The basilic vein: an alternative conduit for complex iliofemoral reconstruction.

OBJECTIVES: To evaluate the basilic vein as an alternative conduit in iliofemoral arterial reconstructions. DESIGN: Retrospective cohort study. METHODS: We reviewed records of all patients undergoing iliofemoral arterial reconstruction with basilic vein between January 2006 and November 2011. Patients were identified via a prospective database, which also provided data on patients' comorbidity, indications for surgery and perioperative outcome. Long term outcome was confirmed by reviewing hospital records; graft patency was confirmed by clinical examination and imaging by ultrasound or CT angiography. RESULTS: We identified 15 patients undergoing 17 procedures (two patients underwent staged bilateral iliofemoral bypasses). Indications for vein (instead of prosthetic) graft use included prosthetic infection (4), suspected infection (2), proven hypercoagulable state (3), young age (3) and multiple graft occlusions (5). Preoperative mapping confirmed vein suitability in all cases, and all conduits were harvested from the upper limb. There were no major perioperative complications. After a median (range) follow up of 21.5 (1-42) months, all grafts were patent; one patient required secondary intervention on the graft. CONCLUSION: Iliofemoral arterial reconstruction with autologous basilic vein is feasible and may be a valid alternative when the use of prosthetic material is contraindicated.

Longevity and outcomes of axillary valve transplantation for severe lower extremity chronic venous insufficiency.

BACKGROUND: To assess the efficacy of axillary vein transplantation in the treatment of severe chronic venous insufficiency (CVI). METHODS: Among 139 complex venous reconstructions performed between 1991 and 2007 for CVI, 18 patients underwent upper extremity to lower extremity venous valve transplantation. An upper extremity valve was transplanted to the popliteal vein in 13 cases, to the common femoral vein in six cases, and to the saphenofemoral junction in two cases for a total of 21 procedures. All patients had follow-up with duplex scanning to assess valve competency and clinical visits to assess clinical improvement. Mean follow-up period was 37 months. RESULTS: Mean patient age was 44 years, and 57% were men. Clinically, 57% of the limbs were Clincal (C) class C5-C6. The mean preoperative venous disability score was 2.95. Most of the patients (66%) had post-thrombotic valvular dysfunction. At the time of valve transplantation, there was no proximal venous obstruction documented. A successful operation was defined as a competent valve at the end of the procedure and was achieved in 20 of 21 (95%) patients. Eight patients had at least one postoperative complication, primarily bleeding. The mean postoperative venous disability score was 2.65 and this increased to 2.75 (p = not significant as compared with baseline) at the last postoperative visit. Median time to return of symptoms was 12 months, and median reflux-free survival period was 15 months. CONCLUSION: Despite initial technical and symptomatic success with venous valve transplantation, there is a poor long-term valve competency rate and symptomatic control. These data suggest that a better understanding and therapy for severe CVI associated with valvular incompetence needs to be found.

Autogenous venous valve construction.

AIM: The aim of this study was to assess the results of a new type of antireflux operation on the deep venous system in patients with venous ulceration not responding to treatment of the superficial system and compression. METHODS: In the period comprised between 1991-2002, the authors treated 56 patients with venous ulceration by Fegan's technique, that consists in compression sclerotherapy combined with antireflux operation of the deep veins. All patients selected had pathological reflux in the deep venous system and their ulcers did not respond to superficial and perforating vein therapy, and elastic compression. RESULTS: Using this technique of complex antireflux treatment, it was possible to heal 53 (95.4%) of the 56 ulcers with average time of complete ulcer epitelisation within 39+/-12 days. The recurrence rate, within the 5 year follow-up was 18% (10 patients), but 7 of the recurrent ulcers responded to compression sclerotherapy and healed within 3 months. CONCLUSIONS: In situ made valvuloplasty has several advantages: the valve is constructed from autogenous vein wall; all luminal valve surfaces have native venous endothelium; intraluminal foreign material is not introduced; the likelihood of thrombosis is reduced; the valve is size-matched to the host vein and this technique provides a competent bicuspid valve.

Keyhole technique for autologous brachiobasilic transposition arteriovenous fistula.

