Hybrid CFV endovenectomy promising, but not for the faint at heart

CHICAGO – Common femoral endovenectomy with endoluminal iliac recanalization should be considered in patients with chronic post-thrombotic iliofemoral venous obstruction.

The procedure substantially reduces post-thrombotic syndrome morbidity and improves quality of life, although it "is not a procedure for the faint of heart," acknowledged Dr. Anthony Comerota, director of the Jobst Vascular Center at ProMedica Toledo (Ohio) Hospital.

Postthrombotic syndrome occurs in 30%-40% of all patients with a lower-extremity deep vein thrombosis (DVT) at 2 years, despite the use of anticoagulation. Postthrombotic syndrome can be particularly debilitating following an iliofemoral DVT if the common femoral vein (CFV) is badly obstructed or occluded, resulting in such poor quality of life that Dr. Comerota compared it with angina, cancer, and congestive heart failure.

Stenting and angioplasty are often successful in treating postthrombotic iliac vein occlusion, although the risk of stent occlusion is at least 3.8-fold higher in postthrombotic limbs if the stent is extended below the inguinal ligament, he noted.

Relative obstruction of the CFV also can persist after percutaneous intervention and compromise drainage from the profunda femoris vein. This mitigates the benefits of iliac vein recanalization and can actually worsen the patient’s post-thrombotic symptoms, Dr. Comerota said at a symposium on vascular surgery sponsored by Northwestern University.

"It is crucial to open up the orifice of the profunda," he said. "One of the problems we’ve seen in patients referred to us is that, when the common femoral was stented and the stent takes that fibrous tissue and plasters it up against the orifice of the profunda, if there was any minimal drainage from the profunda, it will obliterate it and those patients got worse."

Having previously detailed the technical aspects of the procedure (J. Vasc. Surg. 2012;55:129-35), Dr. Comerota highlighted outcomes of 14 patients and 16 limbs treated to date for severe post-thrombotic, iliofemoral/caval venous obstruction with CEAP (clinical severity, etiology, anatomy, pathophysiology) classification of C3-C6. The median duration of obstruction was nearly 7 years (range, 7 months to 25 years) and median follow-up 3 years (range, 5 months to 6 years). Two patients were lost to follow-up.

To date, one death occurred in a 52-year-old woman with multiple cardiovascular risk factors 9 days after discharge because of an acute myocardial infarction, Dr. Comerota said.

Three patients required surgical evacuation of wound hematomas and three developed early postoperative thrombosis treated with lysis in two cases and thrombectomy in one. All three patients were discharged with patency restored.

One segmental occlusion of the CFV has occurred, and a recent patient with longstanding sickle cell disease developed significant acute lymphedema "that we are still at a loss to explain," he said.

At 6 months, significant improvements were observed in preoperative scores on the Villalta scale (mean, 14 vs. 6; P = .002), Venous Clinical Severity Score (mean, 17 vs. 10; P = .02), CEAP (mean, 4.8 vs. 3.8; P less than .05) and Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Sym questionnaire (data not provided; P = .01).

In some patients, the turnaround was quite dramatic, observed Dr. Comerota, who described a patient who suffered severe trauma and was unable to be anticoagulated. He subsequently had chronic iliofemoral and caval obstruction causing a swollen limb and a painful ulcer for 4 years. The day after surgery, there was remarkable change in the color of the ulcer and leg, and within 3 months the ulcer was completely healed, most of the edema was controlled, and his legs were no longer painful to compression, he said. The patient is back to full activity and has lost 30 pounds.

As a result of inactivity, many of the patients had gained a significant amount of weight, thereby requiring a large incision.

"It is a big procedure," said Dr. Comerota, adding that "it is certainly a procedure in evolution."

Some of the issues requiring further study include the risk/benefit of combined preoperative platelet inhibition and the optimal postoperative anticoagulation; location of an arteriovenous (AV) fistula; and size of the wound drain, currently a 7F closed suction drain.

Three days prior to the procedure, patients receive platelet inhibition with aspirin 81 mg/day and clopidogrel 75 mg/day and twice-daily chlorhexidine showers.

On the day of surgery, patients are fully anticoagulated with 100 IU/kg of unfractionated heparin. It is not reversed with protamine after the surgery is complete, but rather followed with a standard intravenous therapeutic heparin infusion, he said. To reduce the need for supratherapeutic systemic anticoagulation in some patients, a silastic intravenous catheter was placed in a dorsal foot vein to infuse the postoperative heparin.

