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Objective: Iliofemoral venous obstructive disease can result in significant, potentially debilitating symptoms that can negatively affect quality of life. Unlike arterial disease, patients with deep venous disease have a significantly lower median age, therefore the need for long term stent patency becomes a matter of decades rather than years. Furthermore, iliofemoral lesions frequently require stent placement across the inguinal ligament. Such stents are subject to dynamic stress from leg movement and associated concerns for device fatigue, resulting in stent fracture. The aim of this study was to describe an in vitro 50 year stent fatigue test method designed to assess durability against dynamic stress induced device fracture., Methods: Through literature review, cadaver studies, and computer modelling, the most challenging loading was confirmed to be hip flexion across the inguinal ligament. This occurs when the patient adjusts between a seated and standing position. Sit to stand hip flexion at the inguinal ligament was effectively simulated on the bench in this in vitro experimental study., Results: When tested under challenge parameters, hip flexion was reliably found to cause fractures in non-venous nitinol stents. However, a dedicated self expanding nitinol venous stent, engineered for improved durability, underwent up to 50 years of simulated loading on the bench with 15% (3/20) of stents experiencing fractures at 50 years, compared with fractures in 35% (14/40) of non-venous stents tested to 1.4 years; no statistical testing was performed as durations do not match and the objective was to demonstrate the test method., Conclusion: The presented fatigue test method is a suitable approach for evaluating the durability of stents intended for venous use. Venous stents demonstrated superior fatigue resistance compared with non-venous stents via in vitro hip flexion testing., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Patients with end-stage renal disease and iliocaval venous obstruction are normally nonviable recipients of kidney transplantation. We report a case of a 34-year-old male patient who has been receiving hemodialysis as renal replacement therapy for 6 years due to immunoglobulin A nephropathy. Past medical history included multiple central venous catheter infections and catheter-associated thrombosis. Iliac confluence and inferior vena cava occlusion previously excluded the patient from the renal transplantation list. The exhaustion of venous access sites was already documented. After multidisciplinary discussion, the patient was proposed for endovascular iliocaval reconstruction aiming for a future kidney transplant. Iliocaval recanalization was achieved through bilateral femoral access. Inferior vena cava and iliac angioplasty were performed. A dedicated venous stent was deployed in the inferior vena cava, followed by a double-barrel reconstruction of the iliac confluence. Successful iliocaval recanalization was accomplished. Five months after kidney transplantation was performed with a deceased donor graft in the right iliac fossa. The postoperative period was uneventful. After 12 months, the patient remained free from kidney replacement therapies with a serum creatinine level of 1.3 mg/dL. To the best of our knowledge, this is the first clinical description of a successful kidney transplant in a patient with a previous iliocaval reconstruction., Competing Interests: Declaration of competing interest The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation., (Copyright © 2024 American Society of Transplantation & American Society of Transplant Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: To examine the safety and efficacy of ZelanteDVT™ catheter rheolytic thrombectomy in the treatment of patients with iliac vein stent thrombosis., Methods: A retrospective analysis method was conducted by means of collecting the data of 32 patients who had completed the treatment of iliac vein stent thrombosis with ZelanteDVT catheter rheolytic thrombectomy from March 2019 to March 2023. Data on clinical characteristics, technical success, clinical success, complications, and early follow-up were analyzed., Results: The technical success rates were 100%, intraoperatively, in which 22 cases were improved to thrombus clearance Grade II (50-90%), 10 were Grade III (>90%). There were 21 cases treated with subsequent catheter-directed thrombolysis, and the average urokinase administration of (120.90 ± 29.63)∗10ˆ4 units. The clinical success rates were 100% and the swelling of the affected limbs were significantly improved, a significant difference in the pre/postoperative between-thigh circumference difference [(5.16 ± 1.08) vs. (1.75 ± 0.84), P < 0.000]. The pre/postoperative Venous Clinical Severity Score was [(12.94 ± 1.70) vs. (7.44 ± 1.31), P < 0.000]. No serious complications occurred during the perioperative period. The postoperative and 12-month stent patency rate was 100.00% (32/32) and 71.88% (23/32), respectively., Conclusions: The ZelanteDVT catheter rheolytic thrombectomy seems to have a promising application prospect for the treatment of patients with iliac vein stent thrombosis., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Spontaneous arteriovenous fistulas (AVF) caused by iliac aneurysms are a rare condition with possible dramatic complications due to secondary hemodynamic changes. Diagnosis can be challenging because patients may present with progressive cardiac failure or even hemodynamic shock as primary symptom. Due to the rarity of the condition, data are scarce and treatment decisions are challenging. The aim of this systematic review is to give an overview of the symptoms, treatment possibilities, and patient outcomes., Methods: Literature searches were performed in PubMed, Embase, Web of Science, and Scopus. Case reports and literature reviews were included in the review. The literature review was performed by 2 independent reviewers according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A third reviewer was available in case of disagreement. The study was registered in Prospero (ID CRD42022335318). All cases of isolated, iliac atherosclerotic aneurysms with spontaneous fistulization into an iliac vein were included., Results: Fifty articles were included, resulting in 62 cases. A case from our own center was included, bringing the total up to 63 cases. Median age was 71 years, ranging from 41 to 87 years. 