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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3786_Библиотеки_им_академика_М_И_Перельмана
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S.S. Desai et al.
35. Sclafani JA. Chronic cerebrospinal insuffi ciency:
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Lower Deep Vein Disease
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Jovan N. Markovic and Mitchell Cox
1 6
Contents
16.1 Overview ..................................................... 217
16.2 Clinical Presentation of Iliocaval
Obstruction ................................................. 218
16.3 Diagnostic Imaging .................................... 220
16.4 Venous Angioplasty and Stenting ............. 222
16.5 Venous Bypass ............................................ 223
16.6 Valve Repair ............................................... 226
16.7 Pelvic Venous Congestion .......................... 228
16.8 Nutcracker Syndrome ............................... 229
16.9 Popliteal Vein Compression ...................... 230
16.10 Summary..................................................... 231
References ................................................................. 231
Abstract
Deep venous insuffi ciency may manifest as
limb edema, chronic leg pain, stasis dermatitis, or ulceration, and the symptoms may be
chronically disabling. Initial therapy is directed
at ulcer healing and control of symptoms with
wound care and compression. Once conservative measures have been instituted, the next step
may be evaluation for any surgically correctable
contributors to the symptomatology. Although
valvular dysfunction and consequent venous
refl ux are a major cause of the venous hypertension that underlies the clinical manifestations of
chronic venous insuffi ciency (CVI), recent studies suggest that iliac venous outfl ow obstruction
plays a more important role in the pathogenesis
of CVI than previously estimated. Any combination of superfi cial, perforator, and/or deep
venous refl ux can result in various stages of
CVI, but when multiple segments of venous
system are affected, the manifestations of CVI
increase in severity. The combination of refl ux
and obstruction produces the highest levels of
venous hypertension and the most severe clinical symptoms. This chapter discusses iliocaval
vein obstructions and pelvic venous congestion.
J. N. Markovic , MD (*) • M. Cox , MD
Department of Surgery ,
Duke University Medical Center , Durham , NC , USA
e-mail: jovan.markovic@duke.edu
mitchell.cox2@duke.edu
E. Mowatt-Larssen et al. (eds.), Phlebology, Vein Surgery and Ultrasonography,
DOI 10.1007/978-3-319-01812-6_16, © Springer International Publishing Switzerland 2014
16.1 Overview
Management of deep venous insuffi ciency can be
a uniquely frustrating endeavor for both patient
and physician. While minimally invasive ablative
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J.N. Markovic and M. Cox
therapy for superfi cial venous refl ux can represent
defi nitive treatment and a symptomatic cure,
there are only rarely surgical or endovascular
solutions for incompetence of the deep veins. For
the phlebologist, the challenge in management is
to select the few patients who are candidates for a
surgical or endovascular approach and avoid an
invasive and expensive workup or a morbid surgical procedure in patients that would be better
served by conservative management with wound
care and compression.
In the past, the only options for surgical treatment of deep venous insuffi ciency were valve
repair or valve transposition for insuffi ciency and
venous bypass for obstruction. These procedures
are both relatively morbid and have had marginal
results and therefore have been performed at only
a relative handful of tertiary referral centers by a
few enthusiastic and persistent surgeons. Over
the past decade, there has been a boom in endovascular approaches which are less technically
demanding and signifi cantly less invasive while
achieving similar or better results than these classic surgical procedures. Given the obvious early
technical success and surprising durability of
venous angioplasty and stenting, a somewhat
more aggressive approach to evaluation and surgical referral may be justifi ed.
As discussed in previous chapters, deep
venous insuffi ciency may manifest as limb
edema, chronic leg pain, stasis dermatitis, or
ulceration, and the symptoms may be chronically
disabling. Initial therapy is directed at ulcer healing and control of symptoms with wound care
and compression. Once conservative measures
have been instituted, the next step may be evaluation for any surgically correctable contributors
to the symptomatology.