BACKGROUND: Autologous brachiobasilic transposition arteriovenous fistulas (AVFs) are desirable but require long incisions and extensive surgical dissection. To minimize the extent of surgery, we developed a catheter-based technique that requires only keyhole incisions and local anesthesia. METHODS: The technique involves exposure and division of the basilic vein at the elbow. A guidewire is introduced into the vein, and a 6F "push catheter" is advanced over the guidewire and attached to the vein with sutures. Gently pushing the catheter proximally inverts, or intussuscepts, the vein. Side branches that are felt as resistances when pushing the catheter forward are localized, clipped, and divided under direct vision. Throughout the procedure, the endothelium always remains intraluminal. The basilic vein is externalized at the axilla without dividing it proximally and is tunneled subcutaneously, where it is anastomosed to the brachial artery. RESULTS: Thirty-two patients underwent the procedure--31 as outpatients. The mean duration of operation was less than 90 minutes. All patients tolerated the procedure well, and 31 required only intravenous sedation and local anesthesia. At a mean follow-up of 8 months, the primary patency rate of AVFs in patients with basilic vein diameters of 4 mm or more on preoperative duplex ultrasonography was 80%, vs 50% for those with vein diameters less than 4 mm. Overall, 78% of patent AVFs were being successfully accessed and 22% were still maturing at last follow-up. CONCLUSIONS: Autologous brachiobasilic transposition AVFs can be created by using catheter-mediated techniques that facilitate the mobilization and tunneling of the basilic vein through small incisions. Medium-term data suggest that the inversion method results in acceptable maturation and functionality of AVFs created with this technique.

Outcome after autogenous brachial-basilic upper arm transpositions in the post-National Kidney Foundation Dialysis Outcomes Quality Initiative era.

BACKGROUND: The Dialysis Outcomes Quality Initiative (DOQI)-inspired push to create autogenous fistulas has led to a resurgence of interest in basilic vein transposition as an autogenous access conduit. We reviewed our experience with autogenous brachial-basilic upper arm transpositions (BTX) to clarify current maturation and patency rates and provide realistic expectations for a tertiary referral vascular practice. METHODS: We follow an aggressive "all-autogenous" policy with regard to dialysis access and recommend BTX when all cephalic options are exhausted. Prosthetic grafts are not attempted unless all upper extremity veins are unusable. The records of all patients undergoing autogenous basilic and brachial vein upper arm transpositions for hemodialysis access between April 2001 and December 2004 were retrospectively evaluated. Mean follow-up was 10 months (range, 0 to 38 months). RESULTS: Eighty-seven patients underwent 100 basilic and 3 brachial vein transpositions. Most of the patients were already receiving hemodialysis (83%), with a mean of 1.1 (range, 0 to 4) previous access attempts. Perioperative complications included 1 death secondary to a myocardial infarction, 7 hematomas (4 requiring reoperation), and 6 infections (2 requiring reoperation). Steal syndrome developed in five patients. Maturation rate was 79%. Functional primary and secondary patency rates were 23% +/- 5% and 47% +/- 6% at 1 year and 11% +/- 5% and 40% +/- 10% at 2 years, respectively (mean +/- SE). The most common causes of failure for a matured fistula were stenosis within the body of the basilic vein (44%) followed by central venous outflow stenosis (20%). No preoperative variable, including gender, age, diabetes mellitus, presence of ipsilateral hemodialysis catheter, number of previous access attempts, maximal or minimal vein diameter, or obesity, had a significant impact on rate of maturation or long term patency. CONCLUSIONS: In our experience, autogenous brachial-basilic upper arm transposition fistulas have initial maturation rates that exceed DOQI guidelines, but disappointing short- to medium-term patency rates. Although these outcomes were obtained within the context of an aggressive all-autogenous policy, the poor durability of these transpositions should prompt further investigation of current access algorithms.

Superficial venous anastomosis in the human upper extremity--a post-mortem study.

The frequent use of veins in surgery, especially in the replacement of clogged arteries in the lower extremities, persuaded the authors to conduct research concerning the morphology of superficial veins in the human upper extremity. In a post-mortem study a group of 40 male subjects of 22-92 years of age was examined. The preparation of the region of the elbow fossa was performed in order to establish the architecture of superficial veins in the extremity. Many detailed anthropometrical measurements were also carried out, enabling a typological evaluation to be made of the deceased under study. Two characteristic pictures of venous anastomosis were tested, one with symmetrical tributaries to the vena basilica et cephalica and the second characterised by a rich set of tributaries to the vena basilica. The characteristics, calibre and structure of both these suggest a fruitful application of them in vessel surgery. The vena cephalica in particular, taken with efficient valves, may successfully play the role of vessel implant.

[Contribution of the semi-free radial forearm flap for head and neck reconstruction]. / Intérêts du lambeau anté-brachial radial semi-libre en reconstruction cranio-maxillo-faciale.

