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Chronic venous obstruction as a factor in the early failure of bypass grafts in the leg
Chronic Venous Obstruction as a Factor in the Early Failure Of Bypass Grafts in the Leg
Nicholas D. Filippone, MD, Albany, New York Dhiraj M. Shah, MD, FACS, Albany, New York Harold F. Welch, MD, FACS, Albany, New York Samuel R. Powers, Jr., MD, FACS, Albany, New York
The importance of adequate venous outflow in the successful repair of acutely injured arteries is now generally acknowledged. The experience of surgeons in Vietnam in treating vascular injuries provided convincing evidence of this [I-3]. Numerous experimental models have also demonstrated significant impairment of arterial flow in the presence of increased venous pressure [4-IO]. This suggested to us that venous obstruction and hypertension in the leg due to deep venous thrombosis or venous insufficiency might adversely influence the early patency of bypass grafts in the leg. Material
and Methods
A 2 year retrospective review was done of patients undergoing bypass procedures below the inguinal ligament for limb salvage who also had evidence of deep venous obstruction and insufficiency in the same limb. These were compared with bypass procedures below the inguinal ligament for limb salvage in patients without venous disease. The venous disease was manifested by a history of chronic deep venous thrombosis (documented by venography), the presence of severe changes of venous insufficiency including nonhealing stasis ulcers, brawny edema, stasis dermatitis or recent deep venous thrombosis. Three such patients underwent a single bypass procedure and three patients underwent two bypasses each. The indications for revascularization consisted of acute ischemia in one patient or failure of venous stasis ulcers to heal after 6 or more weeks of conservative therapy including bed rest with elevation, topical wound care and skin grafting in other patients. Fromthe Department of Surgery, Albany Veterans Administration Medical Center and Albany Medical College, Albany. New ‘fork. Requests for reprints should be addressedto Dhiraj M. shah. MD, Sugical Service, Veterans Administration Medical Center, Albany, New ‘fork 12208.
Volume 140, November 1980
The presence and extent of arterial disease was documented by pulse volume recordings and calculation of ankle to arm pressure ratios with Doppler ultrasound. Arteriographic examination of the involved limb was undertaken when the decision for revascularization was made. Of the nine bypass procedures, extruded Teflon@ (Gore-Tex@) was used in three, Dacron@ (Sauvage) in three, and autogenous vein in two (one reversed saphenous and one in situ saphenous vein). A composite of Dacron and saphenous vein was used in one procedure. The following procedures were performed: four femoropopliteal bypasses; two bypasses between a limb of an axillobifemoral and the popliteal artery; two ileopopliteal bypasses, and one femorotibioperoneal trunk bypass. Except for the last patient, all patients had superficial femoral occlusion with reconstitution of the popliteal artery and three-vessel run-off. In the patient with femorotibioperoneal trunk bypass, there was two-vessel run-off to the ankle. No “isolated segment” bypasses were performed. All patients were followed closely postoperatively in the hospital and in our vascular surgery clinic. Graft patency or failure was documented by serial pulse volume recordings and Doppler ultrasound ankle pressure measurements (Table I). Results Our overall early (1 month) patency rate for bypass below the inguinal ligament with two- or three-vessel run-off is 95 percent. Of the nine bypass procedures done for limb salvage in patients with venous obstruction, five failed due to graft thrombosis within 1 month, for an early patency rate of 44.5 percent. Artificial graft material was used in seven of these bypasses because the saphenous vein was either unavailable or unacceptable as a conduit. Five of these
671
Filippone et al
seven failed within 1 month. In contrast, five bypasses utilizing artificial graft material performed during the same period in patients without venous disease were all open at 1 month. This difference is highly significant (p
TABLE I
pulse volume recordings and ankle Doppler pressures. However, within 1 week of surgery, there was evidence of decreased flow through the graft, and 3 weeks after surgery the Gore-Tex graft had occluded completely. After a protracted course and unsuccessful attempts to save the graft, below-knee amputation was ultimately required. Case 2. A 61 year old white man had had deep venous thrombosis of the right calf 2 years before admission. Three months before admission, he had another episode of deep venous thrombosis of the left calf. At the same time he was diagnosed as having nonresectable squamous cell carcinoma of the lung. He was readmitted with an acutely ischemic left foot. There was no previous history of claudication or rest pain. He had no palpable pulse in the left leg or below the femoral artery in the right leg. The left foot was cool, painful and paralyzed. He had multiple palpable venous cords in both calves and bilateral edema. Pulse volume recordings revealed no pulsatile flow at the level of the calves or ankles. There were no audible Doppler pulses in either the posterior tibia1 or the dorsalis pedis arteries. Arteriography revealed complete left iliac occlusion and bilateral superficial femoral artery occlusion. Both popliteal vessels filled by collateral vessels. Axillobifemoral bypass was performed using an 8 mm Dacron Sauvage graft. The condition of the left foot improved dramatically, but within hours the right foot became acutely ischemic. The patient then underwent a bypass between the right limb of the axillobifemoral graft and the right popliteal artery. Initially there was dramatic subjective improvement in the right foot as well as an improvement in ankle level pulse volume recordings and Doppler pressure. However, within 24 hours there was no flow in this distal graft, although both limbs of the axillobifemoral grafts were open. The graft was declotted with
Case Histories
Case No.
