Venous stasis complications of the use of the superficial femoral and popliteal veins for lower extremity bypass

Transcription

1 Venous stasis complications of the use of the superficial femoral and popliteal veins for lower extremity bypass Michael Coburn, MD, Charles Ashworth, MD, Warren Francis, MD, Christopher Morin, MD, Maryam Broukhim, MD, and Wilfred I. Carney, Jr., MD, Providence, R.I. Purpose: The widely accepted durability of autogenous vein for infrainguinal arterial bypass has led the authors to use the superficial femoral and popliteal vein in selected cases. The results of this experience are presented. Methods: From January through December 1991, during which 92 lower extremity bypass procedures were performed, deep vein bypass was attempted in seven patients (three femoral-popliteal grafts, two femoral-peroneal grafts, one femoral-deep femoral bypass, and one popliteal-posterior tibial bypass). In all cases the saphenous vein was absent or inadequate for use as a bypass conduit. The superficial femoral vein was harvested to below the knee in five patients. Results: At last follow-up six of seven patients had patent grafts with relief of their original symptoms. All the procedures were complicated by venous stasis; acute postoperative phlegmasia developed in two cases. In one of these cases the limb was salvaged by below-knee fasciotomy and deep venous bypass (distal popliteal vein to common femoral vein with polytetrafluoroethylene). In the other case an above-knee amputation was required. Of the five remaining patients three had moderate venous stasis edema unresponsive to limb elevation and compression stockings after operation, and two have had resolution of minimal postoperative venous stasis with simple limb elevation. All cases of severe and moderate venous stasis occurred in patients with popliteal vein harvest to below the knee. Conclusions: The authors conclude that the use of the deep veins of the lower extremity for bypass is effective but is associated with a significant increase incidence of venous stasis edema. Two instances of phlegmasia were associated with popliteal vein harvest below the knee, and the authors caution against harvest of the popliteal vein to this level. (J VASe SURG 1993;17: ) With concern for a perceived potential for increased incidence of complications, we have very selectively applied the use of the superficial femoral and popliteal vein as a conduit for lower extremity arterial bypass. The problem of autogenous vein substitution for arterial reconstruction in the absence of a suitable saphenous vein has been extensively addressed by From the Rhode Island Hospital, Vascular Surgery Service, Brown University School of Medicine, Providence. Presented at the Nineteenth Annual Meeting of the New England Society for Vascular Surgery, Dixville Notch, N.H., Sept , Reprint requests: Wilfred I. Carney, Jr., MD, 110 Lockwood St., Providence, RI Copyright 1993 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter /93/$ /6/46199 Schulman et al., 14 who have pioneered the use of superficial femoral-popliteal vein for lower extremity arterial revascularization. Although these authors report acceptable patency rates and minimal morbidity rates, the results to date have not been substantiated by other authors. We report our entire early experience with the selective use of deep veins for lower extremity bypass. The superficial femoral vein and popliteal vein were harvested as described by Schulman et al. 2"4 A longitudinal incision was made along the course of the superficial femoral vein beginning at its cephalad junction with the deep femoral vein. The dissection was carried distally along the course of the vein, its numerous branches were ligated with placement of two sets of three clips on either side and division of the branches. The dissection was carried through the adductor canal and to the knee joint level with a skin 1005

2 1006 Coburn et al. lune 1993 incision that ended at the knee joint line. In several cases harvest of the popliteal vein was carried distal to the level of the takeoff of the anterior tibial vein. In most cases there was a significant taper of the vein to this level, and the devalved vein was placed in a nonreversed fashion. The valves of the deep vein were lysed with a modified Mills valvulotome (V. Mueller, McGaw Park, Ill.). The superficial femoral vein was divided at its junction with the deep femoral vein, and the junction was sutured in continuous fashion to perserve the communication of the deep femoral vein with the common femoral vein. In no case was there interruption of the deep femoral vein. CASE REPORTS (Table I) Case 1. This patient is a 71-year-old man with cerebrovascular disease and coronary artery disease who had undergone coronary artery ing with right saphenous vein. The