One-year outcomes of a novel venous stent for symptomatic iliofemoral venous obstruction: prospective cohort study.

BACKGROUND: A stent with characteristics of a hybrid design may have advantages in improving the patency of symptomatic iliofemoral vein obstruction. This study assessed the safety and effectiveness of the V-Mixtent Venous Stent in treating symptomatic iliofemoral outflow obstruction. METHODS: Eligible patients had a Clinical-Etiologic-Anatomic-Physiologic (CEAP) C classification of ≥ 3 or a Venous Clinical Severity Score (VCSS) pain score of ≥ 2. The primary safety endpoint was the rate of major adverse events within 30 days. The primary effectiveness endpoint was the 12-month primary patency rate. Secondary endpoints included changes in VCSS from baseline to 6 and 12 months, alterations in CEAP C classification, Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-14) scores at 12 months, and stent durability measures. RESULTS: Between December 2020 and November 2021, 171 patients were enrolled across 15 institutions. A total of 185 endovenous stents were placed, with 91.81% of subjects receiving one stent and 8.19% receiving 2 stents. Within 30 days, only two major adverse events occurred (1.17%; 95% confidence interval [CI], 0.14-4.16%), below the literature-defined performance goal of 11% (P < .001). The 12-month primary patency rate (91.36%; 95% CI, 85.93-95.19%; P < .001) exceeded the literature-defined performance goal. VCSS changes from baseline demonstrated clinical improvement at 6 months (- 4.30 ± 3.66) and 12 months (- 4.98 ± 3.67) (P < .001). Significant reduction in symptoms, as measured by CEAP C classification and CIVIQ-14, was observed from pre-procedure to 12 months (P < .001). CONCLUSIONS: The 12-month outcomes confirm the safety and effectiveness of the V-Mixtent Venous Stent in managing symptomatic iliofemoral venous outflow obstruction, including clinical symptom improvement compared to before treatment.

The Effect of Venous Augmentation on Complication Rates in Deep Inferior Epigastric Perforator Breast Reconstruction.

BACKGROUND: With the rising popularity of the deep inferior epigastric perforator (DIEP) flap in breast reconstruction, use of the superficial inferior epigastric vein (SIEV) to augment venous outflow has been proposed as a strategy to prevent venous congestion, a complication positively associated with flap volume. This study evaluated the impact of routine SIEV venous augmentation on the risk of vascular complications or operative fat necrosis in the context of flap size and operating time. METHODS: A retrospective cohort study compared complication rates of patients with SIEV-augmented DIEP flaps to controls over a 3-year period. Outcomes assessed included vascular complications, defined as venous congestion or compromise requiring take-back, partial flap necrosis, total flap loss, as well as operative fat necrosis. Relative risk was modeled by Cox proportional hazard regression analysis. Sensitivity analysis was performed to assess for an interaction effect by flap mass. RESULTS: The study sample included 197 patients with 316 flaps. The mean mass of the SIEV-augmented flaps was significantly greater than in the control group (832.9 vs. 653.9 g; p = 0.0007). After adjustment for flap characteristics, patient demographic factors, and comorbidities, pooled risk of vascular complication and operative fat necrosis was found to be significantly lower in the SIEV-augmented group compared to controls (hazard ratio = 0.33, 95% CI [0.11-1.00]; p = 0.0489). Sensitivity analysis demonstrated no effect interaction by flap weight (p = 0.5139). CONCLUSION: Routine venous outflow augmentation via anastomosis of SIEV to the internal mammary vein perforator at the second intercostal space significantly reduced the risk of vascular complications and operative fat necrosis, regardless of flap weight. No significant increase in operative time was observed among cases in which augmentation was performed.

Endovascular treatment of symptomatic hepatic venous outflow obstruction post major liver resection.

