Reconstructive procedures of the large veins are infrequently undertaken, yet there may be situations when a vascular surgeon is forced to reestablish or alter a patient's venous circulation. These procedures are technically demanding and often require unusual technical solutions. Many of these reconstructions are undertaken within interdisciplinary team efforts as an adjunct to major tumor surgery, transplantation surgery, or excessive trauma. Over the years, the indications for venous bypass have been changing, but numbers of venous bypass procedures still remain relatively low.
INDICATIONS FOR VENOUS RECONSTRUCTION
The indications for venous reconstructive surgery are summarized in Table 34-1. It is known that under special circumstances, occluded veins may not need any reconstruction at all.1 Even the entire infrarenal inferior vena cava (IVC) can be sacrificed safely during extensive tumor surgery as long as the occlusion or stenosis has created sufficient collateralization. On the other hand, severe morbidity may be prevented if a patent vein, when resection because of tumor encasement is necessary, is reconstructed within the same procedure.2,3 In addition, it has been known for a long time that venous repair of civilian and battlefield vascular trauma leads to an improvement of limb salvage and reduces long-term morbidity.4
TABLE 34-1.Indications for Reconstructive Surgery of the Large Veins
In transplantation surgery, especially in liver and kidney transplantation, the portal vein or the venous drainage of the graft may be too short.5,6 A number of vascular procedures are available for overcoming this special problem. In recent years, because of the increasing use of central lines, long-standing central vein catheters, and pacemaker leads, venous congestion of the head and upper extremities caused by a fibrotic vena cava constriction has become an increasing problem.7 Although endovascular approaches have demonstrated acceptable mid-term relief of symptoms, reconstruction of the superior vena cava (SVC) and its great side branches is increasingly needed, mostly because of reocclusion after endovascular treatment.8
The choice of conduit for venous bypass depends on the location of the repair, the urgency of the intervention, and the availability of autologous material. In general, autologous vein is the material of choice. Nevertheless, the more central the repair and the less the risk of infection, the more alloplastic grafts may be used safely with good results. The different conduits are summarized in Table 34-2.
TABLE 34-2.Suitable Conduits for Reconstructive Surgery of Large Veins