87.3% of patients were male, 6.3% were female, and in 6.3% sex was not reported. The duration of symptoms until presentation ranged from less than an hour to 6 years. 73.0% was treated with open surgery and 17.5% was treated by endovascular way, with 4 reinterventions in the endovascular group. There was an overall mortality rate of 9.5%., Conclusions: Although rare, iliac AVF might cause acute therapy-resistant heart failure and hemodynamic instability. In patients with acute heart failure, especially when combined with a pulsating mass with accompanying bruit or thrill and unilateral swollen leg, an AVF should be suspected. Surgical treatment of AVF has an excellent outcome, provided that the condition had been diagnosed preoperatively., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: This study aimed to compare clinical outcomes associated with the duration of postoperative direct oral anticoagulant (DOACs) therapy in patients with nonthrombotic iliac vein lesions., Methods: We retrospectively analyzed 176 consecutive patients who underwent stenting for nonthrombotic iliac vein lesions between March 2018 and December 2021. In total, 99 and 77 patients were discharged on a 3-month and >3-month regimen of DOAC therapy, respectively. The primary cumulative endpoint was a composite of thrombotic complications, bleeding complications, primary patency, primary-assisted patency, and secondary patency within 1 year., Results: Patients undergoing 3-month and >3-month DOAC therapy were similar in age, sex, lesion site, symptoms, and average stent diameter and length. Upon multivariate analysis, the primary cumulative endpoint did not differ between the 2 groups (hazard ratio [HR]: 1.18; 95% confidence interval [CI]: 0.42-3.30; P = 0.76). Moreover, the primary patency at 1 year did not differ between the groups (HR: 1.50; 95% CI: 0.14-16.54; P = 0.74). Furthermore, there were no discernible differences in the secondary endpoints of bleeding complications (HR: 0.66; 95% CI: 0.22-1.96; P = 0.45) or thrombotic complications (HR: 1.79; 95% CI: 0.55-5.80; P = 0.34) between the groups., Conclusions: The 3-month regimen of DOAC therapy showed a similar risk of postoperative thrombosis and bleeding when compared to longer DOAC therapy durations over the course of 1 year following endovascular intervention. This could be a preferred option for patients with a higher estimated bleeding risk after venous stenting., (Copyright © 2023 Elsevier Inc. All rights reserved.)

When performing stent intervention for iliac vein compression syndrome, the operator selects the appropriate stent and determines its implantation depth according to the type and severity of iliac vein stenosis in the patient. However, there is still uncertainty regarding how the structure of the stent and its implantation depth affect hemodynamics at the site of lesion. In this paper, we analyzed three commonly used stents (Vena stent from Venmedtch, Venovo from Bard, and Smart stent from Cordis) with different implantation depths (0, 10, 20 mm) using computational fluid dynamics (CFD). We focused on evaluating hemorheological parameters such as time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), etc., within one pulsatile cycle after stent implantation. The correlation between geometric parameters of the stents and hemodynamic indicators was assessed using Pearson correlation coefficient (r), which was further validated through PIV velocity measurement experiment. The results revealed that an increase in implantation depth led to a more pronounced disturbance effect on blood flow at bifurcation for densely arranged support body-type stents. This effect was particularly significant during periods of smooth blood flow. On the other hand, crown-shaped Vena stents exhibited relatively less disruption to blood flow post-implantation. Implantation depth showed a strong negative correlation with TAWSS but a strong positive correlation with OSI and RRT. These findings suggest an increased risk of thrombosis at iliac vein bifurcation following stent placement. Amongst all three tested stents, Vena Stent demonstrated more favorable periodic parameters after implantation compared to others. These results provide valuable theoretical insights into understanding contralateral circulation thrombosis associated with iliac vein stenting., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Ltd.)

Objective: Early clot removal using endovascular intervention aims to reduce post-thrombotic syndrome (PTS) following iliofemoral deep venous thrombosis (DVT). This may reduce long term morbidity but incurs a higher initial cost. This study examined the cost effectiveness of catheter directed thrombolysis (CDT) and pharmacochemical thrombectomy (PMT) compared with oral anticoagulation (OAC) alone for treatment of acute iliofemoral DVT in the United Kingdom., Methods: A combined decision tree (acute DVT complications) and Markov model (long term complications [PTS]) was used for decision analytic modelling with five states: no PTS, mild PTS, moderate PTS, severe PTS, and dead. All patients started with acute DVT. Patients who survived acute complications transitioned into the Markov model. Cycle time was six months. A healthcare payer perspective and lifetime horizon was used, adjusting for excess mortality due to history of thrombosis. Data for probabilities, transition probabilities, mortality, and utilities were obtained from the published literature. Cost data were obtained from UK NHS tariffs and published literature. Outcomes were mean lifetime cost, quality adjusted life years (QALYs), and cost effectiveness., Results: Over a patient's lifetime, OAC was more costly (£37 206) than CDT (£32 043) and PMT (£36 288). Mean lifetime QALYs for OAC (12.9) were lower than CDT (13.5) and PMT (13.3). Therefore, in the incremental cost effectiveness analysis, both CDT and PMT were