Abstract Radiation-induced venous stenosis is rare, with only a few cases reported in the literature. We report a case of radiation-induced venous stenosis of the bilateral iliac vein after radiation therapy for the treatment of recurrent bladder cancer. The patient was successfully treated using endovascular kissing stents. Endovascular treatment , Kissing stents , Radiation-induced venous stenosis INTRODUCTION Radiation-induced venous stenosis is extremely rare . The treatment of venous stenosis or occlusion after radiation therapy has not been established. Few reports on endovascular treatments for radiation-induced iliofemoral vein stenosis exist in the literature [1–3]. We report a case of bilateral common iliac vein (CIV) stenosis after radiation therapy for recurrent bladder cancer that was successfully treated using endovascular ‘kissing stents’. CASE REPORT An 86-year-old man who underwent transurethral resection of the bladder 2 years ago was diagnosed with recurrent bladder cancer. He underwent a 2nd transurethral resection of the bladder and received a cumulative dose of 5000 cGy radiation to the bladder and whole pelvis. One month after radiation therapy, he complained of right leg swelling, which did not improve with medication after 3 months. Abdominal computed tomography (CT) both before and 1 month after radiation therapy and lower extremity CT venography 3 months after radiation therapy revealed progressive narrowing of the bilateral CIV and attenuation of the distal infrarenal inferior vena cava (IVC) without evidence of metastases around the iliocaval confluence (Fig. 1). Figure 1: View largeDownload slide Serial abdominal computed tomography both before (A) and 3 months after radiation therapy (B) showing progressive narrowing of the bilateral iliac vein (arrows). Figure 1: View largeDownload slide Serial abdominal computed tomography both before (A) and 3 months after radiation therapy (B) showing progressive narrowing of the bilateral iliac vein (arrows). Venography demonstrated bilateral CIV stenosis just below the IVC confluence with the development of the collateral veins. Two self-expandable metal stents of 10 mm × 8 cm in size (Epic, Boston Scientific, MA, USA) were inserted and simultaneously released side-by-side into the IVC and distally into each CIV. Post-dilatation of the stents was performed simultaneously using 10-mm balloon catheters (Mustang, Boston Scientific, MA, USA). The final venography revealed improvement in stenosis and disappearance of the collateral veins (Fig. 2). He was discharged 1 day later without complications. Right leg swelling improved after 2 weeks. Two months after the procedure, a follow-up CT revealed a ‘figure eight’ appearance of the stents in the IVC and preserved stent expansion in the bilateral CIV. Figure 2: View largeDownload slide Venography (A and B) showing bilateral common iliac vein stenosis (arrows) with the collateral veins (arrowheads). Kissing stents were placed from the inferior vena cava to the bilateral iliac vein. The final venography (C and D) revealed resolution of stenosis (arrows) and disappearance of the collateral veins. Figure 2: View largeDownload slide Venography (A and B) showing bilateral common iliac vein stenosis (arrows) with the collateral veins (arrowheads). Kissing stents were placed from the inferior vena cava to the bilateral iliac vein. The final venography (C and D) revealed resolution of stenosis (arrows) and disappearance of the collateral veins. DISCUSSION Radiation-induced vascular disease can result in progressive stenosis due to damage of the endothelium and surrounding tissue . Peripheral arterial disease as a late complication of radiation therapy is a well-known vasculopathy. Proposed pathogenesis of radiation-induced arterial disease is that injury of the vasa vasorum causes hypoxia in the vessel wall, which in turn induces intimal and smooth muscle proliferation . However, the relevance of this pathological mechanism in radiation-induced venous stenosis is unclear because of the lack of the vasa vasorum and little smooth muscle in the vein wall . In our case, serial CT revealed rapid progression of bilateral CIV stenosis, which is consistent with a previously reported case by Zhou et al. . These cases suggest the involvement of a different mechanism because radiation-induced arterial stenosis usually occurs several years after radiotherapy . Future studies to determine the exact mechanism of radiation-induced venous stenosis are thus warranted. Carlson et al.  reported cases of pelvic venous stenosis due to post-radiation fibrosis. However, the diagnosis of radiation-induced venous stenosis was unclear because the patients had undergone previous pelvic surgeries for gynaecological malignancies. In our case, the patient underwent only transurethral resection of the bladder, which did not cause fibrosis around venous structures. Also, short-term serial follow-up CT revealed progression of CIV stenosis after radiation therapy without evidence of metastases. This case clearly demonstrates radiation-induced CIV stenosis. In our case, evidence of deep vein thrombosis was not observed; however, only venous flow disturbances that caused leg swelling were observed. In this circumstance, restoration of venous flow by resolving the anatomical defect was important. Carlson et al.  reported 5 cases of unilateral iliac vein stenosis, which were treated using stents, although the diagnosis was unclear. Three other cases applied stent deployment in the iliofemoral vein [1–3]. This case is the first to report the use of kissing stents for radiation-induced bilateral CIV stenosis. The first reason for bilateral stenting, despite unilateral leg swelling, is that contralateral CIV narrowing rapidly progressed on serial CT follow-up. Additionally, the stenosis was evident below the iliocaval confluence, and the IVC was attenuated. Patients with iliocaval confluence obstructions are best managed using bilateral kissing stents . This case demonstrates radiation-induced venous stenosis at the iliocaval confluence without evidence of deep vein thrombosis and metastases. Contrary to radiation-induced arterial stenosis, radiation-induced venous stenosis occurs early after radiation therapy. An endovascular intervention using kissing stents is effective for radiation-induced venous stenosis at the iliocaval confluence. Conflict of interest: none declared. REFERENCES 1 Elias HK , Jan MF , Allaqaband SQ. Role of endovascular stenting in radiation-induced stenosis of lower extremity veins . Catheter Cardiovasc Interv 2015 ; 86 : 312 – 5 . Google Scholar CrossRef Search ADS PubMed 2 Franklin WJ , Strickman NE , Hall RJ. Stent deployment for peripheral venous stenosis as a result of radiation therapy . Catheter Cardiovasc Interv 2003 ; 59 : 60 – 2 . Google Scholar CrossRef Search ADS PubMed 3 Zhou W , Bush RL , Lin PH , Lumsden AB. Radiation-associated venous stenosis: endovascular treatment options . J Vasc Surg 2004 ; 40 : 179 – 82 . Google Scholar CrossRef Search ADS PubMed 4 Carlson JW , Nazarian GK , Hartenbach E , Carter JR , Dusenbery KE , Fowler JM et al. Management of pelvic venous stenosis with intravascular stainless steel stents . Gynecol Oncol 1995 ; 56 : 362 – 9 . Google Scholar CrossRef Search ADS PubMed 5 Neglen P , Darcey R , Olivier J , Raju S. Bilateral stenting at the iliocaval confluence . J Vasc Surg 2010 ; 51 : 1457 – 66 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Interactive CardioVascular and Thoracic Surgery – Oxford University Press
Published: Apr 20, 2018
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