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New concept of arteriovenous fistula requiring no fistula interruption with better long-term patency in vein bypass graft: A report of 49 cases
22nd World Congress of the International Society for Cardiovascular Surgery 14.10
Endoscopic Surgery for Venous Disorders H. SA TOKA WA, F. 1WA YA, T. IGARI, H. MIDOROKA WA, S. TAKASE, T. OGAWA and S. HOSHINO, Fukushima,Japan PURPOSE: Angioscopy has been used in cardiovascular surgery, but there are few reports in venous surgery. We have performed endoscopic venous surgery under angioscopic vision. METHOD: Seventy-four patients (109 limbs) were operated on using an angioscope (OLYMPUS OES system, AF type 28C). By angioscopy, external valvuloplasty was performed for valvular incompetence and thrombectomy was done for deep vein thrombosis. RESULTS: Angioscopy allowed excellent visualization of 139 out of 143 venous lesions (97%). It was difficult to see the lumen of the large vessels or sharp angular vessels such as the inferior vena cava or lilac veins. Of 152 valves observed by angioscopy, 124 were incompetent and were classified into three types. External valvuloplasty was performed in 20 superficial femoral veins and 42 long saphenous veins according to the valvular findings. In patients with deep vein thrombosis, it was important to evaluate the characteristics of the thrombus residue and to observe venous valvular disruption. CONCLUSION: Angioscopy assisted valvuloplasty and thrombectomy. We consider that intraoperative angioscopy is useful for the diagnosis and surgically treatment of a few venous disorders. 14.11
The Need for Emergency Treatment in Subclavian Vein Effort Thrombosis I.E. MOLINA, Minneapolis, Minnesota, USA The Paget-Schroetter syndrome is an acute thrombosis of the subclavian vein following a sudden effort using the arm. The syndrome is treated poorly, inefficiently, and late in the majority of cases. This leads to significant morbidity and disability because the changes in the vein occur rapidly and are irreversible. 51 patients were treated at the University of Minnesota for this syndrome. Only nine patients were in the acute stage. The other 42 had had previous treatment for months or years. The plan to cure this condition entails five steps depending on the time of occlusion: (1) Direct infusion of urokinase into the thrombus via a catheter until thrombus is lysed. (2) Emergency surgery follows, removing the first rib via a subclavicular approach. (3) Vein patch angioplasty of the subclavian vein at the stenotic site. (4) If residual stricture persists, balloon angioplasty with or without insertion of stents. (5) Anticoagulation with dipyridamole and warfarin for 3 months. RESULTS: Acute patients only required steps (1) and (2). In the 42 chronic patients, vein patch angioplasty was necessary (steps 1, 2, 3, 5) in 35 (83%), and in four (9.5%), intraluminal wall stents were used with two failures. In nine patients, no surgery could be done. The success rate of the intervention was 100% in the acute stage (steps 1, 2). In chronic cases with short structured segments, success was 94% (33/35), and 100% when balloon angioplasty was added. All veins open at the end of three months remained open permanently. Patients recovered with no restrictions. Non-operated patients remain disabled with chronic edema and recurrent symptoms.
72
CONCLUSIONS: Acute thrombosis of the subclavian vein requires emergency care. All patients must be treated in the acute stage and the use of thrombolytics is mandatory to allow for an urgent operation to cure this condition.
