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Femorocaval bypass with femoral crossover bypass for iliofemoral and caval occlusion
Femorocaval bypass with femoral crossover bypass for iliofemoral and caval occlusion K u m a r IL Patel, M D , D a v i d R a b i n o w i t z , M D , B a r r y H a s t i n g s , M D , and H e r b e r t D a r d i k , M D , Englewood, N.J. Progress in the management of major venous obstruction has lagged far behind advances in arterial reconstruction. As a result, literature reports consist of small numbers of patients, and most vascular surgeons have little or no experience in performing bypass procedures for major venous obstruction. In this setting, individual reports add to our cumulative knowledge in treating this disease. We therefore present our experience in the management o f a patient with extensive bilateral femoropopliteal, iliac, and vena caval occlusion. (J Vasc Surg 1997;26:989-93.)
Consistent success o f major venous bypass grafting is hampered by a n u m b e r o f factors. Low pressure and velocity o f flow, intraoperative intimal injury, propensity for anastomotic stenoses, and external compression often result in early thrombosis o f venous grafts) ,2 Moreover, many patients with venous occlusion have an underlying predisposition for thrombosis as a result o f malignancy or other conditions. 2 The lack o f usable autogenous veins o f sufficient caliber and length has also been a major obstacle. Although all prosthetic grafts are more thrombogenic than autogenous veins, the use o f expanded polytetrafluoroethylene (ePTFE) in the venous system is p r o m i s i n g ? Although chronic venous insufficiency is considered an indication for bypass grafting o f iliofemoral and caval obstruction, we believe that this may not be appropriate in the presence o f valvular incompetence for the following reasons. The efficacy o f the "venous p u m p " is dependent on the presence o f functioning valves. Loss o f valve function results in reduced effective venous return, which in turn causes low flow in vein bypass grafts and may therefore contribute to reduced patency rates. Moreover, although it is logical to assume that major venous obstruction aggraFrom The Vascular Institute at Englewood Hospital and Medical Center. Presented at the EleventhAnnual Meeting of the Eastern Vascular Society, Atlantic City, N.J., May 2-4, 1997. Reprint requests: Herbert Dardik, The Vascular Institute at Englewood Hospital and Medical Center, 350 Engle St., Englewood, NJ 07631. Copyright © 1997 by The Societyfor Vascular Surgeryand International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/97/$5.00 + 0 24/6/84846
vates the effects o f more peripheral venous incompetence, relief o f the obstruction cannot reverse the established valxatlar incompetence. Therefore, even a patent bypass graft may not effectively correct the harmful effects o f severe chronic venous insufficiencY. The following report documents a successful experience with extensive venous occlusion that required bypass grafting and adjunctive measures. CASE REPORT
A 60-year-old man first came to us in 1994 with a history of severe bilateral buttock, thigh, and calf claudication on walking less than one block. In 1971 the patient had undergone vena caval clipping (DeWeese clip) after recurrent bilateral iliofemoral venous thrombosis and pulmonary embolism despite therapeutic anticoagulation medication. There was no history of any other major illness in the past. Femoral, popliteal, and pedal pulses were absent on both sides. There was no evidence of chronic venous stasis. Results of hematologic tests for thrombotic disorders were normal. A pulse volume recording showed severe bilateral reduction of arterial flow at the thigh level with no significant distal disease. Angiography revealed occlusion of the right common iliac artery, the left external iliac artery, and the common femoral artery. An aortobifemoral bypass grafting procedure was performed with endarterectomy of the left common femoral artery and profunda femoris artery. Despite the perioperative and postoperative use of intermittent pneumatic calf compression, leg elevation, and early ambulation, right superficial femoral and popliteal venous thrombosis developed. A few days later, while the patient was taldng a therapeutic dose of heparin, similar extensive deep vein thrombosis developed in the left lower limb. In addition to documenting the thrombosis, a duplex scan also showed bilateral iliac and vena caval thrombosis. At the time of discharge, the patient was 989
990
IOURNAL OF VASCULARSURGERY December 1997
Patelgt al.
Fig. 1. Right femoral venogram shows iliac occlusion.
