Venous Reconstruction for Iliofemoral Occlusive Disease
Related narrative: Iliofemoral Venous Bypass
In 1958 Palma performed the first crossfemoral saphenous veno-venous bypass graft (transposition of the distal end of the contralateral saphenous vein) for unilateral iliofemoral occlusion. In the 1980s, PTFE grafts along with AV fistulas were first used to reconstruct the IVC and iliacs. Indications for venous reconstruction for lower extremity chronic venous occlusion include venous claudication, ulcers and iatrogenic ligature. Methods of reconstruction involve grafts, angioplasty and stents. The grafts include autogenous and prosthetic materials. The use of xenografts has been reported in the literature. Progress in this field has been a result of better patient selection, improved surgical technique, the use of reinforced grafts and AV fistulas, appropriate anticoagulation and close post-operative surveillance. Post-operative management includes no sitting upright for 48 hours to prevent mechanical obstruction, adequate anticoagulation, and early Doppler confirmation of flow.
Reasons for failure include the low pressure, low flow nature of venous physiology, the formation of collaterals and anatomic compression. Complications include pulmonary embolus, death, wound infection (both superficial and deep), complications associated with anticoagulation, retroperitoneal bleeding and early and late thrombosis.
A prospective randomized trial by Alimi in 1997 included 8 patients with an average age of 45 years. Four patients had acute disease and four patients had chronic disease. All had an AV fistula constructed at the time of surgery. The graft size ranged from 8 to 14 mm. Seven of eight grafts were patent at 19.5 months. Three of the eight patients had thrombosis of the graft. Two were successfully thrombectomized, the other accounts for the single graft failure.
A retrospective review by Jost in 2001, included 42 patients with an average age of 42 years. The three-year primary and secondary patency rates for all grafts was 54% and 62% respectfully. Primary and secondary patency rates at four years for Palma procedures were 77% and 83%. Iliocaval and femorcaval PTFE grafts had two-year primary and secondary patency rates of 38% and 54%. All crossfemoral PTFE grafts were occluded by 12 months.
Use of AV Fistulas
In 1996 Menawat published a study in which he created in vitro and canine models to study hemodynamics of flow through venous channels with AV fistulas of different sizes (3, 4, 5 mm). As fistula diameter increased flow increased, but venous return decreased with a resultant increase in distal venous pressure. He found the optimal AVF to graft ratio to be 0.375.
In 1985, Eklof conducted a prospective randomized trial with thrombectomy alone and thrombectomy plus AVF arms. The patency rates increased from 35% for thrombectomy alone to 76% for thrombectomy and AVF. The previously mentioned study by Jost noted a decreased graft patency with use of an AVF.
In conclusion, in selected patients, venous reconstruction may be beneficial, but appropriate counseling is crucial. The Palma procedure has longest patency if feasible. AVFs increase graft patency when sized appropriately for the graft. Stringent post-operative management is essential to optimize outcome.
Alimi YS, Di Mauro P, Fabre D, Juhan C. Iliac vein reconstructions to treat acute and chronic venous occlusive disease. Jour Vasc Surg. 1997; 25:673-81.
Eklof B, Albrechtson U, Einarsson E, Plate G. The temporary arteriovenous fistula in venous reconstructive surgery. Int Angiol. 1985; 4:455-62.
Jost C, Gloviczki P, Cherry K, McKusick M, , Harmsen W, Jenkins G, Bower T. Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease. Jour Vasc Surg. 2001; 33:320-8.
Menawat S, Gloviczki P, Mozes G, Whitley D, Anding W, Serry R. Effect of a femoral arteriovenous fistula on lower extremity venous hemodynamics after femorocaval reconstruction. Jour Vasc Surg. 1996; 24:793-9.