- Email: [email protected]
Surgical Management of Chronic Venous Insufficiency
Basic Data Underlying Clinical Decision Making SECTION EDITOR: Lloyd M. Taylor, MD
Surgical Management of Chronic Venous Insufficiency Victor J. Weiss, MD, Scott M. Surowiec, MD, and Alan B. Lumsden, MB ChB, Atlanta, Georgia
The treatment for patients with chronic venous insufficiency has traditionally been aimed at symptomatic improvement. Leg elevation and compression stockings to control edema, and local wound care for ulcerations often provide adequate palliation of the disease process, but leave an otherwise active patient with ambulatory restrictions, doctor visits, and occasional hospitalization. Progress has been made since the late 1950s in the surgical management of the most severe forms of chronic venous insufficiency. Thanks to advances in imaging and physiologic testing we are now able to differentiate primary venous obstructive problems from those caused by reflux, and selectively treat each type of pathology. Successful surgical treatment of chronic venous insufficiency requires a thorough investigation in order to diagnose all of the venous abnormalities
From the Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA. Correspondence to: A.B. Lumsden, MB ChB, Division of Vascular Surgery, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA 30322, USA.
504
present. This typically includes a clinical, physiologic, and radiologic assessment to identify obstruction and/or reflux if present and the location of the involved venous segments, particularly superficial, deep, or perforator incompetence. Distinguishing primary valvular incompetence from secondary valvular incompetence as a sequelae of the postphlebitic state is of paramount importance when planning surgical intervention, as the treatment of these different entities varies. A goal of surgical intervention for chronic venous insufficiency should be to: 1. Identify easily treatable superficial and/or perforator reflux. 2. Determine the relative contribution of reflux versus obstruction. 3. Identify patients with short segment obstructions amenable to bypass. 4. Carefully evaluate risks and benefits of valve repair, valve transfer, or bypass versus compression therapy for each patient. Finally, as Raju and others have demonstrated,1 careful patient selection is mandatory for optimal surgical results.
Vol. 12, No. 5, 1988
Surgical management of chronic venous insufficiency 505
Table I. Location of venous valvular incompetence in limbs with ulceration or lipodermatosclerosis Reference
Limbs
SVI only (%)
DVI only (%)
SVI + DVI (%)
Perf only (%)
None (%)
2 3 4 5 6
31 192 96 112 120
6 16 38 44 70
29 19 8 11 8
65 42 48 39 20
0 — 2 3 2
0 23 4 4 <1
SVI, saphenous vein insufficiency; DVI, deep venous insufficiency; Perf, perforator vein.
Table II. Frequency of surgical indications with chronic venous insufficiency (CVI) Reference
Limbs evaluated
With CVI due to reflux (%)
Valvuloplasties
Transpositions
Transplants
Patients requiring surgery for CVI (%)
1
1378
774 (56)
71
0
24
8
Table III. Results of saphenous vein stripping and ligation for chronic venous insufficiency*
Procedure
S S S S
& & & &
†
L L L L
alone + valvuloplasty + transposition‡ + valve transplant
Limbs
Follow-up mean (months)
Ulcer healing (%)
No longer requiring external support (%)
33 21 14 8
37 37 37 37
44 80 79 75
20 81 79 75
*See Refs. 7 and 8. † Stripping and ligation (S & L) of the saphenous vein. ‡ Transposition of superficial or deep femoral vein (containing incompetent valve) to superficial or deep femoral vein (containing competent valve).
Table IV. Results of valvuloplasty for CVI
Reference
n
Follow-up
9
32
10 11 7,8
32 27 21
1
61
1-13 years (mean 4 years) 10 years 0.5-9 years 10-73 months (mean 37 months) > 2 years
Clinical success (%)
Healed ulcer (%)
81
83
72 70 76
80
77
85 ST/63 LT
ST, short term (0-12 months); LT, long term (> 24 months).
