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• W2055346283 abstract "Differentiation of the relative roles of venous obstruction versus valvular incompetence in established postphlebitic syndrome can be difficult. We describe a simple method for improving the sensitivity of venous pressure measurements as used to diagnose the presence of obstruction. A 39-year-old woman had a 2-year history of postphlebitic syndrome, manifest by severe lower-leg and thigh edema, chronic skin changes, and a small medial ulcer 12 years after a postpartum iliofemoral venous thrombosis. Venography revealed recanalized, incompetent femoral vessels with partial iliac venous obstruction (Fig. 1). Simultaneous resting femoral venous pressures were low and equal, both 7 mm Hg. Because of thigh edema, the iliac obstruction was believed to be more significant than valvular incompetence, despite normal pressures. At surgery, femoral pressures were again found to be equal. Intraarterial papaverine (30 mg) was injected into both femoral arteries to increase limb blood flow. Within 30 seconds after left-sided injection, left femoral venous pressure rose from 7 to 21 mm Hg. By contrast, femoral venous pressure on the right remained at 7 mm Hg after right-sided injection. A venous bypass was constructed with an 8-mm externally supported expanded polytetrafluoroethylene conduit from the common femoral vein (end-to-end) to the inferior vena cava.1Gloviczki P Pairolero PC Toomey BJ et al.Reconstruction of large veins for nonmalignant venous occlusive disease.J VASC SURG. 1992; 16: 750-761Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar After completion (Fig. 2), papaverine was again injected into the left femoral vein; there was no change in venous pressure. Valvular incompetence was not corrected. Her graft remains patent at 6 months by duplex ultrasonography, with excellent symptom control and full healing of her ulcer. A common quandary in the evaluation of postphlebitic syndrome is whether valvular incompetence or venous outflow obstruction is responsible for symptoms. Classically thought to be rare, obstruction may in fact be present in as many as a third of patients with severe postphlebitic symptoms.2Cockett FB Thomas ML The iliac compression syndrome.Br J Surg. 1965; 52: 816-821Crossref PubMed Scopus (318) Google Scholar, 3Raju S Fredricks RK Late hemodynamic sequelae of deep venous thrombosis.J VASC SURG. 1986; 4: 73-79PubMed Scopus (33) Google Scholar A venous pressure gradient between sides is diagnostic, but patients with abnormal results of phlebograms and disabling symptoms may have normal resting pressures, which suggests the existence of collateral vessels that are sufficient to meet resting, but not ambulatory, flow.3Raju S Fredricks RK Late hemodynamic sequelae of deep venous thrombosis.J VASC SURG. 1986; 4: 73-79PubMed Scopus (33) Google Scholar, 4Negus D Cockett FB Femoral vein pressures in postphlebitic iliac vein obstruction.Br J Surg. 1967; 54: 522-525Crossref PubMed Scopus (54) Google Scholar In a manner analogous to arterial claudication, there may be no pressure gradient and no symptoms at rest, but a significant pressure gradient and associated symptoms when flow is increased by ambulation (Grade II venous obstruction).4Negus D Cockett FB Femoral vein pressures in postphlebitic iliac vein obstruction.Br J Surg. 1967; 54: 522-525Crossref PubMed Scopus (54) Google Scholar Proximal blood pressure cuff occlusion5Raju S New approaches to the diagnosis and treatment of venous obstruction.J Vasc Surg. 1986; 4: 42-54PubMed Scopus (70) Google Scholar and exercise3Raju S Fredricks RK Late hemodynamic sequelae of deep venous thrombosis.J VASC SURG. 1986; 4: 73-79PubMed Scopus (33) Google Scholar have been described as methods to increase limb blood flow in this situation; both are relatively cumbersome. Intraarterial papaverine is a direct, convenient method of reproducibly increasing limb flow. Despite the presence of equal resting pressures, suspicion for obstruction was high in this patient. The finding that papaverine-induced hyperemia increased venous pressure by 300% (in the absence of contralateral change) unmasked the diagnosis of venous obstruction, allowing the performance of venous bypass rather than valve transposition or repair. This method could easily be performed in the outpatient setting to improve the identification of otherwise occult proximal venous obstruction. Our observations suggest that some patients with ambulatory complaints but no pressure gradient at rest will prove to have a hemodynamically significant obstruction when increased flow in the limb is pharmacologically produced." @default.
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• W2055346283 date "1996-07-01" @default.
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• W2055346283 title "Increasing the sensitivity of the diagnosis of chronic venous obstruction" @default.
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• W2055346283 doi "https://doi.org/10.1016/s0741-5214(96)70179-9" @default.
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