Post on 16-Jul-2015
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Combined Common Femoral Endovenectomy and Endoluminal
Recanalization for Chronic Post-Thrombotic Iliofemoral Venous Obstruction
Anthony J. Comerota, MD, FACS, FACCDirector, Jobst Vascular Institute
Adjunct Professor of Surgery, University of Michigan
Labropoulos N et alLabropoulos N et alArch Surg 1997; 132:46Arch Surg 1997; 132:46
Hemodynamics of Venous Obstruction
Arm - Foot Pressure GradientArm - Foot Pressure Gradient
- Post Thrombotic Limbs -
LocationLocation RestRest HyperemicHyperemic
IliofemoralIliofemoral 6.3 mmHg6.3 mmHg 8.9 mmHg8.9 mmHg
Femoral-poplitealFemoral-popliteal 4.4 mmHg4.4 mmHg 7.3 mmHg7.3 mmHg
PoplitealPopliteal 1.5 mmHg1.5 mmHg 3.1 mmHg3.1 mmHg
ControlsControls 1.0 mmHg1.0 mmHg 2.7 mmHg2.7 mmHg
Chronic post-thrombotic iliofemoral Chronic post-thrombotic iliofemoral venous obstruction causing severe venous obstruction causing severe post-thrombotic syndrome, with post-thrombotic syndrome, with common femoral vein occlusioncommon femoral vein occlusion
IndicationIndication
Chronic Iliofemoral Venous Obstruction
Endovenectomy and Endovenectomy and Endoluminal Recanalization for Endoluminal Recanalization for
Chronic Post-Thrombotic, Chronic Post-Thrombotic, Iliofemoral Venous ObstructionIliofemoral Venous Obstruction
A New Treatment OptionA New Treatment Option
Chronic Iliofemoral Venous Obstruction
Endovenectomy and Endoluminal Recanalization
GoalGoal
Provide Provide unobstructedunobstructed venous venous drainage from profunda drainage from profunda
femoris vein to vena cavafemoris vein to vena cava
Endovenectomy and Endoluminal Recanalization
• N=13; 15 limbs
• Severe, post-thrombotic, iliofemoral/caval venous obstruction (C3-C6)
• Duration of obstruction:7 mos – 25 yrs (Mean 6.8 years)
PatientsPatients
PreOp PreparationPreOp Preparation
1.1. Phlebography of target leg and IVCPhlebography of target leg and IVC
2.2. Successful guidewire passage through Successful guidewire passage through occlusion into patent IVCocclusion into patent IVC
3.3. Chlorhexidine showers BID X 3 daysChlorhexidine showers BID X 3 days
4.4. Preoperative platelet inhibitionPreoperative platelet inhibition
Endovenectomy and Endoluminal Recanalization
Common Femoral Vein Obstruction
Post-Thrombotic Iliofemoral Obstruction
Operative InterventionOperative Intervention
Venous PressureVenous PressureCavaCava -- 8mmHg 8mmHgCFVCFV -- 16mmHg16mmHg
Operative InterventionOperative Intervention
Post-Thrombotic CFV LumenPost-Thrombotic CFV Lumen- 4 Years -- 4 Years -
Common Femoral Vein Obstruction
Post-Thrombotic Iliofemoral Obstruction
Operative InterventionOperative Intervention
CFV - Patch VenoplastyCFV - Patch VenoplastyCFV - Post EndovenectomyCFV - Post Endovenectomy
Common Femoral Vein Obstruction
Post-Thrombotic Iliofemoral Obstruction
Operative InterventionOperative Intervention
Venous PressureVenous PressureCavaCava -- 8mmHg 8mmHgCFVCFV -- 8mmHg 8mmHg
Common Femoral Vein Obstruction
Post-Thrombotic Iliofemoral Obstruction
Endovenectomy and Endoluminal Recanalization
• 67 year old woman – active: walked 6 milesa day
• IFDVT 7 months earlier
• Rx’ed with anticoagulation alone
• Unable to ambulate any distance
• Missing work: painful lower limb
• US, APG, venogram → extensive
CaseCase
chronic obstruction
PatientPatient
SymptomsSymptoms• Heaviness left legHeaviness left leg
• Constant pain left legConstant pain left leg
• Venous claudication restricting ambulationVenous claudication restricting ambulation
SignsSigns• Bluish discoloration of left lower legBluish discoloration of left lower leg
• Tense left legTense left leg
• Calf painful to compressionCalf painful to compression
Endovenectomy and Endoluminal Recanalization
PatientPatient
AssessmentAssessment ScoreScore
Villalta ScoreVillalta Score 1818
Venous Clinical Severity ScoreVenous Clinical Severity Score 1212
– – PreOp –PreOp –
Endovenectomy and Endoluminal Recanalization
Endovenectomy and Endoluminal Recanalization
Follow-up:Follow-up: At 3 months postopAt 3 months postopwalking 2 miles…walking 2 miles…and increasingand increasing
PatientPatient
AssessmentAssessment PreOpPreOp2 Months 2 Months Post OpPost Op
Villalta ScoreVillalta Score 1818 33
Venous Clinical Venous Clinical Severity ScoreSeverity Score 1212 44
– – 2 Month Follow-Up –2 Month Follow-Up –
Endovenectomy and Endoluminal Recanalization
Endovenectomy and Endoluminal Recanalization
• 1 operative mortality– 52 year old woman, multiple CV risk
factors, AMI at home 9 days post op
• 3 evacuation hematoma
• 3 early postop thrombosis1 – hematoma under pressure1 – residual stenosis, ext iliac vein
…both lysed and remained patent…all had patency restored
ResultsResults
Endovenectomy and Endoluminal Recanalization
• 2 lost to follow-up
• 7 complete follow-up (mean 1 yr)– Villalta scale– QOL– Duplex
Results (Continued)Results (Continued)
Endovenectomy and Endoluminal Recanalization
ResultsResults
Pre Op Post Op p-value
Villalta 14 6 .002
VCSS 17 10 .02
CEAP 4.8 3.8 <.05
QOL - - .01
Issues Requiring Further StudyIssues Requiring Further Study
1.1. Risk/benefit of combined platelet inhibitionRisk/benefit of combined platelet inhibition
2.2. Intensity of postop anticoagulationIntensity of postop anticoagulation
3.3. Risk/benefit of target leg heparin infusionRisk/benefit of target leg heparin infusion
4.4. Optimal location of AV fistulaOptimal location of AV fistulaA.A. Saphenous – SFASaphenous – SFA
B.B. Caudal CFV – SFACaudal CFV – SFA
5.5. Size of wound drainSize of wound drain
Endovenectomy and Endoluminal Recanalization
Endovenectomy and Endoluminal Recanalization
In patients with chronic, post-thrombotic iliofemoral venous obstruction…
CFV endovenectomy with endoluminal recanalization of the iliac veins:
– Reduces post-thrombotic morbidity…and– Improves quality-of-life
However…it is a procedure in evolution
ConclusionConclusion