Presenter: Professor Oliver Schlager

Hospital: Division of Angiology, Medical University of Vienna

Abstract

This article analyzes key challenges in May-Thurner syndrome (MTS) management, emphasizing IVUS-guided decision-making and evidence-based application of Zilver Vena stent for iliofemoral obstruction. Data-driven strategies address venous outflow pathology.

Introduction

"Angiographic signs cause overtreatment: 63% of physicians misinterpret venous grooves in healthy youth as stenosis." (van Vuuren et al. 2018)

Prof. Schlager warns: MTS/NIVL diagnosis requires moving beyond traditional imaging—

31.4% of asymptomatic individuals have iliac compression (Murtha 2024)

Duplex sensitivity for NIVL is only 58% (IVUS as gold standard)

Stenting demands strict criteria: >50% stenosis + symptoms

Research Insights: Three Critical Challenges

1.Diagnostic Pitfalls

High false-positive rate: 80% of healthy youth show "compression signs" (angiography)

Imaging accuracy comparison:

ESVS Guideline: IVUS-guided intervention (Class IIa)

2.Symptom-Stenosis Mismatch

37% of CEAP C5/C6 (venous ulcer) patients have MTS/NIVL

No significant correlation between stenosis severity and symptoms (p>0.05):

CEAP vs stenosis: r=0.4 (p=0.002)

VCS vs stenosis: r=0.1 (p=0.002)

3.Overtreatment Risks

Inconsistent thresholds across trials (VERNACULAR: unspecified vs VIRTUS: ≥50%)

Alert: 40% of physicians stent based solely on "translucent groove" sign (80% false-positive in healthy)

Solution: Zilver Vena Stent's Evidence Edge

1.Precision Indication

FDA approval requires >50% symptomatic stenosis

Prevents NIVL overtreatment (31.4% compression in asymptomatic)

2.Anatomy-Adaptive Design

Balanced flexibility-strength:

Conforms to Type I-III compression (lateral 70%/central 21%/partial occlusion 9%)

Fracture resistance for long-term patency (critical for inguinal ligament crossing)

Addresses warning: "Stent across ligament increases patency loss risk by 4.36-fold"

3.IVUS-Integrated Lifelong Care

Cook Medical commitment: "Investing in IVUS-guided training"

Aligns with Schlager's principle: Embed stents in comprehensive follow-up

40% post-stent patients retain venous claudication

CEAP C4-C6 cases require combined superficial/perforator intervention

Conclusion

1.Diagnostic Upgrade: Adopt IVUS as gold standard (95% sensitivity for NIVL)

2.Strict Selection: Stent only symptomatic >50% stenosis (CEAP≥C3)

3.Optimized Device: Zilver Vena’s anatomic compliance reduces complications

4.Holistic Management: Couple hemodynamic assessment + superficial vein intervention