PURPOSE: To evaluate efficacy, safety, and outcomes of endovascular treatment of hepatic vein stenosis post major liver resection. METHODS: A retrospective data analysis was performed including all interventional treatments of hepatic vein stenosis post major liver resection since 2010. Post procedural course and clinical parameters including amount of ascites accumulation and relevant laboratory values were assessed during the follow-up period. Primary and primary assisted hepatic venous patency time were calculated. RESULTS: Twelve patients (median age 55.5, IQR 49.75 to 61.5 years) undergoing a total of 16 interventions were included. Interventions were primary stent placement (n = 3), primary balloon angioplasty (n = 8), three re-interventions and two aborted interventions (no significant pressure gradient). Technical success was 100% (16/16). Permanent reduction and / or complete resolution of ascites was achieved in 72% (8/11). Laboratory parameters related to liver function did not show significant improvement after intervention. Median follow-up period was 6 months (IQR: 1.5 to 18 months). The median primary patency time for patients with balloon angioplasty was 11 months (IQR: 1.375 to 22.25 months) and assisted patency time was 13.25 months (IQR: 4.5 to 22.25 months). The median primary patency time for patients with angioplasty and stent placement was 1 months (IQR: 1.0 to 1.5 months) and assisted patency time was 2.0 months (IQR: 1.5 to 2.5months). CONCLUSION: An endovascular approach for the treatment of hepatic venous stenosis post major liver resection is safe and efficient to reduce and / or resolve refractory ascites. However, liver function parameters seem not to be improved by the procedure. Stent placement can be a reasonable option in patients with significant residual stenotic disease post angioplasty.

Automatic cerebral computed tomography venographic imaging based on the prior knowledge of cerebral blood circulation.

BACKGROUND AND PURPOSE: Current clinical computed tomography venographic (cCTV) images present limited cerebral venous profiles. Therefore, this study aimed to develop an automatic cerebral CTV imaging technique using computed tomographic perfusion (CTP) images in a cohort of patients with stroke. MATERIALS AND METHODS: We retrospectively evaluated 10 (intracerebral hemorrhage) and 2 (acute ischemic stroke) patients who underwent institutional CTP imaging. CTV images were processed with the proposed CTV (pCTV) technique, and pCTV and cCTV images were then independently evaluated by two experienced neuroradiologists blinded to all clinical information using a novel scoring method that considered overall image quality, venous visibility, and arterial mis-segmentation. Venous visibility was separately evaluated for the dural sinus, superficial vein, and deep vein. Then, statistical analysis was performed to determine whether the pCTV technique was superior to the cCTV technique. RESULTS: In total, 14 sets of pCTV images were generated and compared with cCTV images. The overall image quality and venous visibility scores of pCTV images were significantly higher than those of cCTV images (all values of p<0.05), especially for the dural sinus (median [25th, 75th percentiles], 14.00 [13.63, 15.50] vs. 7.50 [7.00, 10.88]), and superficial vein (9.00 [8.88, 10.00] vs. 3.25 [1.63, 8.25]), while the difference in arterial mis-segmentation was not statistically significant (p= 0.164). CONCLUSIONS: This study proposed an automatic cerebral CTV imaging technique to eliminate residual bone and soft tissues, minimize the impact of the cerebral arterial system, and present a relatively comprehensive cerebral venous system, which would help physicians assess cerebral venous outflow profiles after stroke and seek imaging markers associated with clinical outcomes.

Long-term patency and comparisons of venous outflow in hemodialysis forearm arteriovenous grafts.

