A Novel Technique of Ilio-Portal Venous Bypass to Relieve Symptoms of Pelvic Vein Congestion in a Patient with Inferior Vena Cava Agenesis

Abstract

A 37 year old man known to have inferior vena cava agenesis, presented to our center with severe symptoms of pelvic venous congestion. Surgical approach was attempted by creating a bypass between the right external iliac vein and the portal vein using an autogenous venous bypass (superficial femoral vein). Over a three year follow up, the bypass remained patent with complete resolution of symptoms. The ilio-portal venous bypass suggests a surgical alternative that has not been previously described.Keywords: deep vein thrombosis, ilio-portal bypass, inferior vena cava agenesis (previous anticoagulation, compressive stockings). He had no antecedent perinatal surgical or medical history. He was suffering from severe symptoms of lumbar and abdominal pain that were exacerbated by physical activity requiring opiate medication. He also experienced recurrent rectal bleeding, recurrent diarrhoea, haematuria and episodes of erection after physical activity.Duplex ultrasound scan and computed tomography angiography (CTA) were performed. The patient had an agenesis of the infra-renal and supra-renal section of inferior vena cava (IVC) and, of the two common iliac veins with occlusion of the renal veins (Figs. 1A and 1B). Radical surgical approach was considered to reduce venous pressure in the lower limbs and the pelvis. We suggest an alternative approach: a bypass between the right iliac vein and the portal vein.The right external iliac vein was chosen because the bypass in this location is short and straight.An abdominal approach was used with a midline incision towards the right inguinal region. The right external iliac vein was exposed at the more distal point in the retroperitoneal space and the portal vein in the intra-peritoneal space.An autogenous graft (superficial right femoral vein) was used to conduct the bypass. Initially, we performed an end-to side portal anastomosis then we did an end-toside right external iliac vein anastomosis (Figs. 2 and 3). In order to enhance venous flow through the bypass an infrainguinal arterio-venous fistula was made.The patient was followed up with clinical visits and duplex scanning at one month and then every six months for up to 36 months. Graft patency was also documented with magnetic resonance angiography (MRA) after 6 months. The majority of the patient's symptoms resolved during follow up. The arterio-venous fistula closed spontaneously within three months. Three years following surgery, he had unrestrained professional and physical activity. This paper shows that the bypass is technically possible in specific clinical situations.

Endovascular treatment for pelvic congestion syndrome associated with inferior vena cava anomaly

“…1 Few reports are available on the association between IVC anomalies and PCS, and endovascular treatment of this condition has been never reported. 4,5 In our case, clinical presentation was quite typical except for laterality. Moreover, IVC duplicity should have implied a double femoral access to treat both ovarian veins, and right jugular access was not an available option.…”

“…3 Few reports are available on the association between IVC anomalies and PCS, and endovascular treatment of this condition has been never reported. 4,5 We report a unique case of PCS associated with a rare IVC anomaly and successfully treated with ovarian vein embolization.…”