Improved pain (%)
Improved edema (%)
90 ST/87 LT
83 ST/83 LT
506
Weiss et al.
Annals of Vascular Surgery
Table V. Results of venous valve transplant for CVI Clinical success (%)
Reference
n
Follow-up
11 12 13,14
35 25 46
0.5-5 years 18 months up to 3 years
1
24
15,16
12
Ulcers healed (%)
Donor/ recipient
> 2 years
31 91 85 ST 78 LT 45
Axillary/SFV
44 months
92
Axillary/popliteal
Brachial/popliteal Brachial/popliteal
88 100 ST 94 LT 79 ST 42 LT 100 immediate 92 LT
Pain relief (%)
Edema relief (%)
65
87 75 71 42
77 ST 50 LT
ST LT ST LT
ST, short term (0-12 months); LT, long term (>24 months); SFV, superficial femoral vein.
Table VI. Results of venous valve transposition for CVI Clinical success (%)
Reference
n
Follow-up
11 17 9 7
4 4 14 14
18* 19
12 12
1-6 years mean 31.5 months mean 36 months 10-73 months (mean 37 months) 24 months Short term (10 days post-op)
Ulcer healing (%)
50 50 79 79
Pain relief (%)
Edema relief (%)
50 86 79
25 75
67 LT 100
79 25 75
75
LT, long term (>24 months). *Perforator or saphenous vein insufficiency intentionally not treated.
Table VII. Treatment of CVI with subfacial endoscopic perforator surgery
Reference
Year
n
Class 5 or 6 (%)
20 21 22
1996 1997 1997
31 19 148
100 95 85
Follow-up mean (months)
Ulcers healed (%)
Infectious complications (%)
8.6 5.4
100 (by 6 months) 100 (by 90 days) 88 (by 5.4 months)
10 16 9
Table VIII. Femoral-femoral/iliac vein bypass results for iliac vein occlusion using saphenous vein
Reference
Year
n
Clinical success (%)
23 24 25 15 26 27 28
1991 1991 1991 1987 1985 1982 1983
20 19 24 6 50 50 83
67 84 88* 100 89 78 59
With AVF (%)
100 0 67 8 0 14
Follow-up
Grafts patent (%)
67 > 3 years 84 months > 2 years 5 years
75 100 75
6-180 months
72
AVF, arteriovenous fistula. *Those with abnormal preop maximal venous outflow measurements (abnormal baseline strain gauge plethysmography).
Vol. 12, No. 5, 1988
Surgical management of chronic venous insufficiency 507
Table IX. Results with polytetrafluoroethylene grafts for iliac vein obstruction
Reference
Year
n
Clinical success (%)
23 29 30
1991 1989 1989
29 10 4
87 22 100
31 32* 33
1986 1985 1981
5 5 4
100 60 100
With AVF (%)
Follow-up
17 month-4 years (mean 32 months) 8-18 months 22 months-3 years 6 months-3 years
100 20 100 100
AVF, arteriovenous fistula. *Includes 4 patients with acute iliac vein occlusion.
Table X. Results of saphenopopliteal bypass for superficial femoral vein occlusion
Reference
Year
n
Clinical success (%)
23 24 25 27 28
1991 1991 1991 1982 1983
9 8 19 6 27
44 75 79* 50 70
Follow-up (months)
Cumulative patency (%)
93
56
12-132
63
*Those with abnormal preop maximum venous outflow measurements.
