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76. Poller L, McKernan A, Thomson JM, et al. Fixed minidose warfarin: a new approach to
prophylaxis against venous thrombosis after major surgery. Br Med J 1987; 295:1309.
77. Kistner RL. Surgical repair of a venous valve. Straub Clin Proc 1968; 24:41–43.
78. Raju S. Venous insufficiency of the lower limb and stasis ulceration: changing concepts and
management. Ann Surg 1983; 197:688–697.
79. Sottiurai VS. Technique in direct venous valvuloplasty. J Vasc Surg 1988; 8:646–648.
80. Tripathi R, Ktenidis KD. Trapdoor internal valvuloplasty: a new technique for primary deep
vein valvular incompetence. Eur J Vasc Endovasc Surg 2001; 22:86–89.
81. Raju S, Fredericks R. Valve reconstruction procedures for nonobstructive venousinsufficiency:
rationale, techniques, and results in 107 procedures with two-to eight-year follow-up. J Vasc
Surg 1988; 7:301–310.
82. Kistner RL. Surgical technique of external venous valve repair. The Straub Found Proc
1990; 55:15.
83. Belcaro G, Nicolaides AN, Ricci A, et al. External femoral vein valvuloplasty with limited
anterior plication (LAP): a 10-year randomized, follow-up study. Angiology 1999;
50:531–536.
84. Gloviczki P, Merrell SW, Bower TC. Femoral vein valve repair under direct vision without
venotomy: a modified technique with use of angioscopy. J Vasc Surg 1991; 14:645–648.
85. Raju S, Berry MA, Neglen P. Transcommissural valvuloplasty: technique and results. J Vasc
Surg 2000; 32:969–976.
86. Taheri SA, Lazar L, Elias SM, Marchand P. Vein valve transplant. Surgery 1982; 91:28–33.
87. Sottiurai VS. Supravalvular incision for valve repair in primary valvular insufficiency. In:
Bergan JJ, Kistner RL, eds. Atlas of Venous Surgery. Philadelphia: W.B. Saunders,
1992:137–138.
88. Raju S, Neglen P, Doolittle J, Meydrech EF. Axillary vein transfer in trabeculated
postthrombotic veins. J Vasc Surg 1999; 29:1050–1064.
89. Cardon JM, Cardon A, Joyeux A, et al. Use of ipsilateral greater saphenous vein as a valved
transplant in management of post-thrombotic deep venous insufficiency: long-term results.
Ann Vasc Surg 1999; 13:284–289.
90. Welch H, McLaughlin RL, O’Donnell TF. Femoral vein valvuloplasty: intraoperative
angioscopic evaluation and hemodynamic improvement. J Vasc Surg 1992; 16:694–700.
91. Jamieson WG, Chinnick B. Clinical results of deep venous valvular repair for chronic venous
insufficiency. Can J Surg 1997; 40:294–299.
92. Perrin M. Reconstructive surgery for deep venous reflux: a report on 144 cases. Cardiovasc
Surg 2000; 8:246–255.
93. Kistner RL. Surgical repair of the incompetent femoral vein valve. Arch Surg 1975;
110:1336–1342.
94. Ferris EB, Kistner RL. Femoral vein reconstruction in the management of chronic venous
insufficiency: a 14-year experience. Arch Surg 1982; 117:1571–1579.
95. Lurie F, Makarova NP, Hmelniker SM. Results of deep-vein reconstruction. Vasc Surg 1997;
31:275–276.
96. Perrin MR. Results of deep-vein reconstruction. Vasc Surg 1997; 31:273–275.
97. Perrin M, Hiltbrand B, Bayon JM. Results of valvuloplasty in patients presenting deep venous
insufficiency and recurring ulceration. Ann Vasc Surg 1999; 13:524–532.
98. Taheri SA, Lazar L, Elias SM, Marchand P. Vein valve transplant. Surgery 1982; 91:28–33.
99. Taheri SA, Elias SM, Yacobucci GN, et al. Indications and results of vein valve transplant.
J Cardiovasc Surg 1986; 27:163–168.