patient presented with severe claudication and a nonhealing ulcer of his right leg. Peripheral pulses were absent in that limb. The ankle/brachial index (ABI) was Arteriography revealed a right superficial femoral artery occlusion. The patient's left greater saphenous vein (GSV) had been previously used for a left femoral-peroneal bypass. The lesser saphenous and arm veins were not considered for grafting in any of the seven patients. A femoral-popliteal bypass was constructed with superficial femoral vein-popliteal vein to below the knee. During follow-up the arterial occlusive symptoms completely abated, and the ulcer healed (ABI 0.90), but severe venous stasis edema persisted for 21/2 years, remitting somewhat at 3 years with knee-high elastic support. At last follow-up the patient's right ankle was 5 cm greater in circumference than his left ankle. A venogram revealed large tibial veins that communicated to a large deep femoral vein in the thigh. Case 2. This patient is a 77-year-old man with a history of coronary artery disease (previous coronary artery bypass), cerebrovascular disease, and laminectomy who presented with severe clandication and a nonhealing ulcer of the right leg. Peripheral pulses were absent (pressure readings were not obtained). A left distal superficial femoral artery occlusion was diagnosed by arteriography. Because both saphenous veins were unavailable (the left was previously used for left femoral-popliteal bypass), a femoral-popliteal bypass was created with superficial femoral-popfiteal vein harvested to above the knee. The patient has done well after operation, with resolution of the claudication. Minimal venous stasis occurred but resolved with limb elevation only. However, the ulcer did not heal, and the patient underwent a transmetatarsal amputation that subsequently healed. Case 3. This patient is a 78-year-old woman with diabetes and coronary artery disease. She presented with rest pain and a nonhealing ulcer of her left lower extremity. She had undergone a left and right femoral-popliteal bypass with both greater saphenous veins. Because of her new symptoms, absent peripheral pulses, and a decline in her ABI to 0.65, arteriography was performed, which revealed a graft occlusion. At surgery the superficial femoral vein-popliteal vein was harvested to below the knee bilaterally for use as a conduit. Femoral-peroneal bypass was performed. Although her symptoms resolved after operation, with an improvement in ABI to 0.89, 10 months later the patient remains troubled by persistent marked venous stasis edema. Limb elevation and compression stockings have not relieved her venous stasis edema. Case 4. This patient is a 55-year-old man with hypertension and cerebrovascular disease who had claudication that progressed to rest pain in a limb that was previously revascularized with a femoral-popliteal bypass graft with greater saphenous vein. In addition, a nonhealing ulcer was present. Peripheral pulses were absent, and the ABI was Arteriography revealed that the femoralpopliteal had occluded. After examination of the left greater saphenous vein in the operating room revealed a narrow sclerotic vein, a femoral--deep femoral artery bypass with the superficial femoral vein (above-knee harvest) was constructed. The patient's symptoms disappeared, and the ABI improved to 1.0. Minimal venous stasis developed that resolved simply with limb elevation. Case 5. This patient is a 64-year-old man with coronary artery disease (previous coronary artery bypass with saphenous vein) and rest pain of his right lower extremity. Absent pulses and a ABI of 0.33 were discovered by physical examination. Arteriography revealed a right superficial femoral artery occlusion and moderate tibial artery disease. At surgery the patient was found to have unex-~ pectedly severe distal vascular disease. A small thin-walled GSV was found at surgery. A femoral-popliteal bypass with polytetrafluoroethylene was followed by a popliteal to posterior tibial bypass with composite superficial femoral vein and GSV. The patient had severe venous stasis edema that progressed to phlegmasia followed by graft failure. An above-knee amputation was required. Case 6. The progression of claudication to rest pain (ABI 0.50) in the right lower extremity of this relatively healthy 54-year-old woman prompted performance of arteriography. This demonstrated a right distal superficial femoral artery occlusion. At operation both GSVs were examined and were believed to be too small and sclerotic for use as a. The patient underwent a femoral-popliteal bypass with the superficial femoralpopliteal vein harvested to below the knee. After operation the patient had tense venous stasis edema. The operated ankle circumference was 9 cm greater than the circumference of the unoperated side. Motor and sensory fimction below the knee were markedly diminished. Large skin vesicles formed at midcalf. The clinical diagnosis of phlegmasia and possible compartment syndrome was made. Four-compartment fasciotomy was performed. After fasciotomy the venous stasis edema of thigh, calf, and foot persisted. A venous decompression with polytetrafluoroethylene was performed from the distal

