Recovery process of patients with iliac vein compression syndrome after stenting: a grounded theory study

Abstract

Background

Iliac vein compression syndrome (IVCS) impedes venous blood return from the lower extremities due to iliac vein compression, manifesting as leg swelling, varicose veins, and thrombosis. These symptoms significantly degrade quality of life. Although iliac vein stenting provides symptomatic relief, the recovery process is protracted and fraught with challenges such as in-stent restenosis and psychological distress. This study aims to deepen our understanding of patient coping strategies by exploring the entire journey from diagnosis through stenting to recovery in individuals affected by IVCS.

Methods

This qualitative study employed a grounded theory approach, conducting in-depth, semi-structured interviews with 16 patients who had undergone stenting for IVCS. Participants were recruited from a teaching hospital in Taiwan and interviewed between August 2022 and July 2023.

Results

The recovery process for the patients involved five stages and 11 subcategories, which outlined a journey toward a new direction of health. The stages were (1) exacerbation—worsening symptoms that disrupt daily life, compelling the patient to finally address the issue; (2) seeking help—medical professional help sought; (3) despondency—ongoing pain and recurring symptoms after surgery; (4) adjustment—self-directed health promotion with support systems aiding in recovery; and (5) health preservation—suitable health care and beneficial exercise habit development.

Conclusions

The recovery process was depicted in a linear diagram of living with a new direction for health. Careful attention should be paid to the importance of clarifying patient expectations after stenting, addressing post-treatment physical discomfort and emotional anxiety issues, and enabling patients to confidently undergo follow-up and rehabilitation to achieve their recovery goals.

Clinical trial number

Not applicable.

Background

Iliac vein compression syndrome (IVCS) is a common condition caused by prolonged periods of sitting or standing. It can result in various manifestations including leg swelling, varicose veins, skin pigmentation, ulcers, and acute problems such as leg redness, swelling, warmth, pain, and even thrombosis [1]. Additionally, IVCS significantly affects the quality of life and emotional well-being of patients, making it a focus of increasing attention [2].

IVCS is often overlooked in its early stages, owing to the subtlety of symptoms, and patients only seek treatment when the condition becomes severe or reaches an advanced stage. Symptom appearance is the primary reason patients with chronic diseases seek medical care [3]. Szewczyk et al. [4] observed that the process of seeking IVCS treatment is challenging because of the difficulty in diagnosing the disease cause and a lack of disease awareness, often leading to insufficient care-related information. This can trigger feelings of helplessness in patients who present with limb heaviness, pain, and swelling, which do not improve, thereby predisposing them to emotional exhaustion. If accompanied by non-healing wounds, this can affect the social lives of these patients, leading to psychological distress.

Stenting is a widely used surgical intervention for managing IVCS by maintaining iliac vein patency, alleviating IVCS-related discomfort, aiding in venous ulcer healing, and improving overall quality of life [5]. However, patients may require prolonged follow-up visits because of potential complications such as in-stent restenosis or persistent venous ulcers, which can lead to uncertainty and emotional challenges during the recovery process [6].

IVCS manifests in two phases: acute and chronic. During the acute phase, which typically occurs within 3 days, the patient presents with sudden severe lower limb swelling, pain, and increased skin temperature. The chronic phase, which lasts 3 days to several months or years, involves progressive discomfort in the lower limbs, including mild-to-moderate edema and pain during walking, varicose veins, changes in skin characteristics (such as pigmentation and eczema), and persistent lower leg venous ulcers [7, 8]. A previous study reported stent patency and ulcer healing rates of 81.8–100% and 71.4–100%, respectively, indicating that stenting is effective for adequate flow maintenance and symptom relief in patients with IVCS [9]. Postoperatively, venous ulcers that are sufficiently managed by patients and their family members can heal within months, resulting in improved patient condition and emotional state [10]. However, according to Wu [11], it can take 13 years for patients with IVCS to receive a correct diagnosis; hence, they usually present with ankle deformation, chronic pain, and increased dependence on others. Family members of patients with IVCS often experience long-term anxiety and worry [11]. More severe forms of the disease increase financial burdens and trigger emotional fluctuations in patients, their spouses, and/or other caregivers [4, 12]. Thus, patients with severe disease forms have a poorer quality of life. Patients without an accurate diagnosis and effective treatment may develop self-generated negative emotions and depression owing to the psychological pressure related to the inability to recover [13].

In a phenomenological study, Wellborn and Moceri [14] interviewed 10 patients to investigate the impact of chronic venous diseases and leg ulcers on their quality of life. The disease reportedly reduced patient abilities to perform daily activities, caused discomfort and pain that interfered with daily routines, and prevented work or enjoyment of favorite activities such as rowing and swimming. The study also highlighted patient lack of awareness and basic information about chronic venous diseases compared with conditions such as hypertension or hyperlipidemia. Van Hecke et al. [15] used grounded theory to assess the healthcare-seeking behaviors of 15 patients with venous ulcers through semi-structured interviews. That study revealed that the patients lacked knowledge about the disease and insufficient care-related information led to venous ulcer recurrence. Therefore, healthcare professionals should provide disease education to patients based on their lifestyle.

