Venous morbidity after superficial femoral-popliteal vein harvest

Post-Operative Ischemia and Surgical Technique Affect Late Mortality of Femoral Artery Pseudoaneurysms Following Injection Drug Use

BACKGROUND

Surgical management of infected common femoral artery (CFA) pseudoaneurysms arising from intravenous drug use (IVDU) is clinically challenging with excellent perioperative outcomes reported for a number of techniques. Long-term outcomes after arterial ligation versus revascularization are not known. We report both short- and long-term comparison of lower extremity perfusion and outcomes for 25 patients that underwent simple or more extensive ligation or revascularization treatment.

METHODS

A retrospective analysis of 25 consecutive patients presenting primarily with infected CFA pseudoaneurysms related to IVDU at one referral institution was performed to determine short- and long-term outcomes at time of discharge, 30 days, and 1 year, including intraoperative differences, postoperative and follow-up ankle-brachial index, bacteriology, and postoperative mortality. In addition to a direct comparison between the revascularization patients (n = 12) and simple ligation patients (n = 13), a comparison within the simple ligation group was performed between those who underwent a ligation of the CFA with preservation of the femoral bifurcation (double ligation) and those who underwent ligation of the CFA, superficial femoral artery, and profunda femoral artery individually (triple ligation [TL]).

RESULTS

All techniques resulted in similar mortality at 30 days. Lower extremity perfusion at discharge was highest in the revascularization group, and lowest in the TL patients. One year mortality was significantly higher in the TL cohort.

CONCLUSIONS

This is the first report of long-term outcomes after surgery for infected CFA pseudoaneurysms, and demonstrates increased late mortality in patients treated with extensive (triple) ligation with persistent ischemia. We conclude that revascularization after resection of infected CFA aneurysms, or surgical techniques that preserve or recreate the femoral artery bifurcation cause less ischemia and late mortality in these challenging patients.

The Femoral Vein as a Long-Term Aorto-Iliac Graft for Aortic Infection and Aortitis

Background

Reconstruction of the aorto-iliac segment with femoral vein (FV) as substitute for infected synthetic grafts or mycotic aneurysms constitutes the most sustainably convenient alternative. The aim of this study was to evaluate the long-term outcome of up to 16 years of follow-up, analysing the morphologic adaption of the FV with special emphasis on the distal and proximal anastomoses.

Methods

We conducted a retrospective study of 22 patients with 109 computed tomography angiograms (CTAs) treated between August 2001 and January 2020 in case of aortic infection/aortitis. Morphologic changes like anastomotic dilatation/stenosis as well as changes of FV wall thickness were retrospectively analysed in pre- and postoperative CTAs.

Results

Elective procedure was done in 17/22 (77%) cases, and 5/22 (23%) patients required emergent surgery. The median follow-up was 91.5 months (P₂₅;P₇₅ = 21;117). Cross-sectional diameter of proximal (20.38 ± 3.77 vs 22.04 ± 3.97 mm, p = 0.007) and distal anastomoses (13.05 ± 4.23 vs 14.61 ± 5.19 mm, p = 0.05) increased significantly, as well as the proximal and distal anastomotic areas (3.36 ± 1.29 vs 4.32 ± 1.63 mm², p = 0.04 and 0.99 ± 0.48 vs 1.25 ± 0.72 mm², p = 0.023, respectively). Venous wall thickness was significantly reduced at the anastomotic site (1.74 ± 0.46 vs 1.24 ± 0.31 mm, p = 0.001). The upper thigh diameter did not differ before and after harvesting of the FV (161.6 ± 29.1 vs. 178.2 ± 23.3 mm, p = 0.326, respectively).

Conclusion

This long-term CTA follow-up study showed that the FV wall becomes thinner at the anastomotic site, and the anastomoses dilate with time without rupture. The FV is a durable conductor after replacement of the aorto-iliac segment due to aortic infection. Further CTA studies from more centres are warranted to evaluate the risk of vein rupture.

Living donor liver transplantation for idiopathic portal hypertension with extrahepatic portal vein stenosis and splenic artery aneurysms: a case report and review of the literature

Background

Idiopathic portal hypertension (IPH) generally has a good prognosis and rarely results in liver transplantation. Furthermore, there are few reports of living donor liver transplantation (LDLT) for IPH with extrahepatic portal vein stenosis.

