Presidential address: Venous disorders—Reflections of the past three decades
1997; Elsevier BV; Volume: 26; Issue: 5 Linguagem: Inglês
10.1016/s0741-5214(97)70083-1
ISSN1097-6809
Autores Tópico(s)Peripheral Artery Disease Management
ResumoIt is a great honor to address the Ninth Annual Meeting of American Venous Forum. This meeting represents the best of American vascular surgeons with a special interest in venous disorders. Disease of the veins not only has long historical interest but also was the dominant feature of the beginning meetings of the Society for Vascular Surgery. Surgery of the venous system was discussed in those first addresses given by Presidents Ochsner,1Ochsner A Venous thrombosis.Surgery. 1948; 24: 445-451PubMed Google Scholar Allen,2Allen AW The present evaluation of the prophylaxis and treatment of venous thrombosis and pulmonary embolism.Surgery. 1949; 26: 1-7PubMed Google Scholar and Veal.3Veal JR Cotsonas Jr, NJ Diseases of the superior vena caval system with special consideration of pathology and diagnosis.Surgery. 1952; 31: 1-12PubMed Google Scholar As arterial surgery flourished, interest in venous disease by vascular surgeons began to fade. At present, the veins get no respect, despite the fact that the venous system contains the greatest part of the blood volume in human beings. I am honored to be part of the mission of the American Venous Forum to restore interest in venous disorders to vascular surgeons. I completed my surgical residency at Cook County Hospital in June 1967 and went to St. Mary's Hospital in London to begin vascular training. Little did I know then that I would be involved in this specialty for 30 years. As I stand here today in 1997, it is interesting to reflect over the period of my own experience and to consider how much the diagnosis and treatment of venous disorders has changed in that time and what needs to change in the future. Because history is important to our future, I would also like to recall some of the historical landmarks of this largely ignored vascular problem. Varicose veins are an ancient disease, and there were references to varicose veins in the early Egyptian and Greek writings. In fact, a votive tablet from the National Museum in Athens illustrating a man holding a huge leg with a varicose vein is a frequent feature in many historical writings of venous disease. My first exposure to venous disorders was varicose veins. In 1967, treatment of varicose veins by sclerotherapy was common in the British Isles. The introduction of injection treatment coincided with the development of the syringe by a Frenchman, Monsieur Pravaz of Lyons School, France, in 1851.4Pravaz Com Rend Acad de Sc Paris. 1851; 36: 88Google Scholar Soon thereafter, in 1853, Chassaignac from Saint Antoine Hospital of Paris suggested the obliteration of varicose veins by injection of perchloride of iron.5Babcock WW A textbook of surgery.2nd ed. W. B. Saunders, Philadelphia1936Google Scholar Sodium morrhuate was introduced in 1931 and was extensively used in the United States during the next two decades.6McPheeters HO Varicose veins: with special reference to the injection treatment. F. A. Davis Co, Philadelphia1931Google Scholar Although modern days have seen better chemicals for sclerosing therapy, treatment of this disorder has evolved into the use of high technology such as laser, high-intensity pulsed light, or duplex ultrasound–guided sclerotherapy.7Villavicencio JL, Pfeifer JR, Lohr JM, Goldman MP, Cranley R, Spence R, et al. Sclerotherapy for varicose veins: practice guidelines and sclerotherapy procedures. In: Gloviczki P, Yao JST, editors. Handbook of venous disorders. London: Chapman & Hall Medical, p. 337-54.Google Scholar How good these techniques are will never be answered scientifically. One fact, however, is true: abuse of treatment of varicose veins is common, and a business approach has been adopted by entrepreneur physicians to franchise for-profit-only vein clinics across the United States. Vein stripping is probably one of the most commonly performed surgical procedures. Historical review of the surgical treatment of varicose veins has been well written in detail by Laufman,8Laufman H The veins. Silvergirl, Inc, Austin, Tex1986Google Scholar Ochsner and Mahorner,9Ochsner A Mahorner H Varicose veins. C.V. Mosby Co, St. Louis1939Google Scholar and Scott.10Scott HJ History of venous disease and early management.Phlebology. 