Deep venous thrombosis associated with caval extension of iliac stents.

Background: It is generally difficult to place an iliac vein stent precisely at the iliocaval junction with venographic control or even with intravascular ultrasound guidance. Furthermore, mechanical properties of the Wallstent (Boston Scientific, Marlborough, Mass) can predispose precisely placed stents to distal displacement or stent collapse. Our center has thus advocated extending Wallstents 3 to 5 cm into the inferior vena cava to prevent complications of missed proximal lesions or stent migration. This technique has gradually been accepted, and concerns of jailing of contralateral flow were not initially recognized. We analyzed deep venous thrombosis (DVT) incidence following iliocaval stenting with two alternative techniques: (1) Wallstents with 3- to 5-cm extension into the inferior vena cava; and (2) a modified Z-stent (Cook Medical, Bloomington, Ind) technique, in which overlapping Wallstents end at the iliac confluence and caval extension is performed with a Z-stent placed at the top of the stack. The function of the Z-stent is to provide improved radial force at the iliocaval confluence and to prevent jailing of contralateral flow with larger stent interstices.

Methods: There were 755 limbs with consecutive Wallstent caval extensions (2006-2010) and 982 limbs with Z-stent extensions (2011-2015) analyzed for DVT incidence postoperatively.

Results: Demographics were similar for both groups. Mean age was 56 and 58 years in the Wallstent and Z-stent groups, respectively. There was a female predominance (Wallstent, 69%; Z-stent, 67%) and a higher incidence of left-sided disease (Wallstent, 66%; Z-stent, 56%) in both groups. There was a slightly higher incidence of post-thrombotic disease in the Z-stent subgroup (Wallstent, 53%; Z-stent, 68%). Cumulative freedom from contralateral DVT was 99% and 90% in the Z-stent and Wallstent groups, respectively (P < .001) during the 5 years following stent placement. However, all three patients with DVT contralateral to a Z-stent actually had high placement of the Wallstent across the confluence. Thus, no patients with proper Z-stent technique had a contralateral DVT. Cumulative freedom from ipsilateral DVT was 97% and 82% in the Z-stent and Wallstent groups, respectively (P < .001) during the 5 years following stent placement. The decrease in incidence of ipsilateral DVT appeared to be attributable to decreased missed distal lesions with increased operator experience and not attributable to the Z-stent itself.

Conclusions: Contralateral DVT incidence was significantly lower with the Z-stent modification. In addition, the Z-stent modification provides greater radial strength at the iliac-caval confluence and simplifies simultaneous or sequential bilateral stenting. Use of proper technique and intravascular ultrasound is essential to limit the incidence of ipsilateral DVT.