Postthrombotisches Syndrom auf dem Boden einer chronischen iliofemoralen Thrombose: Therapieoptionen und -limitationen

Zusammenfassung

Ein 49-jähriger Patient stellte sich mit einer langsam progredienten, ca. 7 cm großen Schwellung in der linken Kniekehle vor. Sonografisch und MR-tomografisch zeigte sich das Bild eines postthrombotischen Syndroms am linken Bein mit einem langstreckigen chronischen venösen iliofemoralen Verschluss und ausgeprägten Kollateralen sowie Varixkonvoluten in der linken Kniekehle, die der beklagten Schwellung entsprachen. Es erfolgte die Endophlebektomie der Vena femoralis und Vena femoralis profunda mit einer ventralen Rekonstruktion durch eine bovine Perikard-Patch-Plastik mit Rekanalisation der chronisch okkludierten venösen Iliakalachse mit langstreckiger Stentangioplastie als Hybridoperation. Abschließend wurde eine inguinale AV-Fistel angelegt. Postoperativ entwickelte der Patient einen Frühverschluss der venösen iliofemoralen Strombahn und eine inguinale Lymphfistel. Aufgrund dieser erfolgte zunächst kein operativer, sondern ein perkutaner transjugulärer, letztlich frustraner Rekanalisationsversuch. Die inguinale Heilung benötigte bis zum Sistieren der Lymphexsudation 8 Wochen. Nach diesem Zeitintervall entschieden wir uns aufgrund der zu erwartenden schlechten sekundären Offenheitsrate gegen eine operative Revision, sodass therapeutisch nur die Antikoagulation und Kompression blieb. Die Ursache des dargestellten Frühverschlusses bleibt unklar, mögliche Ursachen und sich daraus ergebende Konsequenzen werden diskutiert.

Abstract

A 49-year-old patient presented with a slowly progressing about 7 cm tumor in the left fossa poplitea. Ultrasonography and MRI showed a postthrombotic syndrome of the left leg with a chronic occlusion of the iliofemoral venes, pronounced inguinal collaterals as well as varix convolutions in the left fossa poplitea, which corresponded to the tumor complained. Endophlebectomy of the vena femoralis and vena femoralis profunda was carried out with a ventral reconstruction using bovine pericardial patch plasty followed by recanalization of the chronically occluded venous iliofemoral axis with stentangioplasty. Finally, an inguinal AV fistula was created. Postoperatively, the patient developed early reocclusion of the recanalized iliofemoral venous axis and an inguinal lymph fistula. Therefore, initially planned surgical recanalization was not possible. We performed a not successful percutaneous transjugular recanalization attempt. The inguinal healing took eight weeks to stop lymph exudation. After this time, we decided against an operative revision due to the expected poor secondary patency rate. The cause of the early reocclusion remains unclear, possible causes and resulting consequences are discussed.

Schlüsselwörter

postthrombotisches Syndrom - chronische iliofemorale Thrombose - Therapieoptionen und -limitationen

Key words

postthrombotic syndrome - chronic iliofemoral thrombosis - therapeutic options and limitations

