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Background Cervical rib can often be symptomatic causing neurogenic thoracic outlet syndrome (nTOS). Surgical treatment involves rib resection through a supraclavicular, transaxillary or combined approach. We review outcomes of different approaches and describe our technique of transaxillary resection through a video. Methods A single-center retrospective review of perioperative and short-term outcomes in subjects undergoing cervical rib resection for nTOS between 1994 and 2013 was performed. Results Of the 75 operations performed for nTOS, 40% (30 procedures in 29 patients) required resection of cervical ribs. The first and cervical ribs were removed in 24 operations, whereas only the cervical rib was resected in 6. Scalenectomy was performed in all patients. Thirteen (43%) procedures were performed with a supraclavicular-only (SC group) approach, 9 (30%) with a transaxillary-only (TA group) approach, and 8 (27%) with a combined approach (TA + SC group). Incidence of persistent nTOS symptoms occurred in 3 (23%) of SC patients, 1 (13%) TA patient, and 2 (25%) TA + SC patients (P > 0.05). Recurrence of symptoms was noted in one patient (8%) in the SC group at 1-year follow-up. No patient required operative reintervention. Conclusions Resection of cervical ribs and/or first ribs in the treatment of nTOS can be safely performed through SC, TA, or a combined approach. In young patients, a TA incision should be considered to avoid a neck incision, with outcomes similar to alternate approaches.

Background Stimulated by published reports of potentially inappropriate application of venous procedures, the American Venous Forum and its Ethics Task Force in collaboration with multiple other professional societies including the Society for Vascular Surgery (SVS), American Vein and Lymphatic Society (AVLS), and the Society of Interventional Radiology (SIR) developed the appropriate use criteria (AUC) for chronic lower extremity venous disease to provide clarity to the application of venous procedures, duplex ultrasound imaging, timing, and reimbursements. Methods The AUC were developed using the RAND/UCLA Appropriateness Method, a validated method of developing appropriateness criteria in health care. By conducting a modified Delphi exercise and incorporating best available evidence and expert opinion, AUC were developed and scored. Results There were 119 scenarios rated on a scale of 1 to 9 by an expert panel, with 1 being never appropriate and 9 being appropriate. The majority of scenarios consisted of symptomatic indications were deemed appropriate for venous intervention. For scenarios with anatomically short segments of reflux and/or no symptoms, the indications were rated less appropriate. For the indication of edema, a wide dispersion of ratings was observed especially for short segments of saphenous reflux or stenting for iliac/ inferior vena cava disease, noting that there are multifactorial causes of edema, some of which could coexist with venous disease and possibly impact effectiveness of treatment. Several scenarios were considered never appropriate, including treatment of saphenous veins with no reflux, iliac vein or inferior vena cava stenting for iliac vein compression as an incidental finding by imaging with minimal or no symptoms or signs, and incentivizing sonographers to find reflux. Conclusions The AUC statements are intended to serve as a guide to patient care, particularly in areas where high-quality evidence is lacking to aid clinicians in making day-to-day decisions for common venous interventions. This may also prove useful when applied on a population level, such as practice patterns, and not necessarily to dictate decision making for individual cases. As a product of a collaborative effort, it is hoped that this could be utilized by physicians and multiple stakeholders committed toward improving patient care and to identify and stimulate future research priorities.

The CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification is an internationally accepted standard for describing patients with chronic venous disorders and it has been used for reporting clinical research findings in scientific journals. Developed in 1993, updated in 1996, and revised in 2004, CEAP is a classification system based on clinical manifestations of chronic venous disorders, on current understanding of the etiology, the involved anatomy, and the underlying venous pathology. As the evidence related to these aspects of venous disorders, and specifically of chronic venous diseases (CVD, C2-C6) continue to develop, the CEAP classification needs periodic analysis and revisions. In May of 2017, the American Venous Forum created a CEAP Task Force and charged it to critically analyze the current classification system and recommend revisions, where needed. Guided by four basic principles (preservation of the reproducibility of CEAP, compatibility with prior versions, evidence-based, and practical for clinical use), the Task Force has adopted the revised Delphi process and made several changes. These changes include adding Corona phlebectatica as the C4c clinical subclass, introducing the modifier "r" for recurrent varicose veins and recurrent venous ulcers, and replacing numeric descriptions of the venous segments by their common abbreviations. This report describes all these revisions and the rationale for making these changes.