1992; : 2-5Google Scholar In 1833, Davat attempted to eliminate the varicose veins by percutaneous ligation (Fig. 1).11Davat Du traitement curatif des varices.J d conn med Prat, Par. 1837-1838; 5 (102-4): 69-72Google ScholarLigation and saphenous vein stripping was first suggested by Madelung12Madelung H Uber die ausschalung cirsoider Varicen an den unteren Extremitaten.Verhandl Deutsch Gesellsch Chir. 1884; 13: 114-117Google Scholar in 1844. Trendelenburg's operation, which he introduced in 1880,13Trendelenburg F Uber die unterbindung der vena saphena magna bei unterschenkelvaricen.Beitrage zur Klinischen Chirurgie. 1890; 7: 195-210Google Scholar was the forerunner of modern surgery for varicose veins. It consisted of double ligation and division of the long saphenous vein below the saphenofemoral junction. Instrumentation to facilitate removal of the saphenous vein began in 1905 with Keller,14Keller WL A new method of extirpating the internal saphenous and similar veins in varicose condition.New York Medical. 1905; 82: 385-386Google Scholar who described removal of segments of vein by passing a wire through the lumen of the vein (Fig. 2). Fig. 2The Keller method of extirpation of vein by passing the twisted wire intraluminally for extraction. (From Keller WL. A new method of extirpating the internal saphenous and similar veins in varicose condition. New York Medical 1905;82:385. Reprinted with permission from Ochsner A, Mahorner H. Varicose veins. St. Louis: C. V. Mosby Co., 1939:29.)View Large Image Figure ViewerDownload (PPT)This is followed by the external vein stripper designed by Mayo in 1904.15Mayo CH Treatment of varicose veins.Surg Gynecol Obstet. 1906; 2: 385-388Google Scholar Shortly thereafter, Babcock suggested a modification of the Keller method and introduced the acorn-tipped intraluminal stripper, which bears a strong resemblance to the modern disposable plastic stripper.16Babcock WW A new operation for extirpation of varicose veins of the leg.N Y Med J. 1907; 86: 153-156Google Scholar As early as 1904, Tavel17Tavel E Die Behandlung der Varicen durch die kunstliche Thrombose.Deutsche Atschr Chir. 1912; 116: 735Crossref Scopus (1) Google Scholar and, in 1916, Homans18Homans J The operative treatment of varicose veins and ulcers, based upon a classification of these lesions.Surg Gynecol Obstet. 1916; 22: 143-158Google Scholar called attention to the advisability of ligation of the long saphenous vein high above any of its collaterals to prevent recurrence. This dictum still holds true in modern day varicose vein surgery. Unfortunately, treatment of varicose veins is often delegated to the most junior staff who have mediocre knowledge of the disease. The recurrence rate is high if the initial procedure is not conducted properly. Controversy continues about saving the long saphenous in the thigh, but evidence is growing that stripping from groin to knee level gives better results than simple flush ligation of the saphenofemoral junction alone.19Sarin S Scurr JH Coleridge Smith PD Stripping of the long saphenous vein in the treatment of primary varicose veins.Br J Surg. 1994; 81: 1455-1458Crossref PubMed Scopus (156) Google Scholar, 20Bergan JJ Saphenous vein stripping and quality of outcome.Br J Surg. 1996; 83: 1025-1027Crossref Scopus (28) Google Scholar Recently, neovascularization at the groin has been accepted as a major cause of recurrent connections between the femoral vein and the retained long saphenous vein.21Darke SG The morphology of recurrent varicose veins.Eur J Vasc Surg. 1992; 6: 512-517Abstract Full Text PDF PubMed Scopus (145) Google Scholar As a result of this observation, some surgeons have suggested ligation of not only the primary tributaries of the saphenofemoral junction but also tributaries that open directly into the femoral vein.22Tibbs DT Varicose veins.in: Oxford textbook of surgery. Oxford University Press, Oxford, U.K1994: 551Google Scholar, 23Ruckley CV Operations for varicose veins.in: 5th ed. Vascular surgery. Chapman and Hall Medical, London1994: 552-557Google Scholar This extended groin