Although valvular dysfunction and consequent
venous refl ux are a major cause of the venous
hypertension that underlies the clinical manifestations of chronic venous insuffi ciency (CVI),
recent studies suggest that iliac venous outfl ow
obstruction plays a more important role in the
pathogenesis of CVI than previously estimated
[ 1 ]. Any combination of superfi cial, perforator,
and/or deep venous refl ux can result in various
stages of CVI, but when multiple segments of
venous system are affected, the manifestations
of CVI increase in severity. The combination of
refl ux and obstruction produces the highest levels of venous hypertension and the most severe
clinical symptoms. Fortunately, both refl ux and
obstruction can be surgically addressed, resulting in signifi cant symptomatic improvement.
Therefore, a more complete characterization of
the underlying pathophysiology can be critical in
a subset of patients.
16.2 Clinical Presentation
of Iliocaval Obstruction
Iliac vein obstruction in the setting of superfi cial
refl ux disease should be suspected and evaluated
in CVI patients with symptoms that are out of
proportion to detectable infrainguinal pathology,
in patients lacking another explanation for their
CVI symptoms, and in patients with a history of
deep venous thrombosis (DVT). Patients with
isolated left leg symptoms and minimal infrainguinal venous abnormalities on duplex might be
suspected to have May-Thurner syndrome and
represent another high-risk group. In a study
from 1953, May and Thurner examined pelvic
venous anatomy in 430 cadavers and found that
in approximately 22 % of cases, the left iliac vein
was compressed against the fi fth lumbar vertebra
by the right iliac artery [ 2 ]. Authors of the same
study reported that thrombosis of the pelvic veins
was found about eight times more frequently on
the left than the right. Although compression of
the vein by the overlying artery was not necessarily proven to be causative for DVT, the association was highly suggestive, and in fact, symptoms
of CVI may result from this compression even
without a clear history of thrombosis.
Although perimalleolar edema is common in
patients with superfi cial refl ux disease, prominent
edema that involves calf and thigh suggests iliac
vein obstruction. Central venous imaging of a
patient presenting with severe chronic lower
extremity edema, but minimal abnormalities on
duplex, is illustrated in Fig. 16.1 . In this case, a
stricture of the inferior vena cava (IVC) was identifi ed by venogram, confi rmed by intravascular
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Fig. 16.1 This 68-year-old man presented with gradual
onset of massive bilateral lower extremity edema several
years after a course of radiation therapy to the abdomen
for an ampullary carcinoma. Duplex ultrasound showed
no evidence of refl ux; however, venogram and IVUS
ultrasound (IVUS), and successfully treated with
venous angioplasty and stenting. Similarly,
patients who present with lower extremity pain
that is not located near varicosities and patients
who present with exercise-induced pain in the
thigh and the calf muscles (“venous claudication”) should be evaluated for venous outfl ow
obstruction. Some degree of suspicion for iliac
obstruction should also be present in patients with
advanced CVI (C4–C6 stage) [ 3 ]. Collateral
demonstrated a clear stenosis of the IVC. This was treated
with angioplasty and stenting and there was near-complete resolution of the leg edema. IVUS images through
the stenotic portion of the IVC and the more normal distal
IVC are shown in the insets
venous circulation will develop in most patients
with a history of long-standing venous disease,
and the pattern of visible collaterals may be a clue
to the anatomy of a deep venous obstruction.
Suprapubic and abdominal wall collaterals are not
typically present in patients with isolated infrainguinal disease and may be indicative of central
stenosis. The incidence of hemorrhage from highpressure varicosities is also higher in CVI patients
with coexisting iliac obstruction, since venous
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J.N. Markovic and M. Cox
outfl ow obstruction may lead to a particularly
signifi cant elevation of pressure in veins distal to
an obstruction.
Patients with a known history of iliofemoral
DVT represent a uniquely high-risk group for
iliac or caval obstruction. Previous longitudinal
studies have demonstrated that only 20–30 % of
iliac vein thrombi completely recanalize with
anticoagulation alone, while the remaining veins
develop persistent obstruction with variable collateral formation [ 4 , 5 ]. Thus, pelvic imaging
should be obtained in patients with a history of
DVT and/or thrombophilic disorders and coexisting CVI. Although frequently clinically silent,
the importance of primary, non-thrombotic iliac
vein obstruction (May-Thurner syndrome or iliac
vein compression syndrome) can play an important role in the pathogenesis of iliac vein obstruction. As reported by Meissner et al., among
approximately 1,000 limbs that were treated for
iliocaval obstruction, approximately 40 % had
non-thrombotic occlusion [ 6 ].