INTRODUCTION: This retrospective study investigated the factors and the effects of different venous outflows on forearm arteriovenous graft patency. METHODS: The venous outflow sites included basilic, cephalic, median antecubital, and deep veins. Comparisons among multiple groups were analyzed. FINDINGS: A total of 179 patients with forearm loop arteriovenous grafts met the inclusion criteria. Of these, 72 were basilic, 48 were cephalic, 44 were median antecubital, and 15 were deep. The median observation period was 19 months. The survival rate was 84.9% at 24 months and 78.2% at 48 months. Primary, secondary, and assisted primary patency rates for all arteriovenous grafts were 48.9%, 72.4%, and 68.4% at 12 months; 13.8%, 33.9%, and 23.6% at 24 months; and 0.6%, 4.6%, and 2.3% at 48 months, respectively. Differences in primary patency were statistically significant compared with those of secondary and assisted primary patency (P < 0.05). Primary patency rates for cephalic, median antecubital, basilic, and deep were 47.9%, 48.6%, 47.7%, and 40.0% at 12 months and 12.5%, 13.9%, 22.7%, and 0% at 24 months, respectively. Secondary patency rates for cephalic, median antecubital, basilic, and deep were 75.0%, 69.4%, 75.0%, and 73.3% at 12 months and 39.6%, 30.6%, 38.6%, and 13.3% at 24 months, respectively. There was no significant difference in primary thrombosis among basilic, cephalic, median antecubital and deep. There were no significant differences observed in primary or secondary patency rates among all the groups. Stenoses in the venous anastomosis and outflow vein were frequently observed in all types of arteriovenous grafts. Central venous stenosis was most commonly seen in deep (26.67%). On average, 1.9 interventions per patient were performed on the graft to maintain function. CONCLUSION: Different venous outflow selections were not associated with long-term patency and the occurrence of thrombosis in hemodialysis forearm loop arteriovenous grafts.

Acute cerebral venous outflow obstruction during convexity meningioma resection.

BACKGROUND: Cerebral venous outflow obstruction involves idiopathic intracranial hypertension, and the most common related condition is dural venous sinus stenosis or, in other words, an obstruction of the dural venous sinuses. In these cases, the pathological process is often chronic, displays only mild symptoms, and rarely requires urgent surgical intervention. In this study, we present a unique case involving an acute cerebral venous outflow obstruction that occurred during meningioma resection that ultimately had catastrophic consequences. MATERIALS AND METHODS: The patient's preoperative imaging only revealed an unremarkable frontal convexity meningioma with an average diameter exceeding 8 cm. She was admitted for a scheduled right frontoparietal craniotomy for lesion resection. RESULTS: The patient's unique congenital dural venous sinus structure along with a non-surgical epidural hematoma both contributed to a catastrophic outcome, causing a progressive hemispheric encephalocele, significant blood loss, and wound closure difficulties. CONCLUSION: Neurosurgeons should place an additional focus on cerebral venous outflow patency during tumor resection, even if the tumor does not involve the transverse or sigmoid sinuses. It is well known that the tacking sutures play an essential role in preventing an epidural hematoma, but the procedure to mitigate hematomas occurring outside the surgical field of view is not fully recognized by neurosurgeons. If dural tacking sutures are placed after complete tumor resection, the prophylactic effect for preventing EDH in the non-surgical areas may not be guaranteed. Therefore, we strongly advocate for the tacking sutures to be accurately placed before dural incisions are made.

Elusive Neck Carcinoma Simulating Idiopathic Intracranial Hypertension Due to Jugular Venous Outflow Obstruction - Case Report.

Few cases have been reported of extra-cranial tumours in the neck causing intracranial hypertension due to jugular vein compression and consequent outflow obstruction. We present a case of a patient presenting with transient vision loss due to intracranial hypertension of unidentifiable cause on initial imaging workup. Upon further evaluation, the patient was found to have a neck tumour compressing the right jugular vein with stenosis of the ipsilateral transverse sinus - both contributing to his intracranial hypertension. Atypical patients presenting with symptoms concerning for intracranial hypertension may benefit from imaging below the level of the head to evaluate for extra-cranial causes.

Positional outflow obstruction as a cause of early refractory ascites post-pediatric living donor liver transplantation.

Refractory ascites post-liver transplantation can be a challenging problem. Causes of refractory ascites include venous outflow anastomotic stenosis, vessel kinking by the regenerating liver, pre-existing graft disease, and positional outflow obstruction. We present a case report of a child presenting with high drain output and refractory ascites post-LDLT secondary to a positional kinking. Repeating the Doppler studies with patients both supine and sitting may be helpful.

Non-standard hepatic venous reconstruction in the setting of absent inferior vena cava in partial graft pediatric liver transplantation-A matched retrospective cohort study.

