When the saphenous vein is small or not available, a crossover femoral venous prosthetic bypass with an 8- or 10-mm externally supported expanded PTFE (ePTFE) graft is a good alternative. Similar to the autologous femoral suprapubic bypass, the femoral veins are exposed bilaterally, the ePTFE graft is positioned in the subcutaneous suprapubic tunnel, and an end-to-side anastomosis is performed to the common femoral veins at each side. A distal AVF on the affected side is routinely added to the procedure using a 4- to 5-mm tapered or a 6-mm externally supported PTFE graft for the fistula between the PTFE crossover graft and the superficial femoral artery.

Variable patency rates of ePTFE grafts in this location have been reported and range between 0 and 100%, with data from one large series quoting a 100% (19 of 19) patency rate at long-term follow-up [12]. Gruss and Hiemer observed 77% patency at 5 years in 27 PTFE Palma grafts [13]. The authors recommend use of saphenous crossover grafts over prosthetic bypass grafts based on observed patency.

The May–Husni procedure is helpful in relieving unilateral deep venous outflow obstruction involving the femoral vein. A vertical incision at the level of the distal thigh and the great saphenous vein and distal femoral vein/proximal popliteal vein is exposed. A thigh tourniquet is used to provide a bloodless field after administration of heparin. The distal femoral vein/popliteal vein is then opened longitudinally and old recanalized thrombus excised. An end-to-side anastomosis between the great saphenous vein and the distal femoral vein/popliteal vein using a running 6-0 monofilament suture is then performed (Fig. 38.3).

AbuRahma and colleagues reported their results of their review of 19 patients who underwent the procedure. At a mean follow-up of 66 months, a 56% cumulative 8-year patency was noted [10]. A University of Michigan study of 17 patients with a median follow-up of 103 months noted a primary patency of 56%, primary assisted patency of 69%, and a secondary patency of 75%. An 82% success rate for near or complete resolution of venous claudication and a 67% success rate for venous ulcer healing were also observed [14].

Good risk operative candidates with bilateral iliac obstructions or with iliocaval obstruction should be considered for a femorocaval (Fig. 38.4) or iliocaval (Fig. 38.5) bypass. An ePTFE graft with external support is the preferred conduit for in-line reconstruction of iliocaval or caval occlusions. A diameter of 12–14 mm is used for iliocaval bypasses and at least 10 mm for femorocaval bypass. The upper portion of the infrarenal IVC at and immediately distal to the renal veins is best approached transperitoneally through a midline incision, reflecting the ascending colon medially and mobilizing the duodenum using the Kocher maneuver. The lower portion of the IVC just above the iliac bifurcation is well approachable through a right flank incision retroperitoneally. If the occlusion is limited to the right common iliac vein, the same incision is used to expose the external iliac vein for the distal anastomosis. The graft is tunneled under the ureter. If a femorocaval graft is placed, a separate 8-cm-long vertical groin incision is made on the affected side, and the graft is tunneled under the inguinal ligament. To all grafts originating from the femoral vein and to most long iliocaval grafts, an AVF is added at the groin. The use of autologous vein for femoroiliac or femorocaval reconstruction is also an option. Because of a relatively small size, saphenous vein in this location can only rarely be used. If short segment of the common femoral or iliac vein must be reconstructed, a better size match is a spiral saphenous vein graft, prepared using the contralateral saphenous vein. The excised vein is opened longitudinally, the valves are excised, and the graft is wrapped around a 28- or 32-mm argyle chest tube. The edges are approximated with running 6-0 polypropylene sutures or with stainless steel nonpenetrating vascular clips. The internal or external jugular veins are other conduits that can be considered for venous reconstruction . The femoral vein is also an alternative for reconstruction of abdominal veins, although morbidity of removing this vein in many of these patients with underlying thrombophilia or PTS is high and other options are recommended. Cryopreserved saphenous or femoral vein has also been reported for venous reconstruction, but long-term patency of these grafts for venous replacement in our experience has been poor.