Chap 61-62 Iliocaval Occlusion Flashcards
Name causes of venous occlusion.
trauma radiation tumor cyst aneurysm abnormally inserted muscle compression by CIA congenital anomalie (budd-chiari, KTS)
What is perthes test?
Touriniquet prox calf, walk patient (rapid emptying of superficial vein through perforators and deep system)
Distention of superficial veins distal to tourniquet after walking indicates deep venous occlusion
What are test for deep venous occlusion?
duplexy and plethysmography to confirm
CT/MR to rule out other causes
What are conduits for venous bypass?
SVG
contrs SFV
basillic-brachial ax vein
ePTFE for large veins
What is the advantage of an AVF for a prosthetic venous bypass?
improves patency
decreases pot and fibrin deposition
increases flow
What are the disadvantages of an AVF?
longer OR time
redo to close
elevated CO
increase venous pressure in groin
What are the indications for AVF?
all femeral vein anastomosis
all iliocaval >10cm
How long to leave open?
6 months but longer if tolerated
What is surveillance of an AVF?
intraop <300ml/min
POD1 contrast phlebography
duplex at 3-6 months
What is the management strategy for symptomatic venous obstruction?
conservative
endovascular +/- thrombo
surgical thrombectomy
surgical bypass
Describe a saphenopopliteal bypass. where do you do the AVF? how many people get improvement?
occlusion of fem or prox pop
SVG to pop
temp AVF at ankle (PTA/PTV)
80% improvement
Describe the palma procedure. how many people improve?
cross pubic venous bypass for unilateral iliac vein obstruction
need SVG 5 or > or prosthetic
can use AVF
80% improvement
Describe a prosthetic femorocaval, iliocaval or IVC bypass.
in-lin iliac/iliocaval reconstruction
expose fem vessels for AVF (do first)
primary patency 65% at 5 years
What is may-thurner syndrome?
compression of L iliac vein b/w R CIA and 5th lumbar vertebra
Who get may-thurner?
women 2-4th decades
what are symptoms of May-thurner?
left leg swelling, venous claudication, pain, skin changes, rare ulceration
acute comp left iliofem dvt—rare
What is treatment for MT?
surgical for symptom
endo option no LT outcomes
stenting of iliac, failed then palma
80% improvement post-op
What is most common indication for suprarenal IVC reconstruction?
membranous occlusion of the IVC
What are conduits used for reconstruction of suprarenal IVC?
spiral vein graft
SFV
ePTFE
What is pelvic-renal congestion syndrome?
dilated pelvic veins
stretch causes pain
can cause urinary symptoms
Who gets PCS? what are symptoms?
usually child-bearing aged women pelvic pain >6 month heaviness relieved with lying down dyspareunia, dysuria, contipation R>L
What is workup for PCS?
abdo tenderness on pal and hx pain after sex high sensitivity
duplex
PPV high if ovarian vein >6mm
CTV/MRV
Phleobography
What are findings for PCS on phlebography?
ovarian vein >5mm
retention of contrast >2secs
congestion in pelvic venous plexus
opacification of internal iliac vein
What is tx for PCS?
progesterone for 6 months
surgery
ovarian/internal vein/artery ligation
oopherectomy/total hyst
endovascular
coil embo
foam
SVS
coil embo, plugs, sclerotherpay
What is nutcracker syndrome?
Compression of distal segment of LRV b/w SMA and aorta
What are mechanism of LRV compression?
acute angle of SMA
posterior ptosis of left kidney
high course of LRV
What are symptoms
Left flank pain radiating to buttock
hematuria
aggravated by standing
What are findings on duplex?
signif stenosis if diameter on left side of aorta 5x greater tena at level of stenosis
PV at stenosis 5x PV measured at hilum
collaterals
What are other investigations for nutcracker?
reno-caval gradient 3mmHG or higher
CTA/MRA (LRV compression)
phlebography
Who to treat and how?
severe symptomatic endovascular stenting surgery reimplant lrv into IVC renal autotransplantation LRV bypass
What are some consideration for stunting in venous system?
POBA insufficient needs stent kissing technique unessecary redilate after stent insertion can be placed across inguinal ligament do not leave skip areas vein can accept extensive dilatation
How to avoid stent migration?
use long stent