dominant: CDT was less costly (-£5 163) and more effective (+0.6 QALYs) than OAC, and PMT was also less costly (-£917) and more effective (+0.3 QALYs) than OAC. Results were robust to univariable sensitivity analyses, but probabilistic sensitivity analyses suggested considerable parameter uncertainty., Conclusion: Early interventional treatment of iliofemoral DVT is cost effective in the UK. Future clinical and epidemiological studies are needed to characterise parameter uncertainty. Further analysis of modern practice, alternative treatments, and optimised care models is warranted., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Phlegmasia cerulea dolens (PCD) is a rare and serious complication of deep venous thrombosis and iliac vein lesions (IVLs) are the most common cause of PCD. The purpose of this study was to explore the safety and efficacy of single-stage endovascular thrombus removal and stenting to treat PCD caused by IVLs., Methods: Clinical data of 13 patients with PCD secondary to IVL were retrospectively analyzed. They underwent endovascular thrombus removal, including rheolytic thrombectomy, manual aspiration thrombectomy, and simultaneous iliac vein stenting after thrombus removal. The safety and efficacy of single-stage endovascular thrombectomy and stenting in the treatment of PCD were evaluated., Results: The technical success rate was 100% (13/13). Postoperative symptoms were significantly relieved in all patients. There were no perioperative major bleeding complications or other critical adverse events. Two (15.4%) patients had slightly elevated serum creatinine concentration after surgery, which returned to normal before discharge. At the 12-month follow-up, the stent primary patency rate was 81.8% and there were no cases of severe post-thrombotic syndrome., Conclusions: Single-stage endovascular thrombectomy and stenting in PCD due to IVLs was minimally invasive, safe, and effective; it is recommended as a first-line treatment for PCD caused by IVLs., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Venous thoracic outlet syndrome (vTOS) is a relatively rare condition associated with significant morbidity. Its management continues to evolve, with increasing use of endovascular adjuncts, such as percutaneous thrombectomy and angioplasty, in addition to first rib resection. The utility of stenting residual venous stenotic lesions is poorly defined within the literature. This study sought to review the medium term patency rates of upper limb deep venous stenting in the management of vTOS., Methods: A single centre, retrospective review of patients managed for vTOS with first rib resection followed by upper limb deep venous stenting between January 2012 and February 2021 was conducted. Post-procedural ultrasounds were reviewed to determine stent patency., Results: Twenty-six patients were included, with 33 stents placed. The median duration of follow up was 50 months. On venous duplex ultrasound at three years post-operatively, primary patency rates were 66%, primary assisted patency rates were 88%, secondary patency rates were 91%, and total occlusion rates were 9%. After stent placement, 80% of patients remained asymptomatic with regard to compression symptoms., Conclusion: Upper limb deep venous stenting is an effective adjunct to surgical decompression in the management of vTOS. Stent medium term patency rates are promising; however, further studies with longer follow up and larger cohorts with multicentre results are required to confirm these early findings., (Copyright © 2022 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: To develop a large animal model of iliocaval deep venous thrombosis (DVT), which enables development and evaluation of interventional management and existing imaging modalities., Methods: The experimental protocol consisted of a total endovascular approach. Pigs were percutaneously accessed through the right internal jugular and bilateral femoral veins. Three balloon catheters were inflated to induce venous stasis in the infrarenal inferior vena cava (IVC) and bilateral common iliac veins (CIVs). Hypercoagulability was induced by injecting 10 000 IU of thrombin. After 2.5 hours, the balloon catheters were removed before animal recovery. After seven, 14, 21, 28, or 35 days, animals were euthanised; the IVC and CIV were harvested en bloc, cross sectioned and prepared for histological examination. Multimodal imaging was performed before and after thrombus creation, and before animal euthanasia., Results: Thirteen female domestic pigs with a mean weight of 59.3 kilograms were used. The mean maximum IVC diameter and area were 16.4 mm and 1.2 cm 2 , respectively. The procedure was successful in 12 animals with occlusive venous thrombosis in the region of interest on immediate post-operative magnetic resonance venography and a mean thrombus volume of 19.8 cm 3 . Clinical pathology results showed platelet consumption, D dimer increase, and inflammatory response. Histological evaluation demonstrated a red cell, fibrin, and platelet rich thrombus on day 1, with progressive inflammatory cell infiltration from day 7. Collagen deposition appeared in week 2 and neovascularisation in week 3., Conclusion: Endovascular occlusion combined with thrombin infusion is a reliable minimally invasive approach to produce acute and subacute DVT in a large animal model., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Objective: A number of dedicated self expanding nitinol stents have been developed for use in the venous system, with both open cell (OC) and closed cell (CC) designs available. Data comparing these different designs are lacking. The objective of this study was to evaluate outcomes in patients treated with open and closed cells for unilateral chronic iliac vein obstruction., Methods: A single centre retrospective cohort study was conducted, including all patients treated with a dedicated nitinol venous stent between 2014 and 2019. Stent patency and details of re-interventions (including lysis, venoplasty, reinforcement, extension, arteriovenous fistula formation) were examined in the first post-operative year. Subgroup analysis described outcomes for patients