ligation combined with long saphenous vein stripping prevents recurrent varicosities. The argument to save the saphenous vein in the thigh for future coronary bypass grafting is not valid because most cardiac surgeons would not like to use a varicose or dilated thigh segment of the saphenous vein as a conduit for coronary artery bypass grafting. In modern days, most vein stripping procedures are done on outpatient basis. Interestingly, as early as 1930, Geza de Takats advocated vein ligation as an ambulatory procedure for these patients.24DeTakats G Ambulatory ligation of the saphenous vein.JAMA. 1930; 94: 1194-1197Crossref Scopus (13) Google Scholar The role of the short saphenous vein has been emphasized by Hobbs,25Hobbs JT A new approach to short saphenous vein varicosities.in: Surgery of the veins. Grune & Stratton, Inc, Orlando, Fla1985: 301-322Google Scholar as its incompetence is often overlooked. He also called attention to the surgical significance of gastrocnemius vein incompetence, the least-known clinical entity to American vascular surgeons.26Hobbs JT The enigma of the gastrocnemius vein.Phlebology. 1988; 3: 19-30Google Scholar Varicose veins are not always a benign disease; we have encountered fatal hemorrhage in these patients.27McCarthy WJ Dann C Pearce WH Yao JST Management of sudden profuse bleeding from varicose veins.Surgery. 1993; 113: 178-183PubMed Google Scholar Varicose veins are common, and yet we knew very little about the epidemiologic variables of varicose veins in America. Reports from abroad indicate that female sex, increased age, pregnancy, geographic site, and race are risk factors.28Callam MJ Epidemiology of varicose veins.Br J Surg. 1994; 81: 167-173Crossref PubMed Scopus (568) Google Scholar, 29Abenhaim L Kurz X Norgren L Clement D The management of chronic venous disorders of the leg (CVDL): an evidence-based report of an international task force. McGill University, Montreal1995Google Scholar Also, the pathogenesis of this condition remains poorly understood. A familial tendency is common, and the development of varicose veins is eventually based on primary valvular insufficiency of the major saphenous trunk, incompetence of the perforating veins, and venous wall weakness. Recently, progesterone receptor, elastase, and lysosomal enzymes have been implicated as contributing factors in the formation of varicose veins.30Perrot-Applanat M Cohen-Solal K Milgrom E Finet M Progesteron receptor expression in human saphenous veins.Circulation. 1995; 92: 2975-2983Crossref PubMed Scopus (63) Google Scholar, 31Hayer M Caporiccio A Pages A Caporiccio G Toueri MF Magnan de Barnier B Lysosomal enzymes and severity of saphen varicosis.Clin Chim Acta. 1991; 203: 343-348Crossref PubMed Scopus (4) Google Scholar, 32Shields DA Andaz SK Sarin S Scurr JH Coleridge Smith PD Plasma elastase in venous disease.Br J Surg. 1994; 81: 1496-1499Crossref PubMed Scopus (71) Google Scholar Also, venous wall weakness as a result of a significant reduction of elastin content of varicose veins has been reported by Gandhi and colleagues.33Gandhi RH Irizarry E Nackman GB Halpern VJ Mulcare RJ Tilson MD Analysis of the connective tissue matrix and proteolytic activity of primary varicose veins.J Vasc Surg. 1993; 18: 814-820Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar The fibrinolytic potential of the venous system is currently an area of research interest. Increased fibrinolytic activity in varicose veins has been reported.34Wolfe JHN Morland M Browse NL The firbrinolytic activity of varicose veins.Br J Surg. 1979; 66: 185-187Crossref PubMed Scopus (64) Google Scholar We have studied tissue-type plasminogen activator (tPA) and urokinase-type plasminogen activator (uPA) in normal and varicose veins. Levels of uPA in the varicose long saphenous veins were significantly higher than in normal veins at both the groin and ankle positions, which suggests a role for uPA in the pathogenesis of varicose veins.35Shireman PK McCarthy WJ Pearce WH Shively VP Cipollone M Kwan HC Yao JST Plasminogen activator levels are influenced by location and varicosity in greater saphenous vein.J Vasc Surg. 1996; 24: 719-724Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Further study using molecular biologic techniques