Hybrid Common Femoral Vein Endophlebectomy and Iliac Vein Stenting Versus Femoro-Femoral Venous Bypass for Management of Chronic Iliofemoral Venous Occlusion

Abstract

Background:

Balloon angioplasty and stenting are viable and practical options for managing post-thrombotic iliofemoral venous occlusion in most cases. However, common femoral vein (CFV) occlusion and extension of trabeculation into the profunda femoris vein (PFV) or femoral vein (FV) can impair venous drainage, thus increasing the risk of iliac vein rethrombosis and stent occlusion.

Aim:

To present our results for management of chronic advanced post-thrombotic iliofemoral occlusion by comparing hybrid CFV endophlebectomy and iliac vein stenting with femoro-femoral cross-over venous bypass.

Methods:

This was a prospective randomized clinical trial comparing CFV endophlebectomy and iliac vein stenting (group 1) with femoro-femoral cross-over venous bypass (group 2). The study was conducted at a tertiary center during the period from June 2023 to August 2025. Patients were evaluated using Clinical, Etiology, Anatomy, and Pathophysiology classification, the revised Venous Clinical Severity Score, the Villalta scale, and Venous Insufficiency Epidemiological and Economic Study—Quality-of-Life/Symptoms questionnaire. Primary objectives included primary patency and changes in the aforementioned scores. Secondary objectives included secondary patency and perioperative complications.

Results:

A total of 49 patients were included (24 in group 1 and 25 in group 2). Median follow-up was 17 months (range=6–26 months). Primary patency at 12 months was statistically non-significant for both groups (81.5% in group 1 vs 75.9% in group 2, log rank p=0.432). Secondary patency rate at 1 year was 90.8% for group 1, whereas reintervention in group 2 was not possible to restore patency. Perioperative complication rates were higher in group 2, with no statistically significant differences between the 2 groups. Both interventions resulted in significant functional and QoL improvement across the clinical scores (p<0.001 in each group) with greater improvement observed in group 1.

Conclusion:

Both CFV endophlebectomy with iliac vein stenting and femoro-femoral venous bypass were feasible, safe, and effective treatment strategies for chronic iliofemoral venous occlusion with compromised venous inflow. Hybrid reconstruction represented a less invasive strategy, as reflected by shorter operative time and reduced hospital stay. This approach was associated with greater improvement in clinical outcome scores and preserved the feasibility of endovascular reintervention.

Clinical Impact

Both hybrid reconstruction and femoro-femoral venous bypass are associated with meaningful improvements in quality-of-life measures in selected patients with chronic iliofemoral venous obstruction and compromised venous inflow. Although improvements across clinical and patient-reported outcome scores were greater following the hybrid approach, femoro-femoral cross-over bypass remains a valuable bailout technique in cases where endovascular or hybrid intervention fails or is not possible.