treated with OC and CC stents ending above the inguinal ligament and those who required extension into the common femoral vein. Cox regression analysis was used to identify factors associated with loss of primary patency., Results: A total of 207 patients were included (OC 100 patients, CC 107 patients). There was no significant difference between the groups for age (OC 42 years, CC 44 years); gender (OC and CC 67% female); presence of post-thrombotic lesions (OC 71%, CC 73%); stenting across the inguinal ligament (OC 58%, CC 56%), or presence of inflow disease (OC 49%, CC 47%). Primary and cumulative patency at 12 months were similar between groups (primary: OC 63%, CC 65%; cumulative: OC 93%, CC 90%). Patients with a CC stent across the inguinal ligament had a greater risk of needing multiple re-interventions at one year compared with those with an OC stent (odds ratio 2.84, 95% confidence interval [CI] 1.16 - 6.9) but overall, the only factor significantly associated with loss of primary patency was inflow vessel disease (hazard ratio 3.39, 95% CI 1.73 - 6.62, p < .001)., Conclusion: OC and CC dedicated nitinol venous stents were observed to perform similarly in terms of patency and symptom improvement at one year. Disease of the inflow vessels was the most important factor associated with a loss of stent patency irrespective of stent design., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Penetrating injuries to the inferior vena cava and/or iliac veins are a source of hemorrhage but may also predispose patients to venous thromboembolism (VTE). We sought to determine the relationship between iliocaval injury, VTE and mortality., Methods: The National Trauma Data Bank was queried for penetrating abdominal trauma from 2015-2017. Univariate analyses compared baseline characteristics and outcomes based on presence of iliocaval injury. Multivariable analyses determined the effect of iliocaval injury on VTE and mortality., Results: Of 9,974 patients with penetrating abdominal trauma, 329 had iliocaval injury (3.3%). Iliocaval injury patients were more likely to have a firearm mechanism (83% vs. 43%, P < 0.001), concurrent head (P = 0.036), spinal cord (P < 0.001), and pelvic injuries (P < 0.001), and higher total injury severity score (median 20 vs. 8.0, P < 0.001). They were more likely to undergo 24-hr hemorrhage control surgery (69% vs. 17%, P < 0.001), but less likely to receive VTE chemoprophylaxis during admission (64% vs. 68%, P = 0.04). Of patients undergoing iliocaval surgery, 64% underwent repair, 26% ligation, and 10% unknown. Iliocaval injury patients had higher rates of VTE (12% vs. 2%), 24-hr mortality (23% vs. 2.0%) and in-hospital mortality (33% vs. 3.4%) (P < 0.001 for all). VTE rates were similar following repair (14%) and ligation (17%). Iliocaval injury patients also had higher rates of cardiac complications (10.3% vs. 1.4%), acute kidney injury (8.2% vs. 1.3%), extremity compartment syndrome (4.0 vs. 0.2%), and unplanned return to OR (7.9% vs. 2.5%) (P < 0.001 for all). In multivariable analyses, iliocaval injury was independently associated with risk of VTE (OR 2.12; 95% CI, 1.29-3.48; P = 0.003), and in-hospital mortality (OR = 9.61; 95% CI, 4.96-18.64; P < 0.001)., Conclusion: Iliocaval injuries occur in <5% of penetrating abdominal trauma but are associated with more severe injury patterns and high mortality rates. Regardless of repair type, survivors should be considered high risk for developing VTE., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Pelvic local recurrence of colorectal cancer (PRCRC) may be cured if radical surgery is performed. Preoperative assessment normally includes magnetic resonance imaging (MRI). The aim of this study was to evaluate the influence of specific MRI-related findings on outcome of surgery of PRCRC., Materials and Methods: Clinical data from 95 consecutive patients, operated with a curative intent for PRCRC at Karolinska University Hospital during 2003-2013, were collected from medical records. Preoperative MRI examinations of the PRCRC were re-evaluated. The potential influence of clinical factors and specific MRI-findings (location, solid/mucinous, size, volume and border) on surgical resection margins (R0-R1) and survival were calculated with logistic and cox regression., Results: Eighty-seven patients had available MRI scans and were included in the study. Sixty-five patients (75%) had a R0 resection and 22 patients (25%) had a R1 resection of their PRCRC. In all, 47 patients (54%) had an involved lateral compartment. Lateral location was the only MRI finding associated with both an increased risk of R1 resection (OR 3.97, 95%CI: 1.31-12.04) and death (HR 1.94, 95%CI: 1.07-3.51). Lateral location entailed an increased risk of death also after R0 resection (HR2.09, 95%CI: 1.07-4.10). Five-year survival was 35% for all patients, 44% after R0 resection and 7% after R1 resection., Conclusion: Tumour involvement of the lateral and posterior compartments on MRI was a predictor for R1 resection, but only lateral involvement was associated with an increased risk of death. An increased risk of death associated with lateral involvement was still present after R0 resection., Competing Interests: Declaration of competing interest The authors report no conflicts of interest in this study., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Oblique lateral interbody fusion (OLIF) at lumbosacral junction is typically performed on the central window between the bifurcations of iliac vessels. However, the central window of lumbosacral transitional vertebrae (LSTVs) is usually obstructed by the iliocaval venous structures. We aimed to describe the vascular anatomy and surgical approach in OLIF at LSTVs compared with those in OLIF at typical L5-S1 junction., Methods: Sixty-eight consecutive patients who underwent OLIF at lumbosacral junction were included. Of these, 31 patients had LSTVs and 37 patients had typical L5-S1 junction. The position of the iliocaval junction and the configuration of the left common iliac vein were compared using the preoperative CT and MR images of the lumbar spine. The surgical approach and intraoperative vascular findings were