Iliac vein stenting in postmenopausal leg swelling

Seshadri Raju, Matthew Oglesbee, Peter Neglén
Journal of Vascular Surgery 2011, 53 (1): 123-30

BACKGROUND: Leg swelling in menopausal women is well known. Prevailing concept in primary care is that it is polycentric and a treatable cause may not be found. Patients are placed on empiric diuretics often without benefit. Our clinical experience indicates that iliac venous vein obstruction is the core cause; a variety of secondary factors common in postmenopausal women precipitate symptoms.

PATIENTS AND METHODS: A total of 163 limbs in 150 postmenopausal women (≥ 55 years of age) with leg swelling unresponsive to conservative therapy underwent intravascular ultrasound-guided iliac vein stenting over an 11-year period. Preoperative investigations included duplex, airplethysmography, venous pressure tests, contrast studies, and lymphangiography. The postmenopausal group constituted 9% of all limbs (n = 1760) stented for chronic venous disease (CVD) during the same period and 18% of those stented for swelling (n = 922). Median age was 67 (range, 55-92) and left-to-right ratio 2:1.

RESULTS: Iliac vein obstruction was "primary" (nonthrombotic) in 65% and postthrombotic in 35% of limbs; 35% of limbs had obstruction only and 65% combined obstruction/reflux. Lymphatic dysfunction was present in 21% of the limbs. Mean intravascular ultrasound area stenosis was 68% ± 22 SD. Mean follow-up was 22 months (± 26 SD) (range, 1-113 months). Secondary stent patency (6 years) was 100% in primary and 91% in postthrombotic limbs; overall 98%. Swelling improved significantly (P < .0001) from preoperative grade 2.5 (± 0.8 SD) to postoperative grade 1.2 (1.2 SD). Associated pain also improved significantly (P < .0001) from preoperative visual analog scale 3.5 (± 3 SD) to postoperative 0.9 (2.1 ± SD). Quality-of-life (CIVQ) scores improved significantly in every category and overall (P < .0001).

CONCLUSIONS: Patients with postmenopausal leg swelling often have obstructive venous pathology even though suggestive venous history and other signs are often absent. Morbidity arises from painful swelling that affects mobility, quality of life, and ability of self-care at later stages of life. Outpatient percutaneous iliac vein stenting affords substantial symptom relief and improvement in quality-of-life measures. Recognition of the clinical complex as a distinct entity of venous origin may lead to greater awareness and effective treatment.

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