Intraoperative Venography Research Articles

Eliminating the "Pitfalls" of chronic indwelling central venous access device placement in cancer patients by utilizing a venous cutdown approach and by selectively and appropriately utilizing intraoperative venography

There are several very obvious and simple solutions for eliminating the "Pitfalls" and for minimizing the risk of occurrence of any perioperative complications associated with placement of chronic indwelling central venous access devices in cancer patients. The first is the utilization of a venous cutdown approach, such as the cephalic vein or the external jugular vein, which essentially eliminates potentially life-threatening perioperative complications, such as pneumothorax and injury to the great vessels (with or without associated hemothorax). The second is the selective and appropriate utilization of intraoperative venography for defining the central venous anatomy and for providing a venous roadmap in those particularly challenging cases in which difficulties are encountered during chronic indwelling central venous access device placement.

Surgical Thrombectomy Followed by Intraoperative Endovascular Reconstruction for Symptomatic Ilio-femoral Venous Thrombosis

Objectives To evaluate the efficacy of surgical thrombectomy combined with endovascular reconstruction for acute ilio-femoral/caval venous thrombosis. Methods Twenty consecutive patients with acute, symptomatic ilio-femoral/-caval thrombosis underwent valve-preserving thrombectomy with immediate endovascular repair between October 1996 and October 2003. Thrombectomy was classified by intraoperative venography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because endovascular repair was not performed. Results Left-sided venous thrombosis predominated (90%). Lesions were located in the common iliac vein (85%), the external iliac vein (10%), and the inferior vena cava (5%). Three TYPE II lesions and 17 TYPE III lesions (11 spurs, one hypoplasia, one fibrosis, one haematoma, and three others) were diagnosed. Catheter-directed recanalisation (thrombectomy/thrombolysis) resolved TYPE II lesions in three patients. Balloon angioplasty (one patient), iliac stenting (15 patients [two with thrombolysis]), and caval stenting (one patient) were employed in TYPE III stenoses. No serious complication or death occurred. Mean follow-up was 21 months. Of 20 patients clinical results were excellent in 18 patients who maintained patency of their reconstructed iliac veins. Primary and secondary patency rates were 80 and 90%, respectively. Conclusions Ilio-caval venous obstructions detected intraoperatively can be reconstructed in a one-stage combined procedure. The specific endovascular approach depends on the type of residual venous obstruction. Excellent mid-term results indicate that the proposed thrombectomy classification (TYPE I–IV) and treatment algorithm optimises the results in selected patients with symptomatic venous thrombosis.

Combination treatment of venous thoracic outlet syndrome: Open surgical decompression and intraoperative angioplasty

Residual subclavian vein stenosis after thoracic outlet decompression in patients with venous thoracic outlet syndrome is often treated with postoperative percutaneous angioplasty (PTA). However, interval recurrent thrombosis before postoperative angioplasty is performed can be a vexing problem. Therefore we initiated a prospective trial at 2 referral institutions to evaluate the safety and efficacy of combined thoracic outlet decompression with intraoperative PTA performed in 1 stage. Over 3 years 25 consecutive patients (16 women, 9 men; median age, 30 years) underwent treatment for venous thoracic outlet syndrome with a standard protocol at 2 institutions. Twenty-one patients (84%) underwent preoperative thrombolysis to treat axillosubclavian vein thrombosis. First-rib resection was performed through combined supraclavicular and infraclavicular incisions. Intraoperative venography and subclavian vein PTA were performed through a percutaneous basilic vein approach. Postoperative anticoagulation therapy was not used routinely. Venous duplex ultrasound scanning was performed postoperatively and at 1, 6, and 12 months. Intraoperative venography enabled identification of residual subclavian vein stenosis in 16 patients (64%), and all underwent intraoperative PTA with 100% technical success. Postoperative duplex scans documented subclavian vein patency in 23 patients (92%). Complications included subclavian vein recurrent thrombosis in 2 patients (8%), and both underwent percutaneous mechanical thrombectomy, with restoration of patency in 1 patient. One-year primary and secondary patency rates were 92% and 96%, respectively, at life-table analysis. Residual subclavian vein stenosis after operative thoracic outlet decompression is common in patients with venous thoracic outlet syndrome. Combination treatment with surgical thoracic outlet decompression and intraoperative PTA is a safe and effective means for identifying and treating residual subclavian vein stenosis. Moreover, intraoperative PTA may reduce the incidence of postoperative recurrent thrombosis and eliminate the need for venous stent placement or open venous repair.

Selective use of preoperative venous duplex ultrasound and intraoperative venography for central venous access device placement in cancer patients.