analyzed., Results: Almost 70% of LSTVs had the iliocaval junction at low or very low position. Mobilization of left common iliac vein for central window was potentially difficult in almost 74% of OLIF at LSTVs while it was not required or was potentially easy in almost 80% of OLIF at typical L5-S1. Vascular injury was identified in 2 (6.5%) patients with OLIF at LSTVs and in 3 (8.1%) patients with OLIF at typical L5-S1 junction (P = 0.904)., Conclusions: In our series, OLIF at LSTVs was performed through lateral window in 93.5% of the cases. Preoperative evaluation of the iliocaval junction using CT/MR of lumbar spine was reliable and valid in the determination of OLIF approach at lumbosacral junction., Competing Interests: Declaration of Competing Interest Nothing to disclose., (Copyright © 2020 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Objective: To show a surgical video in which an isolated mass was resected off the external iliac vessels for the management of recurrent ovarian cancer., Design: Case report., Setting: Tertiary referral center in New Haven, Connecticut., Interventions: This is a step-by-step demonstration of a robotic tumor debulking in a patient with isolated recurrence of epithelial ovarian cancer [1-3]. The patient is a 70-year-old woman with Lynch syndrome who received a diagnosis for stage IIC high-grade serous ovarian adenocarcinoma and underwent complete debulking in 1996. She had most recently been on pembrolizumab for microsatellite instability-high tumor until February 2019, when she received a diagnosis for isolated hypermetabolic mass in close proximity to the external iliac vessels and right iliac fossa. The patient was placed in dorsal low lithotomy Trendelenburg position, and 15° leftward tilt of the table was obtained to expose the right pelvic sidewall and iliac fossa. To optimally target the surgical field of interest, all robotic trocars were placed in a straight line starting from 5 cm above symphysis pubis on the left side to left subcostal line between the midline vertical and the left midclavicular lines, as per the manufacturer's port placement guidelines (Fig. 1)., Conclusion: Robotic resection of the tumor nodule off the external iliac vessels was successfully performed with adequate range of motion provided by the arms and without any complications. Trocar placement should be tailored to the site of surgical interest. Robotic-assisted laparoscopy should be considered as a valid alternative to the traditional open approach, when managing solitary masses in patients with recurrent ovarian cancer., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Introduction: Iliocaval leiomyosarcoma (ICLM) is a rare and aggressive form of sarcoma within the retroperitoneum. Surgery is the mainstay of treatment, with no consensus on the benefit of chemoradiotherapy in the neo/adjuvant setting. This study aims to describe the natural history of a chemotherapy-naïve ICLM treated in a tertiary cancer centre and to explore potential directions to improve oncological outcome., Materials and Methods: A prospective database was used to identify patient demographics, clinicopathological variables and oncological outcomes in 30 patients who underwent surgical resection in our institution for primary non-metastatic ICLM between 2003 and 2018., Results: There was no 90-day mortality. With a median follow-up time of 70.0 months (95% CI 52.6-87.4), 5/30 patients (16.7%) developed local recurrence while 11/30 (36.7%) developed distant metastatic disease. 1 patient (3.3%) developed both local and distant recurrence. Median overall survival of our cohort was 41.0 months (95% CI 33.6-48.4) and 5-year overall survival rate was 32.1%. Multivariate survival analysis using the Cox proportional hazard model identified tumour grade and blood loss of more than 600 mL as key prognostic factors in our model., Conclusion: Management of ICLM should be centralised in high-volume sarcoma centres with expertise in the management of retroperitoneal sarcomas. Integration of tumour biology with a concerted effort to conduct conclusive multi-centre phase III in histological and molecularly defined sarcoma subgroups is necessary to improve patient outcome. We eagerly await the results of STRASS 2 study to gain more insights to the efficacy of neoadjuvant chemotherapy on patient prognosis., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Acute abdominal arteriovenous fistulas in the setting of ruptured abdominal aortic aneurysms are a life-threatening condition; thus, a prompt diagnosis is required for proper treatment. Open, endovascular, and hybrid repair have been proposed for their management, with pros and cons for each method. In particular, the evolution of endoluminal techniques guarantees an increasing feasibility of these procedures, and a significant reduction in morbidity and mortality rates was usually associated with open surgery. Nevertheless, some concerns still remain regarding the midterm and long-term follow-up. The aim of this article was to review and compare the reported clinical and technical results of conventional open surgery and endoluminal techniques in this scenario and to report the case of an acute aorto-iliac fistula due to a ruptured common iliac artery aneurysm into the iliac vein that was managed by endovascular repair at our institution., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Safe surgical approaches to the anterolateral lumbar spine require a good working knowledge of the anatomy and anatomic variations of this region. As the iliolumbar vein is in the vicinity of both oblique and lateral transpsoas approaches to the lower lumbar spine, the following study was performed to better elucidate its anatomy, variations, and position during such surgical procedures., Methods: Fifteen (30 sides) fresh frozen adult cadavers underwent dissection of the iliolumbar vein (ILV). The origin, course, variants, relations, and morphometrics of each vein were documented. Fluoroscopy of the vessels was performed. Lastly, anterior oblique and lateral transpsoas approaches to the lumbar spine were carried out in order to evaluate for potential ILV injury., Results: An ILV was found