Recipient cava may be unavailable for outflow reconstruction in some children undergoing liver transplantation (PLT) due to caval agenesis, tumor, or fibrotic caval occlusion. Non-standard hepatic venous reconstruction (NHVR) with a direct veno-caval anastomosis or neo-cava reconstruction is necessary in such cases. Retrospective review of all PLT needing NHVR performed in our unit from January 2010 to September 2019 was performed. Outcomes of this group were compared to a 2:1 matched control group who underwent transplantation with standard piggyback technique. Fifteen children (4.9%) of 304 PLT recipients underwent NHVR. Caval agenesis in biliary atresia (n = 5, 33%) and hepatoblastoma infiltrating the cava (n = 4, 27%) were the commonest indications. Ten children had neo-cava reconstruction, while 5 had direct anastomosis to the supra-hepatic caval cuff or right atrium. One child had developed neo-cava thrombosis without graft venous outflow obstruction in the post-operative period. There was no significant difference in major morbidity, need for re-operation (20% vs 16.7%; P = 1.00), hospital stay (24 days, vs 21 days; P = .32), graft & patient survival among the study and control groups. Absent or inadequate recipient cava during PLT with a partial liver graft can be safely managed with technical modifications. Results equivalent to standard piggyback implantation can be achieved.

An Update on the Management of Budd-Chiari Syndrome.

Budd-Chiari syndrome (BCS) is an uncommon condition, caused by obstruction to hepatic venous outflow. It is largely underdiagnosed, and a high index of suspicion is required for any patient with unexplained portal hypertension. The understanding of its etiology and pathology is improving with advances in diagnostic techniques. Recent studies reported an identifiable etiology in > 80% of cases. Myeloproliferative neoplasm (MPN) is the most common etiology, and genetic studies help in diagnosing latent MPN. Better cross-sectional imaging helps delineate the site of obstruction accurately. The majority of BCS patients are now treated by endovascular intervention and anticoagulation which have improved survival in this disease. Angioplasty of hepatic veins/inferior vena cava remains under-utilized at present. While surgical porto-systemic shunts are no longer done for BCS, liver transplantation is reserved for select indications. Some of the unresolved issues in the current management of BCS are also discussed in this review.

Venous anomalies in hypoplastic posterior fossa: unsolved questions.

INTRODUCTION: Anomalous intracranial venous anatomy is described in patients with syndromic craniosynostosis and is of significant importance when it comes to surgical morbidity. However, it is still controversial its origin, type of circulation in each syndrome, how it behaves over time, when it can be interrupted and wether it needs to be studied. The purpose of this paper is to discuss these issues by reviewing the literature. METHODS: A literature search was performed using the PubMed database with a focus on papers including detailed descriptions of the venous outflow in complex and syndromic craniosynostosis. Search details used were the following: ("veins"[MeSH Terms] OR "veins"[All Fields] OR "venous"[All Fields]) AND ("abnormalities"[Subheading] OR "abnormalities"[All Fields] OR "anomalies"[All Fields]) AND syndromic[All Fields] AND ("craniosynostoses" [MeSH Terms] OR "craniosynostoses"[All Fields] OR "craniosynostosis"[All Fields]). Studies that exposed details of venous anomalies found in syndromic or complex craniosynostosis were selected. RESULTS: Of a total of 211 articles found, 11 were selected for this review. Of these, 5 were case reports, 5 retrospective studies, and only 1 prospective study. From the 6 series of cases presented, 5 discussed the relationship between jugular foramen stenosis (JFS) and collateral venous drainage. The authors discuss data from the literature for each leading question presented: 1-collateral circulation: is it an intrinsic trouble, a consequence of stenosis of the cranial base foramina or related to raised intracranial pressure (ICP)?; 2-what venous anomalies should we search for, and what is the best exam to study them?; 3-collateral circulation changes with time?; 4-can neurosurgeons interrupt the collateral circulation?; 5-should we study all complex types of craniosynostosis? CONCLUSION: The importance of the study of the venous outflow in patients with complex craniosynostosis is evident in the literature. The real relationship between intracranial hypertension, hypoplastic skull base foramen, Chiari I malformation, hydrocephalus, and venous collateral circulation remains unknown. Prospective studies focusing on molecular biology analysis will possibly solve all of these leading questions.