Fig. 2. Left femoral venogram shows iliac occlusion.
asymptomatic and advised to continue warfarin and compression stockings. Over the next year and a half, the patient had worsening venous claudication, manifested by severe pain and tense swelling of both thighs on walldng. By July 1996, his claudication distance was reduced to less than 50 yards. A pulse volume recording showed normal arterial circulation at all levels. There were no varicose veins or other signs of chronic venous insufficiency. A duplex scan showed bilateral superficial and common femoral vein occlusion with enlarged saphenous veins and no reflux. This was confirmed by a bilateral femoral venogram (Figs. 1 and 2), which also indicated bilateral iliac and caval occlusion. A retrograde cavogram (Fig. 3) showed caval occlusion at the level of the DeWeese clip (L4); the infrarenal segment of the inferior vena cava was patent above this clip. Right femorocaval and left-to-right femoral crossover bypass procedures were performed using 13 mm externally supported ePTFE grafts. The saphenofemoral junctions were patent bilaterally as a result of contributory flow from the profunda, saphenous, and one or more tributaries at this location. Cephalad to this location, the common femoral veins were occluded and fibrotic on both sides. The anastomoses were performed at the saphenofemoral junction on both sides. Complementary arteriovenous fistulas
were constructed in both groins using a tributary of the saphenous vein on either side. This was accomplished by transecting the tributary about 5 cm caudad to the saphenofemoral junction and anastomosing it in an end-to-side fashion to the superficial femoral artery (Figs. 4 and 5). Venous pressure was recorded at the saphenofemoral junction before and after the bypass graft was constructed; it fell from 33 mm H g to 23 mm H g on both sides. Occlusion of the arteriovenous fistula did not alter the pressure. The inferior vena cava was exposed by the retroperitoneal approach through an oblique right flank incision. Continuous intravenous heparin was maintained after the operation for 7 days. This was overlapped with warfarin therapy. The postoperative course was complicated by seromas of both groins, which required surgical closure on the left side. Since the operation the patient has remained asymptomatic. He is on warfarin and uses compression stockings. A repeat duplex scan at 9 months showed a patent bypass graft and functioning arteriovenous fistulas. DISCUSSION O v e r the past wvo decades t h e r e have b e e n num e r o u s p u b l i s h e d reports t h a t dealt w i t h v e n o u s r e c o n s t r u c t i o n . C o n s i d e r a b l e success has b e e n
JOURNAL OF VASCULAR SURGERY Volume 26, Number 6
Fig. 3. Retrograde cavogram shows occlusion of inferior vena cava at L4.
achieved in reconstruction o f the superior vena cava in patients who have occlusion caused by thrombosis, mediastinal fibrosis, or compression by t u m o r . 2-6 In large part, this success is attributable to the use o f the spiral autogenous vein graft, which was first described by Chiu et al. 7 in 1974, although ePTFE grafts have also been used successfully in this location. 2,3,6 H i g h flow in the superior vena cava further enhances graft patcncy. Gloviczki et al. 6 reported a mean flow o f 1440 m l / m i n in superior vena cava grafts. In the lower limb, the Palma 8 operation, as well as crossover femoral prosthetic grafts, 9,1° have been successfully used in some patients with unilatera] iliac vein occlusion. Experience with iliocaval and femorocaval bypass procedures consists o f a few case reports. 3,n-~s Without long-term follow-up, it is difficult to make firm conclusions, but over the past decade several experimental studies and clinical reports have been encouraging. In most reports, the etiologic mechanism o f iliocaval occlusion includes a variety o f pathologic conditions, such as trauma, membranous occlusion,
Patel et al.
991
Fig. 4. Photograph of right femoral area: right femorocaval (large arrows) and crossover (small arrow) ePTFE grafts. Saphenous vein (S), superficial femoral vein (sly), and venous tributary used to construct arteriovenous fistula (avf).
inferior vena cava clipping, compression by tumor, and chronic venous thrombosis, a,12,13 Significant differences in the clinical implications o f these conditions make it difficult to arrive at universal conclusions. The following discussion is, therefore, based on chronic venous thrombosis as the etiologic mechanism. Careful patient selection is important. In most reports, >a,16 venous clandication and chronic venous insufficiency were the indications for operation. Venous claudication appears to be the effect o f major venous outflow obstruction and is not generally seen as a manifestation o f chronic venous insufficiency without obstruction. Therefore, as in our patient, disabling venous clandication appears to be a valid indication for operative intervention. It is unlikely that major venous bypass grafting can correct chronic venous insufficiency in the absence of obstruction. In a recent report, ~7 a case o f bifemoroca-
992
JOURNALOF VASCULARSURGERY December 1997
Patel et al.