3 Volume 17, Number 6 Coburn et al Table I. Intraoperative findings and procedures Dissection of superficial Operating room Estimated Intraoperativ Patient Status of GSV Type of surgery femoral vein time blood loss trano%sion 1 R coronary artery Femoral-popfiteal To below knee 6 hr 40 min 700 None, L femoral peroneal 2 R coronary artery Femoral-popliteal To below knee 6 hr 30 min 350 None, L femoral peroneal 3 R femoral popliteal Femoral peroneal To below knee 5 hr 10 min 900 2U, L (bilateral) femoral popliteal 4 R femoral popliteal Femoral-deep femoral To above knee 3 hr 53 min 500 None, L sclerotic 5 R coronary artery Femoral-popliteal To below knee 11 hr 20 min U, popliteal-posterior tibial bypass graft, composite (SFV, GSV) 6 2 mm diameter R femoral- To below knee 7 hr 16 min 400 None popliteal bypass graft 7 R femoral- Femoral peroneal To below knee 6 hr 15 min 800 2U popliteal bypass (bilateral) graft, L narrow sclerotic popliteal vein to the common femoral vein. Venous bypass ~. esulted in immediate relief of tense calf and foot edema, with restoration of normal sensation and motion. Although the patient's convalescence was long, her original symptoms resolved (ABI 1.0), and all her wounds healed. The venous decompression was found to be occluded by duplex examination at 1 month. The patient now has minimal venous stasis and is fully ambulatory. Case 7. This patient is an 84-year-old woman with cerebrovascular disease. She presented with rest pain and a nonhealing ulcer of her left foot. Peripheral pulses were absent, and the ABI of 0.40 was recorded. Multiple superficial femoral artery high-grade occlusions were seen by arteriography. The patient's right greater saphenous vein had been previously used in femoral-popliteal bypass graft, and at surgery her left greater saphenous vein was thin-walled and sclerotic. Therefore a femoral-peroneal bypass with the superficial femoral vein-popliteal vein from both lower extremities was constructed. In each limb the vein harvest was carried to below the knee. Symptoms were relieved after operation (ABI 1.0), but moderate venous stasis developed. This resolved with limb elevation and compression stockings. DISCUSSION The use of the deep vein for femoral-popliteal bypass has been extensively studied by Schulman et al.14 The authors' recent publications report a 70% 3-year patency rate with a 4% mortality rate and a 10% mobidity rate. Of note, significant postoperative venous stasis was not witnessed in any patient after 6 months of follow-up. In a comparative series reported by Schulman et al., 2 ankle circumference at 1 month was increased by 2.64 cm in cases with superficial femoral vein and by 1.74 cm in cases with reversed greater saphenous vein. At 36 months the superficial femoral vein limbs were 0.54 cm larger compared with 0.5 cm for limbs with reversed greater saphenous veins? Our recent efforts with the deep vein for dialysis access demonstrated a high rate of both complications and venous stasis (unpublished data, January 1992). Similarly our experience with deep veins for femoropopliteal and more distal bypass reveals a number of venous stasis-related problems. The most serious complications included venous stasis edema, two instances ofphlegmasia, and a graft failure. Venous stasis was judged to be moderate to severe in four patients. In each incidence harvest of the superficial femoral vein extended to below the knee. When the vein was not taken to below the knee, venous stasis was minimal and resolved in a few

4 IOURNAL OF VASCULAR SURGERY 1008 Coburn et al. June 1993 months with simple leg elevation. The presence or absence of the GSV did not seem to affect the incidence of postoperative venous stasis, because it was present in three of four patients who had significant venous stasis and was absent in all patients who had only minimal venous stasis. It seems prudent to limit harvest of the superficial femoral vein to above the knee. Phlegmasia after lower extremity revascularization is uncommon. Reasons for its development include iliofemoral vein thrombosis and deep venous system injury. -In both instances the dissection of the superficial femoral vein was carried to below the knee, and presumably the extent of venous tributary ligation led to phlegmasia. Excision of the deep veins to the distal popliteal is reported by Schulman et al.2 to be a source of no more than minimal calf and ankle venous stasis edema. In