In Taiwan, Wu [11] investigated the journey of discovering and treating IVCS using narrative research methods. Within-stent thrombosis can still occur after iliac vein stenting, leading to frequent hospital visits and a significant gap between expectations and reality. Negative thoughts and anxiety emerge because of the recurring nature of foot ailments. Ongoing support and encouragement from friends and family members as well as self-affirmation to accept the current state of health are crucial. In addition to adjusting daily routines, writing and sketching can be used as outlets to soothe emotions and accept the disease, ultimately bringing peace of mind and reducing negative thoughts.

To date, no studies have explored the experience of patients from diagnosis through stenting to recovery or discussed how surgical interventions reshape their experiences and feelings about adversity. Therefore, to add to the body of evidence from qualitative research, it may be beneficial to assess and highlight the recovery process of patients with IVCS who have undergone stenting. They can share their experiences from sickness to recovery, which can also reduce depression caused by the illness and unmet recovery expectations.

Understanding the coping strategies of patients and how they adjust to their new circumstances is crucial. The present study explored the recovery process for patients with IVCS, from diagnosis through stenting to recovery.

The study

Aim

This study aimed to explore the journey of patients from the onset of illness through stenting to recovery after iliac vein stenting.

Research question

The central research question that guided this study was: What are the key experiences and processes that characterize the recovery of patients with IVCS after undergoing stent placement?

Methods

Design

This study employed grounded theory due to its systematic approach, which was well-suited for defining and exploring the recovery journey of patients who underwent iliac vein stenting. This method is particularly effective in revealing the step-by-step processes in patient experiences, from disease onset to postoperative recovery. Grounded theory systematic data collection and iterative analysis are ideal for capturing the complexities of patient pathways [16].

Theoretical framework

The theoretical framework of this study was grounded theory, which focuses on the actions and processes that underpin the experiences of patients. Denzin and Lincoln [17] assert that grounded theory is well-suited for studies that are deeply process-oriented and experiential, such as this investigation of patient trajectories from the onset of illness to recovery. This methodology not only guides an analytical approach but also enriches the interpretative depth of the study, offering robust insights into the adaptive and responsive character of patient care and recovery processes.

Study setting and recruitment

The study participants were recruited via purposive sampling from the cardiovascular surgery outpatient clinic of a teaching hospital in Taiwan. Since no prior relationship existed between the researcher and the participants, the recruitment process was facilitated through referrals by the attending physician. Suitable patients were assessed and referred to the first author. The attending physician introduced eligible patients to the first author, who invited the patients to participate in the study. The first author then contacted the candidates to further confirm their eligibility and provided them with detailed information about the study, including its objectives, methods, interview procedures, and the role of participants. Once the patients fully understood the study and expressed their willingness to participate, they were required to sign a written informed consent form. Only after completing this process were the patients officially included in the study. Following a comprehensive explanation of the study objectives and methods by the first author, the patients who signed an informed consent form were interviewed face-to-face in the hospital interview room.

Inclusion and exclusion criteria

Patients who met the following criteria were included: (1) diagnosed with IVCS; (2) had undergone iliac vein stenting; (3) aged 20 years or older; (4) assessed by a specialist as recovered, with symptoms almost completely resolved, daily life returned to normal, and capable of sharing their recovery journey; and (5) consented to participate in the interview. Patients who did not undergo iliac vein stenting were excluded.

Data collection

Data were collected between August 2022 and July 2023 via semi-structured interviews guided by the following questions:

• (1) How did you first notice the problem in your leg?

• (2) What measures did you take at that time?

• (3) How have you recovered after treatment?

• (4) What difficulties and problems did you encounter during this process?

• (5) What kind of help did you receive?

Each participant was interviewed once; the interview lasted between 60 and 90 min. All interviews were audio-recorded to ensure accuracy during transcription. Only the participants and the researcher were present during the interviews, with no other individuals involved. No participants refused to participate or dropped out during the study.

Data analysis

The grounded theory methodology emphasizes data conceptualization through coding. The purpose of coding is to break down textual data word-by-word and sentence-by-sentence to identify important, prominent, and recurrent messages, which are then conceptualized. The first author conducted the interviews, interacted with the participants, and initiated the open coding process. The research team, including the first author, possess expertise in cardiovascular nursing and communication skills, and all members have undergone formal training in qualitative research methodologies, which significantly contributed to the data collection and analysis phases. To ensure the reliability and objectivity of the data interpretation, the coding was independently checked by two of the authors. The research team reached consensus on the final themes, with any disagreements resolved through discussions led by the corresponding author, who has extensive experience in qualitative research. Interviews were conducted with 16 participants, based on an outline, and one transcript was produced verbatim for each interview. The collected data were transcribed verbatim within 3 days of completing the interviews. Subsequently, each text record was read, and similar experiences were conceptually categorized. Using the constant comparative method, similar concepts were classified into subcategories and gradually inducted into categories [18]. The analysis proceeded iteratively across different stages, and when no new data or concepts emerged and sufficient depth and breadth of participant understanding were achieved, data saturation was considered reached. Afterwards, the categories were organized into a process-oriented framework to depict the recovery process of patients with IVCS who underwent stenting.