on all but 2 sides (93.3%). It arose as a common trunk from the common iliac vein on 14 sides. Left ILVs tended to have a more distal origin than right ILVs. ILVs had a mean length of 3.7 cm and a mean width of 0.9 cm and were significantly larger on right versus left sides (P < 0.05). Left-sided ILVs tended to have more branches than right-sided veins. The majority of vertical branches of the ILV traveled anterior to the ventral rami of the lumbar spinal nerves, most commonly L4. The ILV and, in particular, its vertical branches coursed next to the L4 and L5 vertebrae., Conclusions: The ILV should be considered during both oblique and lateral transpsoas approaches to the lumbar spine., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Leiomyosarcomas of vascular origin are uncommon. They arise from the smooth muscles of tunica media of major blood vessels. Most of the cases are present in women. We report one such case of external iliac vein leiomyosarcoma in a 77-year-old female and discuss the clinical, radiological, and histopathological findings and the available treatment options., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Ilioiliac fistulae are a rare condition, for which diagnosis and treatment can be challenging. In this report, we describe the case of a 74-year-old patient with a high-flow fistula between the left common iliac artery and the ipsilateral common iliac vein presenting with heart failure. The fistula was probably iatrogenic, caused by prostatic surgery 1 year earlier. We describe imaging findings on computed tomography angiography and the treatment by 2 back-table reversed stent grafts. The satisfactory results demonstrated in our case and those in the literature suggest that an endovascular treatment for this rare condition should be considered as the first-line therapy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aneurysms of the iliac veins are very rare but are potentially fatal due to their potential to cause thromboembolic complications or even rupture. We herein report an unusual case of bilateral external iliac venous aneurysms in a 50-year-old male long-distance runner who presented with bilateral groin pain. The aneurysms were successfully treated with tangential aneurysmectomy with lateral venorrhaphy. Possible causes and management of iliac venous aneurysms are also discussed in this article., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Stent placements are considered as a treatment for post-thrombotic syndrome (PTS) with iliofemoral obstruction, but the application of these iliofemoral venous stents has also caused a lot of controversy. The purpose of this systematic review and meta-analysis was to summarise the efficacy and safety of venous stents in PTS with obstruction in iliofemoral venous segments., Methods: MEDLINE, EMBASE, and the Cochrane Central Register for Controlled Trials databases and key references were searched up to 15 January 2018. The main relevant outcomes included technical success, peri-operative complications, symptom resolution, a change of symptom scores, and long-term patency of the stents., Results: Overall, 504 limbs of 489 patients from seven studies were included in this study. A GRADE assessment showed the quality of the evidence was "very low" for 11 relevant outcomes. The technical success rate was 95%. The pooled rate of complications including 30 day thrombotic event, per-operative venous injury, and back pain was 3.4%, 18.14%, and 52%, respectively. The rates of ulcer healing, pain and oedema relief were 75.66%, 52%, and 42%, respectively. The primary, assisted primary and secondary patency rates were 83.36%, 90.59%, and 94.32%, respectively, at 12 months and 67.98%, 82.26%, and 86.10%, respectively, at 36 months., Conclusions: Endovenous stenting has the potential to be effective and has a low risk of peri-operative complications. The quality of evidence to support this treatment is very low. Endovenous iliofemoral stenting should be considered a treatment option for PTS with iliofemoral obstruction., (Copyright © 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: Iliac vein injury associated with pelvic fracture due to blunt trauma is an uncommon and difficult diagnosis but a life-threatening condition which often requires an emergent management. Although open repair has been traditionally used as the treatment of choice in unstable patients, it is controversial, given the difficulty due to injured vessel exposure in patients with significant retroperitoneal hematoma as well as tamponade effect loss associated with laparotomy. We present a challenging case of iliac vein laceration successfully treated by placement of a self-expanding covered stent., Methods: A 15-year-old male was hemodynamically unstable and was transferred to our emergency department after a severe polytrauma due to a motorcycle accident. Contrast-enhanced computed tomography showed a left external iliac vein laceration with active bleeding and retroperitoneal hematoma as well as complex pelvic and left supracondylar femoral fractures. A 13 × 100 mm self-expanding covered stent was successfully deployed through duplex ultrasound-guided percutaneous approach of both femoral veins., Results: The patient's blood pressure was normalized as soon as the stent graft was placed, and then femoral fracture was reduced and fixed. At 12-month follow-up, the patient remained asymptomatic, and stent-graft patency was confirmed., Conclusions: Covered stent-graft placement can be an effective and rapid treatment for life-threatening iliac vein injury., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Atrial septal device occluders such as amplatzer occluder have been designed to close atrial septal defects of paten formal ovale. Off label use of this device has been reported in pathological conditions that connect two vascular compartments with narrow neck. In this report, we describe a successful closure of a traumatically occurred AV fistula between iliac artery and iliac vein using amplatzer occluder device that has not been reported previously. This rare case is followed by a review of the literature., (Copyright © 2018. Published by Elsevier Inc.)

