Reconstructive procedures of the large veins are infrequently undertaken, yet there may be situations when a vascular surgeon is forced to reestablish or alter a patient’s venous circulation. These procedures are technically demanding and often require unusual technical solutions. Many of these reconstructions are undertaken within interdisciplinary team efforts as an adjunct to major tumor surgery, transplantation surgery, or excessive trauma. Over the years, the indications for venous bypass have been changing, but numbers of venous bypass procedures still remain relatively low.

The indications for venous reconstructive surgery are summarized in Table 34-1. It is known that under special circumstances, occluded veins may not need any reconstruction at all.¹ Even the entire infrarenal inferior vena cava (IVC) can be sacrificed safely during extensive tumor surgery as long as the occlusion or stenosis has created sufficient collateralization. On the other hand, severe morbidity may be prevented if a patent vein, when resection because of tumor encasement is necessary, is reconstructed within the same procedure.^2,3 In addition, it has been known for a long time that venous repair of civilian and battlefield vascular trauma leads to an improvement of limb salvage and reduces long-term morbidity.⁴

In transplantation surgery, especially in liver and kidney transplantation, the portal vein or the venous drainage of the graft may be too short.^5,6 A number of vascular procedures are available for overcoming this special problem. In recent years, because of the increasing use of central lines, long-standing central vein catheters, and pacemaker leads, venous congestion of the head and upper extremities caused by a fibrotic vena cava constriction has become an increasing problem.⁷ Although endovascular approaches have demonstrated acceptable mid-term relief of symptoms, reconstruction of the superior vena cava (SVC) and its great side branches is increasingly needed, mostly because of reocclusion after endovascular treatment.⁸

The choice of conduit for venous bypass depends on the location of the repair, the urgency of the intervention, and the availability of autologous material. In general, autologous vein is the material of choice. Nevertheless, the more central the repair and the less the risk of infection, the more alloplastic grafts may be used safely with good results. The different conduits are summarized in Table 34-2.

Autologous Vein

Several veins can be harvested safely for the purpose of venous repair. The main graft donor is the greater saphenous vein. In trauma cases, the contralateral vein should be harvested to allow the intact ipsilateral vein to serve as a natural collateral in case of venous graft failure. If the ipsilateral greater saphenous vein is already disrupted, it should be used as a primary graft source in trauma cases. In the absence of the greater saphenous vein, the upper arm basilic and axillary vein may be excised with no effect on upper extremity venous drainage. For special cases, the deep femoral vein can be harvested with acceptable morbidity.^9,10

Homologous Conduits

Homologous conduits can be either of human origin, such as cryopreserved deep femoral vein, either prepared by the surgeons themselves in centers equipped with this technology, or obtained commercially through specialized companies. If available, fresh deep femoral vein may also be used under special circumstances (availability, access, local ethics committee). Yet in most cases, a fresh vein will only be available in vascular centers connected with transplant units.

There have been several reports on successful patch repair of the SVC with bovine pericardium. Although this material is readily available in most instances, its use should be limited to circumstances when no autologous material is available and there is a contraindication to alloplastic grafts.

Alloplastic Grafts

Externally supported polytetrafluoroethylene (PTFE) grafts serve well in central positions such as replacement of the vena cava (Figure 34-1) or in emergent situations of deep venous repair if there is no time for preparation of an autologous graft. It is essential to use external support to avoid kinking along the prosthesis and to use larger grafts to avoid a pressure gradient along the graft.

In preparation of an autologous graft, the main problem is adequate graft diameter. Replacement of the popliteal vein requires diameters of 6 to 8 mm. The superficial veins, such as the central saphenous vein or the axillary vein, serve well as replacement for short segments of the popliteal vein. In general, the venous valves in the graft may remain in place, but care has to be taken to implant the venous grafts in a nonreversed fashion (Figure 34-2). Replacement of the iliofemoral veins or the vena cava requires large-bore grafts with diameters from 12 to 20 mm. Therefore, additional measures must be undertaken to create a venous graft of this size. In any case, sufficient length of vein must be harvested for a successful repair. For short grafts, several strips of vein may be sewn together longitudinally, thus creating a graft of sufficient diameter (“panel graft”). The vein valves must be removed within these vein strips to prevent graft constriction at the valve sites and to prevent inadvertent flow obstruction through pertaining valve remnants. The number of strips depends on the diameter of the donor vein and the diameter of the vein to be reconstructed. An advantage of this graft is the rapid preparation for shorter grafts; because these grafts can be created in situ, it is easier to determine the graft length. Additionally, reimplantation of large side branches, such as the deep femoral vein or the renal vein, may be facilitated by this technique. A typical panel graft consists of two to three strips of vein.¹¹

For longer grafts and grafts of extensive diameters, a long strip of devalvulated vein may be sewn together in a spiral fashion over a matrix (“spiral vein graft”). It is important do determine the diameter and the length of the graft before its creation because both cannot be changed thereafter (Figure 34-3).Reimplantation of large side branches may be tricky because of the possibility to disrupt the continuous suture line of the spiral vein graft, and there is a tendency of the graft to kink at the reimplantation site (Figure 34-4). On the other hand, large side branches of the donor vein may serve as access site for intraoperative venography, for pressure measurements, and as anastomotic sites for the venous outflow in cases requiring additional free tissue transfer.