Ethical considerations and consent to participate

Institutional Review Board Statement: The Research Ethics Committee of An Nan Hospital, China Medical University approved this study (case number: TMANH111-REC007). This study adhered strictly to the ethical principles outlined in the Declaration of Helsinki and ensured that all research procedures met ethical standards and prioritized the protection of participants’ rights and well-being. Participants were fully informed about the study’s objectives, methods, potential benefits, and risks. Prior to the commencement of the study, the first author provided participants with a detailed explanation of the study’s purpose, design, possible benefits and risks, data usage, and confidentiality measures. It was emphasized that participation was entirely voluntary, and participants retained the right to withdraw from the study at any stage without affecting their medical care. During data collection, strict confidentiality measures were implemented to protect participant privacy. All identifiable information was anonymized to ensure full privacy protection. Audio recordings of interviews were securely stored in password-protected digital files, accessible only to authorized research team members. These recordings were used solely for data analysis and were not utilized beyond the scope of the study. Additionally, participants were informed of their right to inquire about the study’s progress or withdraw their previously provided data at any time.

Rigor and reflexivity

According to Lincoln and Guba [19], the rigor of a study is upheld by four criteria: (1) Credibility: this refers to the truth value of the data. Before conducting formal interviews, the researcher arranged two informal interviews to gain a preliminary understanding of the experiences of individuals recovering from iliac vein stenting. The analyzed data were then provided to two of the individuals as a member check to verify whether the researcher’s analysis, interpretations, and conclusions accurately represented their actual circumstances. Peer debriefing was used to conceptualize the data and clarify the relationships between concepts [18]. To ensure the quality of the data analysis, two experienced cardiovascular surgical nurses with over 10 years of clinical experience were invited to participate in peer debriefing to explore hidden issues related to the collected data and discuss the categories, subcategories, and concepts analyzed, thus enhancing the sensitivity and credibility of the study. Immediately after each interview, the specific incidents and nonverbal behaviors of the participants were recorded in a reflexive journal, allowing for adjustments in the research direction for data enrichment and credibility enhancement. Data analysis was performed using constant comparative methods. NVivo 11 software was used for the initial management and organization of files to ensure accurate and systematic handling of data. (2) Transferability: the interviews were transcribed verbatim, and excerpts have been presented in this article without the addition of the researcher’s subjective opinions. Through detailed transcription and data saturation analyses, the recovery processes of these patients were exhaustively described to provide a reference for relevant medical professionals. (3) Dependability: all research materials (audio files, transcripts, reflexive journals, and data analysis records) were meticulously preserved. Two cardiovascular surgery experts conducted dependability reviews to enhance the trustworthiness of the study. (4) Confirmability: all the original data, including audio recordings and documents detailing the inductive analysis process and conclusions, are available for scrutiny by future researchers. The COREQ guidelines for qualitative research were followed [20].

Results

After interviewing 14 participants, no new themes emerged from the data analysis, prompting the researcher to conduct follow-up interviews with two additional participants. This confirmed data saturation led to the cessation of further recruitment. The age range of the 16 participants was 26–69 years (average age approximately 51 years). The cohort was evenly divided into women (n = 8) and men (n = 8). Occupations included engineers (n = 4); service industry workers (n = 4); farmers (n = 3); homemakers (n = 2); and one each for tailor, teacher, and medical professional. All 16 stent recipients were interviewed postoperatively; the duration from stenting to interview ranged from 183 to 3,056 (average 750) days. A transcript analysis identified five stages during the recovery process: exacerbation, seeking help, despondency, adjustment, and health preservation.

Stage 1: exacerbation

The recovery process following IVCS began with a growing awareness of long-term pain, which had an intrapersonal and interpersonal impact. The participants reported that upon confirming their IVCS diagnosis, it was initially difficult to detect leg symptoms. However, after several months, years, or even decades, they noticed signs of disease exacerbation. Patients take this issue seriously when their mobility is restricted, social interactions decrease, and daily lives are greatly limited.

Inevitable and progressive pain

Many participants indicated that they gradually noticed lower limb symptoms, which developed over the years (ranging from several months to several decades), because they worked for decades under conditions requiring prolonged standing or sitting. Initially, they observed calf swelling, lower limb fatigue, foot numbness, occasional sharp pain during walking, and gradual calf skin coloration changes. Participants found that the area of skin discoloration would expand significantly; if ignored, the area spread from the size of a coin to covering the entire calf and then extending to the other calf; this represented progressive leg symptom expansion. The symptoms started as inconspicuous tiredness and numbness, which then progressed to a more alarming spread. A few participants noted exacerbation of their condition, with the appearance of ankle wounds causing distress. The wounds healed slowly and sometimes did not heal at all. The area of the unhealed wounds expanded, deepened, and continuously oozed blood. Due to the persistent non-healing wounds, patients felt frustrated, believing that the disease was incurable. A participant who has worked in mechanical engineering for more than 26 years stated:

I began to notice the development of varicose veins and edema in my legs. This progressed to a subtle throbbing pain in my calves when walking. (P7)

Furthermore, participants noticed that healed wounds were prone to seasonal recurrence, which constantly reminded them that the disease was never fully treated. This “pain torture” caused ongoing distress.

starting with redness followed by breaking of the skin and bleeding. The wounds then gradually enlarged from the size of a five-dollar coin to that of a 10-dollar coin, becoming somewhat deep and prone to oozing blood.……Each year, as the season arrives, the pattern repeats: healing followed by recurrence, which is very troubling! (P4)

Severe restrictions on daily life

Many participants reported that during severe episodes, they experienced foot coldness, calf stiffening, and ankle swelling that made it difficult to wear shoes. They could not find comfortable shoes, resulting in a feeling of foot heaviness. Consequently, they lagged behind family members while walking, often finding themselves at the back and struggling to maintain pace. This significantly limited their mobility. Foot discomfort increasingly deterred them from nature walks with friends and family members. Participants noted a decrease in their social interactions, which progressed to a severe reluctance to leave the house. It became difficult and painful to undertake home tasks, such as climbing stairs, standing for a moment, squatting, and standing up. The patients often had to lift their legs to relieve stiffness. One participant with a blood-oozing ankle wound mentioned that the wound required frequent dressing changes, at least four times a day, which made it impossible to go out. The impact extended from a personal level to the family and work. Most patients felt that the pain affected their relationships with others, as participants shifted their focus from themselves to how their condition affected their interaction with others. This distress led patients to feel they could not lead a normal life.