Central venous access in cancer patients is often challenging. A history of access is common. Appropriate indications for venous imaging studies are not clearly defined. This study was a retrospective analysis of selective use of preoperative venous duplex ultrasound and intraoperative venography in 248 consecutive cancer patients undergoing central venous access placement. Ninety patients had a history of central venous access placement. Eleven had a history of deep venous thrombosis of an upper extremity or central vein. One hundred three underwent preoperative ultrasound. Previous central venous access placement was not associated with an abnormal preoperative ultrasound; however, previous central venous access with deep venous thrombosis was (P =.014). Thirty patients underwent intraoperative venography, of which 18 also had preoperative ultrasound. Fifty percent of patients with an abnormal intraoperative venogram had no abnormal findings on preoperative ultrasound. Routine preoperative ultrasound is unnecessary. We advocate the selective use of preoperative ultrasound in those with a history of central venous access associated with deep venous thrombosis. We advocate the use of intraoperative venography when there is difficulty advancing the guidewire or catheter or when preoperative ultrasound is negative despite a history of central venous access with deep venous thrombosis.

Selective Use of Preoperative Venous Duplex Ultrasound and Intraoperative Venography for Central Venous Access Device Placement in Cancer Patients

Selective Use of Preoperative Venous Duplex Ultrasound and Intraoperative Venography for Central Venous Access Device Placement in Cancer Patients

Simultaneous Microsurgical Spermatic Vein Ligation and Sclerotherapy

Objectives: Microsurgical ligation as well as antegrade sclerotherapy have been established in varicocele treatment. The aim of this study was to evaluate whether a combination of microsurgery and sclerotherapy can provide a safe and effective treatment of varicocele recurrence or persistence. Methods: Nine patients with recurrent or persistent varicoceles were operated by means of the combination method. Under microscopic control varix veins were ligated selectively preserving lymphatics and arteries. Ectopic veins as a possible source for varicocele persistence or recurrence were also ligated. Finally, an intraoperative venography with subsequent sclerotherapy was performed through one of the dissected veins. Results: Despite difficult anatomical situations after previous surgical interventions, the operations were performed successfully without any complications. Clinical controls showed varicocele disappearance without damage of the testis. No varicocele recurrence or persistence was observed. Conclusions: This method combines the advantages of both methods. Precision of the microsurgical technique is combined with velocity of sclerotherapy. Thus, it may represent an interesting alternative to conventional operation methods especially in the treatment of recurrent or persistent varicoceles.

RECURRENCE OF VARICOCELE AFTER HIGH RETROPERITONEAL REPAIR: IMPLICATIONS OF INTRAOPERATIVE VENOGRAPHY

We determined whether intraoperative venography results in a decreased recurrence rate after varicocele repair in adolescence. We evaluated 177 male adolescents 14 to 19 years old who underwent varicocele repair via the high retroperitoneal approach with artery sparing and intraoperative venography. Overall the recurrence rate was 2.8% (5 of 177 cases) in the venography group and 11% in historical controls without venography. We identified left-to-right cross communicating vessels in 3 patients with recurrence. Intraoperatively venography revealed nonligated vessels in 21 patients (12%), resulting in revision and repair during the same procedure. Intraoperative venography seems to decrease the rate of recurrence. Left-to-right cross communicating vessels may be present in some adolescents with recurrence after varicocelectomy.

Phlegmasia Cerulea Dolens in a Patient with Ulcerative Colitis Treated by Iliofemoral Venous Thrombectomy

The authors present the case of a 17-year-old woman with ulcerative colitis who presented with phlegmasia cerulea dolens (PCD) of the right leg. On examination, the compartments of her right leg were tense, sensory and motor function were greatly diminished, and pedal pulses were absent. Venous duplex revealed extensive venous thrombosis from the tibial veins to the external iliac vein. Treatment consisted of anticoagulation with systemic heparinization, and she was brought to the operating room for intraoperative venography, inferior vena caval filter placement, and four-compartment fasciotomy. Arterial pulses did not return; therefore, venous thrombectomy was performed by extrusion of distal thrombus with an Esmarch bandage, and fluoroscopic guided balloon catheter thrombectomy of the distal inferior vena cava and iliac veins proximally. Completion venography revealed the absence of residual thrombus. Postoperatively, the patient developed a lower gastrointestinal hemorrhage and anticoagulation was terminated. The fasciotomy skin incisions underwent delayed closure on postoperative day 6, and the patient was subsequently discharged with compression stockings. Total abdominal colectomy with creation of a J-pouch was performed 1 month following discharge. After 1 year, the patient had no complaints related to her leg. On examination, no evidence of venous insufficiency was present. Venous duplex demonstrated a patent deep venous system with no evidence of reflux. Uncomplicated PCD responds to heparin therapy in 50-80% of patients, but the risk for developing the postphlebitic syndrome is high. Venous thrombectomy has been reported to provide better long-term functional outcome. Catheter-directed thrombolysis has the added theoretical benefit of preserving endothelial and valvular function, and high technical success rates have been reported. No long-term functional outcome results for thrombolysis are available. Thrombolysis is contraindicated if compartment syndrome or venous gangrene is present. The aggressive surgical management of PCD may result in improved outcome.