is needed to understand the pathogenesis of varicose veins. Perhaps one of the significant developments in the field of vascular surgery in the late 1960s was noninvasive technology. As a research fellow, my primary assignment was to study limb blood flow in patients with occlusive arterial disease using strain-gauge plethysmography. In 1967, the Doppler ultrasound technique was just being introduced for clinical use. For the first time, we were able to listen to the blood flow of a major vein. Further refinement of technology has made possible the detection of direction of blood flow, recording of blood flow velocity waveforms, and analysis of frequency spectrum. The development of duplex scanning with the ability to image a vessel and to record velocity at the specific site has revolutionized the examination of arteries and veins. An era of noninvasive examination has begun owing to the contribution of D. E. Strandness, incoming president of the American Venous Forum, and his colleagues at the University of Washington, Seattle. In the 1960s, one technique that deserves special mention is the I-125 fibrinogen uptake in the detection of venous thrombosis. Although the technique is no longer in use because of the possibility of viral hepatitis transmission, the I-125 fibrinogen uptake added significant information to our understanding of the natural history of venous thrombosis, especially after surgery. The principle of radioisotope technique was first conceived by Mr. John Hobbs, with whom I had the opportunity to work closely at St. Mary's Hospital.36Hobbs JT Davies JWL Detection of venous thrombosis with 131I-labelled fibrinogen in the rabbit.Lancet. 1960; 2: 134-135Abstract PubMed Scopus (61) Google Scholar The I-125 fibrinogen technique paved the way for the development of various preventive measures for postoperative deep vein thrombosis. In 1972, I returned to the States and joined John Bergan at Northwestern University Medical School, and we began to establish a Blood Flow Laboratory for clinical use. Venous thrombosis is common, and the first patient with deep vein thrombosis was recorded in 1515.37Dexter L Folch-Pi W Venous thrombosis: an account of the first documented case.JAMA. 1974; 228: 195-196Crossref PubMed Scopus (16) Google Scholar The diagnosis of deep vein thrombosis by clinical examination, however, is not always reliable. It soon became apparent that an objective diagnostic test was needed. At that time, both impedance plethysmography and phleborheography emerged as useful diagnostic techniques. We then began to use impedance plethysmography combined with continuous-wave Doppler ultrasound as a standard noninvasive test in patients in whom deep vein thrombosis was suspected. The indirect technique lost its appeal when the B-mode scan was introduced. Compression ultrasonography and, thereafter, the color flow imager became the standard diagnostic test. The duplex scan also provides a better technique to quantitate venous reflux. Also, the venous flow direction and velocity at specific anatomical sites can be recorded accurately. We also developed venous refilling time using photoplethysmography as a screening test for chronic venous insufficiency.38Abramowitz HB Queral LA Flinn WR Nora Jr, PF Peterson LK Bergan JJ The use of photoplethysmography in the assessment of venous insufficiency: a comparison to venous pressure measurments.Surgery. 1979; 86: 434-441PubMed Google Scholar At present, air plethysmography provides a more objective measurement of venous outflow and calf-pump function in these patients. For varicose veins, routine use of duplex scanning before surgery remains uncertain because of the lack of objective studies to firmly establish the validity of routine use. However, there is no doubt that the technique is more reliable than the hand-held Doppler, particularly in the assessment of the saphenopopliteal junction. In recurrent varices, duplex scanning is the most reliable investigation. Duplex scanning is also helpful to resolve the complex anatomy of the popliteal fossa and in patients who have short saphenous vein or gastrocnemius vein incompetence. In patients who have venous ulceration, duplex scanning is as reliable as phlebography in demonstrating the status of