14.12 New Concept of Arteriovenous Fistula Requiring no Fistula Interruption with Better Long-Term Patency in Vein Bypass Graft: A R e p o r t of 49 Cases V.S. SOTTIURAI~ J. GONZALES, M. COOPER, R. LYON and D. LEONO VICZ, New Orleans, Louisiana, USA Long term patency in prosthetic vein bypass for venous obstruction has been disappointing. Interruption of the arteriovenous fistula is also known to enhance graft occlusion. This communication: (1) describes a direct arteriovenous fistula to the PTFE graft that requires no future ligation, (2) presents better late patency of venous bypasses, and (3) reports success in healing ulcer and controlling pain and swelling. Forty-nine patients (28M, 21F) with a mean age of 53 years (range 33-84 years) were followed for 8-128 months (mean 49 months) after venous bypasses for central vein occlusion with non-healing ulcers. Venography, nucleotide scan, plethysmography and Duplex scan identified the obstruction and documented graft patency. All patients were treated with Coumadin to maintain prothrombin time at 14--18 s. Direct connection of arteriovenous fistulae to the ring PTFE grafts has (1) maintained better patency of long-term venous bypass, (2) reduced pain, swelling and allowed ulcer healing (3) provided a controlled non-progressive arteriovenous fistula (Poiseuille's Law) with the benefit of Venturi effects. 14.13
Surgical Treatment for Secondary Lymphedema of the Lower Extremitites H. SAKUDA, Y. KAMADA, M. TAMAKI, K. KOJA and A. KUSABA, Okinawa, Japan We performed lymphatic-venous anastomoses to treat ten lower limbs in eight patients with secondary lymphedema suffering from frequent acute lymphangitis and/or walking disturbance. Six limbs were treated by lymph node-isolated vein anastomosis, in which the node was cut and anastomosed to the long saphenous vein. Four limbs were treated by lymphatic vessel-isolated vein anastomosis using a burying technique. To prevent thrombus formation at the anastomosis, the anastomosis was completely excluded from contact with blood by distal ligation of the saphenous vein and prevention of reverse blood drainage in the presence of competent proximal venous valvular function. In four limbs, additional resection of the fibrous thickened subcutaneous fatty tissues of the lateral aspect of the limb was performed. In 1-7 years follow up, no episodes of acute lymphangitis occurred in eight limbs and a markedly decreased episode in one after surgery. The size of the limb without resection of subcutaneous tissues did not decrease, while in cases with additional resection of subcutaneous tissues, it was apparently decreased by 6-16 cm in the thigh and 3-11 cm in the lower leg. Lymphatic vessel to isolated vein anastomosis with lateral resection of the thickened subcutaneous fatty tissues of the limb is a suggested procedure in patients with secondary lymphedema of the lower extremity.
CARDIOVASCULAR SURGERY SEPTEMBER 1995
Endoscopic Surgery for Venous Disorders H. SA TOKA WA, F. 1WA YA, T. IGARI, H. MIDOROKA WA, S. TAKASE, T. OGAWA and S. HOSHINO, Fukushima,Japan PURPOSE: Angioscopy has been used in cardiovascular surgery, but there are few reports in venous surgery. We have performed endoscopic venous surgery under angioscopic vision. METHOD: Seventy-four patients (109 limbs) were operated on using an angioscope (OLYMPUS OES system, AF type 28C). By angioscopy, external valvuloplasty was performed for valvular incompetence and thrombectomy was done for deep vein thrombosis. RESULTS: Angioscopy allowed excellent visualization of 139 out of 143 venous lesions (97%). It was difficult to see the lumen of the large vessels or sharp angular vessels such as the inferior vena cava or lilac veins. Of 152 valves observed by angioscopy, 124 were incompetent and were classified into three types. External valvuloplasty was performed in 20 superficial femoral veins and 42 long saphenous veins according to the valvular findings. In patients with deep vein thrombosis, it was important to evaluate the characteristics of the thrombus residue and to observe venous valvular disruption. CONCLUSION: Angioscopy assisted valvuloplasty and thrombectomy. We consider that intraoperative angioscopy is useful for the diagnosis and surgically treatment of a few venous disorders. 14.11
The Need for Emergency Treatment in Subclavian Vein Effort Thrombosis I.E. MOLINA, Minneapolis, Minnesota, USA The Paget-Schroetter syndrome is an acute thrombosis of the subclavian vein following a sudden effort using the arm. The syndrome is treated poorly, inefficiently, and late in the majority of cases. This leads to significant morbidity and disability because the changes in the vein occur rapidly and are irreversible. 51 patients were treated at the University of Minnesota for this syndrome. Only nine patients were in the acute stage. The other 42 had had previous treatment for months or years. The plan to cure this condition entails five steps depending on the time of occlusion: (1) Direct infusion of urokinase into the thrombus via a catheter until thrombus is lysed. (2) Emergency surgery follows, removing the first rib via a subclavicular approach. (3) Vein patch angioplasty of the subclavian vein at the stenotic site. (4) If residual stricture persists, balloon angioplasty with or without insertion of stents. (5) Anticoagulation with dipyridamole and warfarin for 3 months. RESULTS: Acute patients only required steps (1) and (2). In the 42 chronic patients, vein patch angioplasty was necessary (steps 1, 2, 3, 5) in 35 (83%), and in four (9.5%), intraluminal wall stents were used with two failures. In nine patients, no surgery could be done. The success rate of the intervention was 100% in the acute stage (steps 1, 2). In chronic cases with short structured segments, success was 94% (33/35), and 100% when balloon angioplasty was added. All veins open at the end of three months remained open permanently. Patients recovered with no restrictions. Non-operated patients remain disabled with chronic edema and recurrent symptoms.
