Chapter 160 - Iliocaval obstruction - open Flashcards
Causes of venous obstruction
1) trauma
2) radiation
3) external compression
4) tumors
5) cysts
6) aneurysms
May Thurner syndrome
compressiong of left CIV by right CIA
Secondary changes in May Thurner
Intraluminal webs or spurs in proximal left CIV
20%
Budd-Chiari syndrome
Membranous occlusion of suprahepatic IVC with thorombosis of hepatic veins
Klippel-Trénaunay syndrome on iliofem occlusive disease
hypoplasia of iliofemoral veins
Ideal patient for surgical treatment of venous obstruction
1) unilateral iliac occlusion
2) minimal distal throbus
3) valve competence
Strategies to improve patency of venous grafts
1) larger diameter
2) distal AV fistula
3) rigid external support
4) anticoagulation
5) intermittent-compression pumps
6) post-op surveillance
Autogenous conduits for venous recon
1) GSV
2) FV
3) arm vein
4) jugular vein
Factors associated with morbidity of FV harvest
1) concurrent GSV harvest
2) ABI < 0.4
distal AV fistula in venous construction first suggested by
1953 Kunlin and Kunlinin
Benefit of AV fistula in venous recon
1) decrease platelet deposition
2) decrease fibrin deposition
Optimal ratio of fistula diameter to graft diameter
< 0.3
Indication for femoral AVF
1) all prosthetic grafts to FV
2) iliocaval graft > 10cm
Minimal duration of the fistula in venous recon
6 weeks
Maximum flow velocity of the fistula that’s generally allowed
300 ml/min
Follow up after venous reconstruction
1) catheter left to infuse heparin
2) next day venogram
3) duplex 3 month, 6 month then twice a year
4) Plethysmography can be used
Palma procedure first described and popularized by
Palma and Esperon (Uruguay)
Popularized by Dale (USA)
Indication for Palma procedure
1) Unilateral iliofemoral occlusion
2) Contralateral normal
3) failed endovascular or contraindicated
Techniques for Palma procedure
1) 25-30 cm segment of contralateral saphenous harvested
2) diameter > 4mm better
3) distended and tunnelled in suprapubic subcutaneous position
4) side biting clamp on affected FV
5) end to side anastamosis with interrupted sutures
6) heparin infusion +/- AVF creation
Alternative to Palma procedure conduit
1) free vein
2) externally supported ePTFE 8-10 mm
Palma procedure results
1) clinical improve 63-89%
2) patency 70-85%
Indication for in-line iliac, iliocaval reconstruction
1) unilateral disease when suprapubic grafting not suitable
2) bilateral iliac, iliocaval obstruction
3) IVC obstruction
Size of grafts used for IVC, iliocaval and femorocaval bypass
IVC 16-20 mm
iliocaval 14 mm
femorocaval 10-12 mm
Exposure of the distal IVC
1) right flank incision
2) retroperitoneal approach
Exposure of the pararenal IVC
1) midline or right subcostal incision
2) ascending colon mobilized medially
Sequence of fistula creation in femorocaval bypass
Fistula made first before unclamping everything
5 year secondary patency for femoroiliac and iliocaval bypass
86% FIBY
57% ICBY
Epidemiology of May Thurner syndrome
1) women
2) 20-40’s age
Another name for May Thurner
iliac vein compression syndrome
1965 Cockett and Thomas
Open surgery for May Thurner
1) Palma
2) Excision of intraluminal web then patch
3) transposition of iliac artery behind vein
4) Transpose right CIA to left IIA
Open reconstruction of suprarenal IVC steps
1) right anterolateral thoracotomy
2) extend incision across costal arch
3) retract liver anteriorly
4) open pericardium anterior to right phrenic to isolate right atrium
5) cross clamp IVC above renal
6) 16-18 mm ePTFE end to side
7) tunnel parallel to IVC to right atrium or suprahepatic IVC
