Venous (V) Stenting: Clinical Indications
Venous stenting is indicated for significant systemic venous obstruction located between the clavicles and inguinal ligaments (Class I recommendation), with the strongest evidence supporting iliac vein stenting for post-thrombotic syndrome and acute deep vein thrombosis management. 1
Primary Indications by Anatomic Location
Iliac Vein Stenting (Strongest Evidence)
Class I Indication:
- Relief of significant systemic venous obstruction inferior to the clavicles and above the inguinal ligaments 1
Class IIa Indications:
- Obstructive lesions after catheter-directed thrombolysis (CDT), pharmacomechanical CDT (PCDT), or surgical venous thrombectomy for acute iliofemoral deep vein thrombosis (IFDVT) 1
- Advanced post-thrombotic syndrome (PTS) with iliac vein obstruction to reduce symptoms and heal venous ulcers 1
- May-Thurner syndrome (iliac vein compression syndrome) identified during acute IFDVT treatment 1
Common Femoral Vein
Class IIa Indication:
- Caudal stent extension into common femoral vein is reasonable when unavoidable for treating iliac vein lesions that extend distally 1
- For isolated common femoral vein obstruction, trial percutaneous transluminal angioplasty without stenting first 1
Pulmonary Veins
Indicated for:
- Pulmonary vein stenosis (congenital or acquired after cardiac surgery, lung transplantation, or radiofrequency ablation for atrial fibrillation) 1
- Stents achieve 95% success rate versus 42% for angioplasty alone, with lower restenosis (33% vs 72%) 1
- Final stent diameter ≥10 mm significantly reduces restenosis risk 1
Cerebral Venous Sinuses
Strong Recommendation:
- Idiopathic intracranial hypertension (IIH) with documented venous sinus stenosis and pressure gradient on manometry 1
- Requires medically refractory symptoms (headaches, papilledema, visual symptoms, tinnitus) despite maximum medical therapy 1
- Must confirm hemodynamically significant stenosis with pressure gradient measurement before stenting 1
Clinical Scenarios Requiring Urgent/Emergent Stenting
Class I (Immediate):
Class IIa (Urgent):
- Rapid thrombus extension despite anticoagulation 1
- Symptomatic deterioration from IFDVT despite anticoagulation 1
Contraindications and Cautions
Avoid Stenting in These Locations:
- Peripheral veins subject to bending/flexing (neck, axilla, groin) - high risk of stent collapse 1
- Femoral vein below inguinal ligament unless absolutely unavoidable (reduced patency: 90% vs 84% for iliac-only) 1
- Very small peripheral veins in small patients - use balloon angioplasty alone 1
High-Risk Situations:
- Perioperative period - increased thrombosis risk 1
- Inadequate flow establishment at implantation - leads to early thrombosis 1
- Chronic DVT symptoms >21 days - CDT/PCDT with stenting not recommended 1
Post-Stenting Management
Class IIa Recommendations:
- Therapeutic anticoagulation with same dosing, monitoring, and duration as IFDVT patients without stents 1
- Target INR 2.0-3.0 if using warfarin, or consider direct oral anticoagulants 2
Class IIb Recommendation:
- Add antiplatelet therapy to anticoagulation for patients at particularly high risk of rethrombosis (poor inflow vein quality, imperfect anatomic result) after individualized bleeding risk assessment 1
- Continue antiplatelet therapy for at least 3-6 months post-stenting 1
Key Clinical Pearls
Common Pitfalls:
- Do not rely solely on CT venography or MR venography to determine stenting candidacy - sensitivity <50% for detecting hemodynamically significant stenosis 1
- Always perform venous manometry to confirm pressure gradient before stenting 1
- Stent displacement and embolization more likely in compliant systemic veins compared to arteries 1
- Post-stenting manometry should confirm gradient resolution 1
Optimal Outcomes: