Ann Thorac Surg 2001;72:957-958
© 2001 The Society of Thoracic Surgeons
How to do it
Iliac vein replacement with a descending aortic homograft
Ashok Handa, FRCSb,
Satoshi Saito, MDa,
Narain Moorjani, FRCSa,
Stephen Westaby, FRCSa
a Department of Cardiothoracic Surgery, Oxford Heart Centre, Oxford, United Kingdom
b Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, United Kingdom
Accepted for publication April 17, 2001.
Address reprint requests to Dr Saito, Department of Cardiothoracic Surgery, Oxford Heart Centre, John Radcliffe Hospital, Oxford OX3 9DU, United Kingdom
e-mail: satoyum{at}aol.com
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Abstract
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We describe successful replacement of the iliac vein using a descending aortic homograft. The ilio femoral system was avulsed after recannulation of the femoral vein during a third cardiac reoperation.
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Introduction
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Iliac vein avulsion is an unusual and taxing complication of femoro-femoral cardiopulmonary bypass. Venous replacement is possible using prosthetic material (polytetrafluoroethylene) or autologous spiral saphenous vein grafts. The alternative, ligation, may result in severe chronic leg edema. This article describes the successful management of complete iliac vein avulsion secondary to femoral venous decannulation using a small-caliber descending aortic homograft from our own tissue bank.
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Technique
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A 36-year-old male with Noonan’s syndrome was operated on for relief of right ventricular outflow tract (RVOT) obstruction. He had previously undergone open pulmonary valvotomy and two pulmonary valve replacements: the first with a porcine xenograft at the age of 12 years and the second with an aortic homograft replacement 13 years later. The homograft became obstructive 8 years later. Femoro-femoral cannulation and cardiopulmonary bypass were used to decompress the right ventricle and reduce the risk of exsanguinating hemorrhage on reentry. Dense adhesions were found between the right ventricle and sternum as in the previous operation. The RVOT obstruction was successfully relieved with a homograft outflow patch and cardiopulmonary bypass was discontinued. On venous decannulation, resistance was encountered and a 12-cm length of ilio-femoral vein was avulsed despite the great care to avoid this. Direct repair was not feasible. Once surgical haemostasis had been achieved with a Foley balloon catheter, the vertical groin incision was lengthened superiorly by 5 cm and the inguinal ligament divided to provide retroperitoneal access. The gap in the external iliac vein extended from the origin of the common iliac vein proximally to the common femoral vein distally. The internal iliac vein was ligated due to uncontrollable bleeding. A 12-mm thoracic aortic homograft, previously harvested from an 8-year-old child, was prepared by ligating the intercostal branches with 5/0 Prolene or ligation clips. It was divided just distal to the origin of the donor left subclavian artery and proximal to the abdominal aorta to create a 15-cm tube. This graft was anastamosed to the origin of external iliac vein proximally and to the common femoral vein distally using 5/0 Prolene. The tube provided an excellent caliber match (Fig 1). On removal of the vascular clamp, venous return was established from the leg and there were no postoperative complications. An echo Doppler scan 7 days later showed the tube graft to be patent. The patient had subcutaneous heparin injection for 5 days and then oral aspirin (75 mg). Repeat scan at 6 weeks again confirmed good flow in the graft (Fig 2). The patient had no limb swelling and normal arterial Doppler pressure at the ankle at 3 months postoperatively.
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Fig 1. Descending aortic homograft anastamosed end-to-end to the external iliac vein proximally and common femoral vein distally.
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Fig 2. Duplex at 6 weeks showing a patent neo-iliac vein descending the aortic homograft. (IIA = internal iliac artery.)
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Comment
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Several factors contribute to a high incidence of thrombosis in venous replacement grafts. These include low pressure and low flow velocity in the venous system, external compression by intraabdominal pressure, and the tightly confined space under the inguinal ligament. In the event of trauma, there may be ragged vessel edges [1]. Reconstructive venous surgery has previously been hampered by the lack of large-caliber biological conduits and inferior patency rates of prosthetic grafts in the venous system [2]. The introduction of autologous spiral saphenous vein grafts (SSVG) and expanded polytetrafluoroethylene (ePTFE) grafts with external ring supports have partly improved this.
Autologous spiral saphenous vein grafts were first described in 1974 to replace the superior vena cava [3]. They confer the advantage of reduced thrombogenicity in comparison with prosthetic conduits and allow veins of any caliber to be reconstructed. However, the construction of these grafts increases operative time and they are prone to compression under the inguinal ligament. The ring-supported ePTFE conduit is able to withstand external compression forces and reduce lumen narrowing. This prevents approxmation of thrombogenic surfaces and turbulence of blood flow, which may stimulate thrombus formation. The long-term patency rate with ringed ePTFE grafts in the venous system is not satisfactory [4]. The use of prophylactic anticoagulation is still recommended with these prosthetic grafts.
The use of small aortic homografts in subclavian and innominate vein reconstruction has been described previously [5]. In emergency situations, the choice of graft for reconstruction can be very limited. In our case, we were fortunate to have a small aortic homograft in the tissue bank, which provided excellent size match. It prevented the need to harvest and construct the SSVG or give postoperative anticoagulation, as would be the case for any readily available prosthetic graft. The alternative, ligation of the vein, may result in problems of chronic limb swelling, venous claudication, and stasis ulcers.
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References
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Chiu C.J., Terzis J., MacRae M.L. Replacement of superior vena cava with the spiral composite vein graft. Ann Thorac Surg 1974;17:555-560.[Abstract/Free Full Text]
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Plate G., Hollier L.H., Gloviczki P., Dewanjee M.K., Kaye M.P. Overcoming failure of venous vascular prostheses. Surgery 1984;96:503-510.[Medline]
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Abstract
Introduction