Publication History

Article published online:
16 October 2020

• Literatur

• 1 White RH. The Epidemiology of Venous Thromboembolism. Circulation 2003; 107: 4I-8I
• 2 Cohen AT, Agnelli G, Anderson FA. et al. Venous thromboembolism (VTE) in Europe. The number of VTE events and associated morbidity and mortality. Thrombosis and haemostasis 2007; 98 (04) 756-764
• 3 Prandoni P. The Long-Term Clinical Course of Acute Deep Venous Thrombosis. Annals of Internal Medicine 1996; 125 (01) 1
• 4 Kahn SR, Shrier I, Julian JA. et al. Determinants and time course of the postthrombotic syndrome after acute deep venous thrombosis. Annals of internal medicine 2008; 149 (10) 698-707
• 5 Kahn SR, Partsch H, Vedantham S. et al. Definition of post-thrombotic syndrome of the leg for use in clinical investigations: a recommendation for standardization. Journal of thrombosis and haemostasis: JTH 2009; 7 (05) 879-883
• 6 Kahn SR, Shbaklo H, Lamping DL. et al. Determinants of health-related quality of life during the 2 years following deep vein thrombosis. Journal of thrombosis and haemostasis: JTH 2008; 6 (07) 1105-1112
• 7 Kahn SR, Ginsberg JS. Relationship Between Deep Venous Thrombosis and the Postthrombotic Syndrome. Archives of Internal Medicine 2004; 164 (01) 17
• 8 Gould MK, Garcia DA, Wren SM. et al. Prevention of VTE in Nonorthopedic Surgical Patients. Chest 2012; 141 (02) e227S-e277S
• 9 Falck-Ytter Y, Francis CW, Johanson NA. et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) e278S-e325S
• 10 Kahn SR, Lim W, Dunn AS. et al. Prevention of VTE in Nonsurgical Patients. Chest 2012; 141 (02) e195S-e226S
• 11 Lichtenberg M, de Graaf R, Erbel C. Standards for recanalisation of chronic venous outflow obstructions. Vasa 2018; 47 (04) 259-266
• 12 Lichtenberg M. Endovenöse Rekanalisationen von chronischen Beckenvenenverschlüssen. DMW – Deutsche Medizinische Wochenschrift 2019; 144 (07) 478-483
• 13 Rollo JC, Farley SM, Jimenez JC. et al. Contemporary outcomes of elective iliocaval and infrainguinal venous intervention for post-thrombotic chronic venous occlusive disease. Journal of vascular surgery Venous and lymphatic disorders 2017; 5 (06) 789-799
• 14 Stuck AK, Reich T, Engelberger RP. et al. Endovascular treatment of post-thrombotic and non-thrombotic iliofemoral venous outflow obstructions with self-expanding nitinol stents. Vasa 2018; 47 (04) 319-325
• 15 Schleimer K, Barbati ME, Gombert A. et al. The Treatment of Post-Thrombotic Syndrome. Deutsches Aerzteblatt Online 2016; 113 (50) 863-870
• 16 Verma H, Tripathi RK. Common femoral endovenectomy in conjunction with iliac vein stenting to improve venous inflow in severe post-thrombotic obstruction. Journal of vascular surgery Venous and lymphatic disorders 2017; 5 (01) 138-142
• 17 de Wolf M, Jalaie H, van Laanen JHH. et al Endophlebectomy of the common femoral vein and arteriovenous fistula creation as adjuncts to venous stenting for post-thrombotic syndrome. The British journal of surgery [Internet] 2017; 104 (06) 718-725 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/28221670
• 18 Neglén P, Berry MA, Raju S. Endovascular surgery in the treatment of chronic primary and post-thrombotic iliac vein obstruction. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery [Internet] 2000; 20 (06) 560-571 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/11136593
• 19 Neglén P. Chronic venous obstruction: diagnostic considerations and therapeutic role of percutaneous iliac stenting. Vascular [Internet] 2007; 15 (05) 273-280 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/17976327
• 20 Jalaie H, Arnoldussen C, Barbati M. et al. What predicts outcome after recanalization of chronic venous obstruction: hemodynamic factors, stent geometry, patient selection, anticoagulation or other factors?. Phlebology: The Journal of Venous Disease 2014; 29 (Suppl. 01) 97-103
• 21 Kurstjens R, de Wolf M, Kleijnen J. et al. The predictive value of haemodynamic parameters for outcome of deep venous reconstructions in patients with chronic deep vein obstruction – A systematic review. Phlebology: The Journal of Venous Disease 2017; 32 (08) 532-542
• 22 Lichtenberg M, de Graaf R, Stahlhoff WF. et al Patency rates, safety and clinical results of the sinus-Obliquus venous stent in the treatment of chronic ilio-femoral venous outflow obstruction – data from the Arnsberg venous registry. VASA Zeitschrift fur Gefasskrankheiten [Internet] 2019; 48 (03) 270-275 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/30526435
• 23 Gombert A, Barbati ME, Grommes J. et al. Wound complications after common femoral vein endophlebectomy: Influence on outcome. Phlebology: The Journal of Venous Disease 2018; 33 (06) 407-417
• 24 Lattimer CR, Mendoza E. Reappraisal of the Utility of the Tilt-table in the Investigation of Venous Disease†. European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery [Internet] 2016; 52 (06) 854-861 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/27789144
• 25 Lattimer CR, Kalodiki E, Mendoza E. Gravitational venous drainage is significantly faster in patients with varicose veins. Phlebology [Internet] 2016; 31 (08) 546-553 . Available from: http://www.ncbi.nlm.nih.gov/pubmed/26338842
• 26 Kahle B, Hennies F, Bolz S. et al. Die Reproduzierbarkeit des veno-arteriellen FlowIndex für die quantitative Erfassung des hämodynamischen Schweregrads von venösen Erkrankungen. Vasa 2003; 32 (04) 199-203
• 27 Rudolphi PB, Recke A, Langan EA. et al. Are Sonographically Measured Vascular Haemodynamic Parameters Reproducible Using Magnetic Resonance Imaging?. European Journal of Vascular and Endovascular Surgery 2016; 52 (05) 665-672
• 28 Lattimer CR, Rudolphi PB, Recke A. et al. Comparison of Four Haemodynamic Tests that Quantify Superficial Venous Insufficiency. European Journal of Vascular and Endovascular Surgery 2019; 57 (04) 570-577
• 29 Coelho A, O’Sullivan G. Usefulness of Direct Computed Tomography Venography in Predicting Inflow for Venous Reconstruction in Chronic Post-thrombotic Syndrome. CardioVascular and Interventional Radiology 2019; 42 (05) 677-684