Case presentation

We report the case of a 51-year-old female patient diagnosed with IPH more than 20 years ago. She suffered severe jaundice, massive ascites, and encephalopathy at the time of her visit to our hospital. The patient’s extrahepatic portal vein showed a scar-like stenosis, and the portal flow was completely hepatofugal. Collateral circulation such as the splenorenal shunt was well developed, and multiple splenic artery aneurysms up to 2 cm were observed in the splenic hilum. Her Model for End-Stage Liver Disease score increased to over 40 because of renal dysfunction, requiring temporary dialysis. We performed LDLT using her husband’s right lobe graft and splenectomy. The extrahepatic stenotic portal vein was completely resected, and the superficial femoral vein (SFV) graft collected from the recipient’s right leg was used for portal reconstruction as an interposition graft. Although the clinical course after LDLT had many complications, the patient was discharged on postoperative day 113 and has been fine for 2 years after LDLT. Histopathologically, the explanted liver had obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal cirrhosis.

Conclusion

This case showed that severe IPH is occasionally associated with extrahepatic portal vein stenosis and can be treated with LDLT with portal vein reconstruction using an interposition graft. It was also suggested that the SFV is a useful choice for the interposition graft.

Aortic reconstruction in infected aortic pathology by femoral vein "neo-aorta"

The use of autologous femoral veins for in situ reconstruction of the aortoiliac segment is an effective technique to treat native aorta or prosthetic graft infections. The indications, technical details, and outcomes of this procedure are detailed. Graft infection involving the aortic segment, while rare, remains one of the most challenging vascular surgery conditions to treat. The original technique of "neo-aortoiliac surgery" with in situ autologous vein grafts has evolved over the past 25 years and remains a worthwhile alternative for the treatment of aortic graft infections, with lower mortality rates compared with other extra-anatomic or in situ surgical options. Acceptance of this surgical option is due to low graft re-infection rates, rare graft disruption, and low long-term aneurysmal degeneration. Excision of the femoral veins is associated with acceptable rates of lower limb edema. The use of an autologous femoral vein graft can be considered the standard of care in selected patients for the management of aortic graft infections. Optimal management of patients with aortic graft infections requires consideration of all potential therapeutic options because no single modality can be used, and individualizing treatment according to the clinical condition will yield the best patient outcomes.

Femoral Vein Transposition Arteriovenous Fistula is a Feasible Option in "Selected" Patients as Hemodialysis Access

Introduction: Lower extremity hemodialysis access is offered to the patients who have severe central venous stenosis. Femoral vein transposition arteriovenous fistula (FV tAVF) is an alternative to lower leg arteriovenous prosthetic grafts. Its safety and patency is under observation.

Materials and Methods: This is a retrospective review of patients who had FV tAVF between January 2011 and March 2016. Preoperative clinical findings, intraoperative findings, postoperative complications, and patency of the AVF were noted and analyzed.

Results: There were 7 patients who underwent FV tAVF during this study period. Most patients were female (6 : 1), with mean age of 45.2 years (range, 33–55 years). All patients were hypertensive. Mean body mass index was 26.1 kg/m². Patient had on average previous 6 dialysis accesses. Most patients had preoperative venograms (6/7). Mean interval between initiation of dialysis and creation of the arteriovenous fistula was 1.08 years. All procedures were done under general anesthesia. Four patients required extension of FV with either the small segment of polytetrafluorethylene or vein graft. Two patients had early postoperative complications. One patient developed hematoma, whereas other had wound dehiscence. All the accesses were utilized for dialysis after a mean interval of 6 weeks. All patients had a patent fistula on average follow-up of 2 years.

Conclusion: Appropriate patient selection for FV tAVF can provide good patency with low incidence of complications. This can be considered for good risk individuals undergoing their first lower extremity access.

Feasibility and Outcomes of Femoral Vein Harvest for Dialysis Access and Arterial Reconstruction

BACKGROUND

We describe the feasibility and long-term outcomes of using femoral vein (FV) for arteriovenous fistula (AVF) and lower extremity bypass (LEB) creation.

METHODS

All patients undergoing AVF or LEB using autogenous FV by a single surgeon (April 2006 to September 2013) were reviewed. Perioperative (30-d) complications and long-term outcomes are described.

RESULTS

Forty-four patients underwent vascular reconstruction with FV (AVF = 27 and LEB = 17). Perioperative morbidity was 43.2%, including harvest site infection and or seroma in 15.9%. No patients suffered from compartment syndrome or venous thromboembolic event. At median follow-up of 50.0 mon, overall patency was 70.4% for AVF (primary = 37.0% and secondary = 70.3%) and 76.5% for LEB (primary = 70.6% and secondary = 76.5%). Long-term lower extremity swelling occurred in 18.2% of patients.