Fig. 5. Photograph of left femoral area: crossover ePTFE graft (arrows), saphenous vein (S), and arteriovenous fistula (avf).
val bypass grafting was considered successful because the patient's stasis ulcer healed 6 m o n t h s later. It is likely that g o o d local care had m o r e to d o with the healing o f the ulcer than a bypass procedure perf o r m e d 6 m o n t h s back.. There is evidence to show that the presence o f venous reflux may be detrimental to the o u t c o m e . Gloviczki et al. a reported that four o f seven patients w h o u n d e r w e n t venous bypass grafting in the presence o f moderate or severe venous reflux had graft occlusion. I n contrast, o f four patients w i t h o u t reflux, three had patent grafts and excellent o u t c o m e . This lends credence to our thesis o f valvular incompetence having an adverse effect o n the results o f the operation. Patients w h o have severe multisegmental venous occlusion are at risk o f the developm e n t o f phlegmasia cerulea dolens. 18a9 A l t h o u g h n o t stressed in previous reports, we consider it a strong indication for attempts to relieve the obstruction. Duplex scanning is necessary for accurate preop-
erative evaluation o f venous occlusion and valvular incompetence. C o m p l e t e preoperative v e n o g r a p h y is also essential for defining the extent o f occlusion and planning the operation. 2 The femoral approach is required to adequately visualize the intraabdominal venous circulation. I f the vena cava is n o t visualized by this approach, retrograde cavography should be performed, is Duplex scanning m u s t be used during follow-up to d o c u m e n t the patency o f the bypass graft and arteriovenous fistulas. C o m p u t e d t o m o graphic scanning can also be used to d o c u m e n t graft patency. T h e inferior vena cava is usually exposed by a retroperitoneal approach. 2 Femoral venous pressures should be recorded before and after bypass construction. At present, e P T F E (10 to 16 ram) appears to be the graft o f choice. M o s t authors prefer to use grafts with external ring support to prevent graft compression.a,11,~5 H o w e v e r , the benefit o f the external supp o r t has n o t been proved. 2° Kunlin et al. 2~ were the first to propose the use o f an arteriovenous fistula to a u g m e n t the patency o f venous reconstruction. Controversy still exists regarding the use o f arteriovenous fistulas. Review o f the literature fails to show evidence o f any major complications that were directly attributable to the arteriovenous fistula unless the fistula is large. For this reason, routine ligation o f the arteriovenous fistula does n o t appear to be necessary. A l t h o u g h treatm e n t o f major venous occlusion remains controversial, considerable progress has been made over the past two decades. O u r case o f successful femorocaval bypass with femoral crossover bypass may add some insight in treating this condition. RElVERENCES
1. Bergan JJ, Yao JST, Flinn WR, McCarthy WJ. Surgical treatment of venous obstruction and insufficiency. J Vasc Surg 1986;3:174-81. 2. Gloviczki P, Pairolero PC. In: Bergan JJ, Kismer RL, editors. Atlas of venous surgery. Philadelphia: W. B. Saunders, 1992: 191-214. 3. Gloviczki P, Pairolero PC, Toomey BJ, Bower TC, Rooke TW, Stanton AW, et al. Reconstruction of large veins for nonmalignant venous occlusive disease. J Vasc Surg 1992;16: 750-61. 4. Dory DB. Bypass of superior vena cava: six years' experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease. J Thorac Cardiovasc Surg 1982;83:326-38. 5. Stanford W, Doty DB. The role ofvenography and surgery in the management of patients with superior vena cava obstruction. Ann Thorac Surg 1986;41:158-63. 6. Gloviczki P, Palrolero PC, Cherry KJ, Hallert JW Jr. Reconstruction of the vena cava and of its primary tributaries: a preliminary report. J Vase Surg 1990;11:373-81.
