Endovascular Iliac Vein Revascularization Versus Conservative Management for Chronic, Symptomatic Iliac Vein Obstruction: A Systematic Review and Meta-Analysis

To synthesize the existing evidence comparing endovascular iliac vein revascularization versus conservative management for chronic, symptomatic venous obstruction.

We searched PubMed, Embase, Scopus, Cochrane CENTRAL, and ClinicalTrials.gov for comparator-controlled studies of endovascular iliac vein revascularization versus conservative management. The primary outcome was the Venous Clinical Severity Score (VCSS); secondary outcomes were the Villalta score, Venous Insufficiency Epidemiological and Economic Study Quality of Life (VEINES-QOL), and Visual Analogue Scale (VAS) pain. Continuous outcomes were pooled as mean differences (MD) using random-effects models with the Hartung-Knapp-Sidik-Jonkman adjustment. Certainty was assessed with GRADE (PROSPERO CRD420261446246).

Four studies (three randomized trials, one cohort; 554 patients; n per outcome: VCSS 317, Villalta 479, VAS 267, VEINES-QOL 274) met eligibility. Revascularization reduced VCSS (MD - 2.24, 95% confidence interval [CI] - 3.86 to -0.63) and the Villalta score (MD - 3.48, 95% CI - 4.75 to - 2.21; both I² = 0%). VAS pain and VEINES-QOL were inconclusive under the primary model. Technical success was 96.6%, stent thrombosis 1.9%. The largest trial showed threefold more bleeding (major and non-major, 11.6% vs. 3.6%), mainly non-major. Certainty was low for VCSS and Villalta and very low for VEINES-QOL and VAS pain.

Revascularization reduced venous symptom severity under the primary model, though neither estimate was robust to omitting individual studies, and the VCSS prediction interval crossed the null. Bleeding risk was increased in the largest trial; quality-of-life and pain effects were inconclusive. The evidence offers modest support for revascularization in patients failing conservative therapy, with short follow-up.