REFERENCES 1. Raju S, Fredericks R. Valve reconstruction procedures for nonobstructive venous insufficiency: rationale, techniques, and results in 107 procedures with two- to eight-year follow-up. J Vasc Surg 1988;7:301-310. 2. Neglen P, Raju S. A rational approach to detection of significant reflux with duplex scanning and air plethysmography. J Vasc Surg 1993;17:590-595. 3. Weingerten MS, Branas CC, Czeredarczuk M, et al. Distribution and quantification of venous reflux in lower extremity chronic venous stasis disease with duplex scanning. J Vasc Surg 1993;18:753-759. 4. Myers KA, Ziegenbein RW, Zeng GH, Mathews PG. Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux. J Vasc Surg 1995;21:605-612. 5. Labropoulos N, Leon M, Geroulakos G, et al. Venous hemodynamic abnormalities in patients with leg ulceration. Am J Surg 1995;169:572-574. 6. van Rij AM, Solomon C, Christie R. Anatomic and physiologic characteristics of venous ulceration. J Vasc Surg 1994; 20:759-764. 7. Sottiurai VS. Surgical correction of recurrent venous ulcer. J Cardiovasc Surg 1991;32:104-109. 8. Sottiurai VS. Comparison of surgical modalities in the treatment of recurrent venous ulcer. Int Angiol 1990;9:231-235. 9. Ferris EB, Kistner RL. Femoral vein reconstruction in the management of chronic venous insufficiency. Arch Surg 1982;117:1571-1579. 10. Masuda EM, Kistner RL. Long-term results of venous valve
11.
12.
13. 14.
15.
16.
17.
18.
19.
reconstruction: A four- to twenty-one-year follow-up. J Vasc Surg 1994;19:391-403. Eriksson I. Reconstructive surgery for deep vein valve incompetence in the lower limb. Eur J Vasc Surg 1990;4:211218. Nash T. Long term results of vein valve transplants placed in the popliteal vein for intractable post-phlebitic venous ulcers and pre-ulcer skin changes. J Cardiovasc Surg 1988;29:712716. Taheri SA, Pendergast DR, Lazar LH, et al. Vein valve transplantation. Arch Surg 1985;150:201-202. Taheri SA, Elias SM, Yacobucci GN, et al. Indications and results of vein valve transplant. J Cardiovasc Surg 1986;27: 163-168. O’Donnell TF Jr, Mackey WC, Shepard AD, Callow AD. Clinical, hemodynamic, and anatomic follow-up of direct venous reconstruction. Arch Surg 1987;122:474-482. O’Donnell TF Jr. Popliteal vein valve transplantation for deep venous valvular reflux: rationale, method, and longterm clinical, hemodynamic and anatomic results. In Bergan JJ, Yao JST, eds. Venous Disorders. Philadelphia: WB Saunders, 1991, pp 273-295. Johnson WC, Nabseth DC, Bush HL, et al. Direct venous surgery for venous valvular insufficiency of the lower extremity: Updated experience. Contemp Surg 1985;26:35-43. Johnson ND, Queral LA, Flinn WR, et al. Late objective assessment of venous valve surgery. Arch Surg 1981;116: 1461-1466. Queral LA, Whitehouse WM, Flinn WR, et al. Surgical cor-
508
20.
21.
22.
23.
24.
25.
26.
Weiss et al.
rection of chronic deep venous insufficiency by valvular transposition. Surgery 1980;87:688-695. Bergan JJ, Murray J, Greason K. Subfascial endoscopic perforator vein surgery: a preliminary report. Ann Vasc Surg 1996;10:211-219. Sparks SR, Ballard JL, Bergan JJ, Killeen JD. Early benefits of subfascial endoscopic perforator surgery (SEPS) in healing venous ulcers. Ann Vasc Surg 1997;11:367-373. Gloviczki P, Bergan JJ, Menawat SS, et al. Safety, feasibility and early efficacy of subfascial endoscopic perforator surgery: a preliminary report from the North American registry. J Vasc Surg 1997;25:94-105. Gruss JD. Venous bypass for chronic venous insufficiency. In Bergan JJ, Yao JST, eds. Venous Disorders. Philadelphia, PA: WB Saunders, 1991, pp 316-330. Danza R, Navarro T, Baldizan J. Reconstructive surgery in chronic venous obstruction of the lower limbs. J Cardiovasc Surg 1991;32:98-103. AbuRahma AF, Robinson PA, Boland JP. Clinical, hemodynamic, and anatomic predictors of long-term outcome of lower extremity venovenous bypasses. J Vasc Surg 1991;14: 635-644. Halliday P, Harris J, May J. Femoro-femoral crossover grafts (Palma operation): A long-term follow-up study. In Bergan JJ, Yao JST, eds. Surgery of the Veins. Orlando, FL: Grune and Stratton, 1985, pp 241-254.