Background Type II endoleaks (T2ELs) are common following endovascular repair of abdominal aortic aneurysms (EVAR). Embolization with ethylene vinyl alcohol copolymer (Onyx) may present an effective treatment alternative for T2ELs. Due to limited data supporting its use, we sought to analyze outcomes of Onyx embolization for T2ELs. Methods Retrospective review of consecutive patients treated for T2ELs utilizing Onyx embolization agent from 2009–2018. All pre- and post-Onyx intervention CT scans were analyzed for diameter and volume changes with 3D reconstruction software. The primary outcomes were change in maximum AAA diameter and volume. Secondary outcomes included additional interventions, rupture, and mortality. A subset analysis was performed with patients with isolated T2ELs (no other types of endoleaks present). Results We identified 85 patients (73 males, mean age 77.6 ± 7.6 years) who underwent 112 Onyx interventions. Average time to first Onyx intervention after index EVAR was 3.3 ± 2.6 years and average sac growth was 6.3 ± 6.7 mm. Patients underwent mean 1.3 Onyx interventions using a mean of 4.9 ± 4.7 ml for treatment. Three complications occurred (Onyx extravasation, colon ischemia, and access site hematoma). Mean follow-up was 2.5 ± 2.1 years after initial Onyx treatment. At the most recent follow-up, sac diameter stabilization was seen in 47% and reduction >5 mm was seen in 19%. Sac growth of >5 mm was seen in 34% of patients following the first Onyx intervention. In our subset of isolated T2EL, 72% had sac stabilization or reduction >5 mm. Four patients experienced a ruptured aneurysm (3 had active type 1 endoleaks). Rupture-free survival was 95% at 5 years, and overall survival was 54% at 5 years. Notably, increasing Onyx interventions were not associated with sac stabilization or reduction (OR 0.6, P = 0.1). On multivariable analysis, AAA sac diameter stabilization or reduction was independently associated with BMI >30 kg/m2 (OR 4.2, P = 0.01) and having only 1 Onyx intervention (OR 3.8, P = 0.02). Conclusions Onyx for embolization of T2ELs resulted in AAA sac diameter stabilization or reduction in 66% of patients, and up to 72% in isolated T2ELs. Further, increasing Onyx interventions were not associated with either aneurysm sac stabilization or reduction. Given its similar outcomes to other embolization strategies in the literature, Onyx embolization for management of T2ELs needs to be judiciously considered, particularly for T2ELs persisting after an initial Onyx embolization intervention.

The aim of this study was to evaluate outcomes of fenestrated-branched endovascular aortic repair (F-BEVAR) of pararenal abdominal aortic aneurysms or thoracoabdominal aortic aneurysms (TAAAs) in patients with a solitary functional kidney (SFK).We analyzed the outcomes of 287 consecutive patients (206 male; mean age, 74 ± 8 years old) enrolled in a prospective nonrandomized study to investigate use of F-BEVAR for treatment of patients with pararenal abdominal aortic aneurysms or TAAAs between 2013 and 2018. Outcomes were analyzed in patients with solitary kidney (functional or congenital) and compared with control patients who had two functioning kidneys. Acute kidney injury (AKI) was defined using Risk, Injury, Failure, Loss of kidney function, and End-stage renal disease criteria, and renal function deterioration (RFD) was defined by a decline in estimated glomerular filtration the estimated glomerular filtration rate of more than 30% from baseline. End points included 30-day mortality and major adverse events, AKI, freedom from RFD, and patient survival.There where 30 patients (10%) with a SFK and 257 patients with two functioning kidneys. Patients with a SFK were younger and had significantly (P .05) higher baseline creatinine (+0.3 mg/dL), lower estimated glomerular filtration rate (-16 mL/minute/1.73 mDespite the worse baseline renal function, F-BEVAR is safe and effective with nearly identical outcomes in patients with a SFK as compared with patients with two functioning kidneys. Development of postoperative AKI is the most important predictor for RFD.

