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Combined common femoral endovenectomy and endoluminal recanalization for chronic post thrombotic iliofemoral venous obstruction
- 1. Combined Common Femoral Endovenectomyand Endoluminal Recanalization for Chronic Post-Thrombotic Iliofemoral Venous Obstruction Anthony J. Comerota, MD, FACS, FACC Director, Jobst Vascular Institute Adjunct Professor of Surgery, University of Michigan
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- 3. Chronic Post-Thrombotic Iliofemoral VenousObstruction • Severe morbidity • High recurrence
- 4. Labropoulos N etalLabropoulos N et al Arch 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
- 5. Chronic post-thrombotic iliofemoralChronicpost-thrombotic iliofemoral venous obstruction causing severevenous obstruction causing severe post-thrombotic syndrome, withpost-thrombotic syndrome, with common femoral vein occlusioncommon femoral vein occlusion IndicationIndication Chronic Iliofemoral Venous Obstruction
- 6. Endovenectomy andEndovenectomy and EndoluminalRecanalization forEndoluminal Recanalization for Chronic Post-Thrombotic,Chronic Post-Thrombotic, Iliofemoral Venous ObstructionIliofemoral Venous Obstruction A New Treatment OptionA New Treatment Option Chronic Iliofemoral Venous Obstruction
- 7. Endovenectomy and EndoluminalRecanalization GoalGoal ProvideProvide unobstructedunobstructed venousvenous drainage from profundadrainage from profunda femoris vein to vena cavafemoris vein to vena cava
- 8. Endovenectomy and EndoluminalRecanalization • 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
- 9. PreOp PreparationPreOp Preparation 1.1.Phlebography of target leg and IVCPhlebography of target leg and IVC 2.2. Successful guidewire passage throughSuccessful 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
- 10. Common Femoral VeinObstruction Post-Thrombotic Iliofemoral Obstruction Operative InterventionOperative Intervention Venous PressureVenous Pressure CavaCava -- 8mmHg8mmHg CFVCFV -- 16mmHg16mmHg
- 11. Operative InterventionOperative Intervention Post-ThromboticCFV LumenPost-Thrombotic CFV Lumen - 4 Years -- 4 Years - Common Femoral Vein Obstruction Post-Thrombotic Iliofemoral Obstruction
- 12. Operative InterventionOperative Intervention CFV- Patch VenoplastyCFV - Patch VenoplastyCFV - Post EndovenectomyCFV - Post Endovenectomy Common Femoral Vein Obstruction Post-Thrombotic Iliofemoral Obstruction
- 13. Operative InterventionOperative Intervention VenousPressureVenous Pressure CavaCava -- 8mmHg8mmHg CFVCFV -- 8mmHg8mmHg Common Femoral Vein Obstruction Post-Thrombotic Iliofemoral Obstruction
- 14. Endovenectomy and EndoluminalRecanalization • 67 year old woman – active: walked 6 miles a 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
- 15. PatientPatient SymptomsSymptoms • Heaviness leftlegHeaviness 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
- 16. PatientPatient AssessmentAssessment ScoreScore Villalta ScoreVillaltaScore 1818 Venous Clinical Severity ScoreVenous Clinical Severity Score 1212 –– PreOp –PreOp – Endovenectomy and Endoluminal Recanalization
- 17. LeftLeft CFVCFV WithCompressionWith Compression Endovenectomy and Endoluminal Recanalization
- 18. Endovenectomy and EndoluminalRecanalization –– 7 Months –7 Months –
- 19. Endovenectomy and EndoluminalRecanalization CFV PFV FV GSV
- 20. Endovenectomy and EndoluminalRecanalization
- 21. Endovenectomy and EndoluminalRecanalization
- 22. Endovenectomy and EndoluminalRecanalization
- 23. Endovenectomy and EndoluminalRecanalization PFV Orifice FV (Occluded)
- 24. Endovenectomy and EndoluminalRecanalization Endovenectomy Specimen CFV FV –– 7 Months –7 Months –
- 25. Endovenectomy and EndoluminalRecanalization PFV
- 26. Endovenectomy and EndoluminalRecanalization
- 27. Endovenectomy and EndoluminalRecanalization
- 28. Endovenectomy and EndoluminalRecanalization
- 29. Endovenectomy and EndoluminalRecanalization
- 30. Endovenectomy and EndoluminalRecanalization
- 31. Endovenectomy and EndoluminalRecanalization
- 32. Endovenectomy and EndoluminalRecanalization Vena Cava Common Iliac Vein Internal Iliac Vein
- 33. Endovenectomy and EndoluminalRecanalization
- 34. Endovenectomy and EndoluminalRecanalization
- 35. Endovenectomy and EndoluminalRecanalization –– Patch Closure –Patch Closure –
- 36. Endovenectomy and EndoluminalRecanalization –– AV Fistula –AV Fistula –
- 37. Endovenectomy and EndoluminalRecanalization CFV PFV
- 38. Endovenectomy and EndoluminalRecanalization Follow-up:Follow-up: At 3 months postopAt 3 months postop walking 2 miles…walking 2 miles…and increasingand increasing
- 39. Endovenectomy and EndoluminalRecanalization –– Duplex PostOp –Duplex PostOp –
- 40. Endovenectomy and EndoluminalRecanalization –– Duplex PostOp –Duplex PostOp –
- 41. PatientPatient AssessmentAssessment PreOpPreOp 2 Months2Months Post OpPost Op Villalta ScoreVillalta Score 1818 33 Venous ClinicalVenous Clinical Severity ScoreSeverity Score 1212 44 –– 2 Month Follow-Up –2 Month Follow-Up – Endovenectomy and Endoluminal Recanalization
- 42. Endovenectomy and EndoluminalRecanalization • 1 operative mortality – 52 year old woman, multiple CV risk factors, AMI at home 9 days post op • 3 evacuation hematoma • 3 early postop thrombosis 1 – hematoma under pressure 1 – residual stenosis, ext iliac vein …both lysed and remained patent …all had patency restored ResultsResults
- 43. Endovenectomy and EndoluminalRecanalization • 2 lost to follow-up • 7 complete follow-up (mean 1 yr) – Villalta scale – QOL – Duplex Results (Continued)Results (Continued)
- 44. Endovenectomy and EndoluminalRecanalization ResultsResults Pre Op Post Op p-value Villalta 14 6 .002 VCSS 17 10 .02 CEAP 4.8 3.8 <.05 QOL - - .01
- 45. Issues Requiring FurtherStudyIssues 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 fistula A.A. Saphenous – SFASaphenous – SFA B.B. Caudal CFV – SFACaudal CFV – SFA 5.5. Size of wound drainSize of wound drain Endovenectomy and Endoluminal Recanalization
- 46. Endovenectomy and EndoluminalRecanalization 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