The day prior to the hybrid procedure, the iliofemoral segment is recanalized from a popliteal approach , and a 5 French catheter is advanced from the popliteal vein into the patent vena cava (Fig. 39.2). This procedure can take 2 h or more. This ensures there will be access to and through the occluded iliac vein segments on the next day, which is the day of operation. If it is not possible to pass the guidewire through the ipsilateral occlusion preoperatively, a cross-pubic, femoral to contralateral external iliac vein bypass or a Palma procedure is planned.

On the operative day, exposure of the entire CFV, proximal femoral vein and profunda femoris vein, saphenofemoral junction, and distal external iliac vein is obtained via a longitudinal inguinal incision (Fig. 39.3). Control of all branches is crucial to a bloodless procedure. Small tributaries are ligated. Patients are fully anticoagulated with 100 IU/kg bolus of unfractionated heparin (UFH) , which is supplemented hourly during the procedure. A limited venotomy is initially performed in order to establish that there is no back-bleeding from any tributary. If bleeding from the limited venotomy is observed, the entire section of CFV is reexamined so that the patent back-bleeding side branch can be controlled. The venotomy extends the entire length of the CFV, extending from the distal external iliac vein to the proximal femoral vein. Dense fibrous tissue and weblike synechiae are removed from within the lumen with sharp and blunt dissection; often the entire lumen is obliterated. The majority of patients require sharp excision of their fibrous occlusion. Occasionally, small segments of fibrous disease can be teased away from the vein wall with an endarterectomy spatula; however, this is the exception rather than the rule. This procedure is unlike an arterial endarterectomy, where atherosclerotic plaque peels away from the vessel wall quite easily.

Care is taken to extend the endovenectomy over the orifice of the profunda femoris vein ; there is always a large posterior branch of the CFV above the profunda, which is likely another important branch of the profunda system. Figure 39.4 shows the catheter traversing the CFV and the dissection of the intraluminal fibrosis away from the vein wall. After the endovenectomy of the entire CFV is completed (Fig. 39.5), patch closure of the venotomy is performed using bovine pericardium, leaving the distal centimeter open to introduce a 10 French sheath through which the endoluminal stenting of the iliac venous segment is performed.

The catheter in the CFV is transected and an Amplatz Super Stiff (Boston Scientific, Natick, MA) guidewire advanced through the catheter into the vena cava. The catheter is then removed and the guidewire used for ipsilateral angioplasty and stenting. A separate stab incision is made below the inguinal wound through which the 10 French sheath is passed traversing the subcutaneous tissue and enters the venotomy over the guidewire (Fig. 39.6) with no angulation.

The iliac venous system and, if necessary, vena cava are sequentially recanalized with balloon dilation and stenting. In general Wallstents (Boston Scientific, Marlborough, MA) are currently preferred because of their resistance to compression. 14–16 mm stents are used for the common iliac veins and 12–14 mm stents for the external iliac veins. Stenting generally progresses from the cephalad CFV or distal external iliac vein superiorly (Fig. 39.7). The stents are post-dilated to their target diameter. A vena cavogram is obtained to facilitate accurate stent delivery into the common iliac vein and IVC (Fig. 39.8). Following recanalization and venographic confirmation of unobstructed venous drainage from the CFV into the IVC (Fig. 39.9), an intravascular ultrasound is performed to further examine stent position and degree of compression (Figs. 39.10 and 39.11). Occasionally, stents have to be reinforced with additional stents to increase the radial force. The sheath is removed and closure of the patch venoplasty is completed.

An arterial venous fistula (AVF) is then constructed from the superficial femoral artery to the distal CFV. A 3.5 mm arterial punch is used to remove a circular piece of arterial and venous wall. The AVF is limited to 3.5–4 mm in diameter. When an autogenous AVF is performed, a piece of bovine pericardium is wrapped circumferentially around the AVF and sutured in place to prohibit enlargement (Fig. 39.12). If a prosthetic is required to construct the AVF, a 4 mm PTFE graft is used.

A 7 French Silastic closed suction drain is brought through the stab incision used for the 10 French sheath and maintained on suction postoperatively until drainage volume is less than 20 mL/12 h. The incision is closed with several layers of running absorbable suture, obliterating dead space with the goal of ensuring lymphostatic and hemostatic closure of the subcutaneous tissue. Heparin is not reversed.

Initially postoperative systemic anticoagulation was used, which was accompanied by an unacceptable number of wound hematomas . Presently, a sheath in the ipsilateral popliteal vein, placed preoperatively, is used for regional anticoagulation. This allows us to use 700–800 IU/h of UFH, delivering a high concentration of heparin into the target vein but minimizing the overall systemic dose of heparin, which has been associated with a major drop in wound hematomas. The patients are converted to warfarin with a target INR of 2.5–3.5. The patient’s leg is wrapped from the base of the toes to the thigh, and the patient is encouraged to ambulate, using a IV pole with wheels carrying the UFH infusion. Most patients are anticoagulated indefinitely. Clopidogrel is continued for 8 weeks, as we believe the stents are endothelialized by that time.