Effect of a femoral arteriovenous fistula on lower extremity venous hemodynamics after femorocaval reconstruction

Modern treatment of a Klippel-Trenaunay syndrome patient with Palma procedure

Klippel-Trenaunay syndrome is a rare congenital anomaly that is associated with abnormalities in the deep venous system. Operative intervention is often used only when patients fail conservative management for chronic venous insufficiency. We present a case of a deep venous abnormality requiring a saphenous vein crossover Palma procedure, in combination with a left femoral arteriovenous PTFE fistula to manage a non-healing wound from chronic venous insufficiency in a 22-year-old man. This case highlights updates for modern treatment tips for technical and medical management decisions to avoid early graft thrombosis.

[Case of endovenectomy and stenting with functioning arteriovenous fistula in extended post-thrombotic occlusion of deep veins]

We describe herein a case of surgical treatment of a 32-year-old female patient presenting with multilevel post-thrombotic occlusion of deep veins of the left lower limb. Laboratory study revealed high-risk hereditary thrombophilia (homozygous mutation of PAI-1, MTR, heterozygous mutation of MTHFR, MTRR, ITGA2). The first stage included endovenectomy from the common femoral vein with creation of an arteriovenous fistula between femoral vessels. An attempt of endovascular stenting of iliac veins was initially unsuccessful. After 3 months, the woman was rehospitalized to undergo successful endovascular operation with stenting of the iliac veins and common femoral artery on the background of the functioning arteriovenous fistula. The clinical outcome of the operation was good. Follow-up ultrasonographic examinations (ultrasound duplex scanning) were performed at 3, 6, 10 and 13 months after the second operation. The findings of ultrasound duplex scanning at 13 months showed that the stented segments of deep veins were freely patent, with the arteriovenous fistula functioning well. There were no signs of impairments of central haemodynamics, with significant regression of clinical symptoms. The total score by the Villalta scale as compared with the baseline values decreased from 13 to 5. Given the pattern of deep vein lesions, complexity of open and endovascular operations, and the presence of thrombophilia, we decided to abstain from disuniting the arteriovenous fistula. This case report demonstrates possibility, efficacy and safety of long functioning of an artificial arteriovenous fistula in a particular patient cohort.

Post-thrombotic Syndrome: Preventative and Risk Reduction Strategies Following Deep Vein Thrombosis

Venous disease is common in the general population, with chronic venous disorders affecting 50–85% of the western population and consuming 2–3% of healthcare funding. It, therefore, represents a significant socioeconomic, physical and psychological burden. Acute deep vein thrombosis, although a well-recognised cause of death through pulmonary embolism, can more commonly lead to post-thrombotic syndrome (PTS). This article summarises the pathophysiology and risk factor profile of PTS, and highlights various strategies that may reduce the risk of PTS, and the endovenous management of iliofemoral deep vein thrombosis. The authors summarise the advances in PTS risk reduction strategies and present the latest evidence for discussion.

Polyester vascular patches acquire arterial or venous identity depending on their environment

Polyester is commonly used in vascular surgery for patch angioplasty and grafts. We hypothesized that polyester patches heal by infiltration of arterial or venous progenitor cells depending on the site of implantation. Polyester patches were implanted into the Wistar rat aorta or inferior vena cava and explanted on day 7 or 30. Neointima that formed on polyester patches was thicker in the venous environment compared to the amount that formed on patches in the arterial environment. Venous patches had more cell proliferation and greater numbers of VCAM-positive and CD68-positive cells, whereas arterial patches had greater numbers of vimentin-positive and alpha-actin-positive cells. Although there were similar numbers of endothelial progenitor cells in the neointimal endothelium, cells in the arterial patch were Ephrin-B2- and notch-4-positive while those in the venous patch were Eph-B4- and COUP-TFII-positive. Venous patches treated with an arteriovenous fistula had decreased neointimal thickness; neointimal endothelial cells expressed Ephrin-B2 and notch-4 in addition to Eph-B4 and COUP-TFII. Polyester patches in the venous environment acquire venous identity, whereas patches in the arterial environment acquire arterial identity; patches in the fistula environment acquire dual arterial-venous identity. These data suggest that synthetic patches heal by acquisition of identity of their environment. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 3422-3431, 2017.