16.3 Diagnostic Imaging
The absence of a “gold standard” imaging modality represents an obstacle in the systematic study
of patients with iliac vein obstruction. There are
now multiple imaging studies that are complementary, however, and together can provide a
clear view of the underlying pathophysiology.
With judicious application of these available
tests, the savvy practitioner can amass enough
information to reliably diagnose and treat nearly
all patients with deep venous refl ux.
The evaluation of both valvular incompetence and obstruction almost always begins with
duplex ultrasonography (US). Unfortunately,
duplex US is unreliable for assessment of the
iliac veins, especially in obese patients. Duplex
US is, however, the starting point for a comprehensive evaluation and will yield the fi rst clues
that there may be an issue above the level of the
inguinal ligament. Loss of respiratory variation
in the femoral tracing or poor signal augmentation with distal limb compression during duplex
US examination of the femoral vein may be
indicative of venous outfl ow obstruction. Data
from a large retrospective study by Lin et al. that
included 2,963 limbs scanned with duplex US
documented abnormal monophasic waveforms
in the common femoral veins in 124 patients [ 7 ].
Just under 50 % of these patients with abnormal
waveforms had evidence of prior DVT or iliac
vein stenosis on computerized tomography (CT)
scan. Based on this and other similar studies, it is
reasonable to pursue central imaging in all CVI
patients with abnormal Doppler waveforms in
the common femoral vein. But while specifi c criteria for duplex detection of central venous stenosis have been described, the most signifi cant
fi nding is usually what the duplex does not show.
That is, if there are severe symptoms of chronic
venous insuffi ciency, but minimal infrainguinal
refl ux or occlusion, a more proximal cause must
be suspected.
Ascending venography provides greater
detail than simple duplex US, detects extensive
iliac vein stenosis, and images collateral fl ow.
It is an essential study when surgical intervention is planned [ 6 ]. The Achilles heel of venog-
raphy is that it often does not provide adequate
visualization of focal obstructions with a postthrombotic or non-thrombotic cause [ 9 ]. For
instance, a post- thrombotic iliac vein may still
appear to have fl ow with multiple small recanalized channels while still representing a major
physiologic obstruction (Fig. 16.2a ). In addi-
tion, anterior- posterior (AP) compression, as
might be present in a May-Thurner syndrome,
will be completely missed by a standard venogram in an AP projection. CT and magnetic
resonance venography (MRV) appear to be more
sensitive for detection of spatially complex and
focal lesions (Fig. 16.3 ). Unfortunately, sig-
nifi cant technical expertise in MRV or CT is
required to produce consistently reliable images
and may not be widely available in all locales.
Signifi cant obstructions are also not uncommon
in asymptomatic patients [ 10 ]. IVUS is increa-
singly viewed as the superior imaging modality in estimating the extent of iliac vein stenosis
since it allows real-time visualization of the
details and morphology of intraluminal obstruction [ 11 , 12 ]. In addition, IVUS allows defi nitive
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221
Fig. 16.2 This 44-year-old woman presented with a his-
tory of approximately 20 years of left leg edema, beginning with a DVT during pregnancy. Duplex fi ndings were
notable only for GSV incompetence; however, after an
ablation of the great saphenous vein, she developed worsening symptoms with chronic, severe pain and worsening
identifi cation of focal lesions and can be used as
a guide during angioplasty and stenting. When
performed in conjunction with direct pressure
measurement, many practitioners feel that it is
the most sensitive and specifi c method of identifying hemodynamically signifi cant stenoses
in the iliocaval system. While IVUS is an invasive procedure, high-quality images are easily
obtained, and interpretation is straightforward.
