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Treatment of chronic headaches with internal jugular vein-to-innominate vein bypass
VENOUS IMAGES Treatment of chronic headaches with internal jugular vein-to-innominate vein bypass Ayman Ahmed, MBBS,a Peter Gloviczki, MD,b Linda G. Canton, RN, BSN,b and Manju Kalra, MBBS,b San Francisco, Calif; and Rochester, Minn
A 19-year-old woman presented with severe headaches and nausea of 5 years’ duration. Her history included four previous attempts to treat her right internal jugular vein (IJV) obstruction at other institutions. She underwent two endovascular procedures (balloon angioplasty and stenting) and two attempts at open IJV reconstructions, using bovine and saphenous vein panel grafts, with excellent, but short-lived clinical success after each procedure, because of reocclusions. Her medical history also included placement of ventriculoperitoneal and lumboperitoneal shunts to control her headaches, without success. On examination, she had right neck scars, no significant neck or head swelling, and no neurologic deficits. Results of a thrombophilia workup were negative. Duplex scanning showed an occluded right IJV with a short patent segment under the base of the skull. Magnetic resonance venography confirmed a ventriculoperitoneal shunt in good position, patent dural venous sinuses, patent left IJV, and occluded right IJV. A contrast venogram showed an occluded right subclavian vein, right innominate vein (IV), and right IJV (A), and a patent left IJV, left IV, and superior vena cava (B). The patient consented for an operation and for the publication of this report. Under general anesthesia, the right IJV was exposed through a short high transverse neck incision, and the left IV was exposed through a partial sternotomy. The right femoral vein was harvested, and right a IJV-to-left IV bypass (C and D) was performed, tunneled subcutaneously in the neck. The venous pressure gradient decreased from 11 mm Hg to 1 mm Hg. The patient’s recovery was uneventful, and she was discharged with oral anticoagulation on day 4, with complete relief of headaches. Postoperative ultrasound imaging demonstrated a patent graft, and a computed tomography venogram at 1 year also confirmed a widely patent graft (E/Cover). She had no more headaches, although she complained of right thigh pain likely resulting from saphenous neuralgia at the harvest site. She had no limb swelling or venous claudication. Unilateral symptomatic IJV obstruction is a rare etiology of headache, usually caused by increased intracerebral pressure. Our patient appeared to have excellent contralateral venous drainage on imaging studies, but the 10 mm Hg pressure gradient found during surgery and the immediate relief after reconstruction suggests increased venous pressure caused her symptoms. Endovascular reconstruction of the IJV with stents has a poor track record.1 As we reported previously,2 we used the femoral vein to perform a successful bypass, with excellent anatomic and cosmetic result and at 1 year relief of her chronic headaches.
From the Department of Surgery, University of California, San Francisco School of Medicine, San Franciscoa; and the Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester.b Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg: Venous and Lym Dis 2017;5:878-9 2213-333X Copyright Ó 2017 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvsv.2017.05.010
878
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Ahmed et al
879
Volume 5, Number 6
REFERENCES 1. Lupattelli T, Bellagamba G, Righi E, Di Donna V, Flaishman I, Fazioli R, et al. Feasibility and safety of endovascular treatment for chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Vasc Surg 2013;58:1609-18. 2. Rizvi AZ, Kalra M, Bjarnason H, Bower TC, Schleck C, Gloviczki P. Benign superior vena cava syndrome: stenting is now the first line of treatment. J Vasc Surg 2008;47:372-80. Submitted May 7, 2017; accepted May 12, 2017.
A 19-year-old woman presented with severe headaches and nausea of 5 years’ duration. Her history included four previous attempts to treat her right internal jugular vein (IJV) obstruction at other institutions. She underwent two endovascular procedures (balloon angioplasty and stenting) and two attempts at open IJV reconstructions, using bovine and saphenous vein panel grafts, with excellent, but short-lived clinical success after each procedure, because of reocclusions. Her medical history also included placement of ventriculoperitoneal and lumboperitoneal shunts to control her headaches, without success. On examination, she had right neck scars, no significant neck or head swelling, and no neurologic deficits. Results of a thrombophilia workup were negative. Duplex scanning showed an occluded right IJV with a short patent segment under the base of the skull. Magnetic resonance venography confirmed a ventriculoperitoneal shunt in good position, patent dural venous sinuses, patent left IJV, and occluded right IJV. A contrast venogram showed an occluded right subclavian vein, right innominate vein (IV), and right IJV (A), and a patent left IJV, left IV, and superior vena cava (B). The patient consented for an operation and for the publication of this report. Under general anesthesia, the right IJV was exposed through a short high transverse neck incision, and the left IV was exposed through a partial sternotomy. The right femoral vein was harvested, and right a IJV-to-left IV bypass (C and D) was performed, tunneled subcutaneously in the neck. The venous pressure gradient decreased from 11 mm Hg to 1 mm Hg. The patient’s recovery was uneventful, and she was discharged with oral anticoagulation on day 4, with complete relief of headaches. Postoperative ultrasound imaging demonstrated a patent graft, and a computed tomography venogram at 1 year also confirmed a widely patent graft (E/Cover). She had no more headaches, although she complained of right thigh pain likely resulting from saphenous neuralgia at the harvest site. She had no limb swelling or venous claudication. Unilateral symptomatic IJV obstruction is a rare etiology of headache, usually caused by increased intracerebral pressure. Our patient appeared to have excellent contralateral venous drainage on imaging studies, but the 10 mm Hg pressure gradient found during surgery and the immediate relief after reconstruction suggests increased venous pressure caused her symptoms. Endovascular reconstruction of the IJV with stents has a poor track record.1 As we reported previously,2 we used the femoral vein to perform a successful bypass, with excellent anatomic and cosmetic result and at 1 year relief of her chronic headaches.
From the Department of Surgery, University of California, San Francisco School of Medicine, San Franciscoa; and the Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester.b Author conflict of interest: none. E-mail: [email protected]. The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. J Vasc Surg: Venous and Lym Dis 2017;5:878-9 2213-333X Copyright Ó 2017 by the Society for Vascular Surgery. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jvsv.2017.05.010
878
Journal of Vascular Surgery: Venous and Lymphatic Disorders
Ahmed et al
879
Volume 5, Number 6
REFERENCES 1. Lupattelli T, Bellagamba G, Righi E, Di Donna V, Flaishman I, Fazioli R, et al. Feasibility and safety of endovascular treatment for chronic cerebrospinal venous insufficiency in patients with multiple sclerosis. J Vasc Surg 2013;58:1609-18. 2. Rizvi AZ, Kalra M, Bjarnason H, Bower TC, Schleck C, Gloviczki P. Benign superior vena cava syndrome: stenting is now the first line of treatment. J Vasc Surg 2008;47:372-80. Submitted May 7, 2017; accepted May 12, 2017.