Iliocaval reconstruction in chronic deep vein thrombosis

Chronic occlusion of the iliac veins and the inferior vena cava is a source of significant morbidity to often otherwise healthy patients, but it can be successfully managed with percutaneous recanalization and stenting. In this article, I summarize our current approach to patients with chronic occlusion of the iliac veins: patient selection, timing of intervention, commonly needed equipment, procedure, difficulties encountered, complications, clinical follow-up, and outcomes. An ideal patient is the one who is physically active (or was so before iliocaval occlusion), is at least 6 months past acute iliocaval thrombosis, has a patent common femoral vein and hepatic vein or caval confluence, and has no thrombophilic state. The duration of the occlusion has not affected our technical success of recanalization but may, by predisposing the patient to recurrent deep vein thrombosis, affect long-term patency by degrading the size and number of inflow vessels. Secondary patency rates at 4 years can be as high as 70%-90%. We anticipate that even higher success rates will follow with ongoing evolutions in device design (stents with appropriate diameter, length, radial conformity to conduits of varying diameter, and resistance to compression); better understanding of the biological interaction of the stent, the veins, and the coagulation system; and improved navigation systems to cross longer, occluded segments that are resistant to guidewire passage.