INTRAOPERATIVE PICTURES OF THE PROCEDURE DONE AT VARIOUS STAGES OF COMPLETION.
Major surgical venous reconstructions have decreased remarkably in the era of endovascular interventions.Open surgical major venous reconstructions are reserved for patients either with failed endovascular approach or for those who are not candidates for the same.Trauma and Malignancy are the two main conditions wherein open surgical reconstructions of the major veins are still done and probably may continue in the years to come.Graft patency in venous reconstructions has been a major issue of concern.Reason for this being the low flow low pressure state in the venous system.The use of adjunct arteriovenous fistula(AVF) has dramatically increased the patency rates to acceptable levels.
We report to you a similar case of a woman aged 50 years with underlying Malignancy.She had her radiotherapy done and landed up with massive swelling of both the lower limbs more on the thighs than legs.A thorough investigation revealed her left iliac vein to be totally occluded with short length occlusion of the right iliac vein and proximal IVC.She was in a real bad shape as she was not able to walk much and the swelling had involved her groin region as well.There was a strong possibility of a residual tumor in the pelvis and therefore we planned an exploratory laparotomy for her with the intention to clear the tumour and reconstruct the major veins to relieve venous congestion/hypertension.Intraoperatively we found the vessels to be badly stuck with the spine probably because of extended RT sittings she had in the past.
We did a bifemoro-caval bypass with PTFE graft with an adjunct AV fistula in the groin region for better patency rates.Lifelong anticoagulation is recommended with a plan to maintain the fistula as long as possible ,for a mimimum of 12 weeks.Experience with femoro-caval reconstructions is limited.The longest series I could gather from the internet is for 56 patients by Sottiuari et al with a patency rate of 93% at one year for prosthetic iliac vein reconstructions.
This patient is recovering well with the swelling of the thighs decreasing remarkably.She certainly is in a better shape now.
It was indeed a very unique experience doing a surgery like this for we had heard and read such surgeries only in the textbooks but never were a part of it before.The whole credit should go to my teachers who instilled in me the work culture of “PERSISTENCE AND HARD WORK”.