CONCLUSIONS

Perioperative morbidity following FV harvest is high, but long-term patency rates are excellent. FV harvest is feasible and should be considered as a valid conduit in patients without useable great saphenous vein or other more commonly used sources of autogenous vein.

Vascular access for Chronic Dialysis using the Superficial Femoral Vein

Purpose

We report our experience in using the superficial femoral vein to create hemodialysis (HD) arteriovenous (AV) fistulas. Surgery was performed on six patients (four female, two male). Indications for surgery included previous fistula loss, graft infection and exhaustion of typical shunt sites.

Methods

The femoral vein was evaluated preoperatively, by Doppler ultrasound, harvested by one long incision on the anteromedial surface of the thigh, followed by suction drainage. In four patients, harvested veins were transplanted in the arm between the brachial artery and axillar vein, followed by an end-to-side anastomosis. In two patients, the venous graft remained on the anterior surface of the thigh. In those patients, they were extended with either a piece of polytetrafluoroethylene (PTFE) graft or the saphenous vein.

Results

Follow-up ranged between 14 months and 2 yrs, ensuring proper dialysis. Two patients presented with complications, including lower leg swelling and axillary lymphorrhea, which subsided spontaneously.

Conclusions

We recommend this type of AV fistula, especially in difficult cases, where all other classical vascular approaches have been used. However, the procedure is time consuming and requires experience in vascular surgery.

Staged reconstruction of the inferior vena cava after gunshot injury

A 23-year-old man with a gunshot injury to the abdomen and cardiac arrest requiring emergency department thoracotomy had a transection of the distal inferior vena cava (IVC) and small bowel injury. Because of persistent hemorrhagic shock, the IVC was ligated. During the next 3 days, he developed worsening bilateral leg edema. He was taken back for reanastomosis of his small bowel and reconstruction of the IVC using autologous femoral vein harvested from the right leg. We think that patients requiring ligation of the vena cava with worsening leg edema can benefit from a staged reconstruction of the IVC.

Superior Vena Cava Reconstruction Using Femoropopliteal Vein as a Panel Graft

There has been an increase in superior vena cava (SVC) syndrome secondary to the growing use of indwelling catheters and pacemaker wire insertions. These 2 factors can account up to 74% cases of benign SVC syndrome. Endovascular therapy is considered the first line of treatment. Surgery is an excellent option and is generally reserved for SVC syndrome not amenable to traditional endovascular procedures. We report a case of central venous reconstruction including an SVC reconstruction using the femoropopliteal vein as a panel graft in a patient with SVC syndrome due to pacemaker wires who failed multiple endovascular interventions.

Operative technique and morbidity of superficial femoral vein harvest

Background

The use of autologous superficial femoral veins (SFV) as an arterial or venous substitute represents a valuable technique in modern vascular surgery with versatile indications. The SFV autografts exhibit excellent control of infection and durable long-term results in terms of graft patency in prosthetic or arterial infections. In cases of elective use of the SFV, duplex ultrasound evaluation of the deep leg vein system should be implemented to confirm the patency of the profunda femoris vein.

Material and methods

The SFV can be harvested distal to the adductor hiatus with a proximal portion of the popliteal vein but should not exceed the level of the knee joint. Formation of a stump of the proximal SFV must be avoided. Simultaneous harvesting of the ipsilateral greater saphenous vein should be avoided to reduce the risk of significant chronic edema.

Results

Early postoperative swelling of the donor leg can be expected but resolves spontaneously in most cases. Chronic mild edema of the leg with a possible indication for compression therapy may occur in up to 20 % of cases but severe complications are very rare if the anatomical borders for vein harvesting are respected. Temporary therapeutic anticoagulation after vein harvest is subject to individual decision making.

Conclusion

Duplex ultrasound is a reliable tool to assess the residual deep and superficial venous system in the long term. Excellent graft function and the tolerable adverse effects of vein harvest on the donor leg justify the use of the SFV in arterial and venous vascular surgery if indicated.