Objective The objective of this study was to determine the incidence rate, outcomes, and risk factors of target vessel-related endoleaks after fenestrated-branched endovascular aortic repair (F-BEVAR) for pararenal aneurysms or thoracoabdominal aortic aneurysms (TAAAs). Methods We reviewed consecutive patients treated by F-BEVAR between 2007 and 2017. Target vessel endoleaks were identified by computed tomography angiography (CTA). Follow-up included CTA and duplex ultrasound before discharge, at 2 months, at 6 months, and annually thereafter. Primary endoleaks were detected by predismissal CTA; secondary endoleaks were absent on the first CTA and were identified during follow-up. End points were spontaneous resolution of primary endoleaks, secondary interventions, and aneurysm rupture. Multivariable analyses were performed for risk factors of target vessel endoleaks and predictors of spontaneous resolution. Results A total of 382 patients (mean age, 75 ± 8 years; 75% male) underwent F-BEVAR for 195 pararenal aneurysms and 187 TAAAs with 1204 renal-mesenteric arteries targeted by 981 fenestrations and 223 directional branches. Fifty-two target vessel endoleaks were identified in 41 patients; 41 were type IIIC (interattachment), 10 were type IC (distal bridging stent sealing zone), and 1 was type IIIB (bridging stent fabric tear). Thirty-three patients (9%) had primary target vessel endoleaks in 41 target vessels (3%). Eight patients (2%) developed 11 secondary target vessel endoleaks. Directional branches were more prone to primary endoleaks (13/223 [6%]) in comparison to fenestrations (28/981 [3%]; P = .03). However, branch endoleaks resolved more often spontaneously (11/14 [79%]) compared with fenestration endoleaks (14/38 [37%]; P = .008). Other risk factors for target vessel endoleaks included inner aortic diameter ≥30 mm at the target vessel origin, four or more targeted vessels, TAAA (for primary endoleaks), and physician-modified endograft (for secondary endoleaks). Four patients with primary endoleaks underwent successful reintervention before discharge, and 29 were observed with a mean follow-up of 24 ± 21 months. Of the 41 primary endoleaks, 25 resolved spontaneously in 20 patients (61%) at first follow-up with no recurrences. Of the observed endoleaks, 11 persisted in 9 patients, and 8 of those endoleaks were treated in 7 patients. All secondary target vessel endoleaks required reintervention. There was one possible aneurysm rupture attributed to persistent secondary target vessel endoleak. Conclusions Target vessel endoleak on CTA at discharge occurs in 1 of 10 patients treated by F-BEVAR. Of these, two-thirds resolve spontaneously, especially those affecting directional branches. Among patients with a persistent endoleak, endovascular reintervention is usually successful and aneurysm rupture is rare.

The objective of this study was to analyze the utility of cone beam computed tomography (CBCT) for technical assessment of standard and complex endovascular aneurysm repair (EVAR).Data of consecutive patients who underwent standard or complex EVAR in 2016 and 2017 at our institution were entered into a prospective database and analyzed retrospectively. There were 154 patients (126 male; mean age, 74 ± 8 years) enrolled in a prospective study between 2016 and 2017. A total of 170 aortic procedures were investigated, including 85 fenestrated-branched EVARs (F-BEVARs), 42 abdominal and thoracic EVARs, 32 EVARs with iliac branch devices, and 11 aorta-related interventions. Technical assessment was done using CBCT with and without contrast enhancement, digital subtraction angiography (DSA), and computed tomography angiography (CTA). Patients with stage 3B or stage 4 chronic kidney disease had CBCT without contrast enhancement. Radiation exposure (mean dose-area product), effective dose (ED), and amount of iodine contrast agent were analyzed. End points were presence of any endoleak, positive findings warranting possible intervention (stent kink or compression, type I or type III endoleak, dissection, thrombus), and need for secondary intervention.Radiation exposure and amount of iodine contrast agent were significantly higher (P .05) for F-BEVAR compared with other aortic procedures (174±101 Gy∙cmCBCT reliably detected positive findings prompting immediate revisions in nearly one of five patients, with the highest rates among F-BEVAR patients. Detection of any endoleak was higher with CBCT compared with DSA or CTA, but most endoleaks were observed. DSA alone failed to detect positive findings warranting revisions.

