BackgroundThis study aimed to compare the efficacy of mechanical thrombus clearance combined with stenting versus direct stenting alone in patients with iliofemoral venous disease,, and to analyze the characteristics of different diagnostic subgroups among non-thrombotic patients.MethodsA retrospective analysis was conducted on 137 patients who underwent iliac vein stent implantation between January 2020 and March 2025. Based on the presence of acute/subacute thrombosis and surgical strategy, patients were divided into a Thrombus Treatment Group (Angiojet thrombus aspiration + stenting, n=87) and a Non-Thrombotic Treatment Group (direct stenting, n=50). Within the Non-Thrombotic Group, further stratification yielded Subgroup A (pure iliac vein compression syndrome, n=29) and Subgroup B (associated thrombotic disease, e.g., post-thrombotic syndrome, n=21). Baseline characteristics, perioperative data, and 3-6 month follow-up outcomes were compared.ResultsPatients in the Thrombus Treatment Group were older (70.2±11.4 vs. 62.1±7.2 years, P<0.001), required fewer stents (1.3±0.6 vs. 1.8±0.9, P<0.001), but had longer procedure times (122.7±38.3 vs. 87.8±51.3 minutes, P<0.001). No significant differences were found between the two main groups in post-operative ultrasound patency rates (69.1% vs. 59.1%, P=0.243) or adverse event rates (2.5% vs. 6.8%, P=0.224). Subgroup analysis revealed that compared to Subgroup A, Subgroup B had a higher prevalence of prior DVT history (47.6% vs. 0%, P<0.001) and pre-operative swelling symptoms (81.0% vs. 6.9%, P<0.001), and required more complex procedures (stent use: 2.3±1.0 vs. 1.5±0.7, P<0.001). However, short-term follow-up outcomes were similar between the subgroups.ConclusionFor iliofemoral venous disease with concomitant thrombosis, a strategy of thrombus clearance combined with selective stenting can reduce stent usage while achieving short-term efficacy comparable to direct stenting alone in its respective clinical context. Among non-thrombotic patients, the subgroup with thrombosis-related disease presents distinct clinical features and higher procedural complexity, yet still benefits from endovascular reconstruction.