Chronic venous obstruction: diagnostic considerations and therapeutic role of percutaneous iliac stenting

Iliac venous outflow obstruction has an important role in the expression of symptomatic chronic venous insufficiency. This anatomic obstruction is frequently overlooked, owing in part to diagnostic difficulty. The combination of venous obstruction and reflux leads to more severe clinical disease. Current diagnostic modalities do not allow an definitive assessment of hemodynamically critical venous obstruction. No single invasive or noninvasive study can accurately detect borderline obstruction of potential hemodynamic significance. A high index of suspicion is critical in the initial recognition of chronic venous obstruction. The diagnosis relies on clinical signs and symptoms and radiologic assessment of morphologic venous outflow obstruction. Treatment strategy should be based on the results of morphologic investigations such as transfemoral phlebography or, preferably, intravascular ultrasonography. Percutaneous iliac venous stenting offers a safe and efficient method to correct pelvic venous obstruction. Percutaneous iliac stenting does not preclude subsequent venous bypass or corrective superficial and deep reflux surgery. This article reviews the etiologic factors and diagnostic modalities of iliac venous obstruction. The therapeutic role of percutaneous iliac stenting in the management of venous obstruction is also discussed.