JOURNAL OF VASCULARSURGERY Volume 26, Number 6
7. Chiu CJ, Terzis J, Mac Rae ML. Replacement of superior vena cava with the spiral composite vein graft. Ann Thorac Surg 1974;17:555-60. 8. I'alma EC, Esperon R. Vein transplants and grafts in the surgical treatment of the postphlebitic syndrome. J Cardiovasc Surg (Torino) 1960;1:94-107. 9. Grnss JD. Venous bypass for chronic venous insufficiency. In: Bergan JJ, Yao ][ST, editors. Venous disorders. Philadelphia: W. B. Saunders, 1991:316-30. 10, Alemany J, Gortz H, Schaarschmidt K. Reconstruction of the iliocaval venous segment in tumor surgery. Int J Angio11996; 5:618-23. 11, Raju S. Venous insufficiency of the lower limb and stasis ulceration: changing concepts and management. Ann Surg 1983;197:688-97. 12. Hutschenreiter S, Vollmar S, Loeprecht H, Abendschein A, Rodl W. Reconstructive interventions of the venous system: clinical evaluation of late results using functional and vascular anatomic criteria. Chirurgica 1979;50:555-63. 13. Husfeldt KL Venous replacement with gore-tex prosthesis: experimental and first clinical results. In: May R, Weber J, editors. Pelvic and abdominal veins: progress in diagnostics and therapy. International Congress Series 550. Amsterdam: Excerpta Medica 1981:249-58.
Patel et aL
993
14. Chan EL, Bardin JA, Bernstein EF. Inferior vena cava bypass: experimental evaluation of externally supported grafts and initial clinical application. J Vasc Surg 1984;1:675-80. 15. Dale WA, Harris 1, Terry RB. Polytetrafluoroethylene reconstruction of the inferior vena cava. Surgery 1984;95:625-30. 16. Gloviczki P, l,airolero PC. Venous reconstruction for obstruction and valvular incompetence. In: Goldstone J, editor. Perspectives in vascular surgery. Philadelphia: W. B. Saunders, 1988:75-93. 17. Alimi YS, DiMauro I,, Fabre D, Juhan C. Iliac vein reconstructions to treat acute and chronic venous occlusive disease. J Vasc Surg 1997;25:673-81. 18. l,atel KR, l,aidas CN. Phlegmasia cerulea dolens: the role of nonoperative therapy. Cardiovasc Surg 1993;1:518-23. 19. Stallworth JM, Bradham GB, Kletke RR, Price RG. Phlegmasia cerulea dolens. Ann Surg 1965;161:802-11. 20. Plate G, Hollier LH, Gloviczki I,, Dewanjee MK, Kaye MI'. Overcoming failure of venous vascular prostheses, Surgery 1984;96:503-10. 21. Kuulin J, Kuulin A, Gottiob R, Blumel G. Experimental venous surgery. Major problems in clinical surgery. 1979;23: 37-75. Submitted May 8, 1997; accepted June 23, 1997.
Consistent success o f major venous bypass grafting is hampered by a n u m b e r o f factors. Low pressure and velocity o f flow, intraoperative intimal injury, propensity for anastomotic stenoses, and external compression often result in early thrombosis o f venous grafts) ,2 Moreover, many patients with venous occlusion have an underlying predisposition for thrombosis as a result o f malignancy or other conditions. 2 The lack o f usable autogenous veins o f sufficient caliber and length has also been a major obstacle. Although all prosthetic grafts are more thrombogenic than autogenous veins, the use o f expanded polytetrafluoroethylene (ePTFE) in the venous system is p r o m i s i n g ? Although chronic venous insufficiency is considered an indication for bypass grafting o f iliofemoral and caval obstruction, we believe that this may not be appropriate in the presence o f valvular incompetence for the following reasons. The efficacy o f the "venous p u m p " is dependent on the presence o f functioning valves. Loss o f valve function results in reduced effective venous return, which in turn causes low flow in vein bypass grafts and may therefore contribute to reduced patency rates. Moreover, although it is logical to assume that major venous obstruction aggraFrom The Vascular Institute at Englewood Hospital and Medical Center. Presented at the EleventhAnnual Meeting of the Eastern Vascular Society, Atlantic City, N.J., May 2-4, 1997. Reprint requests: Herbert Dardik, The Vascular Institute at Englewood Hospital and Medical Center, 350 Engle St., Englewood, NJ 07631. Copyright © 1997 by The Societyfor Vascular Surgeryand International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/97/$5.00 + 0 24/6/84846
vates the effects o f more peripheral venous incompetence, relief o f the obstruction cannot reverse the established valxatlar incompetence. Therefore, even a patent bypass graft may not effectively correct the harmful effects o f severe chronic venous insufficiencY. The following report documents a successful experience with extensive venous occlusion that required bypass grafting and adjunctive measures. CASE REPORT