Figure 16.2 demonstrates a situation in which
a post-thrombotic iliac vein appeared patent on
venogram but was near occluded as demonstrated
by IVUS. In this case, the post-thrombotic vein
was treated successfully with angioplasty and
stenting, resulting in near-complete resolution of
the symptoms. In current practice, while purists
may debate which imaging modality is the gold
standard, the simple fact is that a combination
of venogram and IVUS will identify nearly all
signifi cant obstructive lesions.
edema. Venogram shows what appears to be a patent left
iliac system, but with extensive collaterals ( a ), and IVUS
shows near occlusion of the common and external iliac
veins ( inset ). After angioplasty and stenting, there is free
fl ow through the iliac veins with minimal collateral fl ow
( b ) and IVUS shows a patent, re-expanded lumen ( inset )
The only real concern is that IVUS might be
oversensitive to physiologic compression and
the degree of stenosis which merits intervention
is a matter of discussion and debate. The point
at which stenosis should be considered hemodynamically signifi cant in the venous system
remains controversial, but stenosis of greater
than 50 % is probably considered the minimum
indication for intervention [ 6 , 8 ]. In practice
however, the decision to intervene is based on
multiple factors including the degree of stenosis,
the clinical presentation, and the perceived odds
of success. One might be hard pressed to recommend intervention on an older patient with mild
lower leg edema and a 70 % compression of the
iliac vein by the overlying iliac artery. In contrast, a 70 % stenosis of the iliac vein may wellmerit treatment in a post-thrombotic 35-year-old
with symptomatic thigh and lower leg edema
accompanied by venous claudication.
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Fig. 16.3 A 65-year-old man presented with severe,
recurrent varicosities of the left leg extending up to the
inguinal area and buttocks. Given some suspicion of proximal obstruction, an MRV was ordered which showed
only mild compression of the left common iliac vein by
the left common iliac artery. This was deemed not to be
physiologically signifi cant and was not treated
16.4 Venous Angioplasty
and Stenting
Currently available treatment modalities for the
management of iliac vein obstruction are large
vein bypass and percutaneous stenting. In the
past, the only available option for patients with
iliac vein or IVC obstruction was surgical bypass.
These procedures are, however, maximally invasive and technically challenging and have been
associated with poor long-term results in all but
the most experienced hands. Over the last decade,
the success associated with percutaneous angioplasty and stenting for venous obstruction on an
outpatient basis has largely relegated surgical
procedures to a handful of the most intractable
cases which have failed multiple attempts with an
endovascular approach.
Data from several studies has demonstrated
that venous stenting is associated with low morbidity and strikingly high long-term patency rates.
In a case series including 982 lower extremities,
Neglen et al. reported cumulative patency rates
of 86 and 100 % at 5 years in patients treated
for post-thrombotic and non- thrombotic iliac
vein occlusion, respectively [ 13 , 14 ]. The same
authors reported complete pain relief in 64 % of
patients, resolution of leg swelling in 34 %, and
ulcer healing in 58 % of treated patients, despite
the presence of untreated infrainguinal refl ux in
many limbs [ 13 , 14 ]. Hartung et al. demonstrated
that stenting of iliac obstruction was associated
with signifi cant improvement of the venous clinical severity scores (VCSS). In their study, which
included 44 patients followed for an average of
27 months, VCSS were 8.5 and 2.0 before and
after the procedure, respectively [ 15 ]. These
excellent patency rates, and documented symptomatic improvement with a minimally invasive
procedure, have revolutionized the management
of deep venous obstruction. A typical case of
iliac venous obstruction due to May-Thurner
syndrome which was treated with venous angioplasty and stenting is presented in Fig. 16.4 .
Even very extensive iliocaval obstructions
can be addressed effectively with endovascular
approaches. As recently documented by Neglen
and Raju, long-standing caval obstructions due
to an IVC fi lter can be successfully and durably
addressed with angioplasty and stenting [ 16 ].
Figure 16.5 illustrates a case of extensive iliac
and IVC obstruction in the presence of an IVC
fi lter which was not retrievable. This patient presented with recurrent right leg stasis ulceration
that was refractory to conservative management
with compression and wound care. In this case,
the occluded iliac segment and IVC were recanalized and stented with almost immediate symptomatic improvement and eventual ulcer healing.
The technical approach to venous angioplasty
and stenting begins with percutaneous access
of the popliteal, femoral, or greater saphenous
vein. Our preference is to access the femoral
vein in the mid-thigh under ultrasound guidance,
since the patient can be positioned supine while
still allowing visualization of the entire iliac
and proximal femoral drainage. A venogram is
obtained which will often diagnose obvious longsegment occlusions and document collateral fl ow.
