A New Technique for Bilateral Iliac Vein and Inferior Vena Cava Reconstruction Using Reinforced Polytetrafluoroethylene P. Murchan, MB, M.E. Sugrue, F R C S I , M.K. O'Malley, FRCSI, T.M. Feeley, F R C S I , D.G. Shanik, F R C S I , D.J. Moore, FRCSI, Dublin, Ireland
We report on the management of a patient with intractable venous claudication and ulceration due to bilateral lilac vein and inferior vena cava occlusion, An inverted V graft was constructed from two 8 mm diameter reinforced PTFE grafts. The upper end was anastomosed to the inferior infrarenal vena cava and the lower ends anastomosed to the common femoral veins. Bilateral arteriovenous fistulas were fashioned. Nine months later the graft is patent and the patient's only symptom is mild ankle edema. The theoretical advantage of this type of graft is that occlusion of one limb will not compromise the other, thus leaving a number of secondary options open if this should happen. (Ann Vasc Surg 1990;4:302-304) KEY WORDS: Venous claudication; venous ulceration; inferior vena cava occlusion; lilac vein occlusion; bilateral lilac vein and inferior vena cava reconstruction.
A small number of patients with postphlebitic limbs continue to suffer incapacitating s y m p t o m s despite conservative therapeutic measures. Following investigation, these patients may be found suitable for venous reconstruction or bypass. Modest success has been reported with procedures such as those described by Palma and Esperon to bypass unilateral iliac vein occlusion . Successful reconstruction o f the iliac vein  and the infrarenal  and retrohepatic  inferior vena cava, using polytetrafluoroethylene (PTFE), have also been reported. In 1984 Dale  reported the first successful reconstruction of both c o m m o n iliac veins and infrarenal vena cava. We report the fashioning o f a reinforced P T F E
From the Department of Vascular Surgery, St. James' Hospital, Dublin, Ireland. Reprint requests: Dermot Moore, MD, FRCSI, Department of Vascular Surger3', St. James' Hospital, Dublin 8, Ireland.
inverted V graft and its successful use for bilateral iliac vein and inferior vena cava bypass.
CASE REPORT A 65-year-old man presented with a three year history of bilateral venous ulceration and a two year history of disabling venous claudication. Three years previously a Greenfield filter was inserted because of deep venous thrombosis and recurrent pulmonary emboli despite adequate anticoagulation. Noninvasive investigation showed patent femoral veins but bilateral iliac vein obstruction. Duplex scanning showed the inferior vena cava to be patent at the level of the renal veins. Venous pressures were measured: at rest they were 22 mmHg, 84 mmHg while standing, and increased to 88 mmHg on exercise. Ascending bilateral venography showed occlusion of the iliac veins from the level of the inguinal ligament bilaterally. The inferior vena cava was occluded from its origin to the level of the renal veins. Venous drainage from the lower body was mainly through the testicular veins (Fig. 1), Because of his severe 302
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BILATERAL ILIAC VEIN A N D I V C R E C O N S T R U C T I O N
Fig. 2. Upper end of graft with apposing sides of the 8 mm PTFE graft ostia sutured together prior to anastomosis to the inferior vena cava.
w e e k s postoperatively. A venogram performed three weeks later showed the graft to be patent (Fig. 3). One of the arteriovenous fistulas became enlarged with a palpable thrill and was ligated six months postoperatively, while the other has not enlarged noticeably and has not been ligated.
Fig. 1. Preoperative venogram showing occluded inferior vena cava with Greenfield filter above its origin. Extensive venous collaterals are seen with large testicular veins, particularly on the right.
