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Congenital Vascular Malformations: General Considerations

Our understanding of why some children are born with imperfections while the majority are born with normal anatomy has made a tremendous improvement through the last half century. These often disfiguring anomalies are commonly seen by both general practitioners and specialists but the spectrum of congenital vascular malformations (CVMs) is so wide and complicated that it often requires a wide range of specialists dedicated to their…

Lymphedema: Surgical Treatment

Introduction The lymphatic system is the least understood part of the vascular system. Lymphatic malformations such as chylous disorders, cystic hygromas, and lymphocysts are rare; acquired disorders such as lymphoceles and chylous effusions are also uncommon. However, local interruption and obstruction of the lymphatic vessels occur frequently from either congenital or acquired causes (see Ch. 167 , Lymphedema: Evaluation and Decision Making). In developed countries, most…

Lymphedema: Nonoperative Treatment

Introduction In this chapter, we examine the lymphatic system ( Fig. 168.1 ) and its malfunction with a focus on current nonoperative treatments. The diagnosis and surgical treatment of lymphedema are discussed in other chapters. It is important to know that pathology of the lymphatic system is linked mainly to lipid and protein malabsorption, accumulation of protein-rich interstitial fluid, and the inability to return lymph to…

Lymphedema: Evaluation and Decision Making

Lymphedema is the term used to characterize the various pathological conditions in which there is progressive accumulation of protein-enriched interstitial fluid. Collectively, these forms of edema arise as a consequence of relative impairment of lymphatic vascular function. Lymphatic vascular insufficiency can result from either primary or acquired (secondary) lymphatic defects. Cryptogenic forms of lymphedema are often presumed to represent primary lymphatic dysfunction. Although impaired lymphatic function…

Venous Aneurysms and their Management

Introduction Aneurysms are abnormal dilations of blood vessels and occur most commonly in arteries. Venous aneurysms are rare but have been reported throughout the veins in the body, including the extremities, head and neck, and abdomen. When defining venous aneurysms, Gillespie et al. state: “The definition of a venous aneurysm has been controversial. A venous aneurysm is best described as a solitary area of venous dilation that…

Nutcracker Syndrome

Introduction “The left renal vein as it lies between the aorta and the superior mesenteric artery resembles a nut between the jaws of a nutcracker.” J.C.B. Grant, 1937 Nutcracker syndrome (NCS) is a rare clinical entity characterized by outflow obstruction from the left renal vein (LRV) into the inferior vena cava (IVC) caused by reduction of the LRV diameter either due to extrinsic compression of the…

Portal Hypertension

Introduction Portal hypertension (PHT) occurs when there is an abnormal increase in pressure in the veins that carry blood from the visceral organs to the liver. This can be explained by Ohm’s law, where the change in pressure is equal to the flow times the resistance (P = Q × R). Therefore, the pressure can be increased by increasing the flow or increasing the resistance. Normal…

Superior Vena Cava Occlusion and Management

In the United States each year about 15,000 patients develop symptoms of venous congestion of the head and neck due to occlusion of the superior vena cava (SVC) or innominate veins. SVC syndrome is caused by malignant tumors of the lung and mediastinum in 60% of the cases. The most frequent nonmalignant causes include placement of intravenous catheters, pacemaker wires, or mediastinal fibrosis. Treatment for SVC…

Iliocaval Venous Obstruction: Endovascular Treatment

Introduction A web-like lesion at the iliocaval junction was described by McMurrich, a Canadian physician, in 1908. Recognition of the lesion now commonly known as May–Thurner syndrome (MTS), or iliac compression syndrome, evoked a series of controversies from the start. Initial debate involved the origin of the lesion: was it ontogenic or acquired? Based upon the rarity of the lesion in embryos and infants, an acquired…

Iliocaval Venous Obstruction: Surgical Treatment

Surgical Treatment Of Iliocaval Venous Obstruction The first successful venous reconstruction in a patient was reported more than 50 years ago by Warren and Thayer ; in the past 2 decades improvements in diagnosis, patient selection, surgical technique, and the availability of better graft materials have resulted in more frequently successful implantation of venous bypasses in patients. More recently, endovascular treatment for iliocaval obstruction has progressed…