contrast, we encountered frequent difficulties with venous stasis edema, including two instances of phlegmasia. Finally, acute graft failure occurred in one patient in association with phlegmasia. This somewhat overzealous attempt at distal reconstruction failed in large part because of poor distal runoff vessels. However, the severe venous stasis edema was asso- ciated with hemodynamic instability and seemed to hasten deterioration of the limb. In conclusion, the superficial femoral and popliteal veins are readily available and effective conduits for arterial bypass in the lower extremity, but their use entails added risk of venous stasis-related problems. The risk of phlegmasia seems to increase when deep vein harvest involves the belowknee popliteal segment. REFERENCES 1. Schulman ML, Schulman LG. Deep leg veins as femoropopliteal s. World I Surg 1990;14: Schulman ML, Badhey MR, Yatco R. Superficial femoralpopliteal veins and reversed saphenous veins as primary femoropopfiteal s: a randomized comparative study. J VASC SURG 1987;6: Schulman ML, Badhey MR, Yatco R, Pillari G. A saphenons alternative: preferential use of superficial femoral and popliteal veins as femoropopliteal s. Am J Surg 1986;152: Schulman ML, Badhey MR, Yatco R, Pillari G. An ll-year experience with deep leg veins as femoropopliteal s. Arch Surg 1986;121: Submitted Oct. 8, 1992; accepted Feb. 1, DISCUSSION Dr. Bruce C. Cutler (Worcester, Mass.). I have been intrigued, just as the authors were, by the enthusiastic reports of Dr. Martin Schulman from Great Neck, New York. However, I have been skeptical that the harvest of long segments of the superficial femoral vein could be as benign a procedure as described by Dr. Schulman. My apprehension about this procedure was nicely stated by John Bergan in an editorial in the Yearbook of Vascular Surgery 1986 (Chicago: Mosby-Year Book, 1986: chap 11.) in which he said, ' l'he use of deep veins, as suggested by Schulman and colleagues, is provocative or perhaps unbelievable, especially because they reported insignificant late morbidity. This work must be repeated in another institution before it can be accepted as an additional procedure in femoral distal ing." Dr. Carney and his group are to be congratulated for courageously accepting Dr. Bergan's challenge. As of 1990, Dr. Schulman had performed 93 vein grafts with an 84% 3-year patency rate. In evaluating the merits of the work of Dr. Schulman and now Dr. Carney, it is important to realize that both studies are primarily descriptions of a new surgical technique. Therefore I think it is important that we hold in abeyance questions regarding the indications for operation and the availability of alternate sources of autogenous vein and concentrate on the potential use of deep veins as a graft material. If we exclude the one patient who may have had an ill-advised composite graft with poor runoff, the authors have had a 100% patency rate with complete relief of symptoms in their other six patients. However, with more experience can the frequency of operative complications be reduced? Is Dr. Schulrnan doing something that you are not? I have carefully reviewed his articles looking for explanations for some of the problems that you encountered. He mentions the following as important points, and herein lie my questions for Drs. Coburn and Carney. Dr. Schulman obtains routine preoperative venograms and rejects any anomalous veins or veins that are greater than 12 mm in diameter. Did you perform preoperative venography? Dr. Schulman also advises against harvesting deep veins in patients who have had a previous femoropopliteal bypass graft. Although he does not give the reason, I presume that the lymphatic disruption in the popliteal fossa added to that

5 Volume 17, Number 6 Cobl, t1~l et al produced by the previous harvest of the saphenous vein, may lead to more postoperative edema. In this connection, you had two patients who had previous femoropopliteal s, with development of moderate postoperative edema in one. Would you please comment? Dr. Schulman advises against the use of composite grafts. If you had followed this admonition, you might have avoided the only patient who had a failed graft and underwent amputation. They also use orthograde devalved veins to reduce the size discrepancy at the distal anastomosis. Did you use this technique? Dr. Schulman points out that because the superficial femoral vein terminates 8 cm caudal to the bifurcation of the common femoral artery and because most of his grafts originate from the superficial or deep femoral artery, there is no need to dissect in the region of the common femoral artery and vein. This may further decrease lymphatic obstruction and postoperative edema. Did your dissections involve the region of the common femoral artery? I hope that Drs. Coburn