Ultrasonography in pediatric Budd-Chiari syndrome.

Budd-Chiari syndrome is a vascular pathology of the liver, commonly seen in adults and uncommon in children. Most children with Budd-Chiari syndrome present with ascites, and an etiology is found in only about 50%. Ultrasonography (US) with color Doppler is the main modality used in the diagnosis. US imaging additionally guides radiologic interventions and follow-up after recanalization or shunt procedure. In this pictorial review, we illustrate the findings in pediatric Budd-Chiari syndrome as seen on B-mode and color Doppler US and describe the role of US in guiding percutaneous radiologic interventions, with a brief description of the role of US contrast agent and sonoelastography in this setting.

The Impact of Angiographic Geometry on the Clinical Presentation of True Vein of Galen Aneurysmal Malformations.

BACKGROUND PURPOSE: Vein of Galen aneurysmal malformations (VGAM) may carry life-threatening and catastrophic sequelae in children. Their clinical presentations are differently variable between cardiac and cerebral syndromes. There may be a possible relationship between the Galenic angioarchitecture and the clinical presentation. We aimed to study the effect of the venous outflow impairment on the incidence of high-flow heart failure and the incidence of hydrocephalus. MATERIALS AND METHODS: The angiographies of 21 patients with true VGAM have been studied. MR angiography, 3-dimensional CT angiogram (3D CTA), and conventional digital subtraction angiography were performed for all patients with true VGAM. Transarterial embolization was done in 1 or more sessions for all cases. RESULTS: Among the 21 cases, 14 cases were mural type, 5 cases were choroidal type, and 2 cases were mixed. Hydrocephalus was observed more in infants (92.3%), mural types (92.9%), giant and supergiant (87.5%) aneurysms, and in cases with persistent limbic circle (90.91%). All cases of hydrocephalus were associated with significant stenosis (>70%) of the Falcine sinus draining system (100%). CONCLUSION: Significant stenosis (>70%) of the draining sinus is a significant factor for VGAM aneurysmal enlargement and occurrence of hydrocephalus. Probably, venous outflow impairment decreases the incidence of high-flow heart failure and increases the incidence of hydrocephalus.

Early clinical outcomes for treatment of post-thrombotic syndrome and common iliac vein compression with a hybrid Oblique self-expanding nitinol stent - the TOPOS study.

Background: Physical attributes of conventional stents used in the ilio-caval territory are often unfavorable in the presence of external compression close to the bifurcation. A hybrid oblique stent was developed for the treatment of common iliac vein compression without compromising the contralateral iliac vein inflow. Patients and methods: The ongoing international monitored TOPOS study enrolled 60 patients with post-thrombotic syndrome (PTS) treated with the sinus-Obliquus stent (optimed) and provisional distal stent extension. At 3-month follow-up, patency rates were obtained from duplex ultrasound, and clinical outcomes were assessed by the Villalta score, revised venous severity score (rVCSS), pain intensity score and chronic venous disease quality of life questionnaire (CIVIQ-20). Results: Mean age was 46.6 ± 14.9 years (68.3 % women). Mean number of implanted stents was 1.9 ± 0.6; 12 (20 %) patients received the hybrid oblique stent only. Forty-eight (80 %) patients had distal stent extension, and 42 (70 %) had stents below the inguinal ligament. Four (7 %) patients (all with stent extension) developed stent thrombosis. Primary and secondary patency rates at 3 months were 93.1 % (95 %CI 83.3-98.1 %), and 100 % (95 %CI 93.8-100 %), respectively. Improvement in Villalta, rVCSS, CIVIQ-20, and pain intensity score from baseline to 3-month follow-up was 6.9 ± 1.4 points (95 %CI 4.1-9.8; p < 0.0001), 3.4 ± 1.0 points (95 %CI 1.3-5.4 points; p < 0.01), 13.6 ± 2.7 points (95 %CI 8.2-19.0 points; p < 0.0001), and 2.4 ± 0.5 (95 %CI 1.4-3.3; p < 0.0001), respectively. At follow-up, 38 (63 %) patients were free from the PTS and none developed contralateral deep vein thrombosis. Conclusions: In patients with PTS and common iliac vein compression, treatment with the hybrid oblique stent with provisional stent extension resulted in high patency rates and improvement in PTS severity and quality of life at 3-month. Two-year results of TOPOS will assess the durability of this treatment.