Annals of Vascular Surgery
27. Dale WA. Reconstructive venous surgery. In Veith FJ, ed. Critical Problems in Vascular Surgery. New York, NY: Appleton-Century-Crofts, 1982, pp 199-213. 28. Husni EA. Reconstruction of veins: the need for objectivity. J Cardiovasc Surg 1983;24:525-528. 29. Eklof B. Temporary arteriovenous fistula in reconstruction of iliac vein obstruction using PTFE grafts. In Eklof B, Gjores JE, Thulesius O, et al., eds. Controversies in the Management of Venous Disorders. London, England: Butterworth, 1989, pp 280-290. 30. Okadome K, Muto Y, Eguchi H, et al. Venous reconstruction for iliofemoral venous occlusion facilitated by temporary arteriovenous shunt. Arch Surg 1989;124:957-960. 31. Yamamoto N, Takaba T, Hori G, et al. Reconstruction with insertion of expanded polytetrafluoroethylene (EPTFE) for iliac venous obstruction. J Cardiovasc Surg 1986;27:697702. 32. Ijima H, Kodama M, Hori M. Temporary arteriovenous fistula for venous reconstruction using synthetic graft: A clinical and experimental investigation. J Cardiovasc Surg 1985; 26:131-136. 33. Vollmar JF, Hutschenreiter S. Vascular prosthesis for the venous system. In May R, Weber J, eds. Pelvic and Abdominal Veins: Progress in Diagnostics and Therapy. Amsterdam, Netherlands: Excerpta Medica, 1981, pp 234-240.
Surgical Management of Chronic Venous Insufficiency Victor J. Weiss, MD, Scott M. Surowiec, MD, and Alan B. Lumsden, MB ChB, Atlanta, Georgia
The treatment for patients with chronic venous insufficiency has traditionally been aimed at symptomatic improvement. Leg elevation and compression stockings to control edema, and local wound care for ulcerations often provide adequate palliation of the disease process, but leave an otherwise active patient with ambulatory restrictions, doctor visits, and occasional hospitalization. Progress has been made since the late 1950s in the surgical management of the most severe forms of chronic venous insufficiency. Thanks to advances in imaging and physiologic testing we are now able to differentiate primary venous obstructive problems from those caused by reflux, and selectively treat each type of pathology. Successful surgical treatment of chronic venous insufficiency requires a thorough investigation in order to diagnose all of the venous abnormalities
From the Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA. Correspondence to: A.B. Lumsden, MB ChB, Division of Vascular Surgery, Emory University School of Medicine, 1364 Clifton Road, Atlanta, GA 30322, USA.
504
present. This typically includes a clinical, physiologic, and radiologic assessment to identify obstruction and/or reflux if present and the location of the involved venous segments, particularly superficial, deep, or perforator incompetence. Distinguishing primary valvular incompetence from secondary valvular incompetence as a sequelae of the postphlebitic state is of paramount importance when planning surgical intervention, as the treatment of these different entities varies. A goal of surgical intervention for chronic venous insufficiency should be to: 1. Identify easily treatable superficial and/or perforator reflux. 2. Determine the relative contribution of reflux versus obstruction. 3. Identify patients with short segment obstructions amenable to bypass. 4. Carefully evaluate risks and benefits of valve repair, valve transfer, or bypass versus compression therapy for each patient. Finally, as Raju and others have demonstrated,1 careful patient selection is mandatory for optimal surgical results.