Posttraumatic reconstruction of large lower extremity veins is a challenging and rarely performed procedure. We describe a case of an 18-year-old male traffic accident victim presenting with extensive venous injury of the right inguinal region including external iliac vein and common femoral vein requiring immediate ligation. Owing to life-threatening phlegmasia cerulea dolens, venous reconstruction was successfully performed using an femoral vein interposition autograft from the contralateral lower limb., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Objective/background: The aim was to assess two year outcomes with placement of the Vici Venous Stent ® in patients with chronic iliofemoral venous occlusions (complete blockage)., Methods: This was a retrospective single centre study comprising patients treated with the Vici Venous Stent for venographically verified iliofemoral venous occlusion and post-thrombotic syndrome (Villalta score ≥ 5 points) at least 12 months after acute deep vein thrombosis. Venography and intravascular ultrasound were used peri-operatively; duplex ultrasound was used to assess stent patency during follow up., Results: Eighty-eight patients (101 limbs) had stent placement between March 2014 and October 2016. Median pre-treatment Villalta score was 14 (range 5-33). Stenting extended across the inguinal ligament in 63 limbs (62%) in order to land in a healthy venous segment. Six patients (7%) required endophlebectomy and fistula creation. Median imaging follow up was 21 months (range 0-41 months). Primary, assisted primary and secondary patency rates at one year were 59%, 78%, and 87%, respectively, and two years 51%, 73%, and 82%, respectively. Forty-three limbs (43%) had re-intervention (lysis, venoplasty, and/or placement of stent) during follow up; median time to re-intervention was 32 days (range 0-520 days). At 24 months, 37 of 53 limbs (70%) with available Villalta assessment showed clinically significant improvement (>30% reduction of baseline score). Villalta scores at the 6, 12, and 24 month clinical follow up were significantly lower than before stenting (p < .001, all time points). In a subset analyses of limbs with stenting terminating above and below the inguinal ligament, secondary cumulative patency rates at 24 months were 90% and 79%, respectively; clinical outcome showed 58% vs. 73% of limbs with clinically significant improvement, respectively. There was no statistically significant difference in patency or clinical outcomes., Conclusion: The Vici Venous Stent is associated with a good secondary patency rate and durable and substantial symptomatic resolution in patients with chronic post-thrombotic occlusions, regardless of whether stents extended beneath the inguinal ligament., (Copyright © 2018. Published by Elsevier B.V.)

Background: Phlegmasia cerulea dolens (PCD) is a severe complication of deep veions thrombosis, and there are several treatment methods. This study aimed to investigate the clinical efficacy of surgical thrombectomy and simultaneous iliac vein stent implantation for the treatment of PCD caused by iliac vein occlusion., Purpose: This study aimed to investigate the clinical efficacy of surgical thrombectomy and simultaneous iliac vein stent implantation for the treatment of phlegmasia cerulea dolens (PCD) caused by iliac vein occlusion., Methods: From February 2014 to December 2016, 5 patients with secondary PCD complicated with iliac vein occlusion were treated in our center. Thrombectomy by venous incision was performed with simultaneous iliac vein balloon dilatation and stents implantation. Efficacy and stents patency were assessed. Iliac vein occlusions were confirmed in all 5 patients by angiography after the thrombectomy. Stents implantation were performed after balloon dilatation. Three stents were implanted in 1 case of iliac vein and inferior vena cava (IVC) occlusion, whereas 1 stent was implanted in each of the other 4 cases., Results: Symptoms were significantly relieved after surgery, with no complications. Patients were followed up for 6-24 months, and minor swelling of the affected limb was found in 1 case, with no thrombosis recurrence in all cases and vascular stent patency., Conclusions: Thrombectomy by venous incision and simultaneous iliac vein stent implantation for the treatment of PCD caused by iliac vein occlusion can quickly relieve symptoms, is easily implemented, is associated with fewer complications, and has good midterm efficacy and a high patency rate, making this technique a good treatment method., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The first-line recommendation for the treatment of acute iliofemoral deep vein thrombosis (IFDVT) is catheter-directed thrombolysis or pharmacomechanical thrombolysis. Recent analysis of surgical thrombectomy has shown comparable results. However, this procedure is not commonly given as much importance as interventional techniques. We analyzed the patient outcome of surgical thrombectomy using modern endovascular techniques in both the short and long term., Methods: All consecutive patients who underwent surgical thrombectomy at our institution between April 2008 and April 2017 were included. Only patients with iliofemoral thrombosis, and only those with the first onset of symptoms <10 days, were analyzed. All patients received preoperative duplex ultrasound and contrast-enhanced computed tomography scans for thrombus extension and detection of pulmonary embolism. All operations were performed by vascular surgeons with open and endovascular skills in a C-arm-equipped operating room. During follow-up (FU), all patients received clinical examination for symptoms of postthrombotic syndrome (PTS), as well as duplex ultrasound., Results: Within a 9-year period, 21 patients underwent surgical thrombectomy for IFDVT (17 females/4 males). Primary technical success was 100%; 10 (47.6%) patients received additional primary stenting. 