Large vein reconstructions in the endovascular era

Max Ratschow was a remarkable physician and an international authority in the field of angiology and the Ratschow lectureship helps to fulfill this pioneer’s life purpose: to advance evaluation and treatment of vascular diseases. The 2017 Max Ratschow lecture covers some recent advances and controversies in venous diseases. Phlebology, once a neglected field of angiology, is a discipline that has been in constant progress during the past decades. Endovascular techniques revolutionized treatment of patients with large vein obstruction and provided safe, minimally invasive procedures with excellent long term results. Attention now need to focus on comparative studies to provide scientific evidence of efficacy of venous angioplasty and stenting with properly organized randomized controlled trials. Further attempts are needed to develop special venous stents and to decrease thrombotic complications and formation of pseudointima that cause in-stent restenosis. Open and hybrid reconstructions are safe and durable, but the number of procedures in general is small and special training and expertise for reconstructive venous surgery is recommended. Autologous vein should be used for infrainguinal reconstructions and for treatment of unilateral iliac vein obstruction with a femoro-femoral cross-over bypass (Palma procedure). IVC and iliac vein reconstructions with ePTFE grafts provide superb result in patients who need excision of malignant tumors invading large veins. Open and hybrid reconstructions are here to stay and they remain excellent options for those patients who are unsuitable for or fail endovascular repair.

Percutaneous closure of adjunctive arteriovenous fistulas after surgical reconstruction of iliac veins

In open surgical reconstruction for chronic iliofemoral and iliocaval vein obstruction, addition of an arteriovenous fistula (AVF) can improve patency. The AVF is usually taken down in a second surgical procedure several months after the initial reconstruction. With the advancement of endovascular techniques, percutaneous closure of the fistula has become an option. We have completed percutaneous endovascular takedown of AVFs after surgical reconstruction of iliofemoral veins in three patients using an occlusion device. Complete occlusion was achieved in all cases, and no short-term complications were noted. Endovascular occlusion seems particularly appealing as further surgery in a groin usually scarred by previous open procedures can be avoided.

Arteriovenous fistula geometry in hybrid recanalisation of post-thrombotic venous obstruction

Introduction

Post-thrombotic obstruction can be adequately treated by percutaneous transluminal angioplasty and stenting. When post-thrombotic trabeculations extend below the femoral confluence, proper inflow can be facilitated by endophlebectomy and creation of an arteriovenous fistula. The aim of this study was to investigate whether it is more favourable to place the arteriovenous fistula at the cranial or caudal end of the endophlebectomy to prevent stenosis or occlusion.

Methodology

We retrospectively analysed the clinical data of all patients who underwent a hybrid procedure in our two centres. Demographics, interventional details and post-operative imaging were collected.

Results

Data on 42 limbs with cranially and 23 limbs with caudally placed arteriovenous fistulas were collected. Post-thrombotic disease of the profunda femoral vein alone or in combination with the femoral vein was observed more often in the cranial group. The caudal group more often received a smaller sized and straight polytetrafluoroethylene fistula, while the cranial group comprised a significantly higher amount of stented segments. Logistic regression showed that only reduced femoral inflow (hazard ratio 2.934 (95%CI, 1.148–7.494)) was a significant predictor of stent stenosis and/or occlusion. Logistic regression for risk of occlusion showed a significant influence of stent-related complications (hazard ratio 4.691 (95%CI, 1.205–18.260)) and a tendency towards influence of arteriovenous fistula geometry in favour of the cranially placed fistula.

Conclusion

Placement of the arteriovenous fistula in the cranial part of the endophlebectomy during hybrid recanalisation may result in a more favourable outcome, yet this tendency was not statistically significant. Moreover, femoral inflow is pivotal in maintaining patency and should thus be adequately assessed pre-operatively.

Use of a superficial femoral artery autograft as a femoral vein replacement

Posttraumatic arteriovenous fistulas (AVFs) are common complications of vascular penetrating trauma. Here we present a case of a 59-year-old woman who had a history of gunshot injury 42 years ago causing AVF between superficial femoral artery (SFA) and superficial femoral vein (SFV). SFV was resected. Ipsilateral SFA was used to restore SFV. SFA was reconstituted using a 7-mm polytetrafluorethylene graft. The patient has normal venous and arterial flow at 3- and 15-month follow-up.