Vol. 12, No. 5, 1988
Surgical management of chronic venous insufficiency 505
Table I. Location of venous valvular incompetence in limbs with ulceration or lipodermatosclerosis Reference
Limbs
SVI only (%)
DVI only (%)
SVI + DVI (%)
Perf only (%)
None (%)
2 3 4 5 6
31 192 96 112 120
6 16 38 44 70
29 19 8 11 8
65 42 48 39 20
0 — 2 3 2
0 23 4 4 <1
SVI, saphenous vein insufficiency; DVI, deep venous insufficiency; Perf, perforator vein.
Table II. Frequency of surgical indications with chronic venous insufficiency (CVI) Reference
Limbs evaluated
With CVI due to reflux (%)
Valvuloplasties
Transpositions
Transplants
Patients requiring surgery for CVI (%)
1
1378
774 (56)
71
0
24
8
Table III. Results of saphenous vein stripping and ligation for chronic venous insufficiency*
Procedure
S S S S
& & & &
†
L L L L
alone + valvuloplasty + transposition‡ + valve transplant
Limbs
Follow-up mean (months)
Ulcer healing (%)
No longer requiring external support (%)
33 21 14 8
37 37 37 37
44 80 79 75
20 81 79 75
*See Refs. 7 and 8. † Stripping and ligation (S & L) of the saphenous vein. ‡ Transposition of superficial or deep femoral vein (containing incompetent valve) to superficial or deep femoral vein (containing competent valve).
Table IV. Results of valvuloplasty for CVI
Reference
n
Follow-up
9
32
10 11 7,8
32 27 21
1
61
1-13 years (mean 4 years) 10 years 0.5-9 years 10-73 months (mean 37 months) > 2 years
Clinical success (%)
Healed ulcer (%)
81
83
72 70 76
80
77
85 ST/63 LT
ST, short term (0-12 months); LT, long term (> 24 months).
Improved pain (%)
Improved edema (%)
90 ST/87 LT
83 ST/83 LT
506
Weiss et al.
Annals of Vascular Surgery
Table V. Results of venous valve transplant for CVI Clinical success (%)
Reference
n
Follow-up
11 12 13,14
35 25 46
0.5-5 years 18 months up to 3 years
1
24
15,16
12
Ulcers healed (%)
Donor/ recipient
> 2 years
31 91 85 ST 78 LT 45
Axillary/SFV
44 months
92
Axillary/popliteal
Brachial/popliteal Brachial/popliteal
88 100 ST 94 LT 79 ST 42 LT 100 immediate 92 LT
Pain relief (%)
Edema relief (%)
65
87 75 71 42
77 ST 50 LT
ST LT ST LT
ST, short term (0-12 months); LT, long term (>24 months); SFV, superficial femoral vein.
Table VI. Results of venous valve transposition for CVI Clinical success (%)
Reference
n
Follow-up
11 17 9 7
4 4 14 14
18* 19
12 12
1-6 years mean 31.5 months mean 36 months 10-73 months (mean 37 months) 24 months Short term (10 days post-op)
Ulcer healing (%)
50 50 79 79
Pain relief (%)
Edema relief (%)
50 86 79
25 75
67 LT 100
79 25 75
75
LT, long term (>24 months). *Perforator or saphenous vein insufficiency intentionally not treated.
Table VII. Treatment of CVI with subfacial endoscopic perforator surgery
Reference
Year
n
Class 5 or 6 (%)
20 21 22
1996 1997 1997
31 19 148
100 95 85
Follow-up mean (months)
Ulcers healed (%)
Infectious complications (%)
8.6 5.4
100 (by 6 months) 100 (by 90 days) 88 (by 5.4 months)
10 16 9
Table VIII. Femoral-femoral/iliac vein bypass results for iliac vein occlusion using saphenous vein
Reference
Year
n
Clinical success (%)
23 24 25 15 26 27 28
1991 1991 1991 1987 1985 1982 1983
20 19 24 6 50 50 83
67 84 88* 100 89 78 59
With AVF (%)
100 0 67 8 0 14
Follow-up
Grafts patent (%)
67 > 3 years 84 months > 2 years 5 years
75 100 75
6-180 months
72
AVF, arteriovenous fistula. *Those with abnormal preop maximal venous outflow measurements (abnormal baseline strain gauge plethysmography).