Management of portal hypertension and ascites in polycystic liver disease.

Patients suffering from polycystic liver disease may develop Hepatic Venous Outflow Obstruction, Portal Vein Obstruction and/or Inferior Caval Vein Syndrome because of cystic mass effect. This can cause portal hypertension, leading to ascites, variceal haemorrhage or splenomegaly. For this review, we evaluate the evidence to provide clinical guidance for physicians faced with this complication. Diagnosis is made with imaging such as ultrasound, computed tomography or magnetic resonance imaging. Therapy includes conventional therapy with diuretics and paracentesis, and medical therapy using somatostatin analogues. Based on disease phenotype various (non-)surgical liver-volume reducing therapies, hepatic or portal venous stenting, transjugular intrahepatic portosystemic shunts and liver transplantation may be considered. Because of complicated anatomy, use of high-risk interventions and lack of empirical evidence, patients should be treated in expert centres.

Efficacy of repeated balloon venoplasty for treatment of hepatic venous outflow obstruction after pediatric living-donor liver transplantation: A single-institution experience.

HVOO is a rare complication after LT and an important cause of graft failure. Balloon venoplasty is the first-line treatment for HVOO, but the effect of repeated balloon venoplasty and stent placement for HVOO recurrence after pediatric LDLT remains unclear. Between 1998 and 2016, 147 pediatric patients underwent LDLT in our institution. Among them, the incidence of HVOO and the therapeutic strategy were retrospectively reviewed. Ten patients were diagnosed with HVOO. All the patients underwent LLS grafts. Median age at the initial endovascular intervention was 2.7 years (range, 5 months-8 years). The median interval between the LDLT and the initial interventional radiology was 2.7 months (range, 29 days-35.7 months). Four patients experienced no recurrence after a single balloon venoplasty; 6 underwent balloon venoplasty more than 3 times because of HVOO recurrence; and 2 underwent stent placement due to the failure of repeated balloon venoplasty. All patients are alive with no symptoms of HVOO. The HVOO recurrence-free period after the last intervention ranged from 20 days to 15.5 years (median, 8.9 years). Repeated balloon venoplasty may prevent unnecessary stent placement to treat recurrent HVOO after pediatric LDLT.

Type II Abernethy Malformation in a Patient with Primary Budd-Chiari Syndrome.

Budd-Chiari syndrome (BCS) is a heterogeneous group of disorders characterized by hepatic venous outflow obstruction. Abernethy malformation is a congenital vascular malformation defined by diversion of portal blood away from the liver. Both conditions are rare vascular diseases. We report here the first case of a patient with combined type II Abernethy malformation and BCS from China. The inferior vena cava obstruction was treated with percutaneous balloon angioplasty; close follow-up was elected for the Abernethy malformation.

Modified triangular hepatic vein reconstruction for preventing hepatic venous outflow obstruction in pediatric living donor liver transplantation using left lateral segment grafts.

HVOO can be a critical complication in pediatric LDLT. The aim of this study was to evaluate a modified triangular technique of hepatic vein reconstruction for preventing HVOO in pediatric LDLT. A total of 298 pediatric LDLTs were performed using a left lateral segment graft by 2 methods for reconstruction of the hepatic vein. In 177 recipients, slit-shaped anastomosis was indicated with partial clamp of the IVC. A total of 121 recipients subjected to the modified triangular anastomosis with total clamp of the IVC. We compared the incidence of hepatic vein anastomotic complications between these 2 methods. Nine of the 177 cases (5.3%) treated with the conventional technique were diagnosed with outflow obstruction. All 9 cases underwent hepatic vein reconstruction with the slit-shaped hepatic vein anastomosis. In contrast, there were no cases of outflow obstruction in the 121 cases treated with the modified triangular anastomosis. The modified triangular technique of hepatic vein reconstruction with total clamping of the IVC was useful for preventing HVOO in pediatric LDLT.