A 60-year-old man first came to us in 1994 with a history of severe bilateral buttock, thigh, and calf claudication on walking less than one block. In 1971 the patient had undergone vena caval clipping (DeWeese clip) after recurrent bilateral iliofemoral venous thrombosis and pulmonary embolism despite therapeutic anticoagulation medication. There was no history of any other major illness in the past. Femoral, popliteal, and pedal pulses were absent on both sides. There was no evidence of chronic venous stasis. Results of hematologic tests for thrombotic disorders were normal. A pulse volume recording showed severe bilateral reduction of arterial flow at the thigh level with no significant distal disease. Angiography revealed occlusion of the right common iliac artery, the left external iliac artery, and the common femoral artery. An aortobifemoral bypass grafting procedure was performed with endarterectomy of the left common femoral artery and profunda femoris artery. Despite the perioperative and postoperative use of intermittent pneumatic calf compression, leg elevation, and early ambulation, right superficial femoral and popliteal venous thrombosis developed. A few days later, while the patient was taldng a therapeutic dose of heparin, similar extensive deep vein thrombosis developed in the left lower limb. In addition to documenting the thrombosis, a duplex scan also showed bilateral iliac and vena caval thrombosis. At the time of discharge, the patient was 989
990
IOURNAL OF VASCULARSURGERY December 1997
Patelgt al.
Fig. 1. Right femoral venogram shows iliac occlusion.
Fig. 2. Left femoral venogram shows iliac occlusion.
asymptomatic and advised to continue warfarin and compression stockings. Over the next year and a half, the patient had worsening venous claudication, manifested by severe pain and tense swelling of both thighs on walldng. By July 1996, his claudication distance was reduced to less than 50 yards. A pulse volume recording showed normal arterial circulation at all levels. There were no varicose veins or other signs of chronic venous insufficiency. A duplex scan showed bilateral superficial and common femoral vein occlusion with enlarged saphenous veins and no reflux. This was confirmed by a bilateral femoral venogram (Figs. 1 and 2), which also indicated bilateral iliac and caval occlusion. A retrograde cavogram (Fig. 3) showed caval occlusion at the level of the DeWeese clip (L4); the infrarenal segment of the inferior vena cava was patent above this clip. Right femorocaval and left-to-right femoral crossover bypass procedures were performed using 13 mm externally supported ePTFE grafts. The saphenofemoral junctions were patent bilaterally as a result of contributory flow from the profunda, saphenous, and one or more tributaries at this location. Cephalad to this location, the common femoral veins were occluded and fibrotic on both sides. The anastomoses were performed at the saphenofemoral junction on both sides. Complementary arteriovenous fistulas
were constructed in both groins using a tributary of the saphenous vein on either side. This was accomplished by transecting the tributary about 5 cm caudad to the saphenofemoral junction and anastomosing it in an end-to-side fashion to the superficial femoral artery (Figs. 4 and 5). Venous pressure was recorded at the saphenofemoral junction before and after the bypass graft was constructed; it fell from 33 mm H g to 23 mm H g on both sides. Occlusion of the arteriovenous fistula did not alter the pressure. The inferior vena cava was exposed by the retroperitoneal approach through an oblique right flank incision. Continuous intravenous heparin was maintained after the operation for 7 days. This was overlapped with warfarin therapy. The postoperative course was complicated by seromas of both groins, which required surgical closure on the left side. Since the operation the patient has remained asymptomatic. He is on warfarin and uses compression stockings. A repeat duplex scan at 9 months showed a patent bypass graft and functioning arteriovenous fistulas. DISCUSSION O v e r the past wvo decades t h e r e have b e e n num e r o u s p u b l i s h e d reports t h a t dealt w i t h v e n o u s r e c o n s t r u c t i o n . C o n s i d e r a b l e success has b e e n
JOURNAL OF VASCULAR SURGERY Volume 26, Number 6
Fig. 3. Retrograde cavogram shows occlusion of inferior vena cava at L4.
