Venous stenting across the inguinal ligament.

BACKGROUND: Arterial stenting across joints is not recommended because of increased risk of in-stent focal neointimal hyperplasia and compression or fracture of the stent by joint motion with decreased long-term patency. The aim of this study was to assess the risk of placing stents in the venous system across the inguinal ligament.

MATERIALS AND METHODS: From 1997 to 2006, 177 limbs with chronic non-malignant obstructive lesions had stents placed in the iliofemoral venous outflow across the inguinal ligament into the common femoral vein. Transfemoral venograms and duplex ultrasound scans to assess cumulative patency rates, cumulative rates, site of in-stent restenosis (ISR), and structural integrity of the stents were performed during follow-up. The results were compared to the findings in 316 limbs with stents terminating cephalad to the inguinal ligament.

RESULTS: Overall cumulative secondary patency (CSP) rate at 54 months was greater in the limbs with cephalad than in those caudad stent termination in relation to the inguinal ligament (95% and 86%, respectively; P = .0001). Although CSP of limbs with non-thrombotic obstruction was 100% regardless of the site of stent termination, that of the limbs stented for thrombotic obstruction was greater for stents terminating cephalad than for those caudad to the ligament (90% and 84%, respectively; P = .0378). However, a comparison of CSP rates between limbs treated for thrombotic occlusion and those with thrombotic non-occlusive obstruction at 32 months revealed no difference whether or not the stent was placed across the inguinal ligament (occlusion 77% and 77%, P = .7540, non-occlusive obstruction 96% and 95%, P = .7437). Severe ISR (> or =50%) were rare, 5%. The cumulative rate was, however, not significantly different in limbs stented cephalad and caudad to the inguinal ligament (7% and 11%, respectively, P = .6393). Focal in-stent recurrent stenosis at the site of the inguinal ligament occurred in only 7% of limbs (all <50%). None of the braided stainless steel stents were compressed or fractured.

CONCLUSION: Contrary to arterial stenting, braided stainless stents can be safely placed in the venous system across the inguinal crease with no risk of stent fractures, narrowing due to external compression, focal development of severe in-stent restenosis, and no effect on long-term patency. The patency rate is not related to the length of stented area or the placement of the stent across the inguinal ligament, but is dependent upon the etiology and whether the treated postthrombotic obstruction is occlusive or non-occlusive.