Is venoplasty needed for this patient?

Is Venoplasty Needed?

Venoplasty is indicated when there is hemodynamically significant venous stenosis causing clinical symptoms or access dysfunction, with specific indications varying by anatomic location and clinical context.

Hemodialysis Access-Related Venous Stenosis

Central Vein Stenosis

• Percutaneous transluminal angioplasty is the preferred treatment for central vein stenosis in hemodialysis patients 1
• Venoplasty is indicated when central vein stenosis causes decreased dialysis access flow rates, upper limb swelling, or threatens access patency 2
• Stent placement combined with angioplasty should be added for elastic stenoses (those that recoil >50% after balloon dilation) or if stenosis recurs within 3 months 1
• Surgical treatment of central vein stenosis requires thoracotomy and should be avoided 1

Peripheral Access Stenosis

• For arteriovenous grafts (AVG), venoplasty is indicated when stenosis >50% is associated with abnormal physical findings, decreasing intragraft blood flow (<600 mL/min), or elevated static pressure 1
• Residual stenosis after thrombosis must be corrected by angioplasty or surgical revision, as 85% of graft thromboses have underlying venous stenosis 1
• Repeated venoplasty becomes ineffective when more than two interventions are required within a 3-month interval—at this point, surgical revision should be pursued 1

Expected Outcomes for Dialysis Access

• After venoplasty for AVG stenosis without thrombosis: aim for <30% residual stenosis and 50% primary patency at 6 months 1
• After thrombosis treatment with venoplasty: expect 40% unassisted patency at 3 months for percutaneous approaches 1
• Central venoplasty typically requires repeat procedures at average intervals of 7 months, with assisted primary patency of 87% at 6 months declining to 42% at 24 months 2

Iliofemoral Deep Vein Thrombosis and Post-Thrombotic Syndrome

Acute DVT Setting

• Stent placement in the iliac vein to treat obstructive lesions after catheter-directed thrombolysis or surgical thrombectomy is reasonable 1
• For isolated common femoral vein lesions, trial percutaneous transluminal angioplasty without stenting first 1
• Venoplasty with stenting is particularly effective for iliac vein compression syndrome (May-Thurner syndrome) found in association with left-sided iliofemoral DVT 1

Chronic Post-Thrombotic Syndrome

• Iliac vein stent placement is reasonable to reduce post-thrombotic syndrome symptoms and heal venous ulcers in patients with advanced disease and iliac vein obstruction 1
• Recent evidence shows venoplasty with US-accelerated thrombolysis for chronic femoral DVT produces statistically significant improvement in Villalta scores at 30 and 365 days 1
• When recanalizing femoral and popliteal veins for chronic post-thrombotic changes, angioplasty is typically first-line treatment 1
• Stent patency extending below the inguinal ligament into the common femoral vein is only slightly reduced compared to iliac-only stenting (90% vs 84%) 1

Critical Considerations

• Patients with prior ipsilateral tunneled dialysis catheters have less favorable outcomes with shorter time to repeat procedures 2
• Full-dose anticoagulation should be maintained throughout and after recanalization due to the highly thrombotic environment 1
• Final stent diameter matters—diameters of 8-10 mm are associated with better long-term patency 1

Cardiac Device-Related Venous Obstruction

• Venoplasty is a viable alternative to transvenous lead extraction for symptomatic lead-related venous stenosis unresponsive to >30 days of anticoagulation 3, 4
• Complete symptom resolution occurs in 72% of patients, with better outcomes when intervention occurs earlier (195 vs 690 days from symptom onset) 4
• Most patients (83%) require lead extraction before venoplasty, and durability is best when leads no longer cross the stenosed region 4

Pediatric Applications

Portal Vein Stenosis

• Percutaneous transhepatic portal venoplasty is the procedure of choice for portal vein stenosis in children with reduced-size liver transplants 5
• Technical success achieved in 73% of cases, with portal vein patency maintained for mean 20 months 5
• Intravascular stents should be placed for elastic stenoses or recurrent stenosis (mean 6.3 months to restenosis) 5

Systemic Venous Stenosis

• Stenting is indicated for significant systemic venous obstruction between the clavicles and inguinal ligaments 1
• Balloon angioplasty alone is reasonable for peripheral venous obstruction in areas subject to bending/flexing (neck, axilla, groin) where stents may collapse 1
• Initial balloon angioplasty may be necessary to allow access for larger sheaths needed for stent delivery 1

Key Pitfalls to Avoid

• Do not delay treatment of thrombosed access—intervention should occur rapidly to minimize need for temporary catheters (no more than one femoral catheter placement) 1
• Always perform fistulography post-thrombectomy to identify and correct residual stenosis—failure to do so results in rapid re-thrombosis 1
• Monitor for heparin-induced thrombocytopenia, which occurs in up to 20% of portal vein thrombosis patients treated with unfractionated heparin 1
• Venoplasty is less effective for secondary lymphedema, emphasizing the need for timely intervention before irreversible changes occur 4
• Systemic venous stents can collapse if exposed to flexing/bending and will thrombose if adequate flow is not established at implantation 1