Servier – Phlebolymphology

VIII. Debates session

For the motion
Gerard O’Sullivan (Galway, Ireland)
Venography and pressure gradient, noninvasive imaging, laboratory studies, clinical examination, and symptom history help achieve a diagnosis. Approximately 75% of patients <18 years old have complete resolution of their symptoms by using conservative treatment. Reed et al¹ showed that, at the 39-month follow-up, left renal vein transposition surgery results in 80% of patients having flank pain and 100% with hematuria improvement. Laparoscopic treatment and endovascular treatment, which achieves a 97% improvement in the symptoms, are other options. Dislodgement, complete migration, thrombosis, restenosis, vessel perforation, and visceral injury are complications of stenting. In conclusion, with current technology, stent placement is not safe in the medium or long term.

References:
1. Reed NR, Kalra M, Bower TC, Vrtiska TJ, Ricotta JJ 2nd, Gloviczki P. Left renal vein transposition for nutcracker syndrome. J Vasc Surg. 2009;49(2):386-393.

Against the motion
Olivier Hartung (Marseille, France)
Nutcracker syndrome is an underdiagnosed disease. It is a functional pathology that is not life threatening and it does not carry the risk of renal insufficiency. Interventional treatment options are surgery and stenting. Endovascular treatment is quick and done under local anesthesia/sedation and by using a femoral or jug> which can occur early, but also as late as 5 months; 2 of the stents migrated into the heart. There are multiple surgical techniques, such as left renal vein (LRV) transposition, LRV transposition±patch/cuff, and LRV transposition±patch±stent, LRV-inferior vena cava bypass, left gonadal vein transposition, superior mesenteric artery transposition, auto-transplantation, and nephrectomy. Surgery is invasive, but can be performed by mini laparotomy, laparoscopy-assisted surgery, total laparoscopic surgery, and robotic-assisted surgery, which reduces the length of stay and improves cosmetic results. Somehow, stenting is efficient in the treatment of residual stenosis/restenosis after a surgical procedure; however, in the Nutcracker syndrome where there is aortic prominence and kidney down into the lumbar fossae, the problems, such as indefinite size and length and lack of fixation, such as deployment in the first branch, make stents an unsure option. In the future, dedicated stents may solve these problems. In conclusion, in this functional disease, although there is a risk for stent migration and surgery is not perfect and invasive, all that is needed is a dedicated stent.

References:
1. Wu Z, Zheng X, He Y, Fang X, Li D, Tian L, Zhang H. Stent migration after endovascular stenting in patients with nutcracker syndrome. J Vasc Surg Venous Lymphat Disord. 2016;4(2):193-199.

For the motion
Manj Gohel (Cambridge, UK)
Iliofemoral deep vein thrombosis (DVT) is an important and disabling condition that is associated with developing severe post-thrombotic syndrome in some patients. Aggressive thrombus removal strategies can provide excellent technical and clinical success, but the question is how many cases of severe post-thrombotic syndrome could be prevented with this approach. The CaVenT study (Catheter-directed Venous thrombolysis in acute iliofemoral vein Thrombosis) compared standard DVT treatment with adjunctive use of catheter-directed thrombolysis. The 5-year follow-up showed a significant reduction in the rate of post-thrombotic syndrome (42.5% vs 70.8%) with very few cases of severe post-thrombotic syndrome (4/37 vs 1/63) and no differences in terms of quality of life. The ATTRACT trial (Acute venous Thrombosis: Thrombus Removal with Adjunctive Catheter directed Thrombolysis) compared different techniques of pharmacomechanical catheter directed thrombolysis with standard treatment in patients with femoropopliteal and iliofemoral DVT and found no difference in the rate of post-thrombotic syndrome as shown by the Villalta score between 6 and 24 months (47% vs 48%). The same results were found in the subgroup of patients with iliofemoral DVT (44% vs 45%). Despite some differences in the rate of moderate-to-severe post-thrombotic syndrome (18% vs 28%) and severe post-thrombotic syndrome (8.7% vs 15%), the number of patients with such complications was rather small and the number needed to treat to prevent one moderate or severe post-thrombotic syndrome was 10. Thus, most patients with iliofemoral DVT do not develop significant post-thrombotic syndrome, and aggressive treatment of this entire group would only prevent a small number of patients from developing post-thrombotic syndrome.

Against the motion
Michael Lichtenberg (Arnsberg, Germany)
Thrombectomy is safe and effective because it decreases pain and swelling in the early period and reduces moderate-to-severe post-thrombotic syndrome in the long-term follow-up. The maximal benefits of the thrombectomy may be observed with the use of mechanical or pharmacomechanical techniques in patients with a descending venous thrombus that occurs in the background of a venous obstruction. The standard conservative treatment with anticoagulants and compression stockings cannot prevent post-thrombotic syndrome, especially after a proximal DVT. However, in the ATTRACT trial, adjunctive use of pharmacomechanical catheter-directed thrombolysis leads to a significant decrease in the incidence of moderate-to-severe post-thrombotic syndrome (17.9% vs 23.7%), especially in patients with iliofemoral DVT (18.4% vs 28.2%). The main conditions to achieve good results from a thrombectomy include choosing the right patients(ie, those with a descending DVT) using mechanical or pharmacomechanical techniques instead of catheter-directed thrombolysis, and treating the underlying pathology with venous stenting. The analysis of the BERN venous registry including only patients with descending DVT vs the CaVenT and ATTRACT trials (100% vs 48% and 57%, respectively) with the high rate of venous stenting (80% vs 17% and 30%, respectively) show the very low incidence of post-thrombotic syndrome at 12 to 24 months (6% vs 41% and 47%, respectively). The results of the ASPIREXR device use from the Arnsberg registry support this evidence and provide a low incidence (36%) of post-thrombotic syndrome at 12 months. Therefore, there is excellent evidence for thrombectomy of descending iliofemoral DVT, which is supported by the ATTRACT subanalysis and register studies and the novel thrombectomy devices have the potential to displace the standard pure catheter-directed thrombolysis techniques by providing better results with a one-step treatment approach.