I found myself spending a lot of time managing this wound, which has impacted my work and family life. All the household responsibilities have fallen to my wife, while I continuously care for the wound on my foot. This leaves me feeling constantly troubled and unable to relax. (P5)

Stage 2: seeking help

Patients with IVCS who noticed worsening calf problems initially sought relevant information and help from medical professionals, as the symptoms were unfamiliar to them. Participants moved from exploring answers from peripheral experts to engaging directly with core specialists to navigate their difficulties.

Seeking relevant information

Many participants described the disease as truly baffling and wondered where the problem originated. Owing to advances in internet technology, they initially searched online for information on disease management. They researched doctors’ qualifications and read online reviews before seeking treatment, as well as consulting friends and family for additional information.

I searched online to figure out what exactly was wrong with my foot and which medical specialty dealt with such conditions. I first checked the doctors’ ratings, and I also gathered information about the disease from news reports on the internet, as well as sought advice from friends and family.(P2).

A few participants that they sought guidance from temple deities due to their personal beliefs. They asked for advice which hospital to visit and sought divine directing regarding which doctors were trustworthy and capable of treating their illness. This practice helped them obtain timely medical consultations.

I consulted with a folk deity– Wang Ye, asking which hospital and which doctor I should go to for treatment. After casting divination tools and receiving Wang Ye’s guidance and approval, I followed his instructions on the timing and the specific doctor to seek out at the hospital. (P4)

Seeking help from medical professionals

Upon noticing foot symptoms, most participants actively sought help from medical professionals, visited outpatient or emergency departments to report their symptoms, and underwent medical examinations. If they understood that the disease would persist if left untreated, they decided to address it. Despite feeling apprehensive about the unknown and new minimally invasive surgical methods involving stenting, they mustered courage to accept the treatment. For some participants, the foot condition did not have an initial significant impact on their daily lives, but the high out-of-pocket treatment cost, which exceeded 100,000 TWD (over 3,072 USD), led them to endure discomfort and delay treatment. One participant waited 7 years before receiving treatment and only realized the need for treatment after a significant exacerbation of calf skin discoloration. Initially, some participants visited dermatologists when they experienced skin coloration changes. When treatment did not lead to improvement and the primary physician suspected an immune-related issue, the participants consulted the rheumatology and immunology departments. After several referrals, they identified an appropriate clinic for examination and treatment. In contrast to others who faced a long journey to get the right diagnosis and treatment, some participants felt “fortunate” to have their issue identified quickly.

I was fortunate to have identified exactly what was wrong with my feet.…… Although I was not very familiar with the disease or the treatment at the time, it was inevitable to feel worried and scared. Still, I chose to bravely face it! Therefore, I agreed to the doctor’s suggestion for an intravascular ultrasound. (P1)

Stage 3: despondency

During the recovery process, participants experienced feelings of loss owing to persistent symptoms, and the emotional impact varied from person to person. Most participants reported enduring “post-surgical physical torment” following stenting and a slower recovery process than anticipated, leading to disappointment. Additionally, the presence of a stent as a foreign object in the body caused discomfort and anxiety.

Feeling of being “trapped” after surgery

During the first postoperative month, some middle-aged participants reported feeling like they were enduring “physical torture” and experiencing lower back muscle soreness. They found that changing positions, such as moving from lying flat, rolling over to a semi-reclining position, standing up from a sitting position, or squatting, was challenging. They felt that their bodies were obstructed by the stent, which hampered their movement. The participants, who previously performed their activities independently, now relied on their family members for assistance.

I couldn’t get out of bed on my own, and for the entire month post-surgery, I needed family support.….Any change in position, such as turning over, adjusting to a semi-reclining posture, or even getting up to go to the bathroom for a shower where I needed to squat, was impossible without assistance. My family had to be constantly by my side, and my 7-year-old son even helped me wash my hair.(P10).

In addition to the participants feeling trapped because of the physical disability, a few participants were concerned that the stent might shift or migrate to other parts of the body.

I felt that the normal anatomy of my body became incomplete. A normal body should function without the need for foreign objects to maintain its operations, yet now I rely on a venous stent to keep my compressed blood vessels open and maintain normal blood circulation. I not only feel that my body is incomplete but also feel anxious every day because I cannot see or feel the stent inside me. (P11)

Postoperative recovery not meeting expectations

Postoperatively, many participants closely monitored the leg that underwent venous stenting. They recalled the doctor’s explanation that stenting to alleviate vessel compression would lead to recovery, which was medically true. Lower limb stiffness and swelling disappeared immediately after stenting. However, from postoperative day 3, participants began to feel that the medical outcome was “not as expected” and did not experience the leg recovery described by the doctor. Symptoms of swelling appeared and disappeared repeatedly over the first 3 months, and the slow pace of improvement caused participants to wonder why the symptoms persisted despite stenting. They did not anticipate that the recovery process would take several months. In addition to disease-induced anxiety, a few participants were concerned that the stent might shift or migrate to other parts of the body. One participant felt incomplete because their body function depended on a medical device to keep the compressed blood vessels open. As they could neither see nor feel the stent to ascertain its position, their fears intensified, leading to a loss of bodily autonomy and emotional distress due to unmet recovery expectations. They continuously built mental resilience, reminding themselves to accept the presence of a stent.

