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Medical Intel

Jul 9, 2019

Blood clots, prior abdominal trauma, or abdominal surgeries can lead to scarring in the iliac veins. Dr. Steven Abramowitz discusses how endovascular iliocaval reconstruction can restore healthy blood flow.



Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine.

Host: We’re speaking with Dr. Steven Abramowitz, a vascular surgeon at MedStar Washington Hospital Center. Thank you for joining us, Dr. Abramowitz.

Dr. Abramowitz: Thanks for having me.

Host: Today we’re discussing endovascular iliocaval reconstruction, a treatment for iliocaval thrombosis and other vascular conditions. Dr. Abramowitz, could you begin by discussing who the best candidates are for endovascular iliocaval reconstructions?

Dr. Abramowitz: Sure. It’s a mouthful. Endovascular iliocaval reconstruction is our way of rebuilding the connection in the veins, the structures that bring blood back to your heart. And, when the veins drain from your legs, they merge in your belly, like an upside-down Y and they form one big vein called the inferior vena cava. So, when we say iliocaval, we mean the iliac veins, which drain your legs, and the inferior vena cava, the main vein that they form inside the belly. What can happen is, in certain patients who have had blood clots in the past, or a history of trauma - maybe a gunshot wound to the belly, or even things like radiation therapy for cancer, or prior surgery - scar tissue can form around those veins. And those patients present with significant swelling in their legs and that swelling can also result in significant wound formation in both of the legs, as well. So, what we can do is, in a minimally invasive way, reconstruct the pathway, restoring flow from the legs back up to the heart to alleviate that jam of blood that’s increasing pressure in the veins.

Host: Can you explain how endovascular iliocaval reconstruction works?

Dr. Abramowitz: Absolutely. So, as I mentioned before, when these veins scar down, or block off and narrow, there’s usually a thin little bit left. And the best example I can give is your veins, normally, are like four-lane highways. But let’s say there’s a massive snowstorm and a snowplow has to get through. And it only puts a small path and it piles up all this snow on the sides of the road. Maybe only a bicyclist can get by, or a single car. And that narrowing, when you think about how blood has to flow, is just too little and so the blood builds up in pressure.  But what we can do is say we find that pathway, where that one snowplow went, and we can use a series of balloons and stents, which are metal tubes like tunnels, and we can expand and push that snow or scar tissue to the side, making sure that you get all four lanes flowing back again, and alleviating any pressure that’s built up in the legs.

Host: What is recovery normally like following this procedure?

Dr. Abramowitz: Recovery from this procedure is actually pretty easy. For the most part, we’re not making any incisions. So, this surgery is done through punctures, usually behind the knee or in the groin. So, people have some soreness at those puncture sites. The biggest complaint actually is back pain. We don’t really have nerves that tell us our veins are being stretched and so, after this procedure, the most common thing that people experience is a sense of muscle spasm that can last up to 2 to 3 weeks. And that’s really the stretch of that vein sitting in the body. So, you may not feel like you can get comfortable in your chair but you’re not going to feel like you’re in extreme pain.

Host: Are there any risks involved with the procedure?

Dr. Abramowitz: So, the biggest long-term risk from this procedure is actually tied to what caused the procedure to be needed in the first place. Most people who require iliocaval reconstruction - again, stenting and opening up those veins - had those veins shut down as a result of a blood clot. So, once we open those veins up again, we’ve reestablished a pathway from the legs back up to the heart. And so, it’s really important that people stay on their blood thinners. Now, for a variety of reasons, people can develop scar tissue or other ways that the stents can shut down over time. But the biggest danger is if they shut down suddenly through another new blood clot. And that’s if somebody maybe needs to stop their blood thinner to have another procedure. Or, they stop their blood thinner because they don’t think it’s important anymore. So, the biggest risk that I counsel people about is the risk of future DVT and future pulmonary embolism, or that clot moving back from the legs or from the stents to their heart.

Host: Is there anything patients need to do to prepare for surgery?

Dr. Abramowitz: No. For the most part, to prepare for this procedure, it’s to make sure that you’re ready for your surgical date - you have someone to come pick you up from the hospital - and you’re prepared to have your medications ready, which include your blood thinner and some pain control for those potential back spasms.

Host: Why is this procedure superior to other techniques used to treat similar conditions years ago?

Dr. Abramowitz: That’s a great question. I get asked that a lot. The old way of reconnecting these veins was actually to bypass around them. And a bypass in the venous system is a huge surgery. It means making a big incision, all the way from the bottom of your chest all the way down to below your belly button. And then it means opening up both of your groins, taking plastic tubing or a vein from someone who maybe just died recently and donated their veins for use in medical procedures, sewing them all together, closing you back up, and then waiting for you to heal. But not only was that the problem, the blood that flows in your veins doesn’t flow at a very high rate. It flows actually pretty slowly. So, when we talk about blood pressure, most of the time we’re talking about what it is in your arteries, or the pressure at which it comes out of your heart. And that’s 120 millimeters of mercury. So, just remember 120. On the veins, our pressures are much lower and they’re somewhere between 8 and 12 - so, one tenth that of what’s in your arterial system. So, not only did you just have this huge surgery to bring the blood flow back to your heart, with all this plastic tubing or donor vein, but then, on top of that, the blood that moves through it isn’t moving very fast. So, it’s a very big surgery. And, in the past, it wasn’t really worth it because the failure rate was so high. Over time, most of the things that were done from an open surgical standpoint thrombosed, or clotted off. Now that we can do this within the body, in its natural pathway, we find that the patency rate, or our stents staying open (is really what we call patency), is much higher. And 87 percent of people that undergo iliocaval reconstruction have open stents at five years, which is much, much higher than the previous open bypass rates. So, if you had the bypass, it’s a big, open surgical procedure, usually resulting in a hospital stay that’s anywhere from 5 to 7 days, and then there’s recovery time after that. And, as I said before, the likelihood of that bypass staying open is pretty low. Not to mention, once you have all that scar tissue from the bypass, it pretty much eliminates a lot of other surgical options you may have in that area. Whereas, on this endovascular side, we can do things in a minimally invasive way, via some punctures, you can go home the same day, and it doesn’t necessarily limit your options in the future, should, in the small case that you’re that 13 percent your stents don’t stay open at 5 years, they do fail.

Host: Why is MedStar Washington Hospital Center the best place for patients to seek an endovascular iliocaval reconstruction?

Dr. Abramowitz: Well, there are a lot of great facilities out there that can perform venous stenting. MedStar Washington Hospital Center was one of the first in the country truly performing endovascular iliocaval reconstruction in its entirety. Not only that, we also are engaged in a lot of novel techniques to do this in a way that improve patency and outflow. So, we’re really one of the leaders in this field and we have a lot of new technology that we’re developing, as well as new techniques for patients who may have failed therapy before at other institutions. So, we’re on the forefront of this field and we really do have a comprehensive program in place to care for patients, both before and after their reconstruction.

Host: Thank you for joining us today, Dr. Abramowitz.

Dr. Abramowitz: My pleasure. Thanks for having me.

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