Venous disorders of the abdomen and pelvis are part of the spectrum of chronic venous disease and often play a role in lower extremity disease. The anatomy, pathophysiology, and treatment of pelvic venous disease are only beginning to be understood. Rather than being a disparate group of syndromes (e.g., May- Thurner, pelvic congestion, and nutcrackers syndromes), it is becoming clear that although much more complex, the abdominal and pelvic venous systems should be approached in a systematic way similar to the lower extremities. Reflux and/or obstruction in various components of the abdominal and pelvic veins often results in similar clinical symptoms, posing complex diagnostic and therapeutic questions. It is useful to consider the venous circulation of the pelvis to consist of three multiple interconnected venous systems—the left renal and ovarian veins, the iliac veins (common, external, and internal), and the lower extremity veins. The spectrum of pelvic venous disorders includes four clinical presentations—chronic pelvic pain, pelvic source varices of the leg, symptoms related to renal venous hypertension, and leg swelling. Venography has been the historical gold standard for the diagnosis of pelvic venous disorders. Improving the care of women with these disorders will require a better understanding of abdominal and pelvic venous anatomy; improved comprehension of the relative importance of pelvic venous reflux and obstruction in individual patients; validation of diagnostic protocols, particularly with respect to ultrasound; robust clinical trials evaluating the management of pelvic venous reflux and obstruction; and validated patient-centered outcome measures.

This chapter summarizes the most important current guidelines on evaluation and management of patients with chronic venous disease adopted by our two major vascular societies, SVS and AVF. The best evidence is usually provided by systematic reviews and meta-analyses of prospective randomized trials. The approach developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) working group has been adopted by the Society for Vascular Surgery and the American Venous Forum in developing practice guidelines. Evaluation of the patient with venous disease should include a thorough history, focusing on the underlying etiology (congenital, primary, or secondary), symptoms, and risk factors for venous disease. Duplex ultrasonography, including an evaluation of reflux in the upright position, should be the initial diagnostic test in patients with suspected venous disease. Compression is considered first-line therapy for chronic venous disorders. A systematic review of 44 randomized, placebo-controlled trials evaluating oral phlebotonics suggested efficacy for some signs such as edema, although the global evidence for their efficacy was insufficient to recommend routine use. During the past 2 decades, an array of endovenous techniques have emerged and have largely replaced high ligation and stripping for the management of saphenous vein reflux. The potential value of interruption of pathologic perforators (>3.5 mm, reflux ≥ 0.5 second, located near the ulcer bed) in C5–C6 disease cannot be excluded. Because of lack of controlled prospective studies, the quality of evidence to support iliac vein stenting remains weak.

Persistent pain after iliac vein stenting is rare. Surgical removal of two oversized (20-mm) iliac vein stents was performed in a 36-year-old woman because of severe back pain of 2½ years' duration. Clamping or venotomy were not required for stent removal, which was done by extraction of each wire of the stent through small puncture wounds in the vein wall. Duplex scanning confirmed residual pseudointima obstructing the orifice of the right common iliac vein. The pseudointima was surgically removed. The patient recovered without complications, and her pain completely resolved.

Objective An endovascular-first approach has been widely adopted as an alternative to surgical bypass in patients who need lower extremity revascularization for femoropopliteal disease. This study evaluated anatomic changes in the extent of bypass and outcomes of open bypass (OBP) surgery after failed endovascular treatment (EVT). Methods We reviewed consecutive patients treated by endovascular femoropopliteal revascularization from 2002 to 2012. Patients requiring OBP after failed EVT were analyzed. Blinded investigators reviewed preoperative and postintervention angiographies. The location of the intended distal anastomosis before the endovascular intervention was compared with the open procedure after failed EVT, and results were analyzed for amputation and patency rates. Results There were 566 patients (322 men [57%]) who underwent 836 endovascular femoropopliteal revascularizations in 665 limbs. Patients were a mean age of 72 ± 11 years. Mean follow-up was 20 months. Indication for revascularization was critical limb ischemia in 33% of patients before the index endovascular procedure. Interventions were performed for de novo lesions in 604 procedures (72%) or restenosis in 232 (28%). TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease A and B lesions were treated in 547 patients (65%). Balloon angioplasty was used in 822 interventions (98%), with primary or secondary stenting using self-expandable stents performed in 367 (44%). Thirty OBPs were required in 566 patients (5.3%) at an average of 15 months after the index EVT. OBP consisted of 6 above-knee, 14 below-knee, and 10 tibial bypasses. Vein and prosthetic conduits were used equally. Location of the distal anastomosis changed to a more distal target in 13 (5 below-knee and 8 tibial) of 30 patients (43%). Median follow-up was 36 months (range, 0.5-104 months), with a primary patency of 66% at 1 year and 46% at 3 years. Of the 30 bypasses, seven patients required reintervention with percutaneous angioplasty (n = 4) and patch angioplasty (n = 3). Five patients required redo bypass after failed endovascular salvage (lysis or angioplasty, or both), and redo bypass was not attempted in two. Eight patients (27%) progressed to major amputation, for an amputation-free survival of 79% at 1 year and 67% at 3 years. Conclusions OBP after failed EVT was needed in a minority of patients. A change in the bypass target to a more distal site was identified in nearly half of patients. Although an endovascular-first approach to treating claudication and critical limb ischemia is safe and resulted in few progressing to OBP, poor outcomes of open interventions after EVT can be expected if EVT fails.