72
CONCLUSIONS: Acute thrombosis of the subclavian vein requires emergency care. All patients must be treated in the acute stage and the use of thrombolytics is mandatory to allow for an urgent operation to cure this condition.
14.12 New Concept of Arteriovenous Fistula Requiring no Fistula Interruption with Better Long-Term Patency in Vein Bypass Graft: A R e p o r t of 49 Cases V.S. SOTTIURAI~ J. GONZALES, M. COOPER, R. LYON and D. LEONO VICZ, New Orleans, Louisiana, USA Long term patency in prosthetic vein bypass for venous obstruction has been disappointing. Interruption of the arteriovenous fistula is also known to enhance graft occlusion. This communication: (1) describes a direct arteriovenous fistula to the PTFE graft that requires no future ligation, (2) presents better late patency of venous bypasses, and (3) reports success in healing ulcer and controlling pain and swelling. Forty-nine patients (28M, 21F) with a mean age of 53 years (range 33-84 years) were followed for 8-128 months (mean 49 months) after venous bypasses for central vein occlusion with non-healing ulcers. Venography, nucleotide scan, plethysmography and Duplex scan identified the obstruction and documented graft patency. All patients were treated with Coumadin to maintain prothrombin time at 14--18 s. Direct connection of arteriovenous fistulae to the ring PTFE grafts has (1) maintained better patency of long-term venous bypass, (2) reduced pain, swelling and allowed ulcer healing (3) provided a controlled non-progressive arteriovenous fistula (Poiseuille's Law) with the benefit of Venturi effects. 14.13
Surgical Treatment for Secondary Lymphedema of the Lower Extremitites H. SAKUDA, Y. KAMADA, M. TAMAKI, K. KOJA and A. KUSABA, Okinawa, Japan We performed lymphatic-venous anastomoses to treat ten lower limbs in eight patients with secondary lymphedema suffering from frequent acute lymphangitis and/or walking disturbance. Six limbs were treated by lymph node-isolated vein anastomosis, in which the node was cut and anastomosed to the long saphenous vein. Four limbs were treated by lymphatic vessel-isolated vein anastomosis using a burying technique. To prevent thrombus formation at the anastomosis, the anastomosis was completely excluded from contact with blood by distal ligation of the saphenous vein and prevention of reverse blood drainage in the presence of competent proximal venous valvular function. In four limbs, additional resection of the fibrous thickened subcutaneous fatty tissues of the lateral aspect of the limb was performed. In 1-7 years follow up, no episodes of acute lymphangitis occurred in eight limbs and a markedly decreased episode in one after surgery. The size of the limb without resection of subcutaneous tissues did not decrease, while in cases with additional resection of subcutaneous tissues, it was apparently decreased by 6-16 cm in the thigh and 3-11 cm in the lower leg. Lymphatic vessel to isolated vein anastomosis with lateral resection of the thickened subcutaneous fatty tissues of the limb is a suggested procedure in patients with secondary lymphedema of the lower extremity.
CARDIOVASCULAR SURGERY SEPTEMBER 1995