Lesion Morphology-Guided Endovascular Treatment for Postthrombotic Iliofemoral Venous Obstruction: A Retrospective...

Endovascular treatment of postthrombotic iliofemoral venous obstruction (PIVO) involves balloon angioplasty (percutaneous transluminal angioplasty [PTA]), stenting, or combined pharmacomechanical thrombectomy (PMT) with stenting, yet selection criteria remain poorly defined. This study evaluated outcomes of a lesion morphology-guided treatment allocation strategy.

In this retrospective, single-center cohort study (January 2019 to December 2023), 342 patients with confirmed PIVO (time since index deep vein thrombosis ≥3 months, Villalta score ≥5) treated at a tertiary vascular center were analyzed. Treatment was allocated based on lesion morphology: PTA alone for short-segment (<5 cm), nonocclusive lesions with good inflow (inflow score 0); stenting for long-segment (≥5 cm) or occlusive lesions with adequate inflow; and combined PMT/catheter-directed thrombolysis plus stenting for complex lesions with poor inflow (inflow score ≥2). The primary end point was 36-month primary patency.

Technical success was achieved in 93.6%, 96.3%, and 94.0% of PTA, stenting, and combined procedures, respectively. At 36 months, primary patency was 51.3% (95% confidence interval [CI] 40.2-62.4) for PTA, 64.0% (95% CI 56.5-71.5) for stenting, and 57.0% (95% CI 46.8-67.2) for combined treatment (log-rank P = 0.041). The secondary patency was 65.4%, 80.5%, and 72.0%, respectively (P = 0.018). On multivariable Cox regression, stenting versus PTA was independently associated with reduced patency loss (hazard ratio [HR] 0.62, 95% CI 0.43-0.89; P = 0.009), while inflow score ≥ 2 (HR 1.92, 95% CI 1.35-2.73; P < 0.001), complete occlusion (HR 1.63, 95% CI 1.15-2.31; P = 0.006), and lesion length ≥10 cm (HR 1.56, 95% CI 1.12-2.18; P = 0.009) predicted patency loss. After inverse probability of treatment weighting, stenting remained superior to PTA (HR 0.58, 95% CI 0.39-0.86; P = 0.007). Subgroup analysis showed stenting benefit was concentrated in long-segment lesions (≥5 cm; HR 0.42, P-int [P-value for interaction] = 0.003); for short, nonocclusive lesions, patency did not differ (HR 0.78, P = 0.43).

A lesion morphology-guided treatment allocation strategy yields acceptable mid-term patency in PIVO. Stenting provides superior outcomes for long-segment and occlusive lesions, while PTA alone may be reasonable for carefully selected short-segment, nonocclusive stenoses with preserved inflow.