A small AV fistula of 3.5-4 mm has been required in about half of procedures after continuous wave Doppler failed to identify robust venous velocity signals. The goal of the AV fistula is to increase velocity but not venous pressure, and it has typically been constructed with a wrap around the greater saphenous vein to ensure that it will not enlarge over time, Dr. Comerota said.

"I’ve never been sorry I did an AV fistula. I certainly have been sorry that I have not, so now it’s a routine part of the procedure," he added.

If an iliac venous stenosis or occlusion needs to be stented, Dr. Comerota said that he prefers Wallstents.

"I’m not sure if radial strength is the best term, but Wallstents have the best compression to pressure," he explained. "We’ve used Nitinol [stents] earlier on in our experience, but we had to go back in and reline 50% to 60% of them because they just didn’t hold up the vein properly."

Initially, the team also attempted to keep the stents above the inguinal ligament, but it now takes the approach that the iliac venous occlusion can be stented into the endovenectomized portion of the external iliac vein or CFV, with the caveat that the distal end of the stent must stay above the saphenofemoral junction to preserve profunda femoris venous drainage. Stenting avoids skip lesions that might lead to recurrent thrombosis or continued functional compromise, Dr. Comerota noted.

During a discussion of the procedure, he said that symptomatic presentation and degree of disability are used to determine whether patients should undergo the rigorous procedure.

Surgeons at the Mayo Clinic reported far less promising results in 12 patients who underwent CFV endovenectomy, patch angioplasty, and stenting for chronic iliofemoral venous obstruction, with a 30% 2-year patency and 50% of ulcers with patent grafts recurring (J. Vasc. Surg. 2011;53:383-93).

[email protected]

CHICAGO – Common femoral endovenectomy with endoluminal iliac recanalization should be considered in patients with chronic post-thrombotic iliofemoral venous obstruction.

The procedure substantially reduces post-thrombotic syndrome morbidity and improves quality of life, although it "is not a procedure for the faint of heart," acknowledged Dr. Anthony Comerota, director of the Jobst Vascular Center at ProMedica Toledo (Ohio) Hospital.

Postthrombotic syndrome occurs in 30%-40% of all patients with a lower-extremity deep vein thrombosis (DVT) at 2 years, despite the use of anticoagulation. Postthrombotic syndrome can be particularly debilitating following an iliofemoral DVT if the common femoral vein (CFV) is badly obstructed or occluded, resulting in such poor quality of life that Dr. Comerota compared it with angina, cancer, and congestive heart failure.

Stenting and angioplasty are often successful in treating postthrombotic iliac vein occlusion, although the risk of stent occlusion is at least 3.8-fold higher in postthrombotic limbs if the stent is extended below the inguinal ligament, he noted.

Relative obstruction of the CFV also can persist after percutaneous intervention and compromise drainage from the profunda femoris vein. This mitigates the benefits of iliac vein recanalization and can actually worsen the patient’s post-thrombotic symptoms, Dr. Comerota said at a symposium on vascular surgery sponsored by Northwestern University.

"It is crucial to open up the orifice of the profunda," he said. "One of the problems we’ve seen in patients referred to us is that, when the common femoral was stented and the stent takes that fibrous tissue and plasters it up against the orifice of the profunda, if there was any minimal drainage from the profunda, it will obliterate it and those patients got worse."

Having previously detailed the technical aspects of the procedure (J. Vasc. Surg. 2012;55:129-35), Dr. Comerota highlighted outcomes of 14 patients and 16 limbs treated to date for severe post-thrombotic, iliofemoral/caval venous obstruction with CEAP (clinical severity, etiology, anatomy, pathophysiology) classification of C3-C6. The median duration of obstruction was nearly 7 years (range, 7 months to 25 years) and median follow-up 3 years (range, 5 months to 6 years). Two patients were lost to follow-up.

To date, one death occurred in a 52-year-old woman with multiple cardiovascular risk factors 9 days after discharge because of an acute myocardial infarction, Dr. Comerota said.

Three patients required surgical evacuation of wound hematomas and three developed early postoperative thrombosis treated with lysis in two cases and thrombectomy in one. All three patients were discharged with patency restored.

One segmental occlusion of the CFV has occurred, and a recent patient with longstanding sickle cell disease developed significant acute lymphedema "that we are still at a loss to explain," he said.

At 6 months, significant improvements were observed in preoperative scores on the Villalta scale (mean, 14 vs. 6; P = .002), Venous Clinical Severity Score (mean, 17 vs. 10; P = .02), CEAP (mean, 4.8 vs. 3.8; P less than .05) and Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Sym questionnaire (data not provided; P = .01).

