Iliac Vein Compression: Are We Treating It to Its Full Potential? A Case Study Presentation

Introduction, Objectives, and/or Purpose: Iliac vein compression (IVC) is a condition that primarily affects both the right and left common iliac veins, with the left side being the most commonly affected. This condition is characterized by external compression of the vein, leading to blood flow obstruction and potentially worsening symptoms of venous reflux disease, including severe cases of deep vein thrombosis. While previously considered uncommon, recent research indicates that about one-third of the general population has hemodynamically significant compression. In patients with edema, heaviness, pain, and post-thrombotic obstructions (PTO), IVC is present in 18-49% of cases.
Early diagnosis and treatment of symptomatic patients are critical for improving quality of life outcomes. However, diagnosis can be challenging due to a lack of familiarity with the condition, which can mimic other common conditions. Additionally, a shortage of established guidelines for diagnosis and treatment may deter medical practitioners from managing symptoms, resulting in patients lacking adequate care. 1.This study aims to: 1. Measure the degree of improvement through the reduction of pain after venous stenting.
2. Evaluate the quality of life in patients diagnosed with IVC through regression of symptoms, including heaviness, fatigue, edema, cramping, burning, restless legs, itching, and discoloration after venous stenting.

Methods: This observational study aimed to evaluate the efficacy of venous stenting in patients with IVC greater than 50% diagnosed through intravascular ultrasound at an outpatient vascular surgical center. The study included 50 patients who underwent a total of 67 venous stenting procedures between January and December 2021, with data collected according to the protocol approved by IRB with informed patient consent. Baseline patient demographics including age, gender, weight, and body mass index (BMI), and clinical characteristics of the patients were collected. Patients were evaluated for pain, swelling, itching, cramping, heaviness, tiredness, burning, restless legs, and skin discoloration. Post procedure evaluation were documented at 3, 6, and 12 months for improvement.
Summarized characteristics of the study participants was collected using descriptive statistics. To analyze the statistical significance of the change in pain levels after intervention, χ2 test, analysis of variance and t-test with a two-tailed P value of ≤.05. Regression analysis was used to calculate the significant difference in associated clinical symptoms after intervention.