100. Nash T. Long term results of vein valve transplants placed in the popliteal vein for intractable
post-phlebitic venous ulcers and pre-ulcer skin changes. J Cardiovasc Surg 1988; 29:712–716.
101. Rai DB, Lerner R. Chronic venous insufficiency disease. Its etiology. A new technique for
vein valve transplantation. Int Surg 1991; 76:174–178.
102. Sottiurai VS. Results of deep-vein reconstruction. Vasc Surg 1997; 31:276–278.
103. Plagnol P, Ciostek P, Grimaud JP, Prokopowicz SC. Autogenous valve reconstruction
technique for post-thrombotic reflux. Ann Vasc Surg 1999; 13:339–342.
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https://t.me/med1917
104. Maleti O. Venous valvular reconstruction in post-thrombotic syndrome. A new technique.
J des Mal Vasculaires 2002; 27:218–221.
105. Lugle, M, Maleti, O. Neovalve Construction in Postthrombotic Syndrome. Presented at
American Venous Forum 17th Annual Meeting, San Diego, California, February 9–13, 2005.
106. Psathakis ND, Psathakis DN. Surgical treatment of deep venous insufficiency of the lower
limb. Surg Gynecol Obstet 1988; 166:131–141.
107. Dalsing MD, Ricotta JJ, Wakefield T, et al. Animal models for the study of lower extremity
chronic venous disease: lessons learned and future needs. Ann Vasc Surg 1998; 12:487–494.
108. Neglen P, Raju S. Venous reflux repair with cryopreserved vein valves. J Vasc Surg 2003;
37:552–557.
109. Garcia-Rinaldi R, Soltero E, Gaviria J, et al. Implantation of cryopreserved allograft
pulmonary monocusp patch: to treat nonthrombotic femoral vein incompetence. Tex Heart
Inst J 2002; 29:92–99.
110. Pavcnik D, Uchida BT, Timmermans HA, et al. Percutaneous bioprosthetic venous valve:
a long-term study in sheep. J Vasc Surg 2002; 35:598–602.
111. Brountzos E, Pavcnik D, Timmersmans HA, et al. Remodeling of suspended small intestinal
submucosa venous valve: an experimental study in sheep to assess the host cells’ origin.
J Vasc Interv Radiol 2003; 14:349–356.
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31
Management of Deep Venous Obstruction
of the Lower Extremity: Endovascular
Intervention and Surgery
Peter Negle
´
n and Seshadri Raju
River Oaks Hospital and University of Mississippi Medical Center,
Jackson, Mississippi, U.S.A.
INTRODUCTION
The treatment of chronic outflow obstructions has previously been largely neglected
because of diagnostic difficulties and lack of appropriate surgical interventions. The open
venous bypass surgery has been unattractive for several reasons and restricted to a
minority of patients with severe disabling symptoms. Endovascular treatment of venous
outflow obstruction with percutaneous stenting has drastically changed the treatment
and view on venous outflow obstruction. The introduction of venous stenting has
refocused the interest on the role of venous outflow obstruction in patients with chronic
venous disorders, and has renewed interest in the nature and pathophysiology of venous
obstruction in itself and in tests for detection of hemodynamically significant lesions. Iliac
venous stenting has already largely replaced surgery as the “method of choice” for
treatment of venous blockage. However, venous stenting is still under development, and
there are several issues regarding diagnosis, methods of assessment and selection of
patients, which needs to be resolved.
VENOUS OUTFLOW OBSTRUCTION
Venous obstruction may have many causes, such as a remaining stenosis after
thrombolysis of acute iliofemoral venous thrombosis, complete occlusion or stenosis in
chronic postthrombotic disease, nonthrombotic iliac vein compression syndrome,
retroperitoneal fibrosis, and malignant venous obstruction. The majority of lower
extremity outflow obstructions are observed following acute deep vein thrombosis (DVT)
with subsequent absent or poor venous recanalization. Remaining obstruction is the
principal cause of symptoms in approximately one-third of postthrombotic limbs.