Flap failure is mostly caused by venous thrombosis of the anastomosis. The failure rate is higher in post-irradiated neck. To reduce the risk of venous thrombosis, the authors propose to harvest the radial forearm flap using the cephalic vein as the drainage vein and as a pedicle. Only a single arterial anastomosis is carried out. This technique has been described already in patients who underwent head and neck ablative surgery with radical neck dissection. The authors report 2 cases in patients with post-irradiated neck. The flap transfers were successful in the 2 cases. The operative time of harvesting this hybrid version is the same with the conventional free flap technique. This version of the radial forearm flap can be a method of choice for some complex microvascular reconstruction in the head and neck region.

Post-operative bilateral vision loss.

A 41-year-old man presented with acute bilateral loss of vision upon awakening after elective surgery. After thorough evaluation it was determined that he had suffered bilateral posterior ischemic optic neuropathies secondary to hypotension while under general anesthesia. One eye showed significant improvement over the next 4 weeks, whereas the other remained unchanged.

Axillary vein transfer in trabeculated postthrombotic veins.

PURPOSE: This study assessed whether axillary vein transfer can be successfully performed in trabeculated veins and whether patients with this severe form of postthrombotic syndrome can be helped by an aggressive approach. METHODS: A total of 102 axillary vein transfer procedures were carried out in 83 limbs with trabeculated veins. More than one venous segment was repaired in 38 limbs with a second axillary valve in 19, and a different technique was used in the remainder. The superficial and deep femoral veins were the most common target sites. "Bench repair" of leaky axillary valves was performed before the transfer in 32 cases. Venous stasis dermatitis or ulceration was present in 90% of the limbs. The operability rate and chance of successful valve reconstruction was high, even in the presence of severe venographic appearance. RESULTS: The actuarial transplant patency rate was 83% at 10 years. The actuarial freedom from recurrent ulceration rate was more than 60% at 10 years, similar to the results obtained in a matched group of axillary vein transfers to nontrabeculated veins. Severe preoperative ambulatory venous hypertension (venous filling time [VFT] of less than 5 seconds), which was present in 67% of patients, did not adversely affect outcome, but short VFTs that persisted after surgery did. VFT and VFI90 (venous filling index, air plethysmography) improved after valve transfer. Swelling disappeared or was significantly reduced in 55% of patients (11 of 20 patients) who had moderate or severe preoperative swelling. In 82% of patients (31 of 37 patients) who had mild or no preoperative swelling, the swelling remained stable after surgery, and in 18% of patients (6 of 37 patients), it became worse. Pain was significantly diminished in 70% of patients; 23% of patients with severe pain had complete resolution. CONCLUSION: Axillary vein transfer, in combination with other antirefluxive procedures when indicated, is safe, effective, and durable in patients with trabeculated veins and severe forms of postthrombotic syndrome. It may be considered as an option when conservative therapy or other types of surgery fail.

Distal venous arterialisation for salvage of critically ischaemic inoperable limbs.

BACKGROUND: Amputation remains the only option in patients with extensive arterial disease in whom conventional bypass operations are not feasible. Up to 10000 amputations for vascular disease are estimated to be done annually. We investigated the use of venous perfusion as an alternative method of limb salvage. METHODS: Over 28 months, 18 patients with critical-limb ischaemia underwent bypass procedures to the venous bed of the foot with vein, synthetic graft, or a combination of these as the conduit. Various methods were used to destroy the valves of the venous system. We followed up patients for a mean of 17 months. FINDINGS: Three grafts failed immediately after surgery and necessitated major amputation, with one death. One late failure did not necessitate amputation. 15 patients had relief of symptoms and retained a useful pain-free limb with healing of ulcers and gangrene. Two patients with functioning grafts died at 5 months and 13 months, respectively. Three patients had successful further radiological intervention. The overall limb-salvage rate was 83% and the 1-year limb-salvage rate was 75%. INTERPRETATION: Distal venous arterialisation is a unique procedure that has exciting possibilities for limb salvage and merits further investigation. Increased use of this procedure may help to lower the number of limbs amputated for vascular disease.

Surgical reconstruction for deep venous insufficiency.

All patients with significant venous stasis disease should undergo noninvasive evaluation to determine the magnitude, precise location, and etiology of the problem (i.e. obstruction and/or reflux). Patients who fail aggressive medical therapy (compression and skin care) and who have significant symptoms should be considered candidates for surgical correction. The majority of patients screened will have a significant component of superficial venous insufficiency with or without the presence of incompetent perforating veins. In this case we address the superficial and perforating venous systems prior to consideration of deep venous reconstruction. When correction of superficial venous incompetence fails to improve the patient's symptoms, they are then considered for deep venous reconstruction. Patients with primary venous insufficiency are typically good candidates for direct valvuloplasty performed using the open or angioscopic techniques, while patients with damaged (post thrombotic) or absent valves are best managed by vein valve transplantation or segmental transposition. Results for both valvuloplasty and vein valve transplantation demonstrate good intermediate term valvular patency and ulcer healing. It appears that when used as part of a complete treatment protocol addressing superficial, deep, and perforating venous systems, as well as attention to skin care and appropriate compressive therapy that surgical reconstruction for deep venous reflux affords significant benefit to our patients.

