combined common femoral endovenectomy and endoluminal recanalization for chronic post thrombotic...

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

Conflict of Interest

None

Chronic Post-Thrombotic Iliofemoral Venous Obstruction

• Severe morbidity

• High recurrence

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


• 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


Common Femoral Vein Obstruction

Post-Thrombotic Iliofemoral Obstruction

Operative InterventionOperative Intervention

Venous PressureVenous PressureCavaCava -- 8mmHg 8mmHgCFVCFV -- 16mmHg16mmHg


Post-Thrombotic CFV LumenPost-Thrombotic CFV Lumen- 4 Years -- 4 Years -




CFV - Patch VenoplastyCFV - Patch VenoplastyCFV - Post EndovenectomyCFV - Post Endovenectomy




Venous PressureVenous PressureCavaCava -- 8mmHg 8mmHgCFVCFV -- 8mmHg 8mmHg




• 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


PatientPatient

AssessmentAssessment ScoreScore

Villalta ScoreVillalta Score 1818

Venous Clinical Severity ScoreVenous Clinical Severity Score 1212

– – PreOp –PreOp –


LeftLeft CFV CFV With CompressionWith Compression



– – 7 Months –7 Months –


CFV

PFV

FV

GSV


PFV OrificeFV

(Occluded)


Endovenectomy Specimen

CFV

FV

– – 7 Months –7 Months –


PFV


Vena Cava

CommonIliac Vein

InternalIliac Vein


– – Patch Closure –Patch Closure –


– – AV Fistula –AV Fistula –


CFV

PFV


Follow-up:Follow-up: At 3 months postopAt 3 months postopwalking 2 miles…walking 2 miles…and increasingand increasing


– – Duplex PostOp –Duplex PostOp –

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 –



• 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


• 2 lost to follow-up

• 7 complete follow-up (mean 1 yr)– Villalta scale– QOL– Duplex

Results (Continued)Results (Continued)


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



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

combined common femoral endovenectomy and endoluminal recanalization for chronic post thrombotic...

Presentations & Public Speaking

endoluminal recanalizationn

common femoral endovenectomy

months endovenectomy

profunda femoris vein

months earlierrxed

painful lower limbus

legcalf painful

legconstant pain