Quickshot: Venous Ulcers: How Many Patients Have Suprainguinal Iliac Disease?

Various indirect methods have been employed to determine if patients with venous ulcers have more proximal iliac disease. Methods used have reported an average about 25% having significant disease. Most have been indirect: transabdominal ultrasound, MRV or CTV. Often the patients are NPO and dehydrated. This retrospective study uses direct methods of ascending venography and intravascular ultrasound (IVUS) liberally and early on the in care of C6 patients to better define which patients have significant iliac disease.



Methods:

At our institution the Center for Vein Disease and the Wound Center co-exist in concept and reality. Our vein specialist and wound specialists see patients in the same location. Venous ulcers are identified in the first few visits. The vein specialist is consulted early and venous studies are done: ultrasound from diaphragm to ankle. MRV or CTV are done selectively but not routinely.

The liberal and early use of venography and IVUS is employed. This retrospective study evaluated 42 consecutive C6 patients who underwent this algorithm. Almost all procedures were done as diagnostic and not as intent-to-treat. All patients received 500 – 700 milliliters of fluid prior to procedure.  Intraprocedure provocative measures were used to better identify true lesions.



Results:

The records of 42 patients were analyzed. 22 were male. Average age was 68 and BMI 32. A history of DVT was identified in 10.


27 patients (64%) had >50% narrowing. Further analysis showed that 20 of the 27 (48%) had >60% stenosis/post-thrombotic findings. A total of 15 had stents placed with an average stenosis of 69%. All stented patients healed their ulcers.


Conclusions:

This study is purposely narrow in focus to answer the question: “What percentage of patients with ulcers have significant iliac disease?” using the current “gold standard” of venography and IVUS. Indirect studies have reported around 25% with iliac disease. We have identified a greater percentage than previously reported (48% with >60% stenosis). This paper does not and was not intended to answer when during care stenting should be done. This issue will be briefly discussed at presentation. Our policy of early and comprehensive evaluation of C6 patients gives physicians the complete picture of disease so they can make better educated decisions. If a patient has a gangrenous toe, the arterial system during angiography is evaluated from aorta to toes. Our policy does the same for C6 patients. A policy of early direct evaluation of C6 patients should be considered as almost half will have significant iliac vein disease.