Retroperitoneal Venous Compression Syndromes:

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1 Retroperitoneal Venous Compression : A new surgical strategy based on qualitative and quantitative duplex ultrasound examination in the presence of CTA and/ or MRI imaging W. Sandmann 1, 2, 3 T. Scholbach 3 K. Verginis 2 S. Jacobi 2 K. Rademacher 2 1 HH University Düsseldorf 2 Dept. of Vascular Surgery, EVK Mettmann 3 University of Leipzig

2 Vascular Compression Etiology and Causes Changes of body physics due evolutional antomy: Evolution Heritage Genetic Trauma Modern Life Others From four to two legs and two arms from parents to child connective tissue disease (EDS) Clavicula, vertebral too much, too little physical activity malignant disease, AAA

3 Retroperitoneal Compression and anatomic Region Inferior Vena Cava Compression Nutcracker (posterior; anterior) MAY-THURNER (venous spur, fibrous ring) Internal Iliac Vein Compression Rectal and Pudendal Vein Compression Definition (except for trauma): The Concept of Compression is based on standard morphological imaging in supine body position. Functional (non-static) Duplex-Ultrasound Examination in variable body positions shows that flow acceleration relates to distention of that vein. There is no cracking in anterior Nutcracker.

4 Retroperitoneal Compression According to the hemodynamically based concept of Distention rather than on the morphological appearance of Compression the treatment modalities have to be adapted. Pelvic Congestion is the end stage of impaired drainage out of the left renal and the left common iliac vein and out of the inferior vena cava. The concept of treatment must improve venous return flow to the heart instead of closing collaterals with coiling.

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8 Retroperitoneal Compression Stenting the left renal vein and the left common iliac vein can localy increase the diameter of the vein but does not take into account the distention of the veins and the IVC due to vertebral lordosis. ( stretching ) The ideal Treatment: Lengthening of the distended veins Increasing the diameter if necessary Protection against real compression (squeezing) Protection against temporarily increased risk of thrombosis

9 The concept and the treatment of venous compression in the Retroperitoneum, but may also in other anatomical regions, should be rethought and reassessed. Even a major vein like the IVC can show functional stenosis and interruption of flow by stretching without beeing occluded morphologically. Our concept of transposition, patching stretched veins with autogenous venous material and elongating stretched major veins with autogenous veins and prosthetic bypass material, corrects the overstretching, opens the anatomic space to normal and redirects the flow within the collaterals instead of obstructing those with coils leading to thrombosis. Additional stenting may be an option to maintain the achieved venous diameter in individual cases.

10 Definition: NKS anterior Compression (Distention) of the left renal vein between Aorta and SMA NKS posterior Compression between the Aorta and the Vertebra

11 Techniques of surgical Treatment: (Mayo Clinic 2015)

12 Therapy SANDMANN (1): Transposition of SMA as for WILKIE-Syndrome

13 Therapy SANDMANN (2): Vein Patch into the left Renal Vein and the Inferior Vena Cava

14 Postoperativ Preoperativ

15 Definition MAY-Thurner-Syndrome: Compression left common Iliac Vein between the right common Iliac artery and the Promontorium

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18 Definition Pelvic Congestion: Congestion and venous Hypertention in the pelvis and Gonadal Veins

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23 Venous Compression Syndrome (retroperitoneal) Pat Pat n= 110 (total) n= 50 (total) With neurological Deficit Pat. n=5 (female) sensitive 1 motoric 4 Age (y) 14-60; Mean 30,5 y Gender: female/ male 9:1

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26 Venous Compression Syndrome (retroperitoneal) Patients with neurological Deficit Operative Results Paresis and Paraparesis disappeared (one patient arrived on crutches, went home without, 3 patients arrived in a wheel chair, went home walking) Conclusion The decompression of the left renal vein and of the left common iliac vein reduced the pressure within the para- and intraspinal collaterals and leads to normal function of the spinal nervous system.

27 Summary and Conclusions: The Symptoms and Findings in patients with visceral and retroperitoneal Compression are located on a broad scale. The Patients very often travel from country to country and from Doctor to Doctor and as the Compression are not recognised those Patients end up desperated and being categorised as psychotic and are advised to take pain medication and go to Psychiatry although many loose subtantial body weight and die. Internist and Gastroenterologist have problems to memories that within the abdomen are a number of important arteries and veins. It is very important to consider Compression as cause of their disease.

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29 Thank you for your attention!