Late Stent Graft Infection after the Emergency Endovascular Repair of a Secondary Iliac Artery-Enteric Fistula Treated with Graft Removal and In Situ Aortic Reconstruction Using Femoral Veins

An arterioenteric fistula is a devastating and life-threatening condition that requires urgent treatment. Less-invasive endovascular treatment has emerged as an alternative to conventional open repair, but postoperative graft infection remains a major concern. We herein report a case of late stent graft infection after emergency endovascular repair of a secondary iliac artery-enteric fistula. The patient was a 63-year-old male who presented with a fever, who had undergone successful endovascular stent grafting for a secondary common iliac artery-enteric fistula 29 months prior. The diagnosis of a stent graft infection was confirmed via computed tomography. He underwent graft removal and in situ reconstruction with femoral vein grafts. At 6-month follow-up, the patient is in a good general condition without any symptoms.

Deep Leg Vein Reconstruction for an Isolated Mycotic Common Iliac Artery Aneurysm in an HIV-Positive Patient

Isolated mycotic common iliac artery aneurysms are rare, and as such, there is no consensus opinion on management. Traditional surgical options include resection with extra-anatomic bypass, placement of allograft or antibiotic treated synthetic graft, or autogenous vein reconstruction. We report the case of a 46-year-old, human immunodeficiency virus-positive male who presented with a recurrent pneumonia and new onset of right lower quadrant abdominal pain associated with right lower extremity swelling. computed tomographic scan revealed an isolated 9.5 cm right common iliac artery aneurysm with no evidence of rupture. Preoperative blood cultures grew out Streptococcus pneumoniae. Operative repair included aneurysm resection and reconstruction using an autogenous femoropopliteal vein interposition graft from the ipsilateral thigh. The patient had an uneventful recovery with resolution of his lower extremity swelling and a normal duplex exam at follow-up. Large mycotic common iliac artery aneurysms can be successfully treated with aneurysm resection and reconstruction using an autogenous femoropopliteal vein conduit. This technique obviates the need for extra-anatomic bypass or other forms of reconstruction using prosthetic material.

The effect of smoking and major vein resection on post-therapy lymphedema in soft tissue sarcomas treated with neoadjuvant radiation and limb-salvage surgery

BACKGROUND

Neoadjuvant therapy with radiation +/- chemotherapy is an accepted management for soft tissue sarcomas (STS). The incidence of post-therapy lymphedema is around 30%. The purpose of this study was to identify variables that predict for post-therapy lymphedema.

METHODS

From 2000 to 2010, 132 patients with STS were treated with neoadjuvant radiation +/- chemotherapy followed by resection. Patient variables and treatment outcomes were reviewed. Presence of lymphedema was determined by the treating physician. The Fisher exact test was used for univariate analysis and logistic regression was used for multivariate analysis.

RESULTS

Median follow-up was 3.1 years. Of the lower extremity STS, major veins were sacrificed in 34% of patients. Lymphedema occurred in 22.4% of patients. Smoking negatively predicted for lymphedema on univariate analysis (P=0.007), and sacrifice of a major vein was associated with an increased risk of lymphedema (P=0.02). On multivariate analysis, smoking (P=0.02, odds ratio 0.31) negatively predicted for and sacrifice of a major vein (P=0.03, odds ratio 2.7) positively predicted for lymphedema.

CONCLUSIONS

There may be an association between smoking and decrease post-therapy lymphedema. Also, patients who undergo resection of a major vein seem to be more prone to post-therapy lymphedema.

Customized femoral vein grafts for inferior vena cava reconstruction

After extended en-bloc resection of a retroperitoneal neoplasm, prosthetic grafts can efficiently replace the inferior vena cava. However, in cases of concomitant biliary or bowel surgery, there is a risk of infection, and autogenous materials typically used present with size match. We present a method of autogenous graft construction using the femoral vein for replacement of the inferior vena cava, with an alternate configuration for renal vein implantation.

In situ aortobiiliac reconstruction of infected aneurysm using a single superficial femoral vein

OBJECTIVE

To demonstrate successful in situ aortoiliac reconstruction of an infected infrarenal aneurysm using one single superficial femoral vein (SFV).

METHODS

In situ reconstruction using the right SFV sutured in end-to-end anastomosis with the aorta and distally with the right common iliac artery and in end-to-side anastomosis with the left common iliac artery.

RESULTS

The operating time was less than reported for aortic in situ reconstruction with bilateral SFV harvesting. The duplex scan 3 months postoperatively showed permeability of the bypass without any anastomotic stenosis or pseudoaneurysm. The right common femoral, popliteal, and greater saphenous veins were patent without thrombus, and the patient did not complain about peripheral edema.