symptoms and lack of improvement over the preceding two years it was felt that bypass of the occluded iliocaval system was justified. Exploration of the groin veins revealed diseased recanalized common femoral veins and normal profunda veins. The inferior vena cava was occluded to five centimeters below the renal veins. The Greenfield filter was embedded in the lower thrombosed inferior vena cava. Two lengths of 8 mm reinforced P T F E were used. Two ends were held side-to-side in a hemostat applied obliquely. Cutting along the hemostat edge gave two matching ostia three centimeters tong. While held sideto-side in perfect apposition, the adjacent walls were sutured together using 6/0 P T F E suture resulting in a three centimeter ostium with a septum (Fig. 2). This was joined end-to-side to the normal infrarenal vena cava using 6/0 t ~ F E suture. The graft limbs were tunnelled retroperitoneally and behind the inguinal ligaments to the groin where they were anastomosed end-to-side to the profunda femoris veins. An arteriovenous fistula was created bilaterally from the common femoral artery to the superficial pudendal vein. The patient was systemically anticoagulated with heparin during the peri- and postoperative period, and warfarin was begun on the fourth postoperative day. The patient made a good recovery and his venous claudication improved. He was discharged home two
DISCUSSION T h e u s e o f r e c o n s t r u c t i v e v e n o u s s u r g e r y is c o n t r o v e r s i a l , a n d m o s t e x p e r t s b e l i e v e it is i n d i c a t e d o n l y in d e s p e r a t e c l i n i c a l s i t u a t i o n s . O u r p a t i e n t
Fig. 3. Postoperative venogram showing venous drainage through both limbs of the graft,
BILATERAL ILIAC VEIN A N D IVC RECONSTRUCTION
was classified as such because of intractable venous ulceration and incapacitating venous claudication which failed to improve with two years conservative management. The inverted V graft as fashioned in our patient offers the advantage that thrombosis of one limb will not compromise the other as might be possible with an inverted Y graft. Numerous experimental studies [7,8] have shown that PTFE is the synthetic graft of choice for venous bypass procedures and reports of its clinical use show encouraging results [3-5]. In 1984 Dale and associates  reported the first successful reconstruction of the infrarenal vena cava and common iliac veins. They used reinforced PTFE and constructed the graft by anastomosing one 12 mm graft end-to-side to a second similar graft. Externally supported grafts are favored, since it is believed this reinforcement protects the graft against the compression and possibly occluding effects of overlying intraabdominal viscera. The crucial factor for maintenance of graft patency is the pressure differential across the graft , and intragraft pressure could easily be negated by overlying viscera. While there is almost universal agreement on the use of reinforced PTFE in large vein bypass procedures, the advantage of adjunctive arteriovenous fistula as an aid to maintain patency is controversial. Many experimental studies have demonstrated convincing evidence of the beneficial effect of arteriovenous fistulas in maintaining graft patency, whether it be autologous vein  or PTFE . Several investigators believe that, not only are fistulas of no benefit, but they may even have detrimental effects [ 11,12]. Hobson and Wright [ 11] have shown that, while the fistula placed just distal to the vein graft led to problems such as reduced femoral artery flow and limb edema, placement of the fistula several centimeters distal to the graft was not associated with similar problems. Clinically some authors believe an arteriovenous fistula is essential for graft patency , while others believe they are unnecessary [I3]. Dale  does not use fistulas because of: (1) additional time and dissection needed, (2) the necessity of a later procedure to
ANNALS OF VASCULARSURGERY
close the fistula, and (3) the eventual requirement that the graft remain patent without a fistula, whether it be early or late. The arteriovenous fistulas created in our patient were small. Nevertheless after the relatively short period of six months one had enlarged to such a degree that ligation was necessary. The other fistula remained open but did not enlarge and has not been ligated. Both graft limbs remain open. Obviously the role of arteriovenous fistulas in venous bypass surgery remains unclear. REFERENCES 1. PALMA EC, ESPERON R. Vein transplants and grafts in the surgical treatment of the postphlebitic syndrome. J Cardiovasc Surg 1960;1:94-107. 2. HUSN1 EA. Reconstruction of veins. J Cardiovasc Surg 1981 ;22:481 (abstract). 3. CLOWES AW. Extra-anatomical bypass of iliac vein obstruction. Arch Surg 1980;115:767-769. 4. DALE WA, HARRIS J, TERRY RB. Polytetrafluoroethylene reconstruction of the inferior vena cava. Surgeo' 1984;95:625~30. 5. VICTOR S, JAYANTHI V, KANDASAMY I, RATNASABAPATHY A, MADANAGOPALAN N. Retrohepatic cavoatrial bypass for coarctation of inferior vena cava with a polytetrafluoroethylene graft. J Thorac Cardiovasc Surg 1986;9• :9%105. 6, SCHERCK JP, KERSTEIN MD, STANSEL HC Jr. The current status of vena cava replacement. Surgeo' 1974; 76:209-233. 7, WILSON SE. JABOUR A, STONE RT, STANLEY TM. Patency of biologic and prosthetic inferior vena cava grafts with distal limb fistula. Arch Surg 1978;113:1174-1179. 8. FIORE AC, BROWN JW, CROMARTIE RS, OFSTEIN LC, PEIGH PS, SEARS NS, DESCHNER WP, KING H. Prosthetic replacement for the thoracic vena cava. An experimental study. J Thorac Cardiovasc Surg 1982:84: 560-568. 9. DALE WA, SCOTT HW Jr. Grafts of the venous system. SurgeD' 1963;53:52-84. 10, JOHNSON V, EISEMAN B. Evaluation of arteriovenous fistula shunt to maintain patency of venous autograft. Am J Surg 1969;118:915-920. 11. HOBSON RW, WRIGHT CB. Peripheral side to side arteriovenous fistula, Hemodynamics and application in venous reconstruction. Am J Surg 1973:126:411--414. 12. LEVIN PM, RICH NM, HUTTON JE Jr, BARKER WF, ZELLAR JA. Role of arteriovenous shunts in venous reconstruction. Am J Surg 1971;122:183, 13. DALE WA. Venous bypass surgery. Surg Clin North Am 1982 ;62:391-398.