achieved in reconstruction o f the superior vena cava in patients who have occlusion caused by thrombosis, mediastinal fibrosis, or compression by t u m o r . 2-6 In large part, this success is attributable to the use o f the spiral autogenous vein graft, which was first described by Chiu et al. 7 in 1974, although ePTFE grafts have also been used successfully in this location. 2,3,6 H i g h flow in the superior vena cava further enhances graft patcncy. Gloviczki et al. 6 reported a mean flow o f 1440 m l / m i n in superior vena cava grafts. In the lower limb, the Palma 8 operation, as well as crossover femoral prosthetic grafts, 9,1° have been successfully used in some patients with unilatera] iliac vein occlusion. Experience with iliocaval and femorocaval bypass procedures consists o f a few case reports. 3,n-~s Without long-term follow-up, it is difficult to make firm conclusions, but over the past decade several experimental studies and clinical reports have been encouraging. In most reports, the etiologic mechanism o f iliocaval occlusion includes a variety o f pathologic conditions, such as trauma, membranous occlusion,
Patel et al.
991
Fig. 4. Photograph of right femoral area: right femorocaval (large arrows) and crossover (small arrow) ePTFE grafts. Saphenous vein (S), superficial femoral vein (sly), and venous tributary used to construct arteriovenous fistula (avf).
inferior vena cava clipping, compression by tumor, and chronic venous thrombosis, a,12,13 Significant differences in the clinical implications o f these conditions make it difficult to arrive at universal conclusions. The following discussion is, therefore, based on chronic venous thrombosis as the etiologic mechanism. Careful patient selection is important. In most reports, >a,16 venous clandication and chronic venous insufficiency were the indications for operation. Venous claudication appears to be the effect o f major venous outflow obstruction and is not generally seen as a manifestation o f chronic venous insufficiency without obstruction. Therefore, as in our patient, disabling venous clandication appears to be a valid indication for operative intervention. It is unlikely that major venous bypass grafting can correct chronic venous insufficiency in the absence of obstruction. In a recent report, ~7 a case o f bifemoroca-
992
JOURNALOF VASCULARSURGERY December 1997
Patel et al.
Fig. 5. Photograph of left femoral area: crossover ePTFE graft (arrows), saphenous vein (S), and arteriovenous fistula (avf).
val bypass grafting was considered successful because the patient's stasis ulcer healed 6 m o n t h s later. It is likely that g o o d local care had m o r e to d o with the healing o f the ulcer than a bypass procedure perf o r m e d 6 m o n t h s back.. There is evidence to show that the presence o f venous reflux may be detrimental to the o u t c o m e . Gloviczki et al. a reported that four o f seven patients w h o u n d e r w e n t venous bypass grafting in the presence o f moderate or severe venous reflux had graft occlusion. I n contrast, o f four patients w i t h o u t reflux, three had patent grafts and excellent o u t c o m e . This lends credence to our thesis o f valvular incompetence having an adverse effect o n the results o f the operation. Patients w h o have severe multisegmental venous occlusion are at risk o f the developm e n t o f phlegmasia cerulea dolens. 18a9 A l t h o u g h n o t stressed in previous reports, we consider it a strong indication for attempts to relieve the obstruction. Duplex scanning is necessary for accurate preop-
erative evaluation o f venous occlusion and valvular incompetence. C o m p l e t e preoperative v e n o g r a p h y is also essential for defining the extent o f occlusion and planning the operation. 2 The femoral approach is required to adequately visualize the intraabdominal venous circulation. I f the vena cava is n o t visualized by this approach, retrograde cavography should be performed, is Duplex scanning m u s t be used during follow-up to d o c u m e n t the patency o f the bypass graft and arteriovenous fistulas. C o m p u t e d t o m o graphic scanning can also be used to d o c u m e n t graft patency. T h e inferior vena cava is usually exposed by a retroperitoneal approach. 