In some patients, the turnaround was quite dramatic, observed Dr. Comerota, who described a patient who suffered severe trauma and was unable to be anticoagulated. He subsequently had chronic iliofemoral and caval obstruction causing a swollen limb and a painful ulcer for 4 years. The day after surgery, there was remarkable change in the color of the ulcer and leg, and within 3 months the ulcer was completely healed, most of the edema was controlled, and his legs were no longer painful to compression, he said. The patient is back to full activity and has lost 30 pounds.

As a result of inactivity, many of the patients had gained a significant amount of weight, thereby requiring a large incision.

"It is a big procedure," said Dr. Comerota, adding that "it is certainly a procedure in evolution."

Some of the issues requiring further study include the risk/benefit of combined preoperative platelet inhibition and the optimal postoperative anticoagulation; location of an arteriovenous (AV) fistula; and size of the wound drain, currently a 7F closed suction drain.

Three days prior to the procedure, patients receive platelet inhibition with aspirin 81 mg/day and clopidogrel 75 mg/day and twice-daily chlorhexidine showers.

On the day of surgery, patients are fully anticoagulated with 100 IU/kg of unfractionated heparin. It is not reversed with protamine after the surgery is complete, but rather followed with a standard intravenous therapeutic heparin infusion, he said. To reduce the need for supratherapeutic systemic anticoagulation in some patients, a silastic intravenous catheter was placed in a dorsal foot vein to infuse the postoperative heparin.

A small AV fistula of 3.5-4 mm has been required in about half of procedures after continuous wave Doppler failed to identify robust venous velocity signals. The goal of the AV fistula is to increase velocity but not venous pressure, and it has typically been constructed with a wrap around the greater saphenous vein to ensure that it will not enlarge over time, Dr. Comerota said.

"I’ve never been sorry I did an AV fistula. I certainly have been sorry that I have not, so now it’s a routine part of the procedure," he added.

If an iliac venous stenosis or occlusion needs to be stented, Dr. Comerota said that he prefers Wallstents.

"I’m not sure if radial strength is the best term, but Wallstents have the best compression to pressure," he explained. "We’ve used Nitinol [stents] earlier on in our experience, but we had to go back in and reline 50% to 60% of them because they just didn’t hold up the vein properly."

Initially, the team also attempted to keep the stents above the inguinal ligament, but it now takes the approach that the iliac venous occlusion can be stented into the endovenectomized portion of the external iliac vein or CFV, with the caveat that the distal end of the stent must stay above the saphenofemoral junction to preserve profunda femoris venous drainage. Stenting avoids skip lesions that might lead to recurrent thrombosis or continued functional compromise, Dr. Comerota noted.

During a discussion of the procedure, he said that symptomatic presentation and degree of disability are used to determine whether patients should undergo the rigorous procedure.

Surgeons at the Mayo Clinic reported far less promising results in 12 patients who underwent CFV endovenectomy, patch angioplasty, and stenting for chronic iliofemoral venous obstruction, with a 30% 2-year patency and 50% of ulcers with patent grafts recurring (J. Vasc. Surg. 2011;53:383-93).

[email protected]

CHICAGO – Common femoral endovenectomy with endoluminal iliac recanalization should be considered in patients with chronic post-thrombotic iliofemoral venous obstruction.

The procedure substantially reduces post-thrombotic syndrome morbidity and improves quality of life, although it "is not a procedure for the faint of heart," acknowledged Dr. Anthony Comerota, director of the Jobst Vascular Center at ProMedica Toledo (Ohio) Hospital.

Postthrombotic syndrome occurs in 30%-40% of all patients with a lower-extremity deep vein thrombosis (DVT) at 2 years, despite the use of anticoagulation. Postthrombotic syndrome can be particularly debilitating following an iliofemoral DVT if the common femoral vein (CFV) is badly obstructed or occluded, resulting in such poor quality of life that Dr. Comerota compared it with angina, cancer, and congestive heart failure.

Stenting and angioplasty are often successful in treating postthrombotic iliac vein occlusion, although the risk of stent occlusion is at least 3.8-fold higher in postthrombotic limbs if the stent is extended below the inguinal ligament, he noted.

Relative obstruction of the CFV also can persist after percutaneous intervention and compromise drainage from the profunda femoris vein. This mitigates the benefits of iliac vein recanalization and can actually worsen the patient’s post-thrombotic symptoms, Dr. Comerota said at a symposium on vascular surgery sponsored by Northwestern University.

"It is crucial to open up the orifice of the profunda," he said. "One of the problems we’ve seen in patients referred to us is that, when the common femoral was stented and the stent takes that fibrous tissue and plasters it up against the orifice of the profunda, if there was any minimal drainage from the profunda, it will obliterate it and those patients got worse."