Diagnosis, treatment and outcome of hepatic venous outflow obstruction in paediatric liver transplantation: 24-year experience at a single centre.

BACKGROUND: Hepatic venous outflow obstruction after paediatric liver transplantation is an unusual but critical complication. OBJECTIVES: To review the incidence, diagnosis and therapeutic modalities of hepatic venous outflow obstruction from a large national liver transplant unit. MATERIALS AND METHODS: During the period from October 1992 to March 2016, 917 liver transplant procedures were performed with all types of grafts in 792 children. Transplants suspected to have early or delayed venous outflow obstruction were confirmed by percutaneous venography or surgical revision findings. Therapeutic intervention, recurrence and outcome were evaluated. RESULTS: Twenty-six of 792 children (3.3%) experienced post-transplant hepatic venous outflow obstruction. These patients had been diagnosed from 1 day to 8.75 years after transplantation. Six occurred during the early post-transplant period; in three of them, the graft was lost. Seventeen patients were initially treated by balloon angioplasty with success; 11 of these experienced recurrences. Four stents were implanted; one was complicated by definitive occlusion. Three of the five surgical revisions were successful. The initial stenosis involved the inferior vena cava in 10 grafts, in isolation or associated with hepatic vein involvement. Mean follow-up was 79 months after transplantation. Eight grafts were lost. CONCLUSION: Acute postoperative hepatic venous outflow obstruction was associated with poor prognosis. Diagnostic venography should be performed if there is any suspicion of venous outflow obstruction, even if first-line examinations are normal. Stenosis frequently involved the inferior vena cava. Angioplasty was a safe and efficient treatment for venous outflow obstruction despite frequent recurrence.

Optimizing venous outflow in reconstruction of Gustilo IIIB lower extremity traumas with soft tissue free flap coverage: Are two veins better than one?

PURPOSE: The dependent nature of the lower extremity predisposes to venous congestion, especially following significant trauma. The benefit of a second venous anastomosis, however, remains unclear in lower extremity trauma free flap reconstruction. This study investigated the effect of an additional venous anastomosis on flap outcomes in lower extremity trauma reconstruction. METHODS: Retrospective review between 1979 and 2016 identified 361 soft tissue flaps performed for Gustilo IIIB/C coverage meeting inclusion criteria. Muscle flaps were performed in 287 cases (79.9%) and fasciocutaneous flaps in 72 cases (20.1%). Single-vein anastomosis was performed in 76% of cases and dual-vein anastmoses in 24% of cases. Patient demographics, flap characteristics, and outcomes were examined. RESULTS: Fasciocutaneous flaps were more likely to have two veins performed (P < .001). Complications occurred in 143 flaps (39.8%): 45 take-backs (12.4%), 37 partial losses (10.3%), 31 complete losses (8.6%). Compared to single-vein flaps, two veins reduced major complications (P = .005), partial flap failures (P = .008), and any flap failure (P = .018). Multivariable regression analysis demonstrated two veins to be protective against complications (RR = 2.58, P = .009). Subset regression analysis by flap type demonstrated an even more significant reduction in complications among muscle flaps (RR = 3.92, P = .005). Additionally, a >1 mm vein size mismatch was predictive of total flap failure (RR = 3.02, P = .038). CONCLUSION: Lower extremity trauma free flaps with two venous anastomoses demonstrated a fourfold reduction in complication rates compared to single-vein flaps. Additionally, venous size mismatch >1 mm was an independent predictor of total flap failure, suggesting beneficial effects of both two-vein outflow and matched vessel diameter.