CONCLUSIONS

The use of only one instead of both the SFVs for aortobiiliac in situ reconstruction might be a way to reduce operating time and allow autogenous venous reconstruction even in patients with limited availability of venous material.

Arm composite autogenous vascular access using the great saphenous vein and the femoral vein: results from a single-centre study

OBJECTIVES

The objective is to report our results with the arm composite autogenous vascular access (ACAVA) using the great saphenous vein (GSV) and the femoral vein (FV) in tertiary vascular access surgery.

DESIGN

Retrospective single-centre study. Prospectively collected clinical database.

METHODS

Between August 2009 and March 2011, 17 patients with no suitable upper extremity vein, repeated prosthetic access failure and/or infection underwent the construction of an ACAVA. Outcome measures included the graft patency and complication rates.

RESULTS

The median follow-up was 25 months (5-32). Thirty-day morbidity affected 10 patients (59%): four wound-healing issues, three lower limb swelling, two early thromboses and one upper limb haematoma. No postoperative death occurred. At 3 months, the primary patency rate was 88% ± 8%. At 6 months, the assisted-primary patency rate was 82.4% ± 9.2%. At 12 months, the secondary patency rate was 81.6% ± 9.6%. Twenty-four secondary interventions were performed. Steal syndrome occurred in one patient following a secondary procedure. Swelling of the lower limb remained in two patients at the end of their follow-up. Three ACAVAs developed irreversible occlusion leading to loss of access.

CONCLUSION

With a high rate of postoperative morbidity and re-intervention, the ACAVA is a useful additional technique that should be restricted to difficult cases with limited vascular access options.

Symptomatic venous thromboembolism after femoral vein harvest

OBJECTIVE

The femoral vein is increasingly utilized as a conduit in major arterial and venous reconstruction. However, perioperative complications, especially venous thromboembolism (VTE) associated with femoral vein harvest (FVH), are not well described. The purpose of this study was to determine the incidence and risk factors for the development of symptomatic VTE in patients who undergo FVH.

METHODS

We conducted a retrospective cohort study of all patients who underwent FVH over a 5-year period at a single institution. Patient clinical characteristics, indications for surgery, postoperative venous duplex scans, and computerized tomography scans of the chest were gathered and reviewed from an electronic medical record query. Statistical analysis was performed to determine which factors correlate with development of perioperative complications after FVH.

RESULTS

There were 57 patients (53% male; mean age, 62 years) who underwent 58 FVHs. Of the procedures, 53% were performed for arterial reconstruction and 47% for vascular reconstruction after cancer resection (85% portomesenteric reconstruction). Perioperative VTEs were diagnosed in 17 of 58 (29%) FVH procedures. Sixteen ipsilateral deep vein thromboses (DVTs) occurred distal to the FVH site and five (9%) occurred proximal to the FVH site. The incidence of VTE was significantly greater in patients with malignancy (52% vs 10%; P = .001), and 88% of all VTEs in this series were diagnosed in patients with cancer. All DVTs proximal to the FVH site and all DVTs in the contralateral extremity occurred in patients with malignancy. Pulmonary embolism occurred in two patients. No patients developed compartment syndrome or limb loss. Eight patients (14%) required FVH site wound debridement.

CONCLUSIONS

VTE after FVH occurs more frequently in patients with malignancy. Aggressive and prolonged thromboprophylaxis and routine venous ultrasound surveillance are warranted after FVH in patients with malignancy.

Composite PTFE-transposed superficial femoral vein for lower limb arteriovenous access

PURPOSE

We report our experience in creating a composite loop of transposed superficial femoral vein (tSFV) and polytetrafluoroethylene (PTFE) synthetic graft for lower limb access. The indication for surgery was exhaustion of access sites in both upper limbs.

METHODS

Surgery was performed on 3 male patients. All patients had an ankle brachial index =0.9. The SFV was mobilized up to adductor canal, with ligation of all small tributary branches, up to the level below the profunda femoral vein, then tunneled medially to the skin. A 6-mm PTFE graft was tunneled laterally, deep in the subcutaneous plane in loop fashion to the end of the tSFV, where a beveled end-to-end anastomosis was created.

RESULTS

The blood flow in both fistulas increased gradually to 0.7-1.3 l/min postoperatively. No clinical manifestation indicative of lower limb ischemia, lymphorrhea, or infection was documented. No signs related to chronic venous hypertension were noticed.