Having previously detailed the technical aspects of the procedure (J. Vasc. Surg. 2012;55:129-35), Dr. Comerota highlighted outcomes of 14 patients and 16 limbs treated to date for severe post-thrombotic, iliofemoral/caval venous obstruction with CEAP (clinical severity, etiology, anatomy, pathophysiology) classification of C3-C6. The median duration of obstruction was nearly 7 years (range, 7 months to 25 years) and median follow-up 3 years (range, 5 months to 6 years). Two patients were lost to follow-up.

To date, one death occurred in a 52-year-old woman with multiple cardiovascular risk factors 9 days after discharge because of an acute myocardial infarction, Dr. Comerota said.

Three patients required surgical evacuation of wound hematomas and three developed early postoperative thrombosis treated with lysis in two cases and thrombectomy in one. All three patients were discharged with patency restored.

One segmental occlusion of the CFV has occurred, and a recent patient with longstanding sickle cell disease developed significant acute lymphedema "that we are still at a loss to explain," he said.

At 6 months, significant improvements were observed in preoperative scores on the Villalta scale (mean, 14 vs. 6; P = .002), Venous Clinical Severity Score (mean, 17 vs. 10; P = .02), CEAP (mean, 4.8 vs. 3.8; P less than .05) and Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Sym questionnaire (data not provided; P = .01).

In some patients, the turnaround was quite dramatic, observed Dr. Comerota, who described a patient who suffered severe trauma and was unable to be anticoagulated. He subsequently had chronic iliofemoral and caval obstruction causing a swollen limb and a painful ulcer for 4 years. The day after surgery, there was remarkable change in the color of the ulcer and leg, and within 3 months the ulcer was completely healed, most of the edema was controlled, and his legs were no longer painful to compression, he said. The patient is back to full activity and has lost 30 pounds.

As a result of inactivity, many of the patients had gained a significant amount of weight, thereby requiring a large incision.

"It is a big procedure," said Dr. Comerota, adding that "it is certainly a procedure in evolution."

Some of the issues requiring further study include the risk/benefit of combined preoperative platelet inhibition and the optimal postoperative anticoagulation; location of an arteriovenous (AV) fistula; and size of the wound drain, currently a 7F closed suction drain.

Three days prior to the procedure, patients receive platelet inhibition with aspirin 81 mg/day and clopidogrel 75 mg/day and twice-daily chlorhexidine showers.

On the day of surgery, patients are fully anticoagulated with 100 IU/kg of unfractionated heparin. It is not reversed with protamine after the surgery is complete, but rather followed with a standard intravenous therapeutic heparin infusion, he said. To reduce the need for supratherapeutic systemic anticoagulation in some patients, a silastic intravenous catheter was placed in a dorsal foot vein to infuse the postoperative heparin.

A small AV fistula of 3.5-4 mm has been required in about half of procedures after continuous wave Doppler failed to identify robust venous velocity signals. The goal of the AV fistula is to increase velocity but not venous pressure, and it has typically been constructed with a wrap around the greater saphenous vein to ensure that it will not enlarge over time, Dr. Comerota said.

"I’ve never been sorry I did an AV fistula. I certainly have been sorry that I have not, so now it’s a routine part of the procedure," he added.

If an iliac venous stenosis or occlusion needs to be stented, Dr. Comerota said that he prefers Wallstents.

"I’m not sure if radial strength is the best term, but Wallstents have the best compression to pressure," he explained. "We’ve used Nitinol [stents] earlier on in our experience, but we had to go back in and reline 50% to 60% of them because they just didn’t hold up the vein properly."

Initially, the team also attempted to keep the stents above the inguinal ligament, but it now takes the approach that the iliac venous occlusion can be stented into the endovenectomized portion of the external iliac vein or CFV, with the caveat that the distal end of the stent must stay above the saphenofemoral junction to preserve profunda femoris venous drainage. Stenting avoids skip lesions that might lead to recurrent thrombosis or continued functional compromise, Dr. Comerota noted.

During a discussion of the procedure, he said that symptomatic presentation and degree of disability are used to determine whether patients should undergo the rigorous procedure.

Surgeons at the Mayo Clinic reported far less promising results in 12 patients who underwent CFV endovenectomy, patch angioplasty, and stenting for chronic iliofemoral venous obstruction, with a 30% 2-year patency and 50% of ulcers with patent grafts recurring (J. Vasc. Surg. 2011;53:383-93).

[email protected]