Factors affecting outcome of open and hybrid reconstructions for nonmalignant obstruction of iliofemoral veins and inferior vena cava Nitin Garg, MBBS,

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Presentation transcript:

Factors affecting outcome of open and hybrid reconstructions for nonmalignant obstruction of iliofemoral veins and inferior vena cava Nitin Garg, MBBS, MPH, Peter Gloviczki, MD, Kamran M. Karimi, MD, Audra A. Duncan, MD, Haraldur Bjarnason, MD, Manju Kalra, MBBS, Gustavo S. Oderich, MD, Thomas C. Bower, MD Journal of Vascular Surgery Volume 53, Issue 2, Pages 383-393 (February 2011) DOI: 10.1016/j.jvs.2010.08.086 Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 1 Palma procedure. A 38-year-old male with history of posttraumatic deep vein thrombosis (DVT) had right leg ulcers, swelling, and venous claudication. A, Contrast venogram shows chronic right iliofemoral obstruction. Multiple attempts at endovenous recanalization had failed. B, Right-to-left femoral vein bypass with left great saphenous vein (GSV) (Palma procedure) was performed. C, Computed tomographic (CT) venogram at 2 months revealed a patent bypass. Reproduced with permission of the Mayo Clinic. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 2 Femorofemoral crossover (“Palma” prosthetic) bypass. A 41-year-old male with history of posttraumatic left iliofemoral deep vein thrombosis (DVT) presented with chronic venous ulceration. A, Venogram demonstrating occluded venous stent that could not be recanalized. B, Chronic scarring and postthrombotic changes noted in the left common femoral vein (CFV). C, Left-to-right femoral vein bypass with 12 mm ringed polytetrafluoroethylene (PTFE) (prosthetic “Palma” procedure) was performed, with a left superficial femoral artery (SFA) to graft arteriovenous (AV) fistula (arrow). D, Computed tomographic (CT) venogram performed at 1 year revealed a patent bypass. E, Schematic image demonstrating the bypass and previous occluded stent. The patient's ulcer healed and he had minimal residual symptoms at last follow-up. Reproduced with permission of the Mayo Clinic. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 3 Femoral crossover bypass. A 59-year-old female with history of deep vein thrombosis (DVT) had severe left leg swelling and venous claudication. A, Venogram demonstrated a patent inferior vena cava (IVC) with a clip. B, Chronic left iliofemoral obstruction. C, Computed tomographic (CT) venogram at 14 months revealed a patent femorofemoral prosthetic bypass, left superficial femoral artery (SFA)-graft arteriovenous fistula (AVF) (arrow) and previous Miles clip on inferior vena cava (IVC) (arrowhead). Also seen is left iliac vein calcification from chronic obstruction (circle). The patient had minimal swelling and no claudication on follow-up. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 4 Femorocaval bypass. A 42-year-old male presented with history of leg ulcers, swelling, and venous claudication, more prominent on left side. He had a posttraumatic deep vein thrombosis (DVT), and an inferior vena cava (IVC) filter was placed, leading to IVC and bilateral iliofemoral obstruction. A, Venogram demonstrated failed venous angioplasty and stenting. B, Intraoperative image showing large subcutaneous venous collateral due to chronic obstruction. C, Left femoral-infrahepatic IVC bypass was performed with 12 mm ringed polytetrafluoroethylene (PTFE) and a left arteriovenous fistula (AVF), marked with silastic sheath (arrow). D, Computed tomographic (CT) venogram at 7 months revealed a patent bypass. Previous IVC filter is seen proximal to occluded stents. The patient had minimal residual symptoms at last follow-up. Reproduced with permission of the Mayo Clinic. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 5 Complex venous reconstruction. A 61-year-old male with previous deep vein thrombosis (DVT) and inferior vena cava (IVC) filter presented with severe bilateral swelling and venous claudication. A, Venogram revealed partially occluded IVC filter (arrow) and IVC and bilateral iliac and right femoral obstruction, with occluded bilateral venous stents. B, Proximal and C, distal anastomosis of the left external iliac vein (EIV) to IVC bypass with 14 mm ringed polytetrafluoroethylene (PTFE). D, An interposition PTFE graft to right femoral vein from IVC-left EIV graft was performed. E, Computed tomographic (CT) venogram done at 2 months revealed patent bypass and previous IVC filter (arrowhead). Reproduced with permission of the Mayo Clinic. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 6 Hybrid reconstruction. A 45-year-old male with extensive idiopathic deep vein thrombosis (DVT), managed with anticoagulation, developed severe postthrombotic syndrome with nonhealing ulcers on left leg from inferior vena cava (IVC) and bilateral iliac vein occlusion (A). B, Intraoperative photograph of the chronically occluded left common femoral vein (CFV). C and D, Bilateral venous stents were placed after CFV endophlebectomy and left CFV was repaired with a bovine pericardial patch. E, Completion venogram documented a good result. F, Follow-up venogram at 11 months revealed an occluded left sided stent, but right iliac and IVC stent remained patent. Patient had ulcer recurrence on left but healed with conservative management. Reproduced with permission of the Mayo Clinic. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 7 Cumulative 10-year patency of 64 venous reconstructions. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 8 Cumulative 10-year secondary patency of three main types of venous bypasses. All standard errors of mean >10% except Palma up to 96 months. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 9 Cumulative 10-year patency of 25 Palma grafts (femoral crossover bypass with great saphenous vein). Dotted line indicates standard error of mean >10%. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions

Fig 10 Cumulative 2-year patency of 12 hybrid reconstructions. All standard errors of mean >10%. Journal of Vascular Surgery 2011 53, 383-393DOI: (10.1016/j.jvs.2010.08.086) Copyright © 2011 Society for Vascular Surgery Terms and Conditions