CONCLUSIONS

Our initial experience shows that the creation of a composite PTFE-tSFV conduit is a promising technique, since it can be constructed without compromising the distal perfusion, and without infectious complications.

Management of the infected aortoiliac aneurysms

PURPOSE

We have reviewed ruptured and nonruptured infected aortoiliac aneurysms to study the clinical presentation, management and eventual outcome of patients managed with in situ prostheses, axillofemoral prostheses grafts and endovascular reconstruction.

DESIGN

A retrospective chart review of 16 cases treated at a single institution.

METHODS

From January 2007 to March 2008, a total of 93 patients with aortoiliac aneurysms underwent surgical repair at our institution. Among these, 16 patients (17.2%) were shown to be infected aneurysms of the infrarenal (n = 6), juxtarenal (n = 2), and pararenal aorta (n = 1); the others were 5 common, 1 external, and 1 internal iliac arteries. Fourteen patients were male and 2 were female with the mean age of 66 years (range, 45-79). In all cases, the diagnosis was confirmed by abdominal computed tomography and empirical parenteral antibiotics were administered at least 1 week, unless in patients need emergency operations. At the time of an operation, all were saccular and were classified as primary infected aortoiliac aneurysms. Thirteen patients had surgical debridement with in situ graft interposition and omental wrapping, 2 underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass, 1 underwent aneurysmectomy of left external iliac artery and polytetrafluoroethylene (PTFE) graft interposition, and 1 underwent endovascular exclusion. The parenteral antibiotics were continued in the postoperative period for 4-6 weeks. Chronic renal disease was present in 37.5% (6/16), with diabetes mellitus present in 31.25% (5/16). The most common pathogen was Salmonella sp. (n = 6) and E. coli (n = 5). Thirty-seven percent (6/16) of the patients presented late, with a 37.5% (6/16) incidence of ruptured (4 contained, 2 free ruptured) that needed emergency surgery.

RESULTS

Disease-specific mortality was 31.25% (5/16). The 30-day mortality rate of ruptured cases is high 67% (4/6), because patients present late in the course of the disease. One patient who underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass died 6 months later from burst aortic stump. Salmonella and E. coli are the most common pathogens.

CONCLUSIONS

Early diagnosis followed by surgical intervention with proper antibiotic coverage provides the best results. Mortality rate was still high in patients with sepsis and rupture. An in situ graft interposition and omental wrapping is a safe option for revascularization of infected aneurysms of the iliac arteries and infrarenal aorta.

Peripheral vascular reconstruction using deep vein graft for critically ill patients

The great saphenous veins are gaining wide popularity as acceptable native vascular grafts, but in terms of flow capacity, their small caliber may be unsuitable for immediate replacement of arterial flow. Ten peripheral vascular or central venous reconstructions were performed using superficial femoral vein free grafts for re-establishment of immediate high-flow patency. Seven of the patients were men with a mean age of 61.5 ± 17.9 years (range, 21–81 years). The majority of the patients were of preoperative or intraoperative critically ill statuses in that they had extensive infection ( n = 5), bleeding ( n = 4), renal failure ( n = 3) or hepatic failure ( n = 1). The mean preoperative physiology score of the vascular POSSUM was 24.1 ± 8.8 (range, 15–37), and the mean operative severity score was 18.4 ± 4.9 (range, 10–26). All patients survived and recovered from systemic infection or critical hemodynamic instability. During the mean 28.9 months of follow-up, complications such as aneurysmal dilation, recurrent infection, graft stenosis/occlusion, lower limb edema and other clinical problems that required attention were not observed. In conclusion, we determined that deep veins can be applied as ideal graft conduits for reconstructing the major peripheral vessels under complicated conditions in select patients.

Techniques and results of portal vein/superior mesenteric vein reconstruction using femoral and saphenous vein during pancreaticoduodenectomy

BACKGROUND

Patients with pancreatic tumors may have portal vein (PV) and/or superior mesenteric vein (SMV) invasion. In such cases, lower extremity veins can provide an autogenous conduit for PV/SMV reconstruction. Little data exist, however, describing the technique of PV/SMV reconstruction, patency of such reconstructions, and the morbidity of using lower extremity veins for PV/SMV reconstruction during pancreaticoduodenectomy.

METHODS

Thirty-four patients underwent PV/SMV reconstruction during pancreaticoduodenectomy using lower extremity vein. The saphenous vein was preferred for patching and femoral vein for replacement. We analyzed preoperative imaging, reconstruction patency, vein harvest morbidity, and late mortality.