The influence of surgical approach and intraoperative venography on successful varicocelectomy in adolescents: L.S. Palmer, M. Maizels, W.E. Kaplan, et al. J Urol 158:1201–1204, (September), 1997

The influence of surgical approach and intraoperative venography on successful varicocelectomy in adolescents: L.S. Palmer, M. Maizels, W.E. Kaplan, et al. J Urol 158:1201–1204, (September), 1997

Transvenous Embolizations of Venous Compartments of Dural Arteriovenous Fistulas within Venous Sinus Walls

Transvenous embolization of venous compartments within the venous sinus wall was the method initially attempted for closing dural arteriovenous fistulas in 15 patients (22 sinuses). The venous channel, separate from the sinus lumen and located in the venous sinus wall, could be embolized in 6 lesions (3 patients), including 3 superior sagittal sinus fistulas, 2 transverse sinus fistulas, and 1 straight sinus fistula. This technique resulted in closure of the fistulas and preservation of sinus patency as well as immediate improvement of clinical symptoms. The embolizable venous compartment of the fistula within the venous sinus wall could be detected by preoperative angiography, magnetic resonance imaging, and intraoperative venography. This unique drainage of dural arteriovenous fistulas may develop concurrently with more obvious portions of the fistula. Transvenous embolization of these venous compartments can close the fistulas and normalize impaired sinus function.

The Influence of Surgical Approach and Intraoperative Venography on Successful Varicocelectomy in Adolescents

We evaluated the importance of intraoperative venography and surgical approach on varicocele recurrence after surgical varicocelectomy in male adolescents. The analysis was done using local data and composite data from the literature. We reviewed the records of patients undergoing varicocele ligation between 1986 and 1995 at our institution. Data were stratified by surgical approach and performance of venography, and compared by cross table analysis. Data were then compiled from the literature from series that included cases stratified according to surgical approach and/or performance of venography. The impact of these parameters on recurrence rates was assessed by computing success rates and cross table analysis. At our institution 33 boys underwent ligation via a suprainguinal (27) or inguinal (8) approach. Intraoperative post-ligation venography was performed in 16 cases and omitted in 19. Neither surgical approach nor performance of venography influenced the recurrence rate in these patients (not statistically significant). Similarly, venography did not affect the recurrence rate after stratification by surgical approach (not significant). The overall success rate was 97% (34 of 35 cases). These data were added to those of 3 published studies, totaling 252 varicoceles with comparable groupings. Mean success rate after a suprainguinal and inguinal approach was 95.6 (93.2 to 97.4) and 88.3% (82.7 to 100%), respectively. Recurrence tended to be less common after a suprainguinal than an inguinal approach (p = 0.06). Post-ligation venography did not statistically affect the success rate after stratification according to surgical approach but it was associated with a higher success rate when performed with the inguinal approach. Irrespective of the performance of venography, the suprainguinal surgical approach yields higher success rates than the inguinal approach to varicoceles in adolescents. Post-ligation intraoperative venography fails to affect significantly the success of varicocele ligation but it may be useful during an inguinal approach.

The Influence of Surgical Approach and Intraoperative Venography on Successful Varicocelectomy in Adolescents

Purpose We evaluated the importance of intraoperative venography and surgical approach on varicocele recurrence after surgical varicocelectomy in male adolescents. Materials and Methods The analysis was done using local data and composite data from the literature. We reviewed the records of patients undergoing varicocele ligation between 1986 and 1995 at our institution. Data were stratified by surgical approach and performance of venography, and compared by cross table analysis. Data were then compiled from the literature from series that included cases stratified according to surgical approach and/or performance of venography. The impact of these parameters on recurrence rates was assessed by computing success rates and cross table analysis. Results At our institution 33 boys underwent ligation via a suprainguinal (27) or inguinal (8) approach. Intraoperative post-ligation venography was performed in 16 cases and omitted in 19. Neither surgical approach nor performance of venography influenced the recurrence rate in these patients (not statistically significant). Similarly, venography did not affect the recurrence rate after stratification by surgical approach (not significant). The overall success rate was 97% (34 of 35 cases). These data were added to those of 3 published studies, totaling 252 varicoceles with comparable groupings. Mean success rate after a suprainguinal and inguinal approach was 95.6 (93.2 to 97.4) and 88.3% (82.7 to 100%), respectively. Recurrence tended to be less common after a suprainguinal than an inguinal approach (p = 0.06). Post-ligation venography did not statistically affect the success rate after stratification according to surgical approach but it was associated with a higher success rate when performed with the inguinal approach. Conclusions Irrespective of the performance of venography, the suprainguinal surgical approach yields higher success rates than the inguinal approach to varicoceles in adolescents. Post-ligation intraoperative venography fails to affect significantly the success rate of varicocele ligation but it may be useful during an inguinal approach.

