Asian Cardiovasc Thorac Ann 2000;8:172-174
© 2000 Asia Publishing EXchange Pte Ltd
Crossover Saphenous Vein Bypass in Deep Vein Thrombosis
Bora Farsak, MD,
Mustafa Tok, MD,
anser Ate
, MD,
Riza Do
an, MD
Department of Thoracic and Cardiovascular Surgery
Faculty of Medicine, Hacettepe University
Ankara, Turkey
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For reprint information contact: Bora Farsak, MD Tel: 90 312 490 6076 Fax: 90 312 467 7028 email: efarsak{at}domi.com.tr Atatürk Sitesi Çamlik Apt., C-3 OR-AN, Ankara 06450, Turkey.
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Abstract
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Two women aged 48 and 32 years, suffering from deep vein thrombosis, were successfully treated with cross-femoral saphenous vein bypass grafts. A distal arteriovenous fistula was instituted in both cases and taken down one month postoperatively.
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Introduction
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Approximately 9% of patients with deep venous in-sufficiency have chronic complete or partial iliofemoral venous obstruction. Of these, one-third are appropriate candidates for venous reconstruction by cross-femoral venous bypass as described by Palma and Esperon.1 However, clinical advances in such venous reconstructive surgery have been limited due to difficulty in maintaining the patency of prosthetic or autogenous grafts in the low-pressure low-flow venous system.2 Addition of an adjuvant arteriovenous fistula was found to be effective against early rethrombosis.3
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Case Reports
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Case 1
A 48-year-old woman was admitted with pain, cyanosis, swelling, and ulceration of the right leg, which had increased in the past 2 months. Onset was 6 months previously after repair of a right inguinal hernia when the femoral artery and vein were damaged and repaired by end-to-end anastomosis. There were multiple small ulcers on her right leg and right foot. She was taking aspirin only and had no other disease. Ascending venography revealed obstruction of the right external iliac, common femoral, and proximal superficial femoral veins (Figure 1
). At surgery under general anesthesia, vertical incisions were made in both the right and left groin; the common femoral, proximal superficial femoral, and profunda femoral veins, the saphenofemoral junction, and other femoral branches were exposed and encircled on both sides. Thrombi were found in the right deep, superficial, and common femoral veins. A saphenous vein graft was prepared from the vena saphena magna of the contralateral leg. A deep subcutaneous tunnel was prepared in the suprapubic and subsartorial region. The saphenous vein was passed through the suprapubic tunnel and groin to the right side, then through the subsartorial tunnel, taking great care to avoid twisting of the vessel. The crossover graft of the bifurcated saphenous vein was anastomosed to the right proximal popliteal vein at two points in an end-to-side technique. To increase blood flow and dilate the saphenous vein, a distal arteriovenous fistula was created between the posterior tibial vein and artery by the side-to-side technique. After the operation, antibiotics, dipyridamole, aspirin, and heparin 4 x 5000 IU were given, followed at 12 hours postoperatively by warfarin to elevate the prothrombin time to 2 to 2.5 times normal. The patient was discharged on the 6th postoperative day with dipyridamole, warfarin, aspirin, and an elastic stock-ing. Four weeks later, the arteriovenous fistula was taken down under local anesthesia. The patient was treated with warfarin for 2 years. At 4.5 years postoperatively, her ulcers had completely healed, she had slight swelling with a 1-cm circumferential difference in her legs, which had been 9 cm before the operation. The patency of the crossover graft was confirmed by Doppler ultrasono-graphy and radionuclide (99mTc pertechnetate) venography (Figure 2).
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Figure 1. Ascending venography showing obstruction of the common femoral and the proximal superficial femoral veins.
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Case 2
A 32-year-old woman was admitted with swelling, cyanosis, and pain in the right leg. Her complaints began in pregnancy and had increased in the previous 4 months. Ascending venography revealed a blockage in the right common iliac vein. At surgery, bilateral groin incisions were made. The common femoral vein, superficial femoral, and profunda femoral veins, the saphenofemoral junction, and other femoral branches on the groin were exposed and encircled on both sides. A deep subcutaneous tunnel was prepared in the suprapubic region. On the left leg, a saphenous vein graft was prepared from the vena saphena magna. This vein was passed through the suprapubic tunnel to the right side. The cross-femoral vein graft was anastomosed to the right common femoral vein below the obstruction in an end-to-side fashion. A distal arteriovenous fistula was created between the posterior tibial vein and artery by the side-to-side technique. Antiplatelet therapy and anticoagulants were prescribed postoperatively and an elastic stocking was used. The patient was discharged after 7 days. Four weeks later, the fistula was taken down under local anesthesia and the anticoagulant was discontinued. After 3.5 years she was still using elastic stockings and antiplatelet therapy. She had a 2-cm circumferential difference in her legs, which was 14 cm before the operation. Doppler ultrasonography and radionuclide venography confirmed the patency of the saphenous vein.