RESULTS

The mean age was 62.6 years. All 34 patients had preoperative computed tomography (CT) imaging and/or endoscopic ultrasound (EUS) scan. Fourteen of the 34 patients had evidence of PV/SMV invasion on CT or EUS scans, 14 did not, and six studies were indeterminate. Twenty-five patients had follow-up imaging, and 22 (88%) had patent reconstructions. Fifteen patients had PV/SMV replacement using femoral vein. Seven of these 15 had minor postoperative lower extremity edema that resolved over time, five had wound complications from the femoral vein harvest site, three of which required minor operative procedures for treatment. Fifteen patients had PV/SMV patching with the great saphenous vein, none had postoperative wound problems, and one had minimal postoperative lower extremity edema. Four patients had PV/SMV patching using femoral vein, none had postoperative wound problems, and one had minimal postoperative lower extremity edema. Compared with patients undergoing pancreaticoduodenectomy without PV/SMV reconstruction, by Kaplan-Meier analysis, there was no difference in late mortality.

CONCLUSION

Preoperative imaging may fail to detect PV/SMV involvement in patients undergoing pancreaticoduodenectomy. The PV/SMV reconstruction with leg vein provides good patency with minimal postoperative lower extremity complications and no increase in late mortality. The lower extremities should be routinely included in the operative field of patients undergoing pancreaticoduodenectomy.

Great mediastinal vein reconstruction using autologous superficial femoral vein superficial femoral vein graft

BACKGROUND AND AIM

Great mediastinal veins may be reconstructed using autologous, synthetic, or allograft conduits. Autologous conduits have been found superior to other conduit options. The superficial femoral vein (SFV) offers excellent early patency, minimal lower limb morbidity, and ease of harvest without accessory suture lines. Although rarely used, the SFV provides an acceptable alternative for conduit in large vein reconstructions.

METHODS

Two recent cases using SFV for great mediastinal vein reconstruction were reviewed and operative technique of vein harvest detailed.

RESULTS

This is the first report of successful reconstruction of a left superior vena cava using SFV conduit. Both superior vena cava (SVC) reconstructions reported were perfectly patent at intermediate term follow-up (20 and 14 months) as determined by computed tomography angiogram or magnetic resonance imaging.

CONCLUSIONS

Successful and durable reconstruction of the SVC or a persistent left subclavian vein is possible with minimal morbidity using the SFV.

A cylindrical femoral vein panel graft for caval reconstructions

This report describes a simple venous reconstructive technique that results in an autogenous vascular graft with sufficient luminal diameter for replacing the vena cava. The majority of vena caval reconstructions are performed using prosthetic grafts; however, graft infection is a concern in clean-contaminated hepatobiliary and retroperitoneal resections.

Neoaortoiliac reconstructions using femoropopliteal veins: MDCT angiography findings

OBJECTIVE

In this article, we discuss the neoaortoiliac system procedure, a surgical procedure that uses femoropopliteal vein segments for arterial reconstructions in patients with aortofemoral prosthetic graft infections.

CONCLUSION

CT angiography (CTA) is a powerful imaging tool that can be used in the follow-up of patients after this complex surgery. CTA accurately detects early and late complications that may develop after the neoaortoiliac system procedure.

Femoral vein harvest for vascular reconstructions: pitfalls and tips for success

The femoral-popliteal vein has proved to be an excellent conduit for a variety of indications. These include in situ reconstruction of infected aortic grafts, and mesenteric, brachiocephalic, and lower-extremity bypasses. This article discusses the technical details of successful deep vein harvest. Information regarding the preoperative evaluation, postoperative surveillance, reintervention, and venous morbidity is provided. The femoral-popliteal vein graft has proven to be a durable conduit with minimal late venous morbidity.

Portomesenteric reconstruction during Whipple procedures: review and report of a case

A 60-year-old man undergoing a Whipple procedure to treat a pancreatic cancer was found to have tumor adherence to the portal vein. An en block pancreaticoduodenectomy with segmental portal vein resection (PVR) was performed. A primary portal vein anastomosis was initially attempted but failed. Hemodynamic deterioration led the authors to perform a temporary prosthetic portal vein interposition graft and abdominal closure. The following morning, once stable, the patient was brought back to the operating room for autologous reconstruction with femoral vein and completion of the pancreaticoduodenectomy. The role of PVR for vein invasion or tumor adherence during a Whipple procedure is still under debate. However, there is growing evidence that the perioperative morbidity and long-term survival in patients who undergo a pancreaticoduodenectomy with PVR are similar to those of patients without vein resection. Therefore a combined resection of the pancreatic head and the portal vein has been suggested in the absence of other contraindications for resection to be able to offer a curative surgical intervention to a larger number of patients. The authors herein report the details of a patient's case and also review the currently available methods for PVR and reconstruction.