I thought my lower limbs would recover immediately after the surgery, but upon observing, it wasn’t as I had expected! Symptoms still persisted. After the stent placement, there was noticeable reduction in swelling by the third day up to a month. But from the second month, I experienced daily fluctuations of swelling and subsiding, which worried me about whether it would ever fully recover. (P9)

Stage 4: adjustment

During the first 3 postoperative months, the participants actively pursued recovery by engaging in muscle strength training and self-health promotion. They valued support from family, friends, and medical staff, who motivated them to prioritize their well-being. They also recognized the need for regular follow-up to monitor their health after iliac vein stenting.

Self-health promotion

All participants expressed a strong motivation to recover from the long-standing leg stiffness and swelling. However, after medical examinations and explanations from doctors, they understood that recovery would require time and rehabilitation, which further intensified their desire for speedy recovery. Postoperatively, the participants began using assistive devices owing to lower limb and lumbar muscle weakness. They wore lumbar support belts and used quad canes to balance their body center of gravity, thereby increasing walking stability and support. As the muscle strength improved, they switched to a single cane. During lower limb muscle strength training for self-health promotion, they held onto stair railings with one hand and a cane with the other. They also used medical compression stockings for leg stability maintenance and edema prevention.

I spent at least 5 h each day walking because not practicing would have a negative impact on my recovery. About 2 weeks later, I switched from the quad cane to a single cane and began trying to climb stairs to build muscle strength. I would push myself up the stairs using the handrails and step down cautiously…. I also began wearing medical compression stockings for 3 months to care for my legs. (P7)

Encouragement from the support system

Many participants mentioned that during the recovery process, care from family members and support from friends strengthened them to bravely undergo rehabilitation and adhere to regular follow-up treatments. Participants also emphasized “help from the support system,” including care from medical staff and the comfort of their faith, were significant sources of support that enabled them to undergo rehabilitation, leading to daily progressive anxiety alleviation.

I really felt the warmth and care from everyone around me. I’m truly thankful for the medical team; their help filled me with positive energy. Their support made it easier to avoid anxiety about my illness every day. Staying cheerful really does make a difference in recovery. (P4)

Change in attitude post-illness

Prior to illness, many participants worked for long hours to earn a living, believing that their bodies were strong enough to withstand the strain. This long-term neglect of their health triggered the development of the disease. During treatment, they realized the suffering associated with the disease. Through this experience, they realized that they were getting older, and thus could no longer do the things they did before. Amid the sense of loss, participants gained a new understanding. After falling ill, participants appreciated the importance of health. Their family members, who had set aside their work to care for them from hospitalization to home recovery, made them realize that health should be a priority. Although the participants were initially unfamiliar with IVCS, they gradually gained an accurate understanding of the disease during the recovery process. They recognized that having the new, unfamiliar, and uncertain indwelling venous stent necessitated greater vigilance. They understood the importance of regular follow-up examinations to promote good health.

When I was younger, I took on as much work as I could to support my family.….Now that I’m older, I’ve developed iliac vein stenosis, and I have had a venous stent placed to maintain blood flow.…. I don’t want my husband and children to worry or to become a burden to them, and I want to ensure my legs remain healthy. Taking care of my health is very important. (P6)

Stage 5: health preservation

After recovery (approximately 90–180 days postoperatively), the participants focused on understanding their condition, adhering to treatment, and re-establishing their life goals. After recovery, they prioritized maintaining their health, adopting proper healthcare and exercise habits, and developing their own self-care strategies.

Proper health care

Many participants described their journey from iliac vein stenting to rehabilitation and eventual return to health as a mission accomplished, a burden lifted, and a sense of graduation after a long pursuit of recovery. Their health awareness heightened, and they were clarified on the importance of proper healthcare. They started wearing medical-grade compression stockings in addition to intermittent leg position changes at intervals of 30 min to 1 h for leg health maintenance. Following stenting, the patients adjusted their diet or added health supplements. Participants with hyperlipidemia indicated the need for a low-fat diet, and those with diabetes avoided the addition of seasoning in their meals to maintain an adequate blood circulation in the legs.

Taking good care of my body is crucial now, and it requires daily commitment. I make sure to wear compression stockings before getting out of bed in the morning……. I also make it a point to change my position frequently and avoid crossing my legs to ensure good blood circulation in my legs. (P16)

Development of exercise habits

All participants exercised regularly for more than 180 days, from the time of stenting until the interview. After receiving the promotion of self-health during the adjustment stage, the participants understood their fitness levels and began engaging in consistent exercise. Each participant began exercising at a different times and transitioned to forming consistent exercise habits. They indicated that it took approximately 3 months to explore and establish new exercise habits; they chose activities they could handle such as walking or brisk walking. Through continuous perseverance, they formed exercise habits for at least 6 months and established regular exercise routines. Some participants maintained their health by exercising regularly for over 1 year.

