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R9 > Chapter 160 - Iliocaval obstruction - open > Flashcards

Chapter 160 - Iliocaval obstruction - open Flashcards

1
Q

Causes of venous obstruction

A

1) trauma
2) radiation
3) external compression
4) tumors
5) cysts
6) aneurysms

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2
Q

May Thurner syndrome

A

compressiong of left CIV by right CIA

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3
Q

Secondary changes in May Thurner

A

Intraluminal webs or spurs in proximal left CIV

20%

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4
Q

Budd-Chiari syndrome

A

Membranous occlusion of suprahepatic IVC with thorombosis of hepatic veins

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5
Q

Klippel-Trénaunay syndrome on iliofem occlusive disease

A

hypoplasia of iliofemoral veins

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6
Q

Ideal patient for surgical treatment of venous obstruction

A

1) unilateral iliac occlusion
2) minimal distal throbus
3) valve competence

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7
Q

Strategies to improve patency of venous grafts

A

1) larger diameter
2) distal AV fistula
3) rigid external support
4) anticoagulation
5) intermittent-compression pumps
6) post-op surveillance

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8
Q

Autogenous conduits for venous recon

A

1) GSV
2) FV
3) arm vein
4) jugular vein

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9
Q

Factors associated with morbidity of FV harvest

A

1) concurrent GSV harvest

2) ABI < 0.4

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10
Q

distal AV fistula in venous construction first suggested by

A

1953 Kunlin and Kunlinin

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11
Q

Benefit of AV fistula in venous recon

A

1) decrease platelet deposition

2) decrease fibrin deposition

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12
Q

Optimal ratio of fistula diameter to graft diameter

A

< 0.3

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13
Q

Indication for femoral AVF

A

1) all prosthetic grafts to FV

2) iliocaval graft > 10cm

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14
Q

Minimal duration of the fistula in venous recon

A

6 weeks

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15
Q

Maximum flow velocity of the fistula that’s generally allowed

A

300 ml/min

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16
Q

Follow up after venous reconstruction

A

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

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17
Q

Palma procedure first described and popularized by

A

Palma and Esperon (Uruguay)

Popularized by Dale (USA)

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18
Q

Indication for Palma procedure

A

1) Unilateral iliofemoral occlusion
2) Contralateral normal
3) failed endovascular or contraindicated

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19
Q

Techniques for Palma procedure

A

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

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20
Q

Alternative to Palma procedure conduit

A

1) free vein

2) externally supported ePTFE 8-10 mm

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21
Q

Palma procedure results

A

1) clinical improve 63-89%

2) patency 70-85%

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22
Q

Indication for in-line iliac, iliocaval reconstruction

A

1) unilateral disease when suprapubic grafting not suitable
2) bilateral iliac, iliocaval obstruction
3) IVC obstruction

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23
Q

Size of grafts used for IVC, iliocaval and femorocaval bypass

A

IVC 16-20 mm
iliocaval 14 mm
femorocaval 10-12 mm

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24
Q

Exposure of the distal IVC

A

1) right flank incision

2) retroperitoneal approach

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25
Q

Exposure of the pararenal IVC

A

1) midline or right subcostal incision

2) ascending colon mobilized medially

26
Q

Sequence of fistula creation in femorocaval bypass

A

Fistula made first before unclamping everything

27
Q

5 year secondary patency for femoroiliac and iliocaval bypass

A

86% FIBY

57% ICBY

28
Q

Epidemiology of May Thurner syndrome

A

1) women

2) 20-40’s age

29
Q

Another name for May Thurner

A

iliac vein compression syndrome

1965 Cockett and Thomas

30
Q

Open surgery for May Thurner

A

1) Palma
2) Excision of intraluminal web then patch
3) transposition of iliac artery behind vein
4) Transpose right CIA to left IIA

31
Q

Open reconstruction of suprarenal IVC steps

A

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

32
Q

Pelvic congestion syndrome first description

A

1857 Richet

named eventually by 1949 Taylor

33
Q

Rate of pelvic venous incompetence in women

A

10%

34
Q

Venous outflow of pelvic structures

A

1) Hypogastric

2) genital veins

35
Q

IIV in relation to IIA

A

Posterior and medial

36
Q

Parietal tributaries of the IIV

A

1) superior gluteal
2) inferior gluteal
3) sciatic
4) sacral
5) ascending lumbar
6) obturator

37
Q

Visceral tributaries of the IIV

A

1) internal pudendal
2) middle hemorrhoidal
3) vesicoprostatic plexus
4) uterine
5) gonadal
6) vesicovaginal plexus

38
Q

Rate of two separate trunks of IIV draining

A

27%

39
Q

Frequency of valves in the IIV

A

10% in main trunk

9% in tributaries

40
Q

Normal size of ovarian vein

A

< 5 mm

41
Q

Percentage of people without ovarian vein valves on left and right

A

left 15%

right 6%

42
Q

Ovarian veins are connected to the following

A

1) utero-ovarian veins (broad ligament)
2) salpingo-ovarian veins (broad ligament)
3) rectal vein
4) vaginal vein
5) vesicle vein

43
Q

3 types of mechanisms resulting in pelvic varicose vein

A

TYPE 1: reflux secondary to pelvic and genital vein incompetence
TYPE 2: secondary to obstruction of outflow
TYPE 3: secondary to local compression

44
Q

Estradiol on vein

A

Inhibits reflex vasoconstriction resulting in vasodilatation

45
Q

Causes of outflow obstruction resulting in PCS

A

1) May Thurner
2) nutcracker
3) left renal vein thrombosis
4) post-thrombotic disease
5) Budd chiari syndrome

46
Q

Causes of local compression resulting in PCS

A

1) endometriosis
2) tumors
3) post-traumatic lesions
4) infection

47
Q

Epidemiology of PCS

A

1) young women
2) 20-30’s
3) multiparous

48
Q

Definition of PCS and symptoms

A

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

49
Q

Clinical signs of PCS

A

1) cervical motion tenderness
2) uterine enlargement
3) uterine retroversion
4) perineal varicose vein
5) atypical varicose veins

50
Q

Beard et al two symptoms that suggest PCS

A

1) tender on abd palpation over ovary
2) history of pain after sex

sen 94%
spe 77%

51
Q

Duplex scanning for PCS pre-scan conditions

A

1) transparietal 5 MHz and transvaginal
2) 3 days no residual diet
3) empty stomach
4) image with valsalva

52
Q

Definition of pelvic varicose veins on US

A

1) multiple dilated tubular structure around ovary and uterus
2) diameter > 5 mm

53
Q

PPV of a 6 mm ovarian vein for diagnosis of PCS

A

83.3%

54
Q

Rate of failure to cannulate right ovarian vein from femoral vs from brachial

A

18% fail brachial

58% fail femoral

55
Q

Phlebographic diagnosis of PCS criteria

A

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

56
Q

Differential diagnosis of pelvic pain

A

1) endometriosis
2) uterine fibroma
3) pelvic cancer
4) pudendal nerve compression

57
Q

Medical treatment of PCS

A

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

58
Q

Surgical treatment of PCS

A

1) ovarian/IIV ligation
2) ovarian, uterine artery and vein ligation
3) oophorectomy
4) total hysterectomy with BSO

59
Q

First line treatment of PCS

A

Endovascular

60
Q

Rules of embolization techniques in PCS

A

1) entire internal iliac vein cannot be embolized

2) embolization of gonadal veins to be proximal to last collateral to avoid recurrence

R9 (200 decks)

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