Endovascular Exclusion of a Refluxing Segment of Femoral Vein in Post-Thrombotic Syndrome, Characterized by a Vicious Shunt with the Main Upward Draining Pathway.

Abstract

Purpose: To describe a novel endovascular technique to treat ilio-femoral reflux in post-thrombotic syndrome (PTS). It consists of regulated exclusion of a femoral vein (FV) segment with indication based on Doppler ultrasound (DUS) scan and ascending and descending venogram.

Technique: Through lower limb venous DUS, we identify a post-thrombotic refluxing FV, characterized by a duplicated FV and/or ascending collateral veins draining into a common trunk with a re-entry point into the refluxing FV itself. The above findings indicate a second-level venogram. If the descending phase confirms the FV reflux pattern, we perform an ascending venogram to confidently locate where the draining blood is shunted into the FV. We proceed with the scleroembolization of the segment below the shunt. The postoperative venogram documents the treated segment occlusion and the elimination of the reflux. We described 4 cases: 3 successful reflux eliminations and 1 case where we decided not to treat. Mean follow-up lasts 6.5 months with DUS showing the abolition of the reflux; the overall Villalta score, performed at the baseline and last follow-up visit, resulted statistically significant (p = 0.0087).

Conclusion: Performing an endovascular regulated exclusion of FV refluxing segment opens a great scenario for PTS treatment; multicenter randomized trials are warranted.Clinical ImpactRecanalized post-thrombotic syndrome, with reflux involving the ilio-popliteal segments, affects the patient's life without any clear surgical indication. The proposed protocol and technique are based on performing a descending and ascending venogram to identify the point of femoral vein duplication. The regulated exclusion of the refluxing FV segment, below the duplication, by means of scleroembolization, allowed to permanent abolish the reflux. This novel technique is minimally invasive and presents great potential for treating a significant proportion of patients currently managed exclusively with conservative approaches.