Obstruction is observed combined with reflux in 55% of symptomatic patients with
CVI (1,2). This combination is most harmful. It leads to the highest levels of venous
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hypertension and the most severe symptoms as compared to either alone (3,4). It appears
that proximal obstruction of the venous outflow, especially the iliac vein, is more
symptomatic as compared to lower segmental blockage (5,6). The collateral formation is
relatively poor around an iliofemoral obstruction contrary to blockage of the femoral-
popliteal vein. Following proximal DVT, only 20–30% of iliac veins completely
recanalize spontaneously, while the remaining veins recanalize partly and develops
varying degrees of collaterals (7,8). Although postthrombotic obstruction is most frequent,
an iliac vein obstruction may be “primary” or nonthrombotic in nature (May-Thurner
syndrome (9) or iliac vein compression syndrome (10)). The compression is caused by
arteries compressing the pelvic veins frequently resulting in secondary intraluminal
lesions, and it is probably more common than previously thought (11). These limbs may
have had a subclinical isolated iliac vein thrombosis, which was initiated at the vessel
crossing and then propagated distally into the external iliac vein. On the other hand, limbs
with obvious postthrombotic disease may have had an underlying iliac vein compression
resulting in a clinical iliofemoral vein thrombosis (12). Whatever the chain of events, it
will remind us that those patients with signs and symptoms of chronic venous insufficiency
and absent history and findings of previous DVT may still have iliac vein obstruction, even
in the presence of primary venous reflux (13).
DIAGNOSIS AND SELECTION OF PATIENTS
Unfortunately, there are no reliable tests to measurea hemodynamicallysignificant stenosis.
In fact, it is not known what degree of narrowing constitutes a “critical stenosis” in the
venous system. This lack of “gold standard” is the major obstacle to assess the importance of
chronic outflow obstruction, select limbs for treatment, and evaluate the outcome.
Non-invasive duplex Doppler and plethysmography have been helpful in the
diagnosis of acute complete obstruction. However, in chronic venous obstruction,
ultrasound investigation and outflow fractions obtained by air and strain gauge
plethysmography have been shown to be inaccurate to measure hemodynamically
important obstruction. Significant blockage may be present with normal findings (14–16).
Invasive pressures, i.e., hand/foot pressure differential and reactive hyperemia
pressure increase, and indirect resistance calculations appear better than non-invasive
studies (17–19), but these tests are also relatively insensitive and do not define the level of
obstruction (16). Venous pressures may also be measured during venographic evaluation or
at surgery as a pressure differential over the obstruction or a pressure increase on exercise
or induced hyperemia. The difficulty does not arise when these pressure gradients are high,
but when the pressure differentials are near normal. Although a positive hemodynamic test
may indicate hemodynamic significance, a normal test does not exclude it.
It is presently impossibleto detect potentially hemodynamically important borderline
obstructions. Therefore, the diagnosis of outflow obstruction has to be made by
morphological investigations. Although a positive non-invasive or invasive test may
support to proceed with venography, a negative test should not exclude it. The key for the
physician is to be aware of the importance and possibility of venous blockage combined
with increased suspicion in patients with history and clinical signs and symptoms suggestive
of outflow obstruction. Certainly patients with severe CVI and leg ulcer must undergo
morphological studies. Transfemoral ascending (antegrade) venography is the standard
method to image the venous outflow tract, showing the site of obstruction and the presence
of collaterals. Collaterals appear to be poor substitutes for the original obstructed vein.
Collateral development on venogram should perhaps instead beconsidered an indicator of a
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´
n and Raju412
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significant obstruction (17,18,20). To increase diagnostic accuracy, it is important to take
images in multiple-planes including lateral views. Important lesions at the iliocaval junction
may otherwise be missed. Intravascular ultrasound (IVUS) is superior to standard single-
plane and multi-plane venography for estimating the morphological degree and extent of
iliac vein stenosis and visualize details of intraluminal lesions (20–22). Patients with
significant signs and symptoms of CVI need to have a transfemoral venography, or
preferably an IVUS, performed in addition to routine non-invasive reflux investigations.