Indication
1
Nonhealing ulcers
Femoropopliteal bypass
Gore-Tex
2
Acute ischemia
Dacron Sauvage
3
Acute ischemia
Nonhealing ulcers
Bypass between limb of axillobifemoral and popliteal artery Bypass between limb of axillobifemoral and popliteal artery Right femoropopliteal bypass
Nonhealing ulcers
Right ileopopliteal bypass
Nonhealing ulcers Nonhealing ulcers
lleopopliteal bypass Femoropopliteal bypass
Nonhealing ulcers
Femorotibioperoneal trunk bypass Femoropopliteal bypass
Nonhealing ulcers
672
Procedure
Material
Early and Late Results Clotted at 3 weeks; below-knee amputation Clotted 1st postoperative night (axillobifemoral open)
Dacron Sauvage
Clotted 1st postoperative night (axillobifemoral open): died
Gore-Tex
Open at 1 month; failed at 5.5 months Clotted 1st postoperative night; below-knee amputation Clotted at 2 weeks Open at 1 month; failed at 2.5 months Open at 1 month; below-knee amputation at 2 months Open at 1 month; failed at 6 months
Composite Dacron Sauvage saphenous vein Gore-Tex Dacron Sauvage Saphenous vein (reversed) Saphenous vein (In situ)
The American Journal of Surgery
Chronic Venous Obstruction and Bypass Grafts
Fogarty catheters. Once again, the graft functioned briefly and then rethrombosed. The patient declined further intervention and ultimately died from multiple organ system failure. Comments The successful restoration of venous continuity at the time of repair of acute arterial injuries significantly improved the salvage rate of wounded limbs in Vietnam [l--3]. Severe venostasis with edema may contribute to profound morbidity and amputation, as reported by Sullivan et al [3]. However, venous obstruction might also decrease arterial flow to the point of inadequate perfusion or thrombosis in spite of a technically adequate arterial repair. Numerous elegant experimental models have documented the effect of venous ligation on arterial flow. Hobson et al [6] and Wright and Swan [JO] demonstrated a significant decrease in femoral arterial flow when peripheral venous pressure was acutely increased by ligating the femoral vein of a dog (systemic pressure remained unchanged). Wright and Hobson [9] produced the same results in the baboon and showed an increase in peripheral resistance. Stallworth et al [7] produced a similar model in dogs and demonstrated that although visible arterial pulsation and arterial pressure did not change in the presence of venous hypertension, there was no arterial flow after 6 hours of venous occlusion. Veal et al [8] likewise demonstrated that in the mesentery of a dog, arterial standstill occurred in the presence of transmitted pulsations. The ligation of traumatized veins and the resulting venous hypertension is the clinical corollary of these experimental preparations. Venous obstruction and hypertension are also seen in acute deep venous thrombosis or in chronic venous insufficiency. Extensive acute venous occlusion may lead to gangrene of the extremity in the syndrome of phlegmasia cerulea dolens or venous gangrene. Experimental data suggest that the pathophysiology is related to the diminished arterial flow into a venous bed completely occluded with thrombus [8]. Brockman and Vasko [5], on the other hand, produced experimental data indicating that arterial insufficiency in phlegmasia cerulea dolens is due to the collapse of small arteries under the increasing pressure of edematous tissue. Increased venous pressure is also characteristic of the postphlebitic syndrome. In this situation, deep veins are scarred or occluded by thrombophlebitis. Organization of thrombus destroys valves, rendering them incompetent. Recanalized channels offer high
Volume 140, November 1960
