LEV 1. Endovenectomy of the Common Femoral Vein as Last Option in Severe Post-thrombotic Syndrome

Abstract

The common femoral vein (CFV) and iliac veins compose the common channel for venous drainage of the lower extremity. Occlusive venous thrombosis of the CFV and iliac veins is associated with severe post-thrombotic syndrome and in some cases with nonhealing vein ulcers. After percutaneous intervention, relative obstruction of the CFV can persist, leading to incomplete drainage of the femoral and profunda femoris venous systems, thereby mitigating the benefit of iliac vein recanalization and risking rethrombosis; associated restenosis intrastent could occur, resulting in a great challenge for endovascular management. We describe a patient with incapacitating post-thrombotic syndrome and nonhealing ulcer who underwent angioplasty and stenting in the left common and external iliac veins, presenting with an occlusion intrastent that was impossible to cross with endovascular techniques. For this reason, a common femoral endovenectomy was performed, which allowed the ulcer to heal in 1 month after surgery. A 50-year-old man presented with left lower extremity pain, swelling, discoloration, and a venous ulcer above the lateral and medial malleolus. His medical history includes a left lower extremity deep venous thrombosis in 2012 (iliofemoral segment). He underwent angioplasty and stenting in the left common and external iliac veins in 2015, present ulcer healing. In 2018, he returned to our consultation with a residual ulcer. At that time, he had left leg pain and edema, which limited his daily activities, as well as a 3-cm-diameter venous ulcer above the lateral malleolus and 2 cm above the medial malleolus. The patient was offered a hybrid procedure to treat the chronic proximal venous obstruction, consisting of an open endovenectomy of the CFV and angioplasty. A 10-cm longitudinal incision was made at the left inguinal region. The CFV was identified and referenced with vessel loops. Five profunda femoris veins were controlled (Fig 1), and a venotomy was performed on the CFV. Dense synechiae and endoluminal fibrous tissue were excised. A bovine patch was placed in the venotomy. After that, a 5F introducer was placed over the path; phlebography was performed, observing intrastent occlusion in the common and external iliac veins with important collaterality. After several attempts, it was determined to be impossible to cross the occlusion of the stent. The procedure was finished with the potential to perform a femoral-femoral vein bypass as a second procedure 1 month after the endovenectomy (Fig 2). In this case, the patient’s symptoms improved and the vein ulcers healed 1 month after endovenectomy despite occlusion in the common and external iliac veins. Endovenectomy is a well-known but uncommonly reported procedure that could improve the symptoms of patients with post-thrombotic syndrome and help to heal vein ulcers even when the common and external iliac veins are occluded.Fig 2Healed ulcer 1 month after surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)