Vol. 12, No. 5, 1988
Surgical management of chronic venous insufficiency 507
Table IX. Results with polytetrafluoroethylene grafts for iliac vein obstruction
Reference
Year
n
Clinical success (%)
23 29 30
1991 1989 1989
29 10 4
87 22 100
31 32* 33
1986 1985 1981
5 5 4
100 60 100
With AVF (%)
Follow-up
17 month-4 years (mean 32 months) 8-18 months 22 months-3 years 6 months-3 years
100 20 100 100
AVF, arteriovenous fistula. *Includes 4 patients with acute iliac vein occlusion.
Table X. Results of saphenopopliteal bypass for superficial femoral vein occlusion
Reference
Year
n
Clinical success (%)
23 24 25 27 28
1991 1991 1991 1982 1983
9 8 19 6 27
44 75 79* 50 70
Follow-up (months)
Cumulative patency (%)
93
56
12-132
63
*Those with abnormal preop maximum venous outflow measurements.
REFERENCES 1. Raju S, Fredericks R. Valve reconstruction procedures for nonobstructive venous insufficiency: rationale, techniques, and results in 107 procedures with two- to eight-year follow-up. J Vasc Surg 1988;7:301-310. 2. Neglen P, Raju S. A rational approach to detection of significant reflux with duplex scanning and air plethysmography. J Vasc Surg 1993;17:590-595. 3. Weingerten MS, Branas CC, Czeredarczuk M, et al. Distribution and quantification of venous reflux in lower extremity chronic venous stasis disease with duplex scanning. J Vasc Surg 1993;18:753-759. 4. Myers KA, Ziegenbein RW, Zeng GH, Mathews PG. Duplex ultrasonography scanning for chronic venous disease: patterns of venous reflux. J Vasc Surg 1995;21:605-612. 5. Labropoulos N, Leon M, Geroulakos G, et al. Venous hemodynamic abnormalities in patients with leg ulceration. Am J Surg 1995;169:572-574. 6. van Rij AM, Solomon C, Christie R. Anatomic and physiologic characteristics of venous ulceration. J Vasc Surg 1994; 20:759-764. 7. Sottiurai VS. Surgical correction of recurrent venous ulcer. J Cardiovasc Surg 1991;32:104-109. 8. Sottiurai VS. Comparison of surgical modalities in the treatment of recurrent venous ulcer. Int Angiol 1990;9:231-235. 9. Ferris EB, Kistner RL. Femoral vein reconstruction in the management of chronic venous insufficiency. Arch Surg 1982;117:1571-1579. 10. Masuda EM, Kistner RL. Long-term results of venous valve
11.
12.
13. 14.
15.
16.
17.
18.
19.
reconstruction: A four- to twenty-one-year follow-up. J Vasc Surg 1994;19:391-403. Eriksson I. Reconstructive surgery for deep vein valve incompetence in the lower limb. Eur J Vasc Surg 1990;4:211218. Nash T. Long term results of vein valve transplants placed in the popliteal vein for intractable post-phlebitic venous ulcers and pre-ulcer skin changes. J Cardiovasc Surg 1988;29:712716. Taheri SA, Pendergast DR, Lazar LH, et al. Vein valve transplantation. Arch Surg 1985;150:201-202. Taheri SA, Elias SM, Yacobucci GN, et al. Indications and results of vein valve transplant. J Cardiovasc Surg 1986;27: 163-168. O’Donnell TF Jr, Mackey WC, Shepard AD, Callow AD. Clinical, hemodynamic, and anatomic follow-up of direct venous reconstruction. Arch Surg 1987;122:474-482. O’Donnell TF Jr. Popliteal vein valve transplantation for deep venous valvular reflux: rationale, method, and longterm clinical, hemodynamic and anatomic results. In Bergan JJ, Yao JST, eds. Venous Disorders. Philadelphia: WB Saunders, 1991, pp 273-295. Johnson WC, Nabseth DC, Bush HL, et al. Direct venous surgery for venous valvular insufficiency of the lower extremity: Updated experience. Contemp Surg 1985;26:35-43. Johnson ND, Queral LA, Flinn WR, et al. Late objective assessment of venous valve surgery. Arch Surg 1981;116: 1461-1466. Queral LA, Whitehouse WM, Flinn WR, et al. Surgical cor-
508
20.
