Phlebologie 2019; 48(04): 237-244
DOI: 10.1055/a-0895-2425
Übersicht / Review
© Georg Thieme Verlag KG Stuttgart · New York

What is the value of APG in the diagnosis of iliac vein obstruction?

Article in several languages: deutsch | English
Erika Mendoza
1   Venenpraxis Wunstorf
Christopher R. Lattimer
2   Josef Pflug Vascular Laboratory, Ealing Hospital, Middlesex, UK, Department of Surgery and Cancer, Imperial College, London, UK
3   West London Vascular and Interventional Centre, Northwick Park Hospital, Harrow, UK
› Author Affiliations
Further Information

Publication History

09 April 2019

25 April 2019

Publication Date:
24 May 2019 (online)


It looks like treatment of central venous obstruction has become easy since the introduction of iliac stenting procedures. However, this treatment includes a minimum period of anticoagulation and the stent is for life. Furthermore, there are no accepted criteria for evaluation of the results. It is difficult also to establish robust indications of stenting especially since 25 % of the normal population have a diameter reduction > 50 % in the left iliac vein.

Another confounding fact is that chronic venous insufficiency (CVI) can be the consequence of multiple simultaneous pathologies, like varicose veins, obstruction and deep venous reflux. Thus, the treatment of one of these may not have a significant clinical effect if the cause is multifactorial.

Air Plethysmography (APG) is an objective, non-invasive and patient independent investigation of venous drainage. This includes gravitational filling (venous filling index) and elevation emptying (venous drainage index) all in the same test. This investigation should be performed as a screening test, prior to deep venous stenting and also as a follow-up instrument.

  • Literatur / References

  • 1 Gaweesh AS. Impeded venous drainage: novel view of chronic venous disease pathophysiology. Med Hypotheses 2009; 73: 548-552
  • 2 Lattimer CR, Kalodiki E, Mendoza E. Gravitational venous drainage is significantly faster in patients with varicose veins. Phlebology 2016; 31: 546-553
  • 3 Kibbe MR, Ujiki M, Goodwin AL. et al. Iliac vein com- pression in an asymptomatic patient population. J Vasc Surg 2004; 39: 937-943
  • 4 Lattimer CR, Mendoza E, Kalodiki E. The current status of air-plethysmography in evaluating non-thrombotic iliac vein lesions. Phlebology 2018; 33: 3-4
  • 5 Lattimer CR, Kalodiki E, Kafeza M. et al. Quantifying the degree graduated elastic compression stockings enhance venous emptying. Eur J Vasc Endovasc Surg 2014; 47: 75-80
  • 6 Gianesini S, Zamboni P, Mendoza E. Venous Reflux Patterns. in: Zamboni P, Mendoza E, Gianesini S. (Eds.) Saphenous Vein-Sparing Strategies in Chronic Venous Disease. Springer; 2018: 35-74
  • 7 Allan JC. Volume changes in the lower limb in response to postural alterations and muscular exercise. S Afr J Surg 1964; 2: 75-90
  • 8 Lattimer CR, Mendoza E. Reappraisal of the utility of the tilt-table in the investigation of venous disease. Eur J Vasc Endovasc Surg 2016; 52: 854-861
  • 9 Pannier F, Gerlach H, Stücker M. et al. Leitlinie: Venöse Diagnostik mit der Licht-Reflexions-Rheographie/Photoplethysmographie der Deutschen Gesellschaft für Phlebologie. Phlebologie 2012; 41: 261-263
  • 10 Lattimer CR, Doucet S, Geroulakos G. et al. Validation of the novel venous drainage index with step-wise increases in thigh compression pressure in the quantification of venous obstruction. J Vasc Surg Venous Lymphat Disord 2017; 5: 88-95
  • 11 Lattimer CR, Kalodiki E, Azzam M. et al. Gravitational venous drainage improves significantly after iliac venous stenting but this may result in faster venous filling. J Vasc Surg Venous Lymphat Disord 2016; 4: 137-138
  • 12 Bradbury A, Evans C, Allan P. et al. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. Br Med J 1999; 318: 353-356
  • 13 Blaettler W, Thomae HJ, Amsler F. Venous leg symptoms in healthy subjects assessed during prolonged standing. J Vasc Surg Venous Lymphat Disord 2016; 4: 455-462
  • 14 Obermayer A, Garzon K. Identifying the source of superficial reflux in venous leg ulcers using duplex ultrasound. J Vasc Surg 2010; 52: 1255-1261
  • 15 Hareendran A, Bradbury A, Budd J. et al. Measuring the impact of venous leg ulcers on quality of life. J Wound Care 2005; 14: 53-57
  • 16 Villalta S, Bagatella P, Piccioli A. et al. Assessment of validity and reproducibility of a clinical scale for the post-thrombotic syndrome (abstract). Haemostasis 1994; 24: 158a
  • 17 Trinh F, Paolini D, Fish J. et al. Use of Villalta score for defining post-thrombotic disease may lead to false-positice diagnosis in 42 % of patients with primary chronic venous disease. J Vasc Surg Venous Lymphat Disord 2018; 6: 291
  • 18 Lattiner CR, Kalodiki E, Azzam M. et al. Validation of the Villalta scale in assessing post-thrombotic syndrome using clinical, duplex. and hemodynamic comparators; JVS Venous and Lymphatic Disorders 2014; 2 (01) 8-14
  • 19 Kurstjens RL, Catarinella FS, Lam YL. et al. The inability of venous occlusion air plethysmography to identify patients who will benefit from stenting of deep venous obstruction. Phlebology 2018; 33: 483-491
  • 20 Gagne PJ, Gasparis A, Black S. et al. Analysis of threshold stenosis by multiplanar venogram and intravascular ultrasound examination for predicting clinical improvement after iliofemoral vein stenting in the VIDIO trial. J Vasc Surg Venous Lymphat Disord 2018; 6: 48-56 e1
  • 21 Vedantham S, Goldhaber SZ, Julian JA. et al. Pharmacomechanical catheter-directed thrombolysis for deep-vein thrombosis. N Engl J Med 2017; 377: 2240-2252