the deep veins, and it identifies a subset of patients who may benefit from vein stripping. In 1976, we held the first Northwestern symposium on vascular disease on the topic of Venous Problems. The symposium was dedicated to Dr. Geza de Takats, a well-known Chicago vascular surgeon. At that time, low-dose heparin was just being introduced as a prophylactic measure for deep vein thrombosis. Interestingly, as early as 1960, Dr. Geza de Takats was the first investigator to suggest the principle of low-dose heparin.39de Takats G Anticoagulant in surgery.JAMA. 1950; 142: 527-533Crossref PubMed Scopus (28) Google Scholar At the same time, surgical prevention of pulmonary embolism was also undergoing a rapid evolution. Initial procedures such as intraluminal sutures or ligation have given way to extracaval clips, umbrella, then filter. Further refinement of technology has allowed the placement of the filter percutaneously and has greatly simplified the technique of vena cava interruption. The past three decades have also seen a great advance in our understanding of hematologic risk factors in deep vein thrombosis. Hematologic risk factors that have been found to cause venous thrombosis include deficiency of antithrombin III, protein C or S, the antiphospholipid syndrome, and the recent identification of activated protein C resistance, an autosomal inherited condition caused by a genetic defect, usually in factor V molecule. These tests should be sought in young patients who have deep vein thrombosis. We also know that superficial thrombophlebitis, often considered a benign condition, may be a marker for a hypercoagulable state.40Ascer E Hanson JN DePippo P Lorensen E Superficial vein thrombophlebitis: a marker of hypercoagulability?.in: Presented at the 50th Annual Meeting of The Society for Vascular Surgery, Chicago, IllJune 11-12, 1996Google Scholar Of the Virchow triad in venous thrombosis—stasis, endothelial damage, and coagulability—the endothelial injury has received little attention. Recently, Wakefield et al.41Wakefield TW Strieter RM Wilke CA Kadell AM Wrobleski SK Burdick MO et al.Venous thrombosis-associated inflammation and attenuation with neutralizing antibodies to cytokines and adhesion molecules.Arterioscler Thromb Vasc Biol. 1995; 15: 258-268Crossref PubMed Scopus (167) Google Scholar, 42Wakefield TW Strieter RM Downing LJ Kadell AM Wilke CA Burdick MD et al.P-selectin and TNF inhibition reduce venous thrombosis inflammation.J Surg Res. 1996; 64: 26-31Abstract Full Text PDF PubMed Scopus (61) Google Scholar have found significant inflammatory response in the vein wall in venous thrombosis. They suggested that cell interactions involving neutrophils, monocytes/macrophages, and various kinds of cytokines may play an important role in the pathogenesis of venous thrombosis. The pharmacologic treatment of deep vein thrombosis has undergone gradual evolution since Crafoord et al.43Crafoord C Heparin and postoperative thrombosis.Acta Chir Scand. 1939; 82: 319-335Google Scholar, 44Crafoord C Jorges JF Heparin as a prophylactic against thrombosis.JAMA. 1941; 116: 2831-2835Crossref Scopus (37) Google Scholar introduced heparin for treatment and prevention of deep vein thrombosis. Various dose regimens in conjunction with aspirin or warfarin have been suggested. The introduction of low–molecular weight heparin has great appeal because laboratory monitoring and dose adjustment are no longer needed. Low–molecular weight heparin can be used safely for outpatient treatment of deep vein thrombosis.45Levine M Gent M Hirsh J Leclerc J Anderson D Weitz J A comparison of low-molecular-weight heparin adminstered primarily at home with unfractional heparin administered in the hospital for proximal deep-vein thrombosis.N Engl J Med. 1996; 334: 677-681Crossref PubMed Scopus (1248) Google Scholar This is of particular appeal in the managed care environment because reduction of hospital stay can be achieved safely. From 1976 on, the Division of Vascular Surgery at Northwestern has continued the mission in postgraduate education by holding a 2 ½-day symposium every December. In 1984 and then in 1990, we sponsored symposia on “Surgery of the Veins” and “Venous Disorders,” respectively. Experts in their own field were invited to provide an in-depth presentation of various venous problems. We also published a book to accompany each meeting. This task afforded me a unique opportunity to keep pace with developments in various aspects of venous disorders. No one in vascular surgery is spared the exposure to venous ulcer. This ancient disease was first mentioned by Hippocrates (460-377 BC).46Hippocrates The genuine works of Hippocrates [Adarns EF, trans.]