and Carney and the Rhode Island group are not discouraged by their initial results with this technique. I suspect that with more experience, they will be able to define the indications for the use of deep veins for infrainguinal grafting. Dr. Michael Coburn. Dr. Shulman's articles were extensively reviewed before these operations were undertaken, and some of the procedures that we performed were very similar to what he had performed. We use orthograde devalved veins and avoid dissection around the common femoral artery. However, we do not routinely perform preoperative venography on these patients; despite the ~aveat of previous surgery, two of the patients had had "previous surgery, and both had severe edema. So we believe that these may, as Dr. Shulman has pointed out, be patients who should not undergo this operation. I think a few other reasons for the discrepancy between his data and our data may be that we were a little bit more aggressive in our patients. One patient who did have graft failure had severe ischemia. The operation was performed on a semiurgent basis, and obviously we would avoid this operation on this type of patient in the future. In addition, all the patients were very, very active. One patient is a farmer, and that may make a difference. I'm not sure how active Dr. Shulman's patients were, but these patients were very active and often could not follow the advice of leg elevation and use of compression stocking that we offered them. Dr. William M. Abbott (Boston, Mass.). The Rhode Island group is to be congratulated for further evaluation of this concept for revascularization ofischemic extremities. After I expressed some skepticism about this at a national meeting several years ago, Dr. Shulman replied very vigorously. However, what I said at that meeting was that I am very fearfifl that there would be a significant amount of edema after these procedures, that it would be very destructive to the lower extremity to perform the harvest, and that it would be worse if you had to take it out distal to the adductor canal. Furthermore I thought that the vein itself would be too big in many instances and that it was a fragile structure that in essence might be too weak and would develop aneurysmal dilation over time. Although Dr. Shulman was quite annoyed with me after that meeting, he has pressed forward. And I am very glad to see that someone else is doing the same. However, I must conclude, and I wish that you would respond to this, that I've heard nothing in this presentation this morning to give me enthusiasm that my original skepticism was not justified. Dr. Coburn. Although the patient number is very small and there were two patients who did very well, these are the patients who did not have extremely ischemic extremities, and they underwent above-the-knee harvest of the vein. These patients had minimal edema that resolved within 1 month after operation, and they have not had any complications. I think these patients benefited from this operation and these are the type of patients that would do well from this type of operation when the greater saphenous vein is unavailable. Regarding aneurysmal complications, all these patients have been monitored up to the present time, and the longest follow-up was 19 months, and that patient does not have any problem with aneurysmal-type complications at this point. Dr. Willard C. Johnson (Boston, Mass.). Because I've performed one of these operations, I guess I have the right to make a comment. My patient initially had an in situ graft to the distal leg that failed 1 year later, and the patient presented with acute ischemia. A femoropopliteal aboveknee procedure with the superficial femoral vein was performed, and the outcome has been good except for moderate edema. I think that this type of operation should rekindle our interest in the registry concept to evaluate a larger number of these bypasses. Dr. Coburn. I think that's an excellent idea. It's difficult to draw any conclusions from seven patients, and I think a larger number of procedures performed by a greater number of vascular surgeons would be very helpful. Dr. Jens Jorgenson (Portland, Maine). In this day and age I think most of us make a great effort to use autologous tissue such as lesser saphenous vein, arm vein, and so on. If you're going to fillet the leg open from the groin down to the knee, why not use thromboendarterectomized superficial femoral artery? Most of the time, it will be occluded. Dr. Coburn. That was not contemplated during these operations. We set out before operation to perform these procedures on these patients if the greater saphenous vein was not available or was inadequate, and because of the work of Shulman we were very encouraged. We had discussed the operation with him, so that's basically what we set out to do.