Surgical reconstruction of iliofemoral veins and the inferior vena cava for nonmalignant occlusive disease

Purpose: Venous reconstructions are rarely performed, and factors affecting long-term results of bypass grafts implanted in the venous system are not well defined. In this report we updated our experience. Methods: The clinical data of all patients who underwent venous reconstruct ion for iliofemoral or inferior vena caval (IVC) occlusion due to nonmalign ant disease between January 1985 and Tune 1999 were retrospectively reviewe d. Patients were classified, and outcomes were compared according to the gu idelines of the Joint Vascular Societies. Results: Forty-two patients, 23 males and 19 females (mean age, 40 years; r ange, 16-81), underwent 44 venous reconstructions. Thirty-six patients had Limb swelling or venous claudication, 38 had pain, and 14 had healed or act ive ulcers. The cause of obstruction was congenital in two and acquired in 40 (deep vein thrombosis, 25; trauma, 5; retroperitoneal fibrosis, 4; IVC o cclusion devices, 4; others, 2). Eighteen patients underwent saphenous vein crossover grafts (Palma procedure), 17 had expanded polytetrafluoroethylen e (ePTPE) grafts implanted (femorocaval, 8; iliocaval, 5; crossfemoral, 3; cavoatrial, 1), 6 patients had spiral vein grafts (5 iliac/femoral and 1 ca voatrial), and 1 underwent femoral vein patch angioplasty. Clinical follow- up averaged 3.5 years (median, 2.5), and graft follow-up with imaging studi es averaged 2.6 years (median, 1.6). Seven patients were lost to follow-up. The secondary 3-year patency rate for all reconstructions was 62%. Palma p rocedures had a 4-year patency rate of 83%. The secondary patency rate of i liocaval and femorocaval ePTFE bypass grafts at 2 years was 54%. The second ary patency was lower in patients with an arteriovenous fistula (P = .023). ALL ePTFE grafts had a 45% patency rate at 2 years, not significantly diff erent from saphenous vein grafts (83%, P = .16). Clinical scores improved w ith graft patency (median, 0.0 vs 1.5; P = .044). Conclusion: Venous reconstructions for iliofemoral or IVC obstruction offer 3-year patency rates of 62%. The Palma procedure with autologous saphenous vein had the best long-term patency, whereas long-term success with ePTPE was moderate. The use of an arteriovenous fistula to improve graft patency remains controversial.