Contralateral limb improvement after unilateral iliac vein stenting argues against simultaneous bilateral stenting

Symptoms of chronic venous insufficiency secondary to obstructive iliofemoral disease are often bilateral. The impact of iliofemoral stenting of the more symptomatic lower extremity on clinical outcomes in the less affected contralateral extremity is not clear. Such benefit, secondary to offloading of collaterals, may potentially be of the magnitude that the contralateral extremity does not require intervention.

A retrospective review of contemporaneously entered electronic medical record data of 368 patients/limbs with initial unilateral iliocaval stents (240 left and 128 right) placed during a 3-year period from 2015 to 2017 was performed. Patients who underwent simultaneous bilateral stenting or had occlusive disease were excluded. Of the remainder, the impact of stenting on contralateral leg symptoms was evaluated by analyzing visual analog scale (VAS) pain score (1-10), grade of swelling (1-3), and Venous Clinical Severity Score (VCSS). The duration of any improvement and need for intervention on the contralateral side were also appraised. Kaplan-Meier analysis was used to assess stent patency after intervention, whereas paired t-tests were used to examine clinical outcomes.

Of the 368 limbs that underwent stenting with a combination of a Wallstent (Boston Scientific, Marlborough, Mass) with a Z stent (Cook Medical, Bloomington, Ind) for stenotic lesions, 304 patients (89 men and 215 women) had contralateral symptoms (200 left and 104 right). The cause was post-thrombotic syndrome in 229 limbs and May-Thurner syndrome or nonthrombotic iliac vein lesion in 75 limbs. In this contralateral group, at 12 months, the VAS pain score improved from 5 to 0 (P < .0001), the grade of swelling went from 3 to 1 (P < .0001), and VCSS went from 5 to 3 (P < .0001) after stenting of the ipsilateral side. During the median follow-up of 20 months, 15 contralateral limbs underwent stenting. Median time to stenting of the contralateral limb after ipsilateral stenting was 9 months. The median VAS pain score, grade of swelling, and VCSS in this group before stenting were 6.5, 2, and 5 compared with 0 (P < .0001), 1 (P = .27), and 3 (P = .0021), respectively, in those members of the contralateral group who did not require stenting. Primary and primary assisted patencies at 12 months after contralateral stenting were 78% and 100%, respectively. There were no stent occlusions after contralateral stenting.

Patients with bilateral obstructive iliofemoral venous lesions often experience improvement of the contralateral limb symptoms (95%) after stenting of the worse ipsilateral limb. Only 15 of 304 (5%) symptomatic contralateral limbs had to undergo stenting during the follow-up period because of a worsening clinical picture. Based on this, a staged approach to iliofemoral stenting in patients with bilateral symptoms focusing initially on the more symptomatic limb is suggested.