2 Femoral venous pressures should be recorded before and after bypass construction. At present, e P T F E (10 to 16 ram) appears to be the graft o f choice. M o s t authors prefer to use grafts with external ring support to prevent graft compression.a,11,~5 H o w e v e r , the benefit o f the external supp o r t has n o t been proved. 2° Kunlin et al. 2~ were the first to propose the use o f an arteriovenous fistula to a u g m e n t the patency o f venous reconstruction. Controversy still exists regarding the use o f arteriovenous fistulas. Review o f the literature fails to show evidence o f any major complications that were directly attributable to the arteriovenous fistula unless the fistula is large. For this reason, routine ligation o f the arteriovenous fistula does n o t appear to be necessary. A l t h o u g h treatm e n t o f major venous occlusion remains controversial, considerable progress has been made over the past two decades. O u r case o f successful femorocaval bypass with femoral crossover bypass may add some insight in treating this condition. RElVERENCES
1. Bergan JJ, Yao JST, Flinn WR, McCarthy WJ. Surgical treatment of venous obstruction and insufficiency. J Vasc Surg 1986;3:174-81. 2. Gloviczki P, Pairolero PC. In: Bergan JJ, Kismer RL, editors. Atlas of venous surgery. Philadelphia: W. B. Saunders, 1992: 191-214. 3. Gloviczki P, Pairolero PC, Toomey BJ, Bower TC, Rooke TW, Stanton AW, et al. Reconstruction of large veins for nonmalignant venous occlusive disease. J Vasc Surg 1992;16: 750-61. 4. Dory DB. Bypass of superior vena cava: six years' experience with spiral vein graft for obstruction of superior vena cava due to benign and malignant disease. J Thorac Cardiovasc Surg 1982;83:326-38. 5. Stanford W, Doty DB. The role ofvenography and surgery in the management of patients with superior vena cava obstruction. Ann Thorac Surg 1986;41:158-63. 6. Gloviczki P, Palrolero PC, Cherry KJ, Hallert JW Jr. Reconstruction of the vena cava and of its primary tributaries: a preliminary report. J Vase Surg 1990;11:373-81.
JOURNAL OF VASCULARSURGERY Volume 26, Number 6
7. Chiu CJ, Terzis J, Mac Rae ML. Replacement of superior vena cava with the spiral composite vein graft. Ann Thorac Surg 1974;17:555-60. 8. I'alma EC, Esperon R. Vein transplants and grafts in the surgical treatment of the postphlebitic syndrome. J Cardiovasc Surg (Torino) 1960;1:94-107. 9. Grnss JD. Venous bypass for chronic venous insufficiency. In: Bergan JJ, Yao ][ST, editors. Venous disorders. Philadelphia: W. B. Saunders, 1991:316-30. 10, Alemany J, Gortz H, Schaarschmidt K. Reconstruction of the iliocaval venous segment in tumor surgery. Int J Angio11996; 5:618-23. 11, Raju S. Venous insufficiency of the lower limb and stasis ulceration: changing concepts and management. Ann Surg 1983;197:688-97. 12. Hutschenreiter S, Vollmar S, Loeprecht H, Abendschein A, Rodl W. Reconstructive interventions of the venous system: clinical evaluation of late results using functional and vascular anatomic criteria. Chirurgica 1979;50:555-63. 13. Husfeldt KL Venous replacement with gore-tex prosthesis: experimental and first clinical results. In: May R, Weber J, editors. Pelvic and abdominal veins: progress in diagnostics and therapy. International Congress Series 550. Amsterdam: Excerpta Medica 1981:249-58.
Patel et aL
993
14. Chan EL, Bardin JA, Bernstein EF. Inferior vena cava bypass: experimental evaluation of externally supported grafts and initial clinical application. J Vasc Surg 1984;1:675-80. 15. Dale WA, Harris 1, Terry RB. Polytetrafluoroethylene reconstruction of the inferior vena cava. Surgery 1984;95:625-30. 16. Gloviczki P, l,airolero PC. Venous reconstruction for obstruction and valvular incompetence. In: Goldstone J, editor. Perspectives in vascular surgery. Philadelphia: W. B. Saunders, 1988:75-93. 17. Alimi YS, DiMauro I,, Fabre D, Juhan C. Iliac vein reconstructions to treat acute and chronic venous occlusive disease. J Vasc Surg 1997;25:673-81. 18. l,atel KR, l,aidas CN. Phlegmasia cerulea dolens: the role of nonoperative therapy. Cardiovasc Surg 1993;1:518-23. 19. Stallworth JM, Bradham GB, Kletke RR, Price RG. Phlegmasia cerulea dolens. Ann Surg 1965;161:802-11. 20. Plate G, Hollier LH, Gloviczki I,, Dewanjee MK, Kaye MI'. Overcoming failure of venous vascular prostheses, Surgery 1984;96:503-10. 21. Kuulin J, Kuulin A, Gottiob R, Blumel G. Experimental venous surgery. Major problems in clinical surgery. 1979;23: 37-75. Submitted May 8, 1997; accepted June 23, 1997.