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Discussion
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Although venous occlusive disease is not so dramatic and limb threatening as its arterial counterpart, the associated morbidity may be significant. Cross-femoral venous bypass is suitable for persistent isolated unilateral iliac or common femoral vein occlusions in young and middleaged patients with severe chronic deep venous insuffi-ciency unresponsive to conservative measures. Malig-nancies, especially lymphoma and phlegmasia cerulea dolens, are less frequent indications for surgical treatment. The venous outflow obstruction should be phlebo-graphically and hemodynamically stable or worsening, suggesting that no further resolution is likely to occur by recanalization.2 No conservative measures were con-sidered in either of our patients as they presented late and had no adequate collaterals on venography.
Vollmar4 identified several prerequisites for success of cross-femoral grafts: patent contralateral iliofemoral and caval run-off; a supine resting pressure gradient in excess of 4 to 5 mm Hg between the femoral veins in the involved and contralateral limbs (we found best results if > 10 mm Hg, graft occlusion if > 5 < 10 mm Hg); adequate distal venous system (a patent profunda femoris vein, preferably with an open or partially recanalized superficial femoral vein); a patent and competent greater saphenous vein on the recipient (run-off) side with a minimal diameter of 4 to 5 mm and no varicosities. Gruss and colleagues5 found marked improvements with the introduction of venous pressure measurements to assess the functional efficacy of a reconstructive procedure. A prosthetic graft may be used but autogenous vein grafts have greater patency.5 An adjuvant arteriovenous fistula was found to improve graft patency and dilate the bypass conduit for more adequate venous outflow.3 The fistula is closed 4 to 8 weeks later, depending on the patient's progress. Anticoagulants are used for at least 45 days postoperatively under strict supervision.
In cases of occlusion of the iliac veins, the crossover saphenous vein graft is anastomosed to the common femoral vein and sometimes to the superficial or deep femoral veins by the end-to-side technique. In cases of iliofemoral occlusion, the common femoral and superficial femoral veins should be dissected distally until a patent segment is found, if not, the graft is anastomosed in the popliteal region.1 In such instances, the contralateral saphenous vein graft must be very long, dissection being extended to the leg. The vein graft is passed into the suprapubic canal. To avoid occlusion of this long vein graft (case 1), the subsartorial canal is opened widely. This can be achieved by dividing the fascia that forms the roof of the canal. The tendon of the adductor magnus is divided so as to open the adductor hiatus, thus freeing the vessels.
Postoperatively, graft patency can be assessed by Doppler ultrasound, B-mode imaging, radionuclide venogram, or contrast venography. Although some surgeons considered serial venography to be the only reliable method of post-operative follow-up, others (including ourselves) found radionuclide venography extremely useful and it avoids the risks of repeated contrast venograms.6 Contrast veno-graphy should be reserved for diagnosis of disabling venous claudication, suggesting a stenosing graft. Re-solution of venous ulceration correlates with graft patency. Husni7 reported a 72% patency rate without an adjunctive arteriovenous fistula and 78% patency with a fistula; patients with extrinsic occlusion of the iliac veins by a tumor achieved greater symptomatic relief than those who had thrombosis. Varicose vein stripping and perforator ligation in selected cases enhanced the clinical results.7 Although our experience is limited to only two cases, we found that cross-femoral venous bypass could be per-formed successfully for venous reconstruction.
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References
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Palma EC, Esperon R. Vein transplants and grafts in the surgical treatment of the postphlebitic syndrome. J Cardiovasc Surg 1960;1:94–9.[Medline]
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Dale WA. Reconstructive venous surgery. Arch Surg 1979;114:1312–8.[Abstract/Free Full Text]
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Edwards WS. A-V fistula after venous reconstruction. Ann Surg 1992;196:669–71.
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Vollmar J. Reconstruction of the iliac veins and inferior vena cava. In: Hobbs JT, editor. The treatment of venous disorders. London: MTP Press, 1977:320–31.
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Gruss JD, Vargas-Montano H, Bartels D, Hanschke D, Fietze-Fischer B. Direct reconstructive venous surgery. Int Angiol 1985;4:441–53.[Medline]
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Lalka SG, Malone JM. Surgical management of chronic obstructive venous disease of the lower extremity. In: Rutherford RB, editor. Vascular surgery. Philadelphia: Saunders, 1989:1627–47.
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Husni EA. Reconstruction of veins: the need for objectivity. J Cardiovasc Surg 1983;24:525–8.[Medline]
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Abstract
Introduction