Complex left profunda femoris vein to renal vein bypass for the management of progressive chronic iliofemoral occlusion

Chronic occlusions of the inferior vena cava (IVC) and iliofemoral veins are long-term sequelae of deep venous thrombosis (DVT) that can lead to postthrombotic syndrome (PTS). Patients may present with a wide spectrum of signs and symptoms, ranging from mild discomfort and swelling to severe venous hypertension and ulcerations. We report a 68-year-old man who had a history of left lower extremity DVT after a laminectomy and who developed PTS with nonhealing ulcers. The patient underwent a cross-pubic femorofemoral venous bypass that failed to improve his clinical status. After unsuccessful endovascular attempts for recanalization of the iliofemoral segment, a profunda femoris to IVC bypass was performed. The symptoms recurred 2 years later. Venography revealed restenosis at the caval anastomosis that did not resolve by endovascular means. A surgical revision was performed, and given the quality of the IVC, a jump bypass was created to the left renal vein. The swelling improved and the ulcers healed completely. Twenty-eight months after the complex reconstructions, he remains ulcer-free with mild edema controlled with stockings. Venous reconstructions remain a viable option for patients with symptomatic and recalcitrant nonmalignant obstruction of the large veins.

Surgical femorocaval bypass for recalcitrant iliofemoral venous occlusion to endovascular treatment

Patients with chronic occlusion of iliac veins may present with symptoms ranging from mild discomfort to severe disability, including limb swelling, venous claudication, and ulceration. Endovascular treatment has emerged as first line of interventional therapy. Surgical venous-venous bypasses for the management of these patients in the era of endovascular therapy are rarely performed. These procedures are reserved only for patients with severe symptoms and long occlusive lesions that have failed previous endovascular interventions. We present a clinical scenario involving the use of femorocaval bypass to treat an iliofemoral occlusion recalcitrant to stenting, manifesting with severe lower extremity swelling and venous claudication. The surgical bypass resulted in significant improvement in the patient's clinical status.

Use of a superficial femoral artery autograft as a femoral vein replacement during en bloc sarcoma resection

INTRODUCTION

Soft tissue malignancy encasing axial vessels presents a surgical challenge when the goal is limb-preserving radical excision.

REPORT

We describe a case where limb-preserving resection of a myxoid liposarcoma involving the femoral vessels was successfully performed in the absence of autologous superficial vein for vascular reconstruction. The proximal ipsilateral superficial femoral artery was harvested as an autograft for venous reconstruction, with the arterial defect bridged using a polytetrafluoroethylene interposition graft.

DISCUSSION

This technique may be selectively extended to other indications where limb viability is dependent upon availability of a high-quality graft, and conventional conduits are either unavailable or unreliable.

Iliofemoral deep vein thrombosis: conventional therapy versus lysis and percutaneous transluminal angioplasty and stenting

OBJECTIVE

To compare conventional treatment (heparin and warfarin) of iliofemoral venous thrombosis with multimodality treatment (lysis and stenting).

SUMMARY BACKGROUND DATA

Several studies have reported on conventional therapy for iliofemoral venous thrombosis with disappointing results. However, more recent studies have reported better results with multimodality treatment.

METHODS

Fifty-one consecutive patients with extensive iliofemoral venous thrombosis were treated during a 10-year period. If there were no contraindications, patients were given the option to choose between conventional therapy (group 1) and multimodality therapy (group 2). The multimodality treatment strategy included catheter-directed lysis followed by percutaneous transluminal balloon angioplasty (PTA) and stenting for residual iliac stenoses. All patients underwent routine venous duplex imaging at 30 days, 3 months, 6 months, and every 6 months thereafter.

RESULTS

There were 33 patients in group 1 and 18 patients in group 2. Demographic and clinical characteristics were comparable for both groups. Initial lysis was achieved in 16 of 18 patients (89%) in group 2. Ten of 18 patients in group 2 had residual stenosis after lysis (8 primary and 2 secondary to malignancy), and they were treated with PTA/stenting with an initial success rate of 90%. Two patients in group 1 (6%) had a symptomatic pulmonary embolism (none in group 2). At 30 days, venous patency and symptom resolution were achieved in 1 of 33 patients (3%) in group 1 versus 15 of 18 (83%) in group 2. Kaplan-Meier analysis showed primary iliofemoral venous patency rates at 1, 3, and 5 years of 24%, 18%, and 18% and 83%, 69%, and 69% for groups 1 and 2, respectively. Long-term symptom resolution was achieved in 10 of 33 patients (30%) in group 1 versus 14 of 18 (78%) in group 2. Kaplan-Meier life table analysis showed similar survival rates at 1, 3, and 5 years of 100%, 93%, and 85% for group 1 and 100%, 93%, and 81% for group 2.