Late incidence of chronic venous insufficiency after deep vein harvest

BACKGROUND

The deep veins (DV) of the thigh have proven to be versatile autogenous conduits for arterial reconstruction. Harvesting DV poses a theoretical risk of compromising venous outflow of the limb, which could predispose to chronic venous morbidity. The purpose of this study was to define the late incidence of chronic venous insufficiency (CVI) and to characterize the long-term alterations in venous physiology after DV harvest.

METHODS

Since 1991, 269 patients have undergone arterial reconstructions using DV at our facility. Patients with DV harvest at least 43 months prior to the study (n = 151) were eligible for inclusion. Eighty-nine patients were excluded (deceased = 70; lost to follow-up = 19). Forty-six patients who declined formal testing were queried by phone for signs and symptoms of CVI. The current study presents a case-control series of 16 patients (27 limbs) after DV harvest and six age- and gender-matched control patients (12 limbs) who underwent examination and venous testing.

RESULTS

At a mean follow-up of 70.1 +/- 5.6 months, 23 of 27 limbs (85.2%) had no significant CVI (CEAP C(0) to C(2)). Four limbs (14.8%) had significant venous morbidity (C(3) to C(6)), including edema alone (C(3); n = 2 limbs), edema with skin changes (C(4); n = 1 limb), and a healed venous ulceration (C(5); n = 1 limb). APG testing confirmed relative venous outflow obstruction after DV harvest (mean outflow fraction: harvested limbs = 38.4 +/- 3.9% vs control limbs = 51.7 +/- 4.3%; P = .04). Despite the relative outflow obstruction, the mean VFI was not significantly different between harvested and control limbs (harvested limbs = 1.08 +/- 0.15% vs control limbs = 0.77 +/- 0.16%; P = .19). DV harvest resulted in no significant changes in calf ejection fraction (harvested limbs = 67.4 +/- 6.4% vs control limbs = 86.8 +/- 9.5%; P = .09) or residual volume fraction measured (harvested limbs = 32.3 +/- 6.4% vs control limbs = 47.7 +/- 11.6%; P = .22). Of the 46 patients interviewed by phone, five (10.9%) reported bilateral amputations, seven (15.2%) reported chronic edema in their harvested limbs (C(3)), and 34 (73.9%) reported no signs of CVI in their harvested limbs (C(0)).

CONCLUSIONS

Deep vein harvest produces few symptoms of chronic venous insufficiency, and venous ulceration is infrequent. Despite relative venous outflow obstruction, noninvasive indices of chronic venous insufficiency on APG are often normal, suggesting that the risk of developing venous ulceration is low in the majority of patients after DV harvest.

Vascular reconstruction with the superficial femoral vein following major oncologic resection

INTRODUCTION

Involvement of critical vascular structures has historically been considered a contraindication to tumor resection. This study describes outcomes following radical oncologic resection with concomitant resection of critical vascular structures and reconstruction with the superficial femoral vein (SFV).

METHODS

All patients undergoing radical oncologic resection requiring resection of major vascular structures and concomitant reconstruction using the SFV as conduit were retrospectively reviewed. Primary outcomes were surgical morbidity and mortality; secondary measures included long-term patency and oncologic outcomes.

RESULTS

Seven patients were included. There were three retroperitoneal and two groin sarcomas, and two squamous cell carcinomas metastatic to groin lymph nodes. No perioperative mortality occurred. Five patients experienced minor morbidity. One vein graft in a patient with pre-existing chronic deep venous thrombosis (DVT) occluded post-operatively. No subsequent long-term venous or arterial graft occlusions occurred (median 20.2 months, range 9.0-49.7). Two patients died of tumor recurrence during follow-up.

CONCLUSIONS

Resection of tumors involving critical vascular structures is feasible. The SFV conduit is a versatile option for major vascular reconstruction, providing good long-term patency rates with acceptable morbidity and mortality. Vascular resection and reconstruction with the SFV offers another technique to provide limb-sparing surgery in patients traditionally offered only amputation, while providing favorable oncologic outcomes.