One month after the operation, I started walking briskly for an hour each morning and evening. ……Three months later, I had adapted to the new exercise habit, and now I feel out of sorts if I don’t exercise. So, I walk three laps in the park every day from 7 to 8 in the morning and 4 to 5 in the afternoon. I have been following this routine for more than 6 months now. (P4)

Discussion

This study found that the participant recovery process resembled a continuous, interconnected linear progression. The participants experienced lower limb health recovery through five stages (Fig. 1).The first stage—exacerbation—involved the participants’ type of work that required prolonged standing and sitting, which led to IVCS and the onset of the exacerbation stage wherein leg deterioration occurred over months to decades. The onset of leg symptoms was gradual, and patients had lower-severity symptoms, such as leg fatigue, swelling, heaviness, night cramps, and decreased daytime walking activity. Patients with greater symptom severity experienced severe pain and leg deterioration from pigmentation to ulcer formation, with repeated ulcer healing and recurrence [21, 22]. Consistent with the Transition Theory articulated by Meleis [23], this stage represents a pivotal period of significant transformation as individuals navigate the shift from health to illness. The findings of this study are consistent with those of Franz and Wann-Hansson [24]; untreated acute or chronically worsening cases led to increased pain, worry, fear, and deep anxiety over calf symptom recurrence. Many participants experienced restricted mobility owing to leg pain, reduced social interaction, and severe daily activity limitations. Additionally, changes in leg symptoms and skin coloration led patients to avoid displaying their legs in public, often opting for long trousers or skirts to cover their legs. They also avoided beaches and other places where their legs would be exposed, and feared their condition might progress to leg ulcers. Patients felt distressed living with their unsightly legs and the changes in leg symptoms and skin coloration.

Fig. 1

Recovery process of patients with iIliac vein compression syndrome after stenting A grounded theory

During the second stage—seeking help—participants found it crucial to seek relevant knowledge and consult medical professionals because of their limited understanding of the fundamental IVCS causes and treatments. Transition Theory emphasizes that individuals actively seek to understand their illness and take proactive steps during the transition process. Acquiring knowledge is essential for reducing uncertainty, particularly regarding unfamiliar health conditions [23]. Consistent with the findings of Freund et al. [25], a lack of knowledge can hinder effective disease management, particularly for conditions that are not well understood. To address this gap, participants in our study actively sought information through internet searches, hospital media promotions, and various resources, including guidance from temple deities. This pursuit enhanced their understanding of IVCS and increased their likelihood of seeking appropriate treatment. Such proactive behavior not only improved their problem-solving abilities but also facilitated a more empowered and knowledge-driven transition process, highlighting the critical role of knowledge acquisition in navigating health transitions [23]. While a previous study [26] has indicated that Taiwanese family members may struggle with conflicts between healthcare professionals and the deities they rely on for decision making, our findings suggest that most participants sought solace and direction from folk deities. They expressed gratitude for the blessings received during the recovery process.

Our findings indicate that patients with IVCS experience feelings of despondency, particularly during the first month following surgery. Depending on whether their symptoms improve, this stage can persist for several months. To date, no study has examined the feelings of despondency that occur after iliac vein stenting. However, Zhaoyang et al. [27] suggested that significant life stressors, such as surgery, can lead to a decrease in positive emotions and an increase in negative emotions. Patients without symptom improvement may experience an increase in depressive symptoms over the subsequent 18 months. Aligned with Transition Theory, this phase represents a critical period of significant change, often accompanied by heightened emotional vulnerability, which particularly impacts patients’ overall emotional well-being. This stage is primarily marked by patients experiencing major stressors from uncertainties about their recovery, which can intensify emotional instability and exacerbate negative feelings [23]. Six participants in the present study also stated that despite daily exercises and lifestyle adjustment within 3 months of stenting, they still experienced recurring manifestations such as swelling and slow wound healing. Although no studies have evaluated bodily changes and feelings within 3 months after iliac vein stenting, Molloy et al. [28] noted that postoperative patients increasingly focus on the symptom persistence duration and the possibility of full recovery, which influence their motivation for rehabilitation and cause either positive or negative psychological shifts. Clinical considerations should prioritize the establishment of a postoperative mental health screening mechanism to identify patients requiring additional support at an early stage. Moreover, targeted psychological health programs, such as patient-centered psychoeducation and group support activities, should be implemented to alleviate emotional distress and promote psychological adaptation [29, 30]. This approach addresses the emotional vulnerability highlighted during the despondency stage and provides practical strategies for managing these challenges. Meleis highlights the necessity for effective health maintenance strategies that involve persistent communication and collaboration between healthcare professionals and patients to ensure these practices are consistently implemented and tailored according to the evolving needs of the patients [23]. Such strategies should incorporate structured protocols for the regular evaluation of patient health, enabling adjustments to treatment plans based on continuous feedback and crafting of individualized treatment approaches that align with specific patient circumstances and preferences [31]. Moreover, strengthening communication between healthcare professionals and patients is critical and can be facilitated through digital platforms such as hospital health applications or through direct communication channels, ensuring that patients receive timely support as required [32]. Additionally, equipping patients with educational resources and self-management training empower them with a deeper understanding of their conditions and the skills necessary for effective self-care, while actively involving family members in their care plans boosts their commitment to adhering to health maintenance protocols [33]. Healthcare professionals administer pretreatment disease education, relevant treatment information, and pre-discharge advice on lifestyle adjustments to patients and their family members, thereby preparing patients for home recovery. This comprehensive approach helps alleviate anxiety by providing continuous psychological support and care during outpatient follow-up, enhancing patients’ ability to address concerns about their postoperative condition, and reducing internal unrest [34].