resistance. Consequently, venous pressure increases as resistance to venous flow increases. Edema, dermatitis, aching fullness and stasis ulceration are the clinically observed sequelae of this process [11]. We propose that this elevated venous pressure also causes outflow obstruction when arterial reconstruction is undertaken in acutely thrombosed venous channels or in postphlebitic venous systems. The patency of arterial bypass grafts in the early postoperative period is influenced by several factors, including adequate outflow or run-off. It may therefore be reasonably proposed that increased venous resistance on the other side of the capillary bed would compromise run-off and result in significant early graft failure in patients with acute thrombophlebitis or the postphlebitic syndrome. Our data appear to support this hypothesis. In the clinical setting, the importance of venous occlusion appears greatest at the level of the popliteal vein. More proximal bypasses (aortofemoral or ileofemoral), because of the more extensive collateral venous flow above the knee, are unlikely to be compromised by more distal venous obstruction. This was our experience with case 2, in which the axillofemoral limbs remained patent despite occlusion of the femoropopliteal segments. These conclusions may be useful in the management of patients with venous hypertension in whom arterial reconstruction is contemplated. Since a low flow state may exist, it is important to use autogenous vein whenever possible. Although the numbers are small, our data suggest that the early patency of autogenous vein grafts is better. Since many of these patients have unavailable or unusable greater saphenous veins, the cephalic vein or the lesser saphenous vein should be evaluated carefully before an artificial graft material is selected. Several experimental preparations demonstrated that after venous ligation, impaired arterial flow could be improved or restored by sympathetic interruption, thereby decreasing capillary tone [7,9]. Concomittant sympathectomy may be considered in these patients with venous obstruction. Summary It is suggested that the early failure of bypass grafts in patients with clinical evidence of venous hypertension is a result of increased resistance caused by venous obstruction. The importance of using autogenous vein grafts in such cases is emphasized. One should accept the possibility that arterial reconstruction may result in a less successful outcome in patients with chronic venous disease.
673
Filippone
et al
References 1. Rich NM, Hughes CW, Bough JE. Management of venous injuries. Ann Surg 1970;171:724. 2. Rich NM, Jarstfer BS, Geer TM. Popliteal artery repair failure: causes and possible prevention. J Cardiovasc Surg 1974; 15:346. 3. Sullivan WG, Thornton FH, Baker LH, LaPlante ES, Cohen A. Early influence of popliteal vein repair in the treatment of popliteal vessel injuries. Am J Surg 1971;122:528. 4. Barcia PH, Nelson TG, Whelan TJ. Importance of venous occlusion in arterial repair failure: an experimental study. Ann Surg 1972;175:223. 5. Brockman SK, Vasko JS. The pathologic physiology of phlegmasia cerulea dolens. Surgery 1986:59:997. 6. Hobson RW, Howard EW, Wright CB, Collins GJ, Rich NM. Hemodynamics of canine femoral venous ligation: signifi-
674
cance in combined 1973;74:824.
arterial and venous injuries. Surgery
7. Stallworth JM. Najib A, Kletke RR, Ramirez A. Phlegmasia cerulea dolens: an experimental study. Ann Surg 1967; 165860. 8. Veal JR, Dugan TJ, Jamison WL. Bauersfeld RS. Acute massive venous occlusion of the lower extremities. Surgery 1951; 29:355. 9. Wright CB, Hobson RW. Hemodynamic effects of femoral venous occlusion in the subhuman primate. Surgery 1974; 751453. 10. Wright CB, Swan KG. Hemodynamics of venous occlusion in the canine hind limb. Surgery 1973;73:141. 11. Sumner DS. The hemcdynamic and pathophysiology of venous disease. In: Rutherford RB, ed. Vascular surgery. Philadelphia: WB Saunders, 1977:147-63.
