Large vein reconstructions in the endovascular era^[1]

Summary

Max Ratschow was a remarkable physician and an international authority in the field of angiology and the Ratschow lectureship helps to fulfill this pioneer’s life purpose: to advance evaluation and treatment of vascular diseases. The 2017 Max Ratschow lecture covers some recent advances and controversies in venous diseases. Phlebology, once a neglected field of angiology, is a discipline that has been in constant progress during the past decades. Endovascular techniques revolutionized treatment of patients with large vein obstruction and provided safe, minimally invasive procedures with excellent long term results. Attention now need to focus on comparative studies to provide scientific evidence of efficacy of venous angioplasty and stenting with properly organized randomized controlled trials. Further attempts are needed to develop special venous stents and to decrease thrombotic complications and formation of pseudointima that cause in-stent restenosis. Open and hybrid reconstructions are safe and durable, but the number of procedures in general is small and special training and expertise for reconstructive venous surgery is recommended. Autologous vein should be used for infrainguinal reconstructions and for treatment of unilateral iliac vein obstruction with a femoro-femoral cross-over bypass (Palma procedure). IVC and iliac vein reconstructions with ePTFE grafts provide superb result in patients who need excision of malignant tumors invading large veins. Open and hybrid reconstructions are here to stay and they remain excellent options for those patients who are unsuitable for or fail endovascular repair.

Zusammenfassung

Max Ratschow war ein bemerkenswerter Arzt und eine internationale Autorität im Bereich der Angiologie. Die Ratschow-Vorlesung führt das Lebenswerk dieses Pioniers weiter: die Untersuchung und Behandlung vaskulärer Erkrankungen voran zu bringen. Die Max RatschowVorlesung 2017 behandelt einige aktuelle Entwicklungen und Kontroversen im Bereich der venösen Erkrankungen. Die Phlebologie, einst ein vernachlässigtes Gebiet in der Angiologie, ist eine Disziplin mit konstantem Fort-schritt innerhalb der letzten Jahrzehnte. Endovaskulare Techniken revolutionierten die Behandlung der Patienten mit großen Venenobstruktionen und stellten sichere, minimal-invasive Eingriffe mit exzellenten Langzeitergebnissen dar. Die Aufmerksamkeit sollte sich nun fokussieren auf vergleichende Studien, um die wissenschaftliche Nachweisbarkeit der Effektivität der venösen Angioplastie und des Stentings mit entsprechenden kontrollierten, randomisierten Studien zu stützen. Weitere Untersuchungen sind notwendig, um spezielle venöse Stents zu entwickeln und thrombotische Komplikationen und die Entwicklung von Pseudointima zu reduzieren, die die In-stentRestenosis verursachen. Offene und Hybrid-Rekonstruktionen sind sicher und dauerhaft, aber die Zahl der Eingriffe dieser Art sind ge-ring und ein Spezialtraining und Expertise für rekonstruktive Venenchirurgie wird empfohlen. Autologe Venen können für infrainguinale Rekonstruktionen genutzt werden und für die Behandlung von unilateralen Iliac-Venenrekonstruktionen mit einem femoro-femoral Crossover-Bypass (Palma Prozedur). IVC und die Iliac-Venenrekonstruktionen mit ePTFE-Grafts zeigen ein hervorragendes Ergebnis bei Patienten, die eine Exzision von malignen Tumoren benötigen, die in die großen Venen einwachsen. Offene und Hybrid-Rekonstuktionen sind dafür geeignet und bleiben eine exzellente Option für Patienten, die nicht geeignet sind für eine endovaskuläre Intervention.

Keywords

Vein reconstruction - endovascular technique - vein surgery

Schlüsselwörter

Venenrekonstruktion - endovaskuläre Techniken - Venenchirurgie

^* Presented at the 58^th Annual Meeting of the German Society of Phlebology and the 17^th Annual Meeting of the German, Austrian and Swiss Societies of Angiologie, in Dresden, Germany, September 9, 2016.

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