21.
22.
23.
24.
25.
26.
Weiss et al.
rection of chronic deep venous insufficiency by valvular transposition. Surgery 1980;87:688-695. Bergan JJ, Murray J, Greason K. Subfascial endoscopic perforator vein surgery: a preliminary report. Ann Vasc Surg 1996;10:211-219. Sparks SR, Ballard JL, Bergan JJ, Killeen JD. Early benefits of subfascial endoscopic perforator surgery (SEPS) in healing venous ulcers. Ann Vasc Surg 1997;11:367-373. Gloviczki P, Bergan JJ, Menawat SS, et al. Safety, feasibility and early efficacy of subfascial endoscopic perforator surgery: a preliminary report from the North American registry. J Vasc Surg 1997;25:94-105. Gruss JD. Venous bypass for chronic venous insufficiency. In Bergan JJ, Yao JST, eds. Venous Disorders. Philadelphia, PA: WB Saunders, 1991, pp 316-330. Danza R, Navarro T, Baldizan J. Reconstructive surgery in chronic venous obstruction of the lower limbs. J Cardiovasc Surg 1991;32:98-103. AbuRahma AF, Robinson PA, Boland JP. Clinical, hemodynamic, and anatomic predictors of long-term outcome of lower extremity venovenous bypasses. J Vasc Surg 1991;14: 635-644. Halliday P, Harris J, May J. Femoro-femoral crossover grafts (Palma operation): A long-term follow-up study. In Bergan JJ, Yao JST, eds. Surgery of the Veins. Orlando, FL: Grune and Stratton, 1985, pp 241-254.
Annals of Vascular Surgery
27. Dale WA. Reconstructive venous surgery. In Veith FJ, ed. Critical Problems in Vascular Surgery. New York, NY: Appleton-Century-Crofts, 1982, pp 199-213. 28. Husni EA. Reconstruction of veins: the need for objectivity. J Cardiovasc Surg 1983;24:525-528. 29. Eklof B. Temporary arteriovenous fistula in reconstruction of iliac vein obstruction using PTFE grafts. In Eklof B, Gjores JE, Thulesius O, et al., eds. Controversies in the Management of Venous Disorders. London, England: Butterworth, 1989, pp 280-290. 30. Okadome K, Muto Y, Eguchi H, et al. Venous reconstruction for iliofemoral venous occlusion facilitated by temporary arteriovenous shunt. Arch Surg 1989;124:957-960. 31. Yamamoto N, Takaba T, Hori G, et al. Reconstruction with insertion of expanded polytetrafluoroethylene (EPTFE) for iliac venous obstruction. J Cardiovasc Surg 1986;27:697702. 32. Ijima H, Kodama M, Hori M. Temporary arteriovenous fistula for venous reconstruction using synthetic graft: A clinical and experimental investigation. J Cardiovasc Surg 1985; 26:131-136. 33. Vollmar JF, Hutschenreiter S. Vascular prosthesis for the venous system. In May R, Weber J, eds. Pelvic and Abdominal Veins: Progress in Diagnostics and Therapy. Amsterdam, Netherlands: Excerpta Medica, 1981, pp 234-240.