Intraoperative Spermatic Venography Reconsidered

Intraoperative Spermatic Venography Reconsidered

Extended vein ligation: a new aspect of the surgical treatment of varicocele.

Conventional varicocelectomy is complicated by a postoperative recurrence rate of 5-20% in patients with varicocele. On the other hand, the exact location and relationship of the internal, external and gubernacular veins, arteries and lymphatics within the inguinoscrotal portion of the spermatic cord have not been well described. The results of detailed intraoperative observations and surgical dissection of the spermatic cord and gubernaculum are presented in 32 patients with clinically palpable varicocele. Following the identification of all veins within and around the spermatic cord and gubernaculum, dilated veins originating from the testis and traversing the gubernaculum were observed in 31% of the patients. External spermatic veins were present in 70% of all spermatic cords evaluated. The majority of patients (> 65%) had more than 3 internal spermatic veins. An average of 3.1 lymphatics per spermatic cord was identified and preserved during dissection of the cord. A solitary testicular artery was observed in 55% of the patients treated. In 3 patients with recurrent varicocele, by using intraoperative venography, we tried to demonstrate the relationship between the gubernacular, external spermatic veins and the plexus pampiniformis. Our results indicate that by giving a precise attention to varicocele anatomy and performing an extended vein ligation, better results together with decreased recurrence rates may be obtained.

Significance of Intraoperative Venographic Patterns on the Postoperative Recurrence and Surgical Incision Placement of Pediatric Varicoceles

Intraoperative post-ligation spermatic venography has proved to be a reliable adjunct in pediatric varicocele surgery. In a previous study we described the technique and initial results. In this series of 60 consecutive patients with pediatric varicoceles having intraoperative venography, we specifically studied the collateral venous circulation and crossover veins to characterize the venographic patterns associated with varicocelectomy failure. The relationship of incision site and number of venograms necessary to ensure complete interruption of the internal spermatic system was evaluated to determine if an optimum incision placement exists, minimizing the number of venograms necessary. Our data indicate that the most common etiology of recurrent varicocele in children seems to be residual proximal (central) collateral veins, pelvic collateral veins (that is cremasteric, deferential and crossover veins) rarely seem to contribute to varicocelectomy failure and there is an inherent but low risk of varicocelectomy failure despite radiological evidence of complete internal spermatic vein interruption.

Routine Intraoperative Post-Ligation Venography in the Treatment of the Pediatric Varicocele

Varicocelectomy in the adult is followed by a relatively low recurrence rate but children treated by conventional techniques seem prone to have more frequent recurrences. We believe that the higher recurrence rate observed in children after routine varicocelectomy actually represents residual varicose communications that had been missed at the primary operation. Routine post-ligation intraoperative venography has been used to detect these occult communications in 26 children undergoing varicocelectomy. Our results indicate a low recurrence rate (3.6 per cent), suggesting that routine use of this procedure with childhood varicocelectomy is beneficial.

Renal Cell Carcinoma Invading the Inferior Vena Cava: The Use of the Greenfield Filter to Prevent Tumor Emboli During Nephrectomy

Renal cell carcinoma with tumor thrombus extension into the inferior vena cava occurs in approximately 5 per cent of the cases. Despite invasion of the inferior vena cava an aggressive surgical approach for these neoplasms is recommended but prevention of a tumor thrombus pulmonary embolus during operation is necessary. Placement of a suprarenal Greenfield filter, with its ease of insertion, excellent late patency rates and minimal morbidity, has made it the procedure of choice today. Preoperative venacavography with radiopaque marking of the tumor thrombus will prevent filter displacement, malpositioning and the awkward use of intraoperative venography, while shortening operative time and minimizing patient risk.

Femoral vein thrombosis and total hip replacement.

Of 160 patients who underwent total hip replacement, 81 developed venographic evidence of thrombi in the operated leg. In 46 cases (57%) the thrombus originated from the femoral vein, and in 43 of these the exact site of origin was defined by venography. In 34 cases (74%) the thrombus arose from the wall of the femoral vein at the level of the lesser trochanter. This region was studied by intraoperative venography in eight patients undergoing total hip replacement, and in every case severe distortion of the common femoral vein was observed, producing almost total occlusion. We suggest that intraoperative damage to the femoral vein results from manipulation of the leg, and that this is one reason why the operation is followed by a high incidence of deep vein thrombosis in the upper femoral region.