"Chain-link" combined tissue transfer for the reconstruction of the mandible.

We describe a procedure for "chain-link" combined tissue transfer connecting the vascular pedicle of a deep circumflex iliac flap with that of a forearm flap after wide resection of the mandible. Combination of these flaps facilitated the reconstruction of the defect in both intra- and extraoral soft tissue and the mandibular bone. This method is useful when cervical recipient blood vessels are limited due to the wide resection of the primary tumor and radical neck dissection.

Durability of venous valve reconstruction techniques for "primary" and postthrombotic reflux.

PURPOSE: The durability of the variety of valve reconstruction techniques in "primary" reflux and postthrombotic reflux was studied. METHODS: A total of 423 valve repairs in 235 patients with a follow-up period ranging from 1 to 12 years were analyzed. End points for assessment consisted of ulcer recurrence and Doppler competence in serial duplex examination. Multivariate analysis with Cox proportional hazards model was used. RESULTS: Ulcer-free survival curves were similar for "primary" and postthrombotic reflux. No significant difference in ulcer recurrence was seen regardless of the technique used. Different results were obtained when valve competence instead of ulcer recurrence was used for assessment of durability. Reconstructions in "primary" reflux were more durable than those in postthrombotic reflux. Durability differences were also noted among different techniques. A cohort of posterior tibial repairs proved extraordinarily durable (0 failures in 23 repairs). CONCLUSION: Valve reconstruction in postthrombotic reflux can yield clinical results similar to those in "primary" reflux. Although any of the several described techniques can produce similar clinical results, Doppler competence suggests the following order for choice of procedures: (1) internal valvuloplasty, (2) prosthetic sleeve in situ, (3) external valvuloplasty, and (4) axillary vein transfer.

The clinical and hemodynamic results after axillary-to-popliteal vein valve transplantation.

PURPOSE: To evaluate the results of axillary vein to popliteal vein valve transplantation (VVTX), we reviewed the clinical, phlebographic, and noninvasive hemodynamic results in 15 patients. METHODS: All patients had postthrombotic destruction of deep venous valves as determined by ascending phlebography, whereas descending phlebography demonstrated grade III or IV reflux in all patients. A segment of valve-bearing axillary vein was transplanted to the popliteal vein in the affected limb. Postoperative evaluation was by clinical, noninvasive, and phlebographic means. RESULTS: Over a mean follow-up period of 5.3 years (1.25 to 11 years), 13 of 14 patients (93%) had symptomatic improvement with relief of swelling, whereas all 14 patients who were admitted with pain had relief after operation. Thirteen of 15 patients (87%) returned to work or household duties. Physical findings of edema, skin pigmentation, and lipodermatosclerosis improved in most patients. Only three patients (21%) had development of recurrent ulcers, with an average postoperative ulcer-free interval of 4 years by life-table analysis. The cumulative ulcer-free survival rate for the group averaged 62% at late follow-up. All three patients with ulcer recurrence had a functioning valve by descending phlebography, but recurrent perforating veins were found in two patients, and deep venous thrombosis above a patent VVTX was observed in the third. Late assessment of reflux by venous filling index and valve closure times for the entire sample demonstrated mean values of 4.9 seconds in the latter and 6.8 ml/sec in the former. Residual volume fraction, which correlates with invasive ambulatory venous pressures, was reduced to a mean of 31%. No deterioration in late sequential noninvasive values could be detected. CONCLUSION: VVTX is a durable procedure for preventing recurrent venous ulcers.

Long-term results of venous valve reconstruction: a four- to twenty-one-year follow-up.

