Hybrid Iliofemoral Venous Bypass and Stenting for Post Thrombotic Syndrome
Rajavi Parikh1, Erin Murphy1, Frank Arko, III2, Gregory A Stanley1
1Atrium Health, Charlotte, NC;2Frank Arko, Charlotte, NC
BACKGROUND: 74-year-old Caucasian female with left lower extremity post-thrombotic syndrome. METHODS: Initial left iliofemoral DVT at age 40 treated with anticoagulation with subsequent development of post-thrombotic syndrome. At age 52, she underwent a left to right Palma procedure with vein for chronic left iliac vein occlusion, with near-immediate thrombosis. She presented to us with persistent post-thrombotic syndrome manifesting as left leg edema, discomfort, mild hyperpigmentation and lifestyle-limiting venous claudication. She was referred after an unsuccessful attempt at endovascular reconstruction. Imaging revealed chronic occlusion of left external iliac and common femoral veins, with patent femoral and profunda inflow vessels and extensive collateralization. The cranial CFV appeared surgically occluded, likely at the time of the initial venous bypass. Patient was taken for a reattempt at endovascular reconstruction with plans for conversion to venous bypass with immediate stenting if endovascular recanalization failed. RESULTS: Dual access from the left femoral and right internal jugular veins were obtained. The EIV occlusion was crossed but we were unsuccessful at crossing the surgically occluded CFV segment. Therefore, a surgical approach was pursued. Exposure via a groin and a lower-midline abdominal incision demonstrated a patent femoral-profunda confluence and a healthy common iliac vein with only a thin, fibrotic cord connecting these vessels. We proceeded with venous bypass. An end-to-end anastomosis was created between the left CFV at the femoral-profunda confluence and a 14mm PTFE graft. A retroperitoneal tunnel was used and an end-to-end anastomosis was created to the left CIV. To reinforce the anastomoses and maintain lumen diameter, stenting was pursued. A 14x150mm Abre self-expanding bare-metal stent was placed caudally and a 16x120mm Abre stent was placed cranially with 3cm overlap. We serially post-dilated the stent with a 12mm, then 14mm balloon. Anastomotic bleeding was noted during stent dilation, controlled with manual pressure. She had a prolonged hospital stay complicated by atrial fibrillation with RVR, retroperitoneal bleed, and acute kidney injury. She was discharged on post-operative day 15 on full anticoagulation. At 4-month follow-up she is doing well with symptoms resolved. Stented bypass is patent on duplex with minimal ISR. She is tolerating coumadin. CONCLUSIONS: Endovascular treatment has largely replaced surgical venous bypass for iliofemoral occlusive disease secondary to improved patency rates. In cases of non-crossable venous lesions, surgical bypass remains an option. Concurrent stenting of the bypass may improve venous bypass patency rates but must be weighed against surgical complications which can be significant.
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