PALMA PROCEDURE FOR VENOUS CLAUDICATION:IS IT FORGOTTEN

Venous surgeries in our modern day scenario are more or less limited to surgery of the varicose veins.This paradigm shift probably comes from the very fact that different vascular surgery centres have given different results regarding venous surgeries over a period of time.Unfortunately these indifferent surgical results also stem from the fact that the choice of patients was not appropriate and venous surgery was in its infancy.All said and done,venous surgery is here to stay provided we stick to the basic rules of vascular surgery,know basics of venous heamodynamics and pathophysiology and institute timely treatment to the patients.An example to quote is the fresh revival of interest in venous thrombectomies in acute cases especially after the work presented by Germans in different vascular conferences.

We present to you a unique case of a 21 year old young man who came to us with ‘May Turner Syndrome’ which subsequently led to thrombosis of his common and external iliac vein.This patient came with swelling of the left leg and thigh for the last three years and had a recurrent ulcer at his medial ankle region.He was on acitrom for the last almost 3 years but to no avail.He had significant venous claudication and was practically handicapped for life so to speak.We were left with a difficult situation to deal with.A convetional venogram was done which was suggestive of the above mentionted findings.We tried opening the left iliac vein by endovascular methods inspite of me not a keen follower of this methodology and as expected, it did not work.

PALMA procedure was done in him wherein the Great Saphenous Vein was harvested from the right thigh and anastomosed to his left Common Femoral Vein through a crossover procedure thereby restoring the drainage of the left limb through the saphenous vein via Right Iliac Vein.Its almost eight weeks now from the day of surgery and the patient is doing ok.His venous ulcer has healed and the swelling on the leg has reduced remarkably.The patient is on tab.acitrom and compression stockings.I don’t know for how long would this work for him but one thing is for sure i.e its not going to add a great deal to his morbidity.

This procedure is unique for many reasons.One we were never ever taught as to what extra can be done other than routine stuff in patients suffering from CVI resulting from iliac vein thrombosis .Secondly we never came across much of papers presented in National vascular surgery conferences catering to venous diseases other than the usual papers on laser surgery for varicosities.I think its time we have more of venous conferences wherein all these issues are addressed in interactive sessions without any prejudice or else we need to switch back to our standard textbooks for answers for books to me ‘never lie’.