CONCLUSIONS

Lysis/stenting treatment was more effective than conventional treatment in patients with iliofemoral vein thrombosis.

Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease

PURPOSE

Venous reconstructions are rarely performed, and factors affecting long-term results of bypass grafts implanted in the venous system are not well defined. In this report we updated our experience.

METHODS

The clinical data of all patients who underwent venous reconstruction for iliofemoral or inferior vena caval (IVC) occlusion due to nonmalignant disease between January 1985 and June 1999 were retrospectively reviewed. Patients were classified, and outcomes were compared according to the guidelines of the Joint Vascular Societies.

RESULTS

Forty-two patients, 23 males and 19 females (mean age, 40 years; range, 16-81), underwent 44 venous reconstructions. Thirty-six patients had limb swelling or venous claudication, 38 had pain, and 14 had healed or active ulcers. The cause of obstruction was congenital in two and acquired in 40 (deep vein thrombosis, 25; trauma, 5; retroperitoneal fibrosis, 4; IVC occlusion devices, 4; others, 2). Eighteen patients underwent saphenous vein crossover grafts (Palma procedure), 17 had expanded polytetrafluoroethylene (ePTFE) grafts implanted (femorocaval, 8; iliocaval, 5; crossfemoral, 3; cavoatrial, 1), 6 patients had spiral vein grafts (5 iliac/femoral and 1 cavoatrial), and 1 underwent femoral vein patch angioplasty. Clinical follow-up averaged 3.5 years (median, 2.5), and graft follow-up with imaging studies averaged 2.6 years (median, 1.6). Seven patients were lost to follow-up. The secondary 3-year patency rate for all reconstructions was 62%. Palma procedures had a 4-year patency rate of 83%. The secondary patency rate of iliocaval and femorocaval ePTFE bypass grafts at 2 years was 54%. The secondary patency was lower in patients with an arteriovenous fistula (P =.023). All ePTFE grafts had a 45% patency rate at 2 years, not significantly different from saphenous vein grafts (83%, P =.16). Clinical scores improved with graft patency (median, 0.0 vs 1.5; P =.044).

CONCLUSIONS

Venous reconstructions for iliofemoral or IVC obstruction offer 3-year patency rates of 62%. The Palma procedure with autologous saphenous vein had the best long-term patency, whereas long-term success with ePTFE was moderate. The use of an arteriovenous fistula to improve graft patency remains controversial.

Left iliac venous thrombosis caused by venous spur: treatment with thrombectomy and stent implantation

PURPOSE

To determine the frequency of iliac venous spurs in left iliofemoral venous thrombosis and to report the results of interventional management of venous spurs after transfemoral venous thrombectomy.

METHODS

From 1990 through 1996, 77 patients with acute iliac venous thrombosis (61 left and 16 right) underwent surgical treatment. Patients with malignant disease were excluded from this series. All patients had transfemoral venous thrombectomy with construction of an inguinal arteriovenous fistula and perioperative anticoagulation with heparin with a switch to warfarin sodium for at least 12 postoperative months. Immediate results of thrombectomy were documented by means of intraoperative completion venography. Arteriovenous fistulas were ligated 3 months after control arteriovenography. Since 1995 venous spurs eventually detected during thrombectomy were treated immediately by means of stent implantation.

RESULTS

Among 61 patients with left-sided thrombosis, intraoperative phlebography revealed common iliac venous obstruction suggestive of venous spurs in 30 patients (49%). In 16 of 22 patients (73%) with untreated spurs, postoperative rethrombosis of the iliac vein was documented despite adequate anticoagulation. Only one of eight patients (13%) with stented spurs had reocclusion (chi2 test P < .01).

CONCLUSION

Venous spurs are found among about half of patients with left-sided iliac venous thrombosis. As long as the underlying venous pathologic process is left untreated, thrombectomy will not restore patency. Stent implantation is a simple and safe means to correct central venous strictures and provides excellent long-term results.