. vol. 2. Wm. Wood & Co, New York1866: 305Google Scholar In 1676, Richard Wiseman, Sergeant Surgeon to Charles II, coined the term “varicose ulcer” and described a laced stocking for compression treatment (Fig. 3).47Wiseman R Severall chirurgical treatises. Rogston & Took, London1676Google ScholarA leg ulcer caused by a perforating vein was first diagnosed by John Gay in 1868.48Gay J Varicose disease of lower extremities and its allied disorders. Lettsomian Lecturer of 1867. Churchill, London1868Google Scholar He described the perforating veins of the calf and ankle, recorded the fact that ulcers could occur in the absence of varicose veins if there had been postthrombotic damage to the deep veins, and introduced the term “venous ulcer.” In 1916, John Homans first popularized the concept of ulcers as those associated with varicose veins of the leg, easily cured by removal of these veins, and as postthrombotic ulcers as always intractable to treatment.18Homans J The operative treatment of varicose veins and ulcers, based upon a classification of these lesions.Surg Gynecol Obstet. 1916; 22: 143-158Google Scholar Since then, venous ulcer continues to be a challenging problem for surgeons. At present, there is no breakthrough for treatment of venous ulcer, and gradient compression therapy pioneered by Conrad Jobst remains the mainstay of treatment.49Schad F Conrad Jobst. M.E. Media Words & Pictures Inc, Columbus, Ohio1979Google Scholar Surprisingly, Unna paste, introduced in 1893, is highly effective in healing venous ulcer.50Laufman H Selections from the dermatological writings of Dr. P.G. Unna, The New Sydenham Society, 1893.in: The veins. Silvergirl, Inc, Austin, Tex1986Google Scholar Subfascial ligation of perforating veins, introduced by Linton in 1938,51Linton RR The communicating veins of the lower leg and the operative technique for their ligation.Ann Surg. 1938; 107: 582-593Crossref PubMed Google Scholar the modification of Linton's operation by Dodd,52Dodd H The diagnosis and ligation of incompetent perforating veins.Ann Royal Coll Surg Engl. 1964; 34: 186-196PubMed Google Scholar and Rob's procedure53Rob C Surgery of the vascular system.in: University of Minnesota, Minneapolis1972: 267Google Scholar have only historical value. Most surgeons now favor compression treatment. Whether the new technique using endoscopy-assisted perforator ligation will make a difference awaits the conclusion of a multicenter trial being conducted by Dr. Peter Gloviczki. Other than reflux from incompetent perforating veins, we know very little about the pathogenesis of ulcer formation. In 1982, Browse and Burnand proposed that oxygen diffusion into the tissues of the skin was restricted by a pericapillary fibrin cuff that they had observed.54Browse NL Burnand KG The cause of venous ulceration.Lancet. 1982; 2: 243-245Abstract PubMed Scopus (469) Google Scholar The fibrin deposited around the capillary forms a barrier to the passage of oxygen and other nutrients that sustain the cells of the epidermis. This leads directly to cell death and ulceration. The white cell theory originated with Coleridge Smith and Scurr.55Coleridge Smith PD Scurr JH Current views on the pathogenesis of venous ulceration.in: Venous disorders. W. B. Saunders Co, Philadelphia1991: 36-54Google Scholar They suggested that white cell sequestration (trapping) may cause degradation of tissues. Adhesion of white cells to endothelium, activation of neutrophils, and release of free radicals all cause tissue damage. In liposclerotic skin, they found significant increase of white cells. The “trap” hypothesis was suggested by Falanga and Eaglstein of Miami University.56Falanga V Eaglstein WH The “trap” hypothesis of venous ulceration.Lancet. 