Arbitrarily, we consider to stent limbs with ilio-caval vein stenosis with more than 50%
reduction of the luminal cross-cut area as measured by IVUS, especially if pre- or intra-
operative pressures gradients indicate hemodynamic significance. Pressure changes are not
decisive to allow stenting, but markedly increased venous pressure levels have been
considered compulsory to perform open surgery.
OPEN SURGICAL RECONSTRUCTION
Open surgical bypasses can be performed to alleviate severe venous outflow obstruction.
The operations most frequently used are femoro-femoral crossover or unilateral ilio-caval
bypass for proximal iliofemoral vein occlusion, and, rarely, sapheno-popliteal bypass for
distal femoro-popliteal obstruction. For short left iliac venous stenosis at the vessel
crossing (iliac vein compression syndrome) right iliac artery transposition and iliac vein
patch angioplasty have been used in selected patients (23).
The results following open reconstructions are usually presented in series with small
numbers of treated limbs and with poor reporting standards; rarely are cumulative patency
and success rates given. The outcome of open surgery has not been so convincing as to
make a major impact on the routine treatment outflow obstruction and has only been
limited to a selective group of patients with the most severe clinical condition. The general
problem with bypass grafting is relatively poor long-term patency. The reasons for this are
several. The grafts tend to clot because the area of insertion has low velocity flow, external
compression of the low pressure bypass may occur, non-saphenous graft material is
inherently thrombogenetic, and the distal inflow is often poor due to extensive distal
disease. The best clinical results has been achieved with large-diameter polyterafluoro-
ethylene (PTFE) graft (10 mm) with external support (ringed), adjunct use of an
arteriovenous fistulae and meticulous perioperative anticoagulation (24,25). The
arteriovenous fistula is left in place and anticoagulation continued as long as no side
effects occur and the bypass stays patent. Life-long anticoagulation is usually necessary to
keep the bypass open. If the graft suddenly occludes with a functioning fistula, symptoms
of pain and swelling are accentuated and the fistula has to be disconnected.
THE CROSS-OVER BYPASS
The cross-over bypass can be constructed either by using the contralateral saphenous vein
or a prosthetic graft (Fig. 1). The donor vein is exposed and then rotated at the sapheno-
femoral junction to cross to the other side [classic Palma technique (26)] or used as a free
femoro-femoral graft. This free saphenous graft appears to do better than rotation of the
vein avoiding kinking at the sapheno-femoral junction (27). The autogenous cross-femoral
venous bypass appears to be less thrombogenetic with better patency than prosthetic
grafts (28). The cross-over reconstruction has been reported to be durable with good
symptom relief, so called “clinical” and venographic patency ranging from 44% to 100%
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with a follow-up of five years (27–37). Most series have small number of patients with
inconsistent clinical and venographic follow-up (Tables 1 and 2).
Halliday et al. performed the only cumulative analysis existing, showing a 75%
cumulative venographic patency rate at five years (30). This excellent result has not been
reproduced elsewhere. Clinical improvement is unfortunately not necessarily related to
graft patency. Superior results are achieved if the inflow channel is normal. Despite
remaining patent the saphenous grafts may give poor symptom relief owing to its small
Figure 1 Femoro-iliac cross-over bypass with ringed PTFE-graft, usually constructed with
temporary arteriovenous fistula. Source: From Atlas of Venous Surgery, (eds) Bergan JJ, Kistner RL,
W.B. Saunders.
Table 1 Results of Saphenous Vein Femoro-Femoral Bypass
Author
Number of
limbs
Follow-up
(months)
Clinical success
(%) Patency (%)
Husni (32) 78 7–144 74 73
Hutschenreiter et al. (34) 20 6–28 69 44
O’Donnell et al. (31) 6 24 100 100
Halliday et al. (30) 47 60 89 75
AbuRahma et al. (29) 24 66 88 75
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cross-cut area and relatively large resistance to flow. It has been shown that at least a
4.0 mm diameter vein is necessary to adequately relieve the iliac vein outflow
obstruction (24). This is the reason for recommended size of a 10 mm PTFE graft for
femoral cross-over bypass as an alternative to the absence or an inadequate size of the
saphenous vein.
