Venous bypass for iliofemoral venous occlusion: a possible answer for patients with no endovascular solution

Abstract

INTRODUCTION: Percutaneous endovenous treatment is the first-line therapy for chronic nonmalignant iliocaval venous obstruction (ICVO) due to low morbidity and suitable medium and long-term results. Open surgical procedures are only used as a last resort therapy. However, there is a lack of updated data regarding surgical techniques and outcomes. We present two cases of surgical venous reconstructions to treat ICVO using expanded polytetrafluoroethylene (ePTFE) grafts and discuss the evidence regarding technical aspects to improve long-term patency. CASE REPORTS: The first case concerns a 69-year-old male with chronic edema and venous ulceration associated with ICVO secondary to iliocaval stent thrombosis. After an unsuccessful endovascular treatment attempt, we performed a surgical iliocaval bypass using a 10mm ringed ePTFE graft. After three months, complete ulcer healing was observed. The other patient was a 63-year-old female with disabling chronic edema of the right lower limb and venous claudication consequent to the ligation of the right common femoral vein to correct an iatrogenic vascular injury during orthopedic surgery. The patient underwent venous bypass between the deep femoral vein and the ipsilateral common iliac vein using a 12mm ringed ePTFE graft. A marked improvement in clinical symptoms was observed after treatment. A venous stent was used later to treat an anastomotic stenosis. CONCLUSION: Our experience supports open venous reconstruction as a viable option for patients with benign ICVO and debilitating symptoms not amenable to endovascular treatment. Important technical aspects such as adequate inflow vein, the choice of the prosthetic graft, long-term anticoagulation, and the creation of a distal arteriovenous fistula should be considered to improve patency.

Keywords

• iliocaval venous obstruction
• post-thrombotic syndrome
• venous bypass
• iliocaval reconstruction