If the venogram is relatively normal or equivocal, the IVUS catheter is passed up over a wire
and the entire iliocaval system is interrogated.
If there is an occlusion, we attempt to cross the
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Fig. 16.4 A classic presentation of May-Thurner syn-
drome is illustrated by this 35-year-old woman with sudden onset of massive left leg swelling. After thrombolysis
of an occluded iliac vein, there is a residual iliac stenosis
lesion with a guidewire/catheter combination and
then obtain imaging proximal to the occlusion, as
well as IVUS of the affected segment. Pullback
pressures across a stenosis or occlusion may be
obtained; however, venous pressure differentials
may be quite small and diffi cult to interpret and
are not typically a major part of our decisionmaking process.
If the stenosis or occlusion is deemed to be
clinically signifi cant, the next step is serial predilation to near the normal expected diameter
of the vein segment. Balloon dilation alone will
almost never be suffi cient for venous obstructions
of the lower extremities, and a self- expanding
stent, sized to a diameter 10–20 % greater than the
expected vein diameter, is nearly always placed.
The Wallstent® (Boston Scientifi c, Natick, MA)
and SmartStent (Cordis, Bridgewater, NJ) are the
most frequently used devices in this setting. After
post-dilation, a completion venogram and IVUS
are obtained. In our practice, patients requiring
long-term warfarin are restarted on enoxaparin
and warfarin immediately post-procedure, while
those not on long- term systemic anticoagulation are begun on aspirin and Plavix. Presence
( a ), which was addressed successfully with angioplasty
and stenting ( b ). The leg returned to a normal diameter
within 48 h
of a stent in the iliac system alone does not
necessarily mandate long- term anticoagulation
with warfarin.
16.5 Venous Bypass
For a patient with the most severe and intractable
symptoms of CVI, a documented central venous
occlusion, and multiple failed attempts at endovascular recanalization, one of the traditional venous
bypass procedures might still be considered. The
fi rst and most famous large vein bypass procedure,
described by Dr. Palma (“Palma procedure”), uses
contralateral great saphenous vein as a bypass conduit [ 17 ]. This procedure is designed to bypass a
chronically obstructed iliac vein by mobilizing the
contralateral greater saphenous vein and turning it
over onto the ipsilateral femoral vein (Fig. 16.6 ).
The largest available series, with data from an
analysis of 412 procedures, demonstrated clinical
improvement in 63–89 % of patients and longterm patency rates of up to 80 % [ 6 ]. A particularly
optimistic review from the Mayo Clinic documented patency rates for the Palma procedure as
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a
b
J.N. Markovic and M. Cox
c
Fig. 16.5 This 55-year-old woman had a history of mul-
tiple bilateral DVTs as well as prior placement of an IVC
fi lter and presented with recurrent right leg stasis ulcers.
Complete iliocaval occlusion is demonstrated by venogram
( a ); however, the right iliac veins were easily crossed with
a wire and the entire segment, including the occluded fi lter,
was balloon dilated and stented ( b ). Completion venogram
shows brisk fl ow across the treated segment ( c )
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225
Fig. 16.6 The Palma procedure is designed to address
unilateral iliac occlusion ( a ) by mobilization and anasto-
mosis of the contralateral great saphenous vein to the ipsi-
high as 83 %, at 4 years [ 18 ]. Unfortunately, clini-
cal success hinges on long-term patency of a fairly
small conduit with relatively low fl ow, and the
procedure is technically challenging, so real-world
results may not be as advertised. Nevertheless, the
morbidity of the procedure is limited, and it may
be worthwhile in a small subset of patients.
lateral common femoral vein ( b , c ). Drainage of the
affected leg then fl ows through the saphenous vein and the
contralateral iliac system ( d ) [
30 ]
The Palma procedure is not, however,
appropriate for patients with bilateral iliac
occlusions or patients with complex iliocaval
stenosis or occlusion. In such cases, an in-line
bypass with polytetrafl uoroethylene (PTFE)
may be considered. In-line bypass (femorocaval, iliocaval, or even ilioatrial) may be indicated
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