Within the first 3 months after stenting for IVCS, the patients entered the fourth stage of recovery—adjustment. This phase marks a shift from emotional vulnerability to active adaptation, where patients begin to take control of their recovery by adopting new health behaviors and routines. Echoing Transition Theory, this phase is identified as a significant period of change, during which individuals not only experience profound physical and emotional transitions but are also adapting to new health patterns [23]. During this stage, many patients reported the need to continue lower limb strength training to hasten bodily recovery. According to Almutary and Tayyib [35], postoperative care includes encouraging patients to get out of bed and perform exercises, such as straight leg raises, to ensure normal venous return. Adjustments in daily activities are recommended to alter long-standing habits of prolonged sitting or standing, and patients are urged to commit to a personal exercise regimen. Most participants indicated that having a support system made them comfortable during the adjustment process. Lin and Liu [36] emphasized that maintaining close communication with healthcare professionals about physical and emotional conditions is essential for promoting sustained mental and physical stability. Moreover, adequate family support and strong relationship maintenance can soothe patients’ emotions during postoperative rehabilitation. Research also points to the soothing effects of sincere religious beliefs, which, through prayer and meditation, can mitigate anxiety and bring peace, thus supporting postoperative emotional recovery [37]. This study also revealed that cultural background significantly influences the recovery process, a factor not previously addressed in venous intervention recovery literature. Yelton [38] emphasized that cultural beliefs and values significantly impact patients’ engagement in rehabilitation activities. For instance, attitudes toward endurance, acceptance of medical guidance, and expectations of family roles vary across cultures, potentially altering patients’ recovery experiences. Incorporating culturally sensitive education and tailored interventions can reduce psychological stress and improve the quality of patient-provider interactions. Clinical practice should include assessing patients’ cultural backgrounds to design recovery plans that align with their cultural needs.We found that the patients experienced a significant shift in their attitudes toward their own health. Many recognized that money is not everything and that maintaining good health is crucial for a longer, more fulfilling life. This realization is consistent with the findings of Rehnsfeldt and Arman [39] who highlighted that individuals reflect on their lives during treatment and recovery, thereby seeking ways to enhance their recovery. They view the challenges faced during the recovery process as a necessary path to regaining health despite the difficulties and insecurities involved. Over time, as patients adjust their lifestyles, they rebuild new health-promoting behaviors, thus appreciating the value of recovery [40]. Moreover, the participants in the present study indicated that the motivation for change during the recovery period stemmed from the desire to alleviate lower limb pain associated with IVCS and regain good mobility to reduce dependence on others. Having a healthy body reduces the burden on family members [41]. Participants also mentioned the importance of regular postoperative follow-up visits to discuss health issues with medical staff, which is crucial for promoting recovery and maintaining post-recovery stability. Good communication between patients and medical staff can enhance individual resilience by acknowledging the stress of ongoing symptoms and their impact on patient quality of life. Providing education about the lengthy recovery and sharing other patient recovery experiences can boost confidence and understanding, thereby enhancing the recovery process [42]. Regular check-ups during follow-up visits allow patients to monitor their progress, enabling them to continuously advance toward a new state of health.

After 3 to 6 months, the study patients progressed to the fifth and final stage of recovery—health preservation. During this stage, patients adopted various health maintenance practices to preserve their lower limb health, including wearing compression stockings postoperatively. Meleis [23] emphasize that these health maintenance behaviors are not merely part of daily care, but actually play a pivotal role in facilitating patients’ transition from their current health state to a more stable and enduring state of health. Cahall and Spence [43] noted that medical-grade compression stockings constitute the first-line treatment for patients with varicose veins or other lower limb venous disorders. Many participants in the present study mentioned the importance of frequently changing their posture to avoid prolonged standing or sitting, as extended periods of inactivity can negatively impact health, potentially causing cardiovascular and metabolic issues [44]. Several participants with a history of metabolic diseases, such as hyperlipidemia (n = 5) and diabetes (n = 5), noted the necessity of dietary adjustments. Yuan et al. [45] reported that patients with these conditions are significantly predisposed to cardiovascular diseases. Most of the participants indicated that post-recovery dietary changes were essential. Moreover, they emphasized the critical role of developing regular exercise habits. The participants were at approximately 750 days with stent placement at the time of their interviews and had engaged in regular physical activity continuously for 6 months to over 1-year post-recovery. No studies have specifically documented how long postoperative patients with iliac vein stents have maintained their exercise routines; however, Connolly et al. [46] highlighted that structured, planned, and repetitive physical activity is crucial for maintaining physical health and can alleviate anxiety and depressive symptoms. Exercise not only promotes leg blood circulation stability, but also reduces the risk of cardiovascular diseases, diabetes, disability, depression, anxiety, and mortality.

Study strengths and limitations

This study explored the recovery experiences of patients who underwent iliac vein stenting and highlighted the physical and psychological aspects of the recovery process. This enhances the understanding of patient needs and outcomes, thereby potentially guiding clinical practice and patient care. Moreover, this study adds relevant information to the existing literature on vascular interventions. By focusing on a specific group of successfully recovered patients, the study provides valuable insights into effective recovery trajectories and factors that contribute to successful outcomes.

