Asma Khaliq1, Sandrine Labrune1, and Cristina Sanina2 1 Department of Cardiology, Lenox Hill Heart & Vascular Institute, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, New York, NY, USA 2 Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA There three major type of outflow obstruction: 1) Post‐thrombotic non‐occlusive obstruction; 2) Post‐thrombotic occlusive; 3) Non‐thrombotic iliac vein lesions (May‐Thurner Syndrome). Post‐thrombotic syndrome (PTS) (non‐occlusive and occlusive) occur as a complication of acute deep vein thrombosis manifesting in leg pain that limits activity, edema, and leg ulcers. PTS will develop in 20–50% of patients and severe PTS, including venous ulcers in up to 10% of patients [1]. Risk of PTS is high with proximal DVT involving iliac or common femoral vein [2]. The Villalta scale has been developed, used and validated to diagnose PTS (Table 15.1) [3]. In selected patients with severe PTS endovascular treatment of chronic femoroiliocaval venous disease can be safely performed with acceptable patency result and symptoms alleviation [4]. For May‐Thurnes syndrome (non‐thrombotic left common iliac vein compression by right common iliac artery [Figure 15.1]), endovascular treatment is highly successful, leading to significant clinical improvement: 50% of patients has symptoms resolution, 33% experience symptoms relieve and 55% has complete healing of venous ulcers. Patency of iliac stent is 75% in 3 years. Close follow‐up is mandatory to recognize the recurrence of the symptoms which can indicate stent thrombosis or re‐stenosis [5, 6]. Step 1. Place the patient in the supine position for planned femoral vein access in case of iliofemoral DVT. Choose prone positioning if planning on popliteal vein access. The popliteal vein is located in the popliteal fossa between the popliteal artery and tibial nerve. Generally, the vein is lateral to the artery proximally in the popliteal fossa and medial to the popliteal artery distally. Table 15.1 Villalta PTS Scale. Source: Adopted from Utne et al. [3]. Figure 15.1 CT scan axial view showing left common iliac vein (CIV) compression by right common iliac artery (CIA). Source: Case courtesy of Donna D’Souza, Radiopaedia.org, rID: 4373. TIP: Place the patient in a slight reverse Trendelenburg position. It helps dilate the vein for easier puncture. Step 2. Anesthesia: Light conscious sedation is favored over general anesthesia. Step 3. Intraprocedural use of anticoagulation. Step 4. Use the ultrasound to identify the best femoral vein access point:
15
Lower‐Extremity Venous Stenting
Introduction
Villalta PTS scale
Assessment of:
Severity of each symptom and sign is rated as 0 (absent), 1 (mild), 2 (moderate), or 3 (severe). In addition, ulcer is noted as present or absent.
Points are summed to yield the total Villalta score:
0–4:
No PTS
5–9:
Mild PTS
10–14:
Moderate PTS
≥15, or presence of ulcer
Severe PTS 
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