NewsWounds update Clinical update
Severe post-thrombotic venous ulcers due to iliofemoral/caval occlusion
T
his short paper describes a new technique using common femoral
endovenectomy and endovenous recanalisation for chronic iliofemoral/vena caval post-thrombotic occlusion. The early results using this technique show that restoring
unobstructed venous drainage from the common femoral vein (CFV) into the vena cava can make an enormous difference to outcome in patients with recalcitrant venous ulcers. The ulcer heals rapidly and as venous pressures fall substantially, oedema is controlled and pain is relieved. Chronic post-thrombotic iliofemoral venous obstruction is associated with severe morbidity and high recurrent thrombosis rates. Labropoulos et al[1]
measured venous
pressures in a spectrum of patients with post-thrombotic venous disease and controls. They found that chronic iliofemoral venous occlusion was associated with the highest venous pressures, both when resting and exercising. The technique detailed here is indicated for those
patients with chronic post-thrombotic iliofemoral venous obstruction causing severe post-thrombotic syndrome who have common femoral vein occlusion. The goal of the procedure is to provide unobstructed venous drainage from the profunda femoris vein to the vena cava. To date, 13 patients with severe post-thrombotic iliofemoral/vena caval venous obstruction presenting with clinical class C3–C6 (CEAP classification) have been treated[2, 3]
. The duration of
their obstruction ranged from seven months to 25 years (mean 6.8 years). Preoperative preparation includes complete
phlebography of the target leg, including the inferior vena cava. A guide wire is passed through the occlusion into the patent inferior vena cava. All patients are given preoperative platelet inhibition and take chlorhexidine showers twice daily for three days prior to the operation.
Operative procedure The common femoral vein, common distal external iliac vein, cephalad portion of the femoral vein, and profunda femoris vein are exposed through a standard longitudinal inguinal incision [Fig 2]. A longitudinal venotomy [Fig 3] exposes the extensive endoluminal fibrosis and the endovenectomy is performed with a sharp dissection. The vein is then patched with a bovine pericardial patch, leaving the distal end of the closure open to admit a 10 Fr sheath, which is inserted into the inguinal wound from a separate thigh puncture. Endoluminal recanalisation is performed with sequential balloon dilation and stenting, generally building from the distal external iliac vein to the vena cava. Once recanalization is complete, the sheath is removed and patch closure completed. A small arteriovenous fistula is constructed and the wound is closed. A closed system wound drain is then put in place. Following the operation, patients remain on systemic anticoagulation.
Results There was one perioperative mortality — a patient who died nine days after discharge from an acute myocardial infarction. Three patients developed wound haematomas requiring operative evacuation and three developed early
Figure 2: Exposure of the common femoral vein (CFV), femoral vein (FV), origin of profunda femoris (PFV), and saphenous vein (SV). Multiple, sizeable collaterals are controlled with vessel loops.
9 Wounds International Vol 2 | Issue 4 | ©Wounds International 2011
Figure 3: Venogram shows a diseased left common and external iliac vein and a stenotic left common iliac vein.
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