This study had a few limitations. First, it was difficult to recruit patients who recovered after iliac vein stenting to constitute the ideal group of participants. Many recovered patients only underwent follow up every 6 months and were available for interviews only during their clinic visits. It was challenging to locate such participants at other times, which complicated the recruitment process. Moreover, some participants who had recovered nearly 2 years before recruitment recounted their past experiences and post-treatment memories with some inevitable vagueness, leading to potential recall biases. This highlights the need to address potential biases in participant selection, as they may affect the reliability of the findings. Second, the study results may not be generalizable to patients who cannot afford the high treatment costs. Owing to the high cost (over 3,072 USD) of the procedure, patients who are economically disadvantaged or do not perceive their symptoms as severe often choose not to undergo treatment. This affects their subsequent self-managed health adaptation and the direction of future treatment. As a qualitative study, the findings are context-specific and cannot be generalized to broader populations. Explicitly acknowledging the limited generalizability of qualitative research findings will enhance the study’s rigor. Finally, this study did not include patients who underwent stenting because of temporary pregnancy- or tumor-induced iliac vein compression; therefore, it lacked data on the experiences and post-treatment recovery processes of these patients. Discussing these limitations in detail highlights the contextual boundaries of the findings and ensures a more transparent interpretation of the study’s contributions.

Implications for policy and practice

Preoperative education on the recovery process after iliac vein stenting is crucial because informing patients about the expected recovery timeline can significantly reduce anxiety and despondency if recovery is not immediate. Moreover, understanding the timeline and stages of recovery can help patients recognize the stages they will undergo postoperatively. This knowledge empowers patients and provides them with greater control over the recovery process. Additionally, the recovery stage is not a journey to be undertaken alone, and the involvement of a patient’s support system is encouraged. This ensures that a patient does not feel isolated during the recovery period, adheres to the advice from the medical team, and continues rehabilitation. These factors contribute to a more positive outlook during recovery, potentially leading to quicker and smoother recovery and significantly improving the overall experience of patients undergoing iliac vein stenting.

Recommendations for further research

This study highlighted critical aspects of the recovery process for patients with IVCS following stent placement. However, several important areas require further exploration to improve patient outcomes. Future research should focus on the long-term effects of stent placement on quality of life and recovery, utilizing longitudinal studies to assess the durability of these treatment outcomes. Additionally, the psychological impacts of IVCS and its treatment, such as anxiety and depression, need to be more thoroughly investigated to fully understand their effects on patient recovery. Targeted interventions to address the emotional impacts of living with a stent, such as structured psychological counseling or support groups, should also be explored, as these measures could mitigate anxiety and depression while improving overall recovery trajectories. Interdisciplinary research is essential, integrating the expertise of vascular surgeons, psychologists, and physical therapists to develop comprehensive care models that address the multifaceted needs of patient recovery and enhance overall care strategies.

Implications for policy and practice

Preoperative education on the recovery process after iliac vein stenting is crucial because informing patients about the expected recovery timeline can significantly reduce anxiety and despondency if recovery is not immediate. Moreover, understanding the timeline and stages of recovery can help patients recognize the stages they will undergo postoperatively. This knowledge empowers patients and provides them with greater control over the recovery process. Additionally, the recovery stage is not a journey to be undertaken alone, and the involvement of a patient’s support system is encouraged. This ensures that a patient does not feel isolated during the recovery period, adheres to the advice from the medical team, and continues rehabilitation. Practical strategies, such as implementing structured postoperative follow-up programs that include psychological screening and tailored rehabilitation plans, could enhance recovery outcomes by addressing both physical and emotional challenges more effectively. These factors contribute to a more positive outlook during recovery, potentially leading to quicker and smoother recovery and significantly improving the overall experience of patients undergoing iliac vein stenting.

Conclusions

Patients with IVCS undergoing stenting experienced a five-stage journey to lower limb health recovery. Initially, owing to prolonged static postures, patients experienced disruptive leg symptoms, escalating to severe pain and worsening conditions before acknowledging disease progression. This realization prompted them to seek help, gather relevant knowledge to understand the causes, and consult medical professionals for treatment to address the lower limb issues. However, physical torment continued postoperatively, with leg symptom recurrence, often leading to persistent anxiety and a subsequent feeling of loss despite anticipation of recovery. Nevertheless, patients persisted in their efforts to regain their health through continuous self-care and adjustments. Due to the support of their care system, they managed to face the illness positively. Hardships related to recovery transformed their attitudes toward the illness, underscoring the importance of health monitoring. After recovery, they learned to cherish their restored health, engaged in regular health maintenance, and developed exercise habits to nurture their well-being.

These study findings from patients who had undergone stenting for IVCS can guide future patients who need similar treatments and enhance their understanding of how to foster recovery both before and after surgery. This includes understanding the disease and treatment process, recognizing that postoperative recovery may not always align with the expected timelines, and acknowledging that recovery requires time, muscle training, and ongoing maintenance of regular living and exercise habits. It also encourages patients to discuss any issues that arise during recovery with medical staff who should provide continuous psychological support and immediate care. This approach enhances patient understanding on how to care for their bodies and adjust to issues independently, thereby reducing postoperative anxiety. Moreover, the study findings will enable medical professionals to understand the recovery, treatment, and rehabilitation processes experienced by patients. Nurses can offer relevant pretreatment education and prepare patients for potential posttreatment scenarios. In collaboration with patients, healthcare professionals can facilitate smooth follow-up and rehabilitation, thereby enhancing postoperative recovery.