PURPOSE: The purpose of this study is to describe the very long-term clinical, hemodynamic, and imaging results of venous valve reconstruction for reflux disease in patients with chronic venous insufficiency. METHODS: There were 51 extremities (48 patients) with follow-up of 4 to 21 years with a mean of 10.6 years. Clinical severity was graded as asymptomatic (class 0), mildly symptomatic (class 1), moderately symptomatic but without ulceration (class 2), or severely symptomatic with or without ulceration (class 3). Preoperative and postoperative evaluation consisted of history and physical examination, ascending venography (preoperative only), ambulatory venous pressures or photoplethysmography, and descending venography or duplex scanning. RESULTS: Before surgery, 49 (96%) of 51 limbs demonstrated severe, class 3 disease, and two limbs were classified as class 2 disease. After venous valve reconstruction by either direct femoral vein valve repair, transposition, or transplantation, long-term clinical success of achieving a class 0 or 1 result (by life-table analysis) was 60% at 10 years. Thirty-three percent demonstrated a class 0 result in which the limbs were free from symptoms and had no need for long-term elastic support. After 6 years clinical results were stable and did not deteriorate. Incompetent perforators were identified in 31 cases and were treated selectively. Three disease patterns of chronic venous insufficiency were identified: primary valve insufficiency 43%, postthrombotic syndrome 31%, and a group consisting of both primary valve insufficiency of the superficial femoral vein and postthrombotic syndrome of the calf veins (primary valve insufficiency-postthrombotic syndrome) 26%. Ten-year cumulative clinical success was clearly superior in limbs with primary valve insufficiency corrected by valve repair (73%) as opposed to those with postthrombotic syndrome treated by either valve transposition or transplantation (43%) (p = 0.029). Clinical outcome correlated strongly with postoperative imaging results, and durability of valve repair was confirmed by demonstrating competence up to 16 years after the operation. Significant improvement in ambulatory venous pressure (mean percentage of pressure fall and refill time) was found in limbs with class 0 or 1 outcome; however, values did not reach "normal" levels in all cases. Recurrent ulcerations after the operation were attributed to failed reconstructions (10), incompetent profunda femoris veins (three), incompetent perforators (three), and concomitant lymphedema (one). CONCLUSIONS: This report highlights a difference found in very long-term prognosis of surgical treatment of primary valve insufficiency as opposed to postthrombotic syndrome. Long-term elimination of symptoms of chronic venous insufficiency is achieved by valve repair for primary valve insufficiency beyond 10 years, whereas late results of treatment of postthrombotic syndrome in this study was accompanied by high recurrence rates and warrants further investigation.

Clinical, hemodynamic, and anatomic follow-up of direct venous reconstruction.

Conventional therapy for the advanced clinical stages of the postthrombotic syndrome is associated with recurrence of symptoms and ulcer. Direct venous reconstruction may relieve the symptoms of patients with either iliac vein obstruction or valvular incompetence, but there are few reports detailing late hemodynamic and anatomic findings. We summarized the clinical, hemodynamic, and anatomic follow-up of six patients with saphenofemoral bypass (SFB) and ten patients with axillary vein valve-to-popliteal vein transplants (PVTs) who were followed up for a minimum of two years. All ten ulcers in the PVT group healed and symptoms of venous claudication, limb swelling, and all ulcers healed in the SFB group. Late (greater than 2 years) anatomic and functional assessment showed that the SFB bypasses were patent and the PVTs were both patent and functional.

Influence of the profunda femoris vein on venous hemodynamics of the limb. Experience from thirty-one deep vein valve reconstructions.

Venous valve reconstruction in 31 limbs (28 patients) with chronic deep venous insufficiency is analyzed. The indications for operation were primary or secondary deep valvular incompetence with severe reflux and venous hypertension. Valvuloplasty was performed on a proximal valve of the superficial femoral vein (SFV) in 17 limbs and on a common femoral vein valve in two limbs; transplantation of a valve-bearing segment of the axillary vein was made to the common femoral vein in two limbs, to the SFV in seven limbs, and to the popliteal vein in three limbs. The results of valvuloplasty were satisfactory, with six failures observed during a follow-up period extending to 84 months (mean, 44 months). Eight of 12 valve transplant reconstructions failed within 2 years. Patency and competence of the reconstruction were obtained in 27 limbs at the 6-month postoperative control period. The effects on venous pressure were analyzed regarding the presence or absence of reflux into the profunda femoral vein (PFV) with preoperative retrograde phlebography. The results showed significant reduction of the ambulatory venous pressure (p less than 0.05) and increase in venous recovery time (p less than 0.01) in limbs with PFV competence. In limbs in which the PFV was incompetent the pressure values remained unchanged. These findings suggest that the functional state of the PFV is of great importance to the venous hemodynamics of the limb. This study also indicates that the principle of one-level repair in the SFV seems appropriate in limbs with a competent PFV.

Valvuloplasty and valve transfer.

The technique and results of valvuloplasty and valve transfer are presented. The rationale and theoretical background for these procedures are outlined. Results of reconstructive valve surgery have been good and justify continued application of this therapeutic modality in chronic venous insufficiency.