The Am&can Journal ol Surgery
Nicholas D. Filippone, MD, Albany, New York Dhiraj M. Shah, MD, FACS, Albany, New York Harold F. Welch, MD, FACS, Albany, New York Samuel R. Powers, Jr., MD, FACS, Albany, New York
The importance of adequate venous outflow in the successful repair of acutely injured arteries is now generally acknowledged. The experience of surgeons in Vietnam in treating vascular injuries provided convincing evidence of this [I-3]. Numerous experimental models have also demonstrated significant impairment of arterial flow in the presence of increased venous pressure [4-IO]. This suggested to us that venous obstruction and hypertension in the leg due to deep venous thrombosis or venous insufficiency might adversely influence the early patency of bypass grafts in the leg. Material
and Methods
A 2 year retrospective review was done of patients undergoing bypass procedures below the inguinal ligament for limb salvage who also had evidence of deep venous obstruction and insufficiency in the same limb. These were compared with bypass procedures below the inguinal ligament for limb salvage in patients without venous disease. The venous disease was manifested by a history of chronic deep venous thrombosis (documented by venography), the presence of severe changes of venous insufficiency including nonhealing stasis ulcers, brawny edema, stasis dermatitis or recent deep venous thrombosis. Three such patients underwent a single bypass procedure and three patients underwent two bypasses each. The indications for revascularization consisted of acute ischemia in one patient or failure of venous stasis ulcers to heal after 6 or more weeks of conservative therapy including bed rest with elevation, topical wound care and skin grafting in other patients. Fromthe Department of Surgery, Albany Veterans Administration Medical Center and Albany Medical College, Albany. New ‘fork. Requests for reprints should be addressedto Dhiraj M. shah. MD, Sugical Service, Veterans Administration Medical Center, Albany, New ‘fork 12208.
Volume 140, November 1980
The presence and extent of arterial disease was documented by pulse volume recordings and calculation of ankle to arm pressure ratios with Doppler ultrasound. Arteriographic examination of the involved limb was undertaken when the decision for revascularization was made. Of the nine bypass procedures, extruded Teflon@ (Gore-Tex@) was used in three, Dacron@ (Sauvage) in three, and autogenous vein in two (one reversed saphenous and one in situ saphenous vein). A composite of Dacron and saphenous vein was used in one procedure. The following procedures were performed: four femoropopliteal bypasses; two bypasses between a limb of an axillobifemoral and the popliteal artery; two ileopopliteal bypasses, and one femorotibioperoneal trunk bypass. Except for the last patient, all patients had superficial femoral occlusion with reconstitution of the popliteal artery and three-vessel run-off. In the patient with femorotibioperoneal trunk bypass, there was two-vessel run-off to the ankle. No “isolated segment” bypasses were performed. All patients were followed closely postoperatively in the hospital and in our vascular surgery clinic. Graft patency or failure was documented by serial pulse volume recordings and Doppler ultrasound ankle pressure measurements (Table I). Results Our overall early (1 month) patency rate for bypass below the inguinal ligament with two- or three-vessel run-off is 95 percent. Of the nine bypass procedures done for limb salvage in patients with venous obstruction, five failed due to graft thrombosis within 1 month, for an early patency rate of 44.5 percent. Artificial graft material was used in seven of these bypasses because the saphenous vein was either unavailable or unacceptable as a conduit. Five of these
671
Filippone et al
seven failed within 1 month. In contrast, five bypasses utilizing artificial graft material performed during the same period in patients without venous disease were all open at 1 month. This difference is highly significant (p
TABLE I
pulse volume recordings and ankle Doppler pressures. However, within 1 week of surgery, there was evidence of decreased flow through the graft, and 3 weeks after surgery the Gore-Tex graft had occluded completely. After a protracted course and unsuccessful attempts to save the graft, below-knee amputation was ultimately required. Case 2. A 61 year old white man had had deep venous thrombosis of the right calf 2 years before admission. Three months before admission, he had another episode of deep venous thrombosis of the left calf. At the same time he was diagnosed as having nonresectable squamous cell carcinoma of the lung. He was readmitted with an acutely ischemic left foot. There was no previous history of claudication or rest pain. He had no palpable pulse in the left leg or below the femoral artery in the right leg. The left foot was cool, painful and paralyzed. He had multiple palpable venous cords in both calves and bilateral edema. Pulse volume recordings revealed no pulsatile flow at the level of the calves or ankles. There were no audible Doppler pulses in either the posterior tibia1 or the dorsalis pedis arteries. Arteriography revealed complete left iliac occlusion and bilateral superficial femoral artery occlusion. Both popliteal vessels filled by collateral vessels. Axillobifemoral bypass was performed using an 8 mm Dacron Sauvage graft. The condition of the left foot improved dramatically, but within hours the right foot became acutely ischemic. The patient then underwent a bypass between the right limb of the axillobifemoral graft and the right popliteal artery. Initially there was dramatic subjective improvement in the right foot as well as an improvement in ankle level pulse volume recordings and Doppler pressure. However, within 24 hours there was no flow in this distal graft, although both limbs of the axillobifemoral grafts were open. The graft was declotted with
Case Histories
Case No.