Chronic Venous Insufficiency: Deep Vein Valve Reconstruction

Introduction Using modern classification methods for lower extremity venous disease and considering the entire disease spectrum within given populations, roughly 15% of patients will have edema, 7% skin hyperpigmentation, 1.4% healed and 0.7% active venous ulcers. , Due to the technical challenges and increased risks of a venous valve repair in relation to less invasive treatments, essentially all other venous pathology is treated before deep venous…

Chronic Venous Insufficiency: Treatment of Perforator Vein Incompetence

Perforating veins (PVs) were not described until drawings by Justus Christian Von Loder were published in 1794. From that time, for more than a century, their role in venous disease remained unappreciated despite the illuminating work of M. Verneuil and subsequent analysis by John Gay. In 1917, John Homans suggested that incompetent perforating veins (IPVs) played a key role in the genesis of venous ulcers. Subsequently,…

Treatment of Chronic Venous Disorders

Chronic venous disease (CVD) of the lower extremity is one of the most common chronic diseases in western Europe and the United States. The manifestations of CVD vary and include telangiectasias, enlarged reticular veins, varicose veins, lipodermatosclerosis, lower extremity pain and swelling, and venous ulcers. Its prevalence reported in studies from different countries ranges from 2% to 56% in men and 1% to 60% in women.…

Postthrombotic Syndrome: Natural History, Pathophysiology, and Etiology

Introduction Chronic venous disorders (CVD) are a spectrum of venous diseases that affect the lower limb. The manifestations include varicose veins, pain, edema, skin changes, and venous ulcerations. The pathophysiology involves reflux within the deep, superficial, and perforating vein valves and/or venous obstruction, usually postthrombotic in etiology. Both reflux and residual obstruction can produce venous hypertension and the manifestations of CVD. Compared with nonthrombotic etiologies, lower…

Varicose Veins: Endovenous Ablation and Sclerotherapy

Background Endovenous treatments for varicose veins emerged as an alternative to open surgery and are now the standard of care due to improved safety and efficacy. , The most widespread technologies used for the treatment of truncal vein reflux are radiofrequency ablation (RFA) and endovenous laser ablation (EVLA). Sclerotherapy remains the treatment of choice for telangiectasias and reticular veins, but may also be used for truncal…

Varicose Veins: Surgical Treatment

In the past, venous disease received relatively little attention in the public arena and in vascular training programs, despite the fact that it is more prevalent in the United States than coronary artery disease, peripheral arterial disease, congestive heart failure, and stroke combined. The latter half of the 20th century saw dramatic advances in diagnostic testing; however, surgical treatment of varicose veins benefited from only modest…

Vena Cava Interruption

Numerous techniques of vena cava interruption have been described in the past for the prevention of PE, including femoral vein and IVC ligation, and partial interruption of the IVC by means of plastic clips, plication, or mechanical staplers. These later measures were developed to compartmentalize the vena cava to allow blood flow but trap large emboli, and they were the mainstay of treatment through the 1950s…

Pulmonary Embolism: Presentation, Natural History, and Treatment

Introduction Acute pulmonary embolism (PE) is a partial or complete occlusion of the pulmonary arteries, with hemodynamic consequences determined by the size and location of the embolus, preexisting cardiopulmonary disease, and the severity of ventilation and oxygenation compromise. Acute PE is the third leading cause of cardiovascular mortality, with well over 100,000 deaths per year in the United States. Recent registries and cohort studies suggest that…

Superficial Thrombophlebitis and its Management

Superficial venous thrombophlebitis (SVT) has been the focus of increased attention because of growing recognition of the potential morbidity and mortality associated with it. Although a global disorder, SVT develops in approximately 125,000 people per year in the United States; nonetheless, it is underestimated because many cases go unreported. It has been historically assumed that SVT is a self-limited process of little consequence and of small…