8) cross clamp suprahepatic IVC or right atrium
9) flush out air
Pelvic congestion syndrome first description
1857 Richet
named eventually by 1949 Taylor
Rate of pelvic venous incompetence in women
10%
Venous outflow of pelvic structures
1) Hypogastric
2) genital veins
IIV in relation to IIA
Posterior and medial
Parietal tributaries of the IIV
1) superior gluteal
2) inferior gluteal
3) sciatic
4) sacral
5) ascending lumbar
6) obturator
Visceral tributaries of the IIV
1) internal pudendal
2) middle hemorrhoidal
3) vesicoprostatic plexus
4) uterine
5) gonadal
6) vesicovaginal plexus
Rate of two separate trunks of IIV draining
27%
Frequency of valves in the IIV
10% in main trunk
9% in tributaries
Normal size of ovarian vein
< 5 mm
Percentage of people without ovarian vein valves on left and right
left 15%
right 6%
Ovarian veins are connected to the following
1) utero-ovarian veins (broad ligament)
2) salpingo-ovarian veins (broad ligament)
3) rectal vein
4) vaginal vein
5) vesicle vein
3 types of mechanisms resulting in pelvic varicose vein
TYPE 1: reflux secondary to pelvic and genital vein incompetence
TYPE 2: secondary to obstruction of outflow
TYPE 3: secondary to local compression
Estradiol on vein
Inhibits reflex vasoconstriction resulting in vasodilatation
Causes of outflow obstruction resulting in PCS
1) May Thurner
2) nutcracker
3) left renal vein thrombosis
4) post-thrombotic disease
5) Budd chiari syndrome
Causes of local compression resulting in PCS
1) endometriosis
2) tumors
3) post-traumatic lesions
4) infection
Epidemiology of PCS
1) young women
2) 20-30’s
3) multiparous
Definition of PCS and symptoms
1) chronic (6 months) of pelvic pain
2) worse during day if sitting or standing and lifting
3) relief in supine
4) dyspareunia
5) dysmenorrhea
6) urinary symptom
7) rectal constipation
8) unilateral mostly but can be bilateral
9) hemorrhoid frequent
Clinical signs of PCS
1) cervical motion tenderness
2) uterine enlargement
3) uterine retroversion
4) perineal varicose vein
5) atypical varicose veins
Beard et al two symptoms that suggest PCS
1) tender on abd palpation over ovary
2) history of pain after sex
sen 94%
spe 77%
Duplex scanning for PCS pre-scan conditions
1) transparietal 5 MHz and transvaginal
2) 3 days no residual diet
3) empty stomach
4) image with valsalva
Definition of pelvic varicose veins on US
1) multiple dilated tubular structure around ovary and uterus
2) diameter > 5 mm
PPV of a 6 mm ovarian vein for diagnosis of PCS
83.3%
Rate of failure to cannulate right ovarian vein from femoral vs from brachial
18% fail brachial
58% fail femoral
Phlebographic diagnosis of PCS criteria
Chung and Huh
1) ovarian vein > 5 mm
2) retention of contrast in ovarian vein > 20 s
3) congestion in pelvic venous plexus
4) opacification of IIV
5) filling of vulvovaginal and thigh varicosities
Each score 1-3
Total score > 5 = PCS
Differential diagnosis of pelvic pain
1) endometriosis
2) uterine fibroma
3) pelvic cancer
4) pudendal nerve compression
Medical treatment of PCS
1) Medroxyprogesterone acetate (Provera) 30 mg/day x 6 months
2) Goserelin acetate 3.6 mg/month x 6 month
3) MPFF (Daflon) 500 mg BID x 6 months
All are temporary and will recur once stopped
Surgical treatment of PCS
1) ovarian/IIV ligation
2) ovarian, uterine artery and vein ligation
3) oophorectomy
4) total hysterectomy with BSO
First line treatment of PCS
Endovascular
Rules of embolization techniques in PCS
1) entire internal iliac vein cannot be embolized
2) embolization of gonadal veins to be proximal to last collateral to avoid recurrence