Indication
1
Nonhealing ulcers
Femoropopliteal bypass
Gore-Tex
2
Acute ischemia
Dacron Sauvage
3
Acute ischemia
Nonhealing ulcers
Bypass between limb of axillobifemoral and popliteal artery Bypass between limb of axillobifemoral and popliteal artery Right femoropopliteal bypass
Nonhealing ulcers
Right ileopopliteal bypass
Nonhealing ulcers Nonhealing ulcers
lleopopliteal bypass Femoropopliteal bypass
Nonhealing ulcers
Femorotibioperoneal trunk bypass Femoropopliteal bypass
Nonhealing ulcers
672
Procedure
Material
Early and Late Results Clotted at 3 weeks; below-knee amputation Clotted 1st postoperative night (axillobifemoral open)
Dacron Sauvage
Clotted 1st postoperative night (axillobifemoral open): died
Gore-Tex
Open at 1 month; failed at 5.5 months Clotted 1st postoperative night; below-knee amputation Clotted at 2 weeks Open at 1 month; failed at 2.5 months Open at 1 month; below-knee amputation at 2 months Open at 1 month; failed at 6 months
Composite Dacron Sauvage saphenous vein Gore-Tex Dacron Sauvage Saphenous vein (reversed) Saphenous vein (In situ)
The American Journal of Surgery
Chronic Venous Obstruction and Bypass Grafts
Fogarty catheters. Once again, the graft functioned briefly and then rethrombosed. The patient declined further intervention and ultimately died from multiple organ system failure. Comments The successful restoration of venous continuity at the time of repair of acute arterial injuries significantly improved the salvage rate of wounded limbs in Vietnam [l--3]. Severe venostasis with edema may contribute to profound morbidity and amputation, as reported by Sullivan et al [3]. However, venous obstruction might also decrease arterial flow to the point of inadequate perfusion or thrombosis in spite of a technically adequate arterial repair. Numerous elegant experimental models have documented the effect of venous ligation on arterial flow. Hobson et al [6] and Wright and Swan [JO] demonstrated a significant decrease in femoral arterial flow when peripheral venous pressure was acutely increased by ligating the femoral vein of a dog (systemic pressure remained unchanged). Wright and Hobson [9] produced the same results in the baboon and showed an increase in peripheral resistance. Stallworth et al [7] produced a similar model in dogs and demonstrated that although visible arterial pulsation and arterial pressure did not change in the presence of venous hypertension, there was no arterial flow after 6 hours of venous occlusion. Veal et al [8] likewise demonstrated that in the mesentery of a dog, arterial standstill occurred in the presence of transmitted pulsations. The ligation of traumatized veins and the resulting venous hypertension is the clinical corollary of these experimental preparations. Venous obstruction and hypertension are also seen in acute deep venous thrombosis or in chronic venous insufficiency. Extensive acute venous occlusion may lead to gangrene of the extremity in the syndrome of phlegmasia cerulea dolens or venous gangrene. Experimental data suggest that the pathophysiology is related to the diminished arterial flow into a venous bed completely occluded with thrombus [8]. Brockman and Vasko [5], on the other hand, produced experimental data indicating that arterial insufficiency in phlegmasia cerulea dolens is due to the collapse of small arteries under the increasing pressure of edematous tissue. Increased venous pressure is also characteristic of the postphlebitic syndrome. In this situation, deep veins are scarred or occluded by thrombophlebitis. Organization of thrombus destroys valves, rendering them incompetent. Recanalized channels offer high
Volume 140, November 1960
