Large vein reconstructions in the endovascular era

Abstract

SummaryMax Ratschow was a remarkable physician and an international authority in the field of angiology and the Ratschow lectureship helps to fulfill this pioneer’s life purpose: to advance evaluation and treatment of vascular diseases. The 2017 Max Ratschow lecture covers some recent advances and controversies in venous diseases. Phlebology, once a neglected field of angiology, is a discipline that has been in constant progress during the past decades. Endovascular techniques revolutionized treatment of patients with large vein obstruction and provided safe, minimally invasive procedures with excellent long term results. Attention now need to focus on comparative studies to provide scientific evidence of efficacy of venous angioplasty and stenting with properly organized randomized controlled trials. Further attempts are needed to develop special venous stents and to decrease thrombotic complications and formation of pseudointima that cause in-stent restenosis. Open and hybrid reconstructions are safe and durable, but the number of procedures in general is small and special training and expertise for reconstructive venous surgery is recommended. Autologous vein should be used for infrainguinal reconstructions and for treatment of unilateral iliac vein obstruction with a femoro-femoral cross-over bypass (Palma procedure). IVC and iliac vein reconstructions with ePTFE grafts provide superb result in patients who need excision of malignant tumors invading large veins. Open and hybrid reconstructions are here to stay and they remain excellent options for those patients who are unsuitable for or fail endovascular repair.