing patients come to urgent care centers... "You're okay. Just take an oral anticoagulation agent. You can have your elective visit in a few days. Call a vascular surgeon on Monday," or something like that...
[Dr. Kush Desai]
Actually, I couldn't agree more with that just to pick up on the thread... It's actually sobering how many practitioners these patients touch. The matter of whether you get the appropriate care is unfortunately a function of where you are and what practitioner you're seeing and who they're connected to...
For us in the expert community... it means that we need to pollinate. We need to get out. We need to make sure that people are aware that there are experts throughout their area and that we're willing to help and manage these patients...
[Dr. Steven Abramowitz]
I couldn't agree with Kush more... We're really focused on data that's been generated to show the benefit of early intervention for patients with acute DVT...
I think that creating an environment where you're able to acknowledge others' expertise in this field and then say it's not just we have a widget or a tool that we want to use to treat DVT because we're proceduralists, we actually think that there's-- a downstream benefit is a really important conversation to have...
[Dr. Steven Abramowitz]
Yes. I think part of the conversation and the messaging... is looking at the data that a lot of people point to for a lack of efficacy and showing how that data when you look beyond the one-year or two-year data that got the first splash that people were really excited about, how it's actually trended out over 5 and 10 years.
We start to see post-thrombotic syndrome really spike and increase in its frequency at that 5, 10-year mark... We have not yet developed excellent statistical or clinical tools for predicting who they're going to be.
It's similar to having the conversation around treating an asymptomatic carotid artery lesion, right? What's your number needed to treat to prevent one stroke? In this instance, as Kush was implying, when you're talking to people, you may not be saying, "Hey, listen, I can promise, in this one patient, I will be making the fundamental groundbreaking difference in their life," but in aggregate... we know that these procedures can help prevent post-thrombotic syndrome. It may be variable in its impact, but for the patient who is that one out of the nine needed to treat to get that one benefit, it makes a significant difference in their life.
Pre-procedure Workup for Iliofemoral Disease
Beyond understanding patient pathways and referral patterns, a critical aspect of managing iliofemoral venous disease lies in the diagnostic workup and the initiation of conservative treatments. When patients arrive at the clinic, Initially, the focus is on assessing symptom severity using established scales like the Villalta and venous clinical severity score. Imaging plays a crucial role, with practices varying based on local expertise; typically, CT venography and duplex ultrasound are employed to assess iliofemoral segments and superficial venous disease.
Establishing a clear partnership with the patient is also crucial in order to ensure compliance with treatments like blood thinners and compression therapy. The discussion also touches on the differentiation of symptoms, particularly distinguishing between lymphedema and venous hypertension, using clinical signs and patient history. Additionally, conservative treatment approaches, including the use of compression therapy, anticoagulation, and venoactives, are discussed, underscoring the importance of patient compliance and multidisciplinary care in managing complex venous diseases.
[Dr. Kush Desai]
What the workup consists of, I would say, is you start with, obviously, what are the symptom burdens. We have numerous scales, both the Villalta and the venous clinical severity score to inform how severe the symptoms are. We actually have a little bit of data to guide us on which patients are the most likely to benefit.
The next thing you're going to do is look at your imaging…
I would say the next part, for me, and probably the most important part after those two things is ensure that you have a very clear, defined partnership with the patient. They have to know what to expect, and they have to know their part in the process, in the journey
[Dr. Christopher Beck]
Can we talk a little bit more about some of the conservative treatments that you may initiate during the clinic visit? Say they haven't been booked for either/or the cath lab, but some of the things you have the patient do, just leaving the hospital, either medication regimens that you tune up or compression therapy. Steve, let's start with you.
[Dr. Steven Abramowitz]
I'm a big believer in compression therapy, whether it's pneumatic, non-pneumatic, mechanical, whether it's simply a wrap or a stocking, anything that the patient will use, I find to be very beneficial… and the anticoagulation agent that someone will take is the best anticoagulation agent in my mind.
[Dr. Kush Desai]
Any compression that a patient wears is better than no compression. Then I agree on the anticoagulation.
The only other thing I would add is venoactives... For those that can take them and can tolerate them, they can be really, really helpful. It's a subset of patients. It's not all patients.
Podcast Contributors
Dr. Kush Desai
Dr. Kush Desai is an associate professor and the director of deep venous interventions at Northwestern University Feinberg School of Medicine in Chicago, Illinois.
Dr. Steven Abramowitz
Dr. Steven Abramowitz is a practicing vascular surgeon at MedStar Georgetown University Hospital in Washington, D.C.
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Cite This Podcast
BackTable, LLC (Producer). (2023, November 6). Ep. 382 – Iliofemoral Stenting: Decision-Making & Best Practices Explored [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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