resistance. Consequently, venous pressure increases as resistance to venous flow increases. Edema, dermatitis, aching fullness and stasis ulceration are the clinically observed sequelae of this process [11]. We propose that this elevated venous pressure also causes outflow obstruction when arterial reconstruction is undertaken in acutely thrombosed venous channels or in postphlebitic venous systems. The patency of arterial bypass grafts in the early postoperative period is influenced by several factors, including adequate outflow or run-off. It may therefore be reasonably proposed that increased venous resistance on the other side of the capillary bed would compromise run-off and result in significant early graft failure in patients with acute thrombophlebitis or the postphlebitic syndrome. Our data appear to support this hypothesis. In the clinical setting, the importance of venous occlusion appears greatest at the level of the popliteal vein. More proximal bypasses (aortofemoral or ileofemoral), because of the more extensive collateral venous flow above the knee, are unlikely to be compromised by more distal venous obstruction. This was our experience with case 2, in which the axillofemoral limbs remained patent despite occlusion of the femoropopliteal segments. These conclusions may be useful in the management of patients with venous hypertension in whom arterial reconstruction is contemplated. Since a low flow state may exist, it is important to use autogenous vein whenever possible. Although the numbers are small, our data suggest that the early patency of autogenous vein grafts is better. Since many of these patients have unavailable or unusable greater saphenous veins, the cephalic vein or the lesser saphenous vein should be evaluated carefully before an artificial graft material is selected. Several experimental preparations demonstrated that after venous ligation, impaired arterial flow could be improved or restored by sympathetic interruption, thereby decreasing capillary tone [7,9]. Concomittant sympathectomy may be considered in these patients with venous obstruction. Summary It is suggested that the early failure of bypass grafts in patients with clinical evidence of venous hypertension is a result of increased resistance caused by venous obstruction. The importance of using autogenous vein grafts in such cases is emphasized. One should accept the possibility that arterial reconstruction may result in a less successful outcome in patients with chronic venous disease.
673
Filippone
et al
References 1. Rich NM, Hughes CW, Bough JE. Management of venous injuries. Ann Surg 1970;171:724. 2. Rich NM, Jarstfer BS, Geer TM. Popliteal artery repair failure: causes and possible prevention. J Cardiovasc Surg 1974; 15:346. 3. Sullivan WG, Thornton FH, Baker LH, LaPlante ES, Cohen A. Early influence of popliteal vein repair in the treatment of popliteal vessel injuries. Am J Surg 1971;122:528. 4. Barcia PH, Nelson TG, Whelan TJ. Importance of venous occlusion in arterial repair failure: an experimental study. Ann Surg 1972;175:223. 5. Brockman SK, Vasko JS. The pathologic physiology of phlegmasia cerulea dolens. Surgery 1986:59:997. 6. Hobson RW, Howard EW, Wright CB, Collins GJ, Rich NM. Hemodynamics of canine femoral venous ligation: signifi-
674
cance in combined 1973;74:824.
arterial and venous injuries. Surgery
7. Stallworth JM. Najib A, Kletke RR, Ramirez A. Phlegmasia cerulea dolens: an experimental study. Ann Surg 1967; 165860. 8. Veal JR, Dugan TJ, Jamison WL. Bauersfeld RS. Acute massive venous occlusion of the lower extremities. Surgery 1951; 29:355. 9. Wright CB, Hobson RW. Hemodynamic effects of femoral venous occlusion in the subhuman primate. Surgery 1974; 751453. 10. Wright CB, Swan KG. Hemodynamics of venous occlusion in the canine hind limb. Surgery 1973;73:141. 11. Sumner DS. The hemcdynamic and pathophysiology of venous disease. In: Rutherford RB, ed. Vascular surgery. Philadelphia: WB Saunders, 1977:147-63.
The Am&can Journal ol Surgery