THE IN-LINE BYPASS
Anatomic in-line bypass reconstruction can be used in the femoro-ilio-caval axial outflow
axis with segmental obstruction in the presence of a sufficient venous in- and outflow of
Table 2 Results of Prosthetic Femoro-Femoral Bypass
Author
Number of
limbs
Follow-up
(months)
Clinical success
(%) Patency (%)
Eklof et al. (25) 7 2–31 86 17
Yamamoto et al. (35) 5 1–18 60 60
Comerota et al. (36) 3 40–60 67 67
Gruss and Hiemer (37) 32 85 85
Figure 2 In-line ilio-caval bypass with ringed PTFE-graft and arterivenous fistula.
Source: Ref. 39.
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the graft (Fig. 2). As with cross-over bypasses, the in-line reconstructions, especially
when starting in the groin, are constructed with a concomitant arteriovenous fistula, and
life-long anticoagulation is usually necessary for patency. Patency rates during follow-up
from 1–150 months vary from 29–100% (Table 3) (38–44).
The only cumulative study by Jost et al. shows a secondary patency rate of 54% at
two years for prosthetic in-line bypass (28). This should be compared to 83% for
saphenous vein femoro-femoral cross-over bypass in the same study. Early patency for
caval reconstruction with excision of the cava and interposition graft for malignant disease
is better than in-line bypasses for postthrombotic obstruction (45).
SAPHENO-POPLITEAL BYPASS
Sapheno-popliteal vein bypass is a rarely performed surgery for outflow obstruction. It is
possible to perform only in extremely selected limbs with chronic segmental occlusion
confined to the femoro-popliteal vein segment. The saphenous vein cannot be involved in
the phlebitic process, which is very unusual. Limbs for treatment must have a patent,
non-varicose great saphenous vein with competent valves and a patent tibial inflow tract
(essentially normal calf views on venography). In addition, the results are not impressive.
The few reported series of patients (29,32,46,47), show a clinical success and patency
rates of 31–58% and 56–67%, respectively, at follow-up of one to five years.
FEMORO-ILIO-CAVAL STENTING
The surgical treatment of limbs with suspected venous outflow obstruction has been
limited to a minority of patients with chronic venous insufficiency owing to the
invasiveness and magnitude of the described operations, continuous anticoagulation with
inherent risk of complications, and uncertain long-term results. Strict criteria for selection,
including severe disabling symptoms and markedly increased venous pressure levels, have
been used, and, for technical reasons, the saphenous vein in order to be utilized must be
unaffected by any disease. Inadequate size, phlebitic obstruction or valve incompetence
are factors often precluding the use of the autogenous vein. The introduction of
percutaneous iliac venous balloon dilation and stenting has dramatically changed the
premises for treatment.
Table 3 Results of Femoro-Caval/Ilio-Caval Prosthetic Bypass Grafting
Number of
limbs
Follow-up
(months)
Clinical success
(%) Patency (%)
Husfeldt (44) 4 4–30 100 100
Dale et al. (43) 3 1–30 100 100
Ijima et al. (40) 5 22–36 60 60
Eklof et al. (25) 7 2–31 86 29
Plate et al. (38) 3 1–11 67 33
Okadome et al. (41) 4 17–48 100 100
Gloviczki et al. (39) 12 1–60 67 58
Alimi et al. (42) 8 10–45 88 88
Jost et al. (28) 13 1–150 49 54
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n and Raju416
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The endovascular technique makes it possible to correct pelvic and caval vein
obstruction more safely and less invasively, and, therefore, can be offered to a larger group
of patients. Venous stenting has been used to successfully treat iliac vein obstruction of
various etiologies (Figs. 3–5). The complication rate related to the endovascular
intervention is minimal and comprises mostly cannulation site hematoma, but a minimal
number of acquired arteriovenous fistula when the cannulation site is distal on the thigh
Figure 3 Recanalization of a postthrombotic iliofemoral obstruction before and after stent
placement. While the initial venogram suggests otherwise, it is more often than not possible to
transverse this type of occlusion.
Figure 4 Images of stenting of a complex nonthrombotic obstruction due to iliac compression
syndrome (common iliac vein compressed in the frontal and external iliac vein in the sagital plane).
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