1993; 341: 1006-1007Abstract PubMed Scopus (265) Google Scholar This was based on the assumption that macromolecules leaking into the dermis as a result of venous hypertension bind or “trap” growth factors and matrix material, which then become unavailable for tissue repair and for the maintenance of tissue integrity. All of these theories point toward the need for a molecular biologic approach to study venous ulcer formation. Of interest in the treatment of venous ulcer is the renewed attention to identifying varicose veins as the contributing factor. Several reports have mentioned the use of duplex scanning or refilling time to identify this group of patients.57Grabs AJ Wakely MC Nyamekye I Ghauri ASK Poskitt KR Color duplex ultrasonography in the rational management of chronic venous leg ulcers.Br J Surg. 1996; 83: 1380-1382Crossref PubMed Scopus (57) Google Scholar, 58Coleridge Smith PD. Impact of duplex ultrasound scanning in varicose vein surgery.in: Progress in vascular surgery. Appleton & Lange, Stamford, Conn1997: 523-533Google Scholar Unlike arterial bypass grafting for arterial occlusive disease, bypass grafting for venous occlusion continues to be a surgical challenge. Development of venous bypass grafting started with Warren and Thayer59Warren R Thayer T Transplantation of the saphenous vein for post-phlebitic stasis.Surgery. 1954; 35: 867-876PubMed Google Scholarin 1954 on the use of saphenous vein for bypassing a postthrombotic occlusion of the superficial vein, and the operation was further developed by Husni60Husni EA Clinical experience with femoropopliteal venous reconstruction.in: Venous problems. Year Book Medical Publishing, Chicago1978: 485-492Google Scholar in 1970 and May61May R Der Femoralisbypass beim postthrombotischen Zustandsbild.Vasa. 1972; 1: 267Google Scholar in 1972. Iliac vein occlusion was first similarly treated by femorofemoral bypass by Palma et al.62Palma EC Esperon R Vein transplants and grafts in the surgical treatment of the postphletitic syndrome.J Cardiovasc Surg (Torino). 1960; 1: 94-107PubMed Google Scholar in 1958. The technique was further popularized by Dale63Dale WA Crossover vein grafts for relief of iliofemoral venous block.Surgery. 1965; 57: 608-612PubMed Google Scholar and Halliday et al.64Halliday P Harris J May J Femorofemoral crossover grafts (Palma operation): a long-term follow-up study.in: Surgery of the veins. Grune & Stratton, Orlando, Fla1985: 241-254Google ScholarIn recent years, polytetrafluoroethylene grafts have been used for femorofemoral crossover grafting with simultaneous reconstruction of an arteriovenous fistula to maintain graft patency.65Gruss JD Venous bypass for chronic venous insufficiency.in: Venous disorders. W. B. Saunders, Philadelphia1991: 316-332Google Scholar The fistula is then ligated several months later. Maintaining patency of venous bypass grafts is often difficult because of the low flow rate of venous flow and, possibly, hematologic factors that predispose the graft to thrombosis. In acute venous thrombosis, thrombectomy has nearly become extinct from the surgical scene in this country. However, some European colleagues have claimed success in restoring flow in acute iliac vein thrombosis by combining thrombectomy with an arteriovenous fistula.66Ekhof B Juhan C Neglen P Iliofemoral thrombectomy and temporary arteriovenous fistula.in: Atlas of venous surgery. W. B. Saunders, Philadelphia1992: 223-231Google Scholar In our vascular service, we have used vein bypass grafting for thrombotic occlusion only in selected instances. Another frequent use of bypass grafting is in patients who have nonthrombotic conditions. These include panel grafting for popliteal venous aneurysm resection,67Winchester DJ Pearce WH McCarthy WJ McGee GS Yao JST Popliteal venous aneurysms.Surgery. 1993; 114: 600-607PubMed Google Scholar spiral grafting for superior vena cava syndrome,68Yao JST Pearce WH McCarthy WJ Reconstructive venous surgery.in: Venous disorders. W.B. Saunders, 1991: 306-315Google Scholar and brachial vein grafting for patients who have hemodialysis arteriovenous fistula with subclavian thrombosis and in patients who have thoracic outlet compression syndrome. One of the most intriguing developments to occur in venous surgery in the past three decades is venous
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