Results: The study was based on the quarterly observation of the associated clinical symptoms of the patients who underwent venous stenting procedures. Demographics of the patients have been described. Mean age of the patients was 57 ± 15.0, with the minimum age of 25 and the maximum age of 87. Gender analysis of the study cohort showed 59 (88.05%) female patients and only 8 (11.94%) male patients. Mean body mass index of the participants was 31.40± 8.29, with minimum BMI of 18, and maximum of 64. Likewise, mean weight of the study cohort was 180.01± 49.5 lbs., with the maximum weight of 396 lbs., and minimum weight of 104 lbs., with P <.01. Only 9 (13.43%) patients had deep vein thrombosis, whereas, 58 (86.56%) patients did not have any DVT. The data showed significance level of P <.0001.
To analyze the statistical significance of the change in pain levels after intervention, t-test was used. The results indicated a significant decrease in pain levels of all the patients following intervention. The observed mean difference between initial pain scores and after intervention was statistically significant with P <.000, and mean ± SD= 3.220±4.451 with CI= 95% (1.752, 4.485) of RT-stented patients, and P <.000, and mean ± SD= 2.840±3.830 with CI= 95% (1.955, 3.928). Chi-square test of independence in addition to t-test was also used to compare the pain frequencies before and after intervention. Chi-square distribution table with 2 degrees of freedom and a significance level of 0.05, demonstrated a critical value of 5.99 suggesting a statistically significant difference in pain levels before and after intervention. When compared, initially, 20 patients of RT stent placement indicated high pain scores, 13 patients showed median pain scores, whereas, 17 patients displayed low levels of pain treated. Likewise, for LT stented patients, 28 patients complained of high pain levels before intervention, 11 showed average pain symptoms, and other 11 indicated baseline pain scores. However, a significant decline in pain levels of RT stented patients was observed following 3 months of intervention. Thirty-five patients after 3 months of RT stent placement showed baseline pain levels as compared to initial observation, whereas, 10 patients showed median pain scores and 5 showed highest pain scores (Figure 1). A significant decline in pain scores for LT-stented patients was also observed where 31 patients showed baseline pain scores as compared to initially observed 11 patients showing preliminary pain scores.
Post-intervention 6 months analysis of RT and LT-stented patients showed 29 individuals with baseline pain scores, 13 with median pain scores, and 8 patients with high levels of pain. Similarly, 27 patients after one year of RT stent placement, and 33 patients of LT stent placement showed baseline pain scores. Likewise, 17 patients of RT stent placement, and 13 of LT stented individuals complained of median pain after 12 months of procedure. Whereas, only 6 RT stented and 4 LT stented patients showed high pain scores after one year of the procedure. Besides comparing the pre and post-intervention changes in the pain scores of the patients, patients after 6 months of intervention were compared with the pain scores after 12 months of the procedure. The values for the both RT stented and LT stented patients showed insignificant results with P= .668, and P= .160, respectively. This indicates the efficacy of intervention method to considerably alleviate the pain symptoms in the very few first months of procedure which do not aggravate even at the later stages of the intervention. Although statistically insignificant, however, number of patients reported less pain even after 6 months of intervention showing that method improves an overall quality of life. The observations are of high significance as there is only limited literature has observed the improvement of pain levels post-treatment. It was observed that intervention had a statistically significant effect on pain levels, and there were fewer patients with high levels of pain and more patients with low levels of pain, indicating the effectiveness of the intervention in reducing pain.
Besides decreased pain levels after intervention, the patients showed an overall improvement in quality of life through decrease in the associated symptoms (Figure 2). A considerable statistically significant difference, P <.0001, was shown for all associated symptoms compromising the quality of life. For instance, edema was complained initially by 43 patients, whereas, 22, 19, and 27 patients complained it after 3, 6, and 12 months of intervention, respectively. Likewise, a significant decline in heaviness was observed after intervention. Initially, 36 patients complained of heaviness, however, after intervention, it was complained by 13, 14, and 10 patients when quarterly checked for heaviness. Tiredness and discoloration were also significantly lowered post-intervention and was complained by only few participants. The complain of burning was initially recorded for 30 patients, nonetheless, only 8, 9, and 6 patients complained it in post-intervention examination, respectively. A similar trend was observed for itching which was initially complained by 24 patients, however, gradually decreased to 7 patients by the end of the year of intervention. Likewise, 21 patients complained of restlessness before the intervention which was reduced to only 8 patients after the year of the procedure. The overall decrease in associated symptoms indicate the efficacy of the intervention in improving the overall quality of life.

Conclusion(s): Iliac vein compression predominantly affects the left common iliac vein, resulting in the development of blood flow obstruction and consequent venous reflux disease, with severe cases leading to deep vein thrombosis. The increasing prevalence of this condition has led to the development of several intervention methods amongst a dedicated venous stent. However, the efficacy of the venous stenting procedure in decreasing disease-associated symptoms and enhancing overall quality of life remains inadequately studied. In this study, fifty patients who underwent venous stenting were monitored for one year for pain scores and associated health factors. The data analysis indicated a significant decrease in pain scores, as well as a reduction in complaints of edema, heaviness, tiredness, cramping, discoloration, burning, itching, and restlessness, thereby demonstrating the efficacy of the venous stenting procedure in enhancing overall life and health improvement. These findings suggest that physicians should consider treating with venous stenting, as it can provide significant relief of symptoms and improve patients' overall quality of life. Moreover, this study highlights the need for further research to better understand the optimal management, including the appropriate timing and selection of patients for intervention. In addition, every patient is unique and may respond differently to venous stenting. It is important to conduct research on a large and diverse group of patients to understand the variability in their responses and to identify any factors that may impact the duration of symptom relief.