30-day mortality was 0%, 3 patients (14.3%) needed reoperation for early rethrombosis, while secondary 30-day patency was 100%. During FU (median, 6 years; range, 1-104 months), 1 patient received additional stenting for stenosis of the common iliac vein. Nineteen patients (90.5%) presented patent iliofemoral veins without signs of rethrombosis. Two patients (9.5%) died during FU of cancer without signs for recurrent IFDVT. All patients with patent veins were free of symptoms for PTS., Conclusions: Surgical thrombectomy for acute IFDVT is a successful, safe, and durable procedure and provides alternative treatment options for acute IFDVT in selected cases., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: The incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries., Methods: Patients in the National Trauma Data Bank (NTDB; 2007-2012) with at least one iliac vascular injury were analyzed. Isolated iliac vessels were defined as cases with Abbreviated Injury Scale severity score of greater than 3 for extraabdominal injuries and an Organ Injury Scale grade of greater than 3 for intraabdominal injuries., Results: Overall, 6262 iliac vascular injuries (2809 penetrating, 3453 blunt) were identified in 271,076 patients with abdominal trauma (2.3%). There were 3379 patients (1841 penetrating, 1538 blunt) with isolated iliac vascular injuries (1.2%) and 557 patients (514 penetrating, 43 blunt) with combined iliac artery and vein injuries (0.2%). The 30-day mortality rate was 16.5% for isolated iliac vein injury, 19.3% for isolated iliac artery injury, and 48.7% for combined isolated iliac artery and vein injury. The 30-day mortality rate was 23.4% for isolated iliac vascular injuries compared with 39.0% for nonisolated iliac vascular injuries (P < .001). Patients with isolated iliac vein injuries had morbidity rates of deep venous thrombosis (repair, 14.6%; ligation, 14.1%; P = .875), pulmonary embolism (repair, 1.8%; ligation, 0.5%; P = .38), fasciotomy (repair, 9.3%; ligation, 14.6%; P = .094), amputation (repair, 1.8%; ligation, 2.6%; P = .738), acute kidney injury (repair, 5.8%; ligation, 4.7%; P = .627). Multivariate logistic regression demonstrated that ligation of isolated iliac vein injuries had an odds ratio of 2.2 for mortality compared with repair (95% confidence interval, 1.08-4.66)., Conclusions: Isolated iliac vascular injuries are associated with a high incidence of mortality, especially for combined venous and arterial injury, but mortality is significantly lower than in patients with nonisolated iliac vascular injuries. In patients with isolated iliac vein injuries, mortality was higher in patients who underwent ligation compared with repair; however, the rates of deep venous thrombosis, pulmonary embolism, fasciotomy, amputation, and acute kidney injury were not different between the treatment groups. These data lend credence to the assessment that repair of iliac vein injuries is preferable to ligation whenever feasible., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Nutcracker syndrome, caused by mesoaortic compression of the left renal vein leading to symptoms related to venous hypertension, is an uncommon entity that may require operative intervention. Traditional open transposition of the left renal vein to the vena cava has been shown to have a reintervention rate of up to 30%, while also having additional morbidity associated with laparotomy. More recently, endovascular stenting has been described in several small series but have reported stent fracture, thrombosis, and migration., Methods: We report the case of a 26-year-old woman with 4 months of intermittent flank pain and hematuria, diagnosed with nutcracker syndrome by both duplex ultrasound and axial based imaging., Results: The patient underwent catheter venography confirming left renal vein compression, which also demonstrated a dilated gonadal vein measuring 11 mm leading to significant pelvic varices. Through a left lower quadrant retroperitoneal exposure, the gonadal vein was transposed to the left common iliac vein with completion venography demonstrating relief of renal venous congestion. The patient was discharged uneventfully with immediate resolution of symptoms and remains symptom-free at 6-month follow-up., Conclusions: Gonadal vein transposition is an effective alternative surgical treatment for nutcracker syndrome., (Published by Elsevier Inc.)

Background: Rates of major venous injury are now being reported at between 1% and 15%. Risk factors for injury include the previous spine surgery, level of exposure, and number of retractors used. To review and describe the evolution of our use of stent grafts for repair of life-threatening ilio-caval injuries encountered during anterior exposure lumbosacral (L-S) spine surgery from rescue utilization after failed direct repair to preferred modality using occlusion balloons and covered stents akin to the modern management of the ruptured abdominal aortic aneurysm (AAA) with endovascular aneurysm repair., Methods: Five-year retrospective review of all anterior and retroperitoneal spine procedures was performed at our institution., Results: One hundred two procedures were done. Major ilio-caval injury occurred in 3/102 (2.9%) cases. Average blood loss per case decreased as our approach evolved from unsuccessful direct open repair with percutaneous endovascular rescue to primary percutaneous endovascular repair. All treated patients had patent venous repair in short-term follow-up with computed tomography angiography., Conclusions: Identification and rapid direct repair of major ilio-caval injuries during anterior approach spine surgery can be extremely challenging. When control of these potentially fatal injuries is required, our choice is primary endovascular repair using the modern techniques for endovascular management of ruptured AAA with endovascular aneurysm repair., (Copyright © 2017 Elsevier Inc. All rights reserved.)

We report the endovascular treatment of an arteriovenous fistula involving the right common iliac artery (CIA) and left common iliac vein in a 48-year-old male patient who had previously undergone lumbar spine disc surgery. A balloon expandable covered stent was deployed in the CIA which got partially dislodged into the aorta during attempted postdilatation of the stent. The proximal end of the stent was secured in place with an inflated balloon in the aorta, introduced from the contralateral iliac artery, allowing successful retrieval and dilatation of the stent graft through the ipsilateral femoral vascular access. The stent migration was managed without complications, and the fistula was successfully occluded., (Copyright © 2017 Elsevier Inc. All rights reserved.)