Purpose: To describe a bailout technique for use during branched/fenestrated thoracoabdominal aortic aneurysm (TAAA) repair to address celiac artery (CA) dissection. Technique: The technique is demonstrated in a 69-year-old man who underwent fenestrated stent-graft repair of a 6-cm type III TAAA. The main fenestrated stent-graft was positioned without difficulty, and the renal and superior mesenteric arteries were stented. A stent-graft was placed in the CA, but angiography showed the vessel to be occluded by dissection beyond the stent-graft. Wire manipulations to regain access to the true lumen culminated in perforation. At this point, the gastroduodenal artery was catheterized with a 0.035-inch guidewire, which was advanced in retrograde fashion into the CA true lumen and then snared back to the left brachial artery forming a loop. After exchange for a 0.014-inch system, self-expanding stents were deployed into the hepatic artery. Postoperative recovery was uneventful, and the patient was discharged on day 6. At 1-year follow-up, the patient was doing very well. Imaging demonstrated no endoleak, no graft migration, and sac shrinkage to a diameter of 5.1 cm. Conclusion: The “loop technique” can be a very useful and effective bailout maneuver in regaining access to the true lumen of a dissected CA in patients undergoing branched/fenestrated thoracoabdominal aortic aneurysm repair.

Background Popliteal artery aneurysms (PAAs) in women are rare and their outcomes compared with men with PAA are unknown. The purpose of this study was to compare the surgical outcomes of PAA of women with men. Methods All patients who underwent PAA repair at a single institution from 1985 to 2013 were reviewed. All women with degenerative PAA treated during that time frame were matched on year of repair to men. Presentation, mode of repair, and outcomes were reviewed. Survival and amputation-free survival were evaluated by life table analysis. Results During the study interval, 8 women with degenerative PAA underwent surgical treatment (1.6% of 485 total PAA repairs). The overall median follow-up was 5 years (range 1 month to 19 years), but the median follow-up was shorter for women than men (1.6 vs. 6 years, P = 0.04). At the time of repair, women were of similar age compared with men (73.5 vs. 71.7 years) and had similar aneurysm size (2.7 vs. 2.9 cm). Women had similar urgency (25 vs. 17.5% emergent) and symptomatic status (50% vs. 55% acute) even though 7 of the 8 women had a thrombosed PAA at the time of repair. Operative time, approach, graft type, and inflow and outflow sources were similar between genders. No women received endovascular repair (0% vs. 10%, P = 0.5). One patient of each gender underwent major amputation (one woman on post-operative day 158 and one man on post-operative day 3). Overall, women had lower survival and amputation-free survival at 2 years (51% vs. 100% and 20% vs. 94%, P

Background The role of inferior mesenteric artery (IMA) reimplantation during open aortic reconstruction is debated. We assessed outcomes after inferior mesenteric artery reimplantation (IMAR) for aortic aneurysmal disease to help shed light on this question. Methods A single-center retrospective review of all IMARs performed during open aortic surgery over a 10-year period between 2000 and 2009 was carried out. The primary outcome was patency, while secondary outcomes included colonic ischemia and overall survival. Analysis was performed using Cox models and Kaplan-Meier estimates. Results Of 840 patients who underwent elective abdominal aortic aneurysm (AAA) reconstructions during this period, 70 underwent IMAR. Indications for IMAR included intraoperative colonic ischemia (n = 24), poor back bleeding (n = 52), large IMA (n = 5), internal iliac disease (n = 5), and prior colon surgery (n = 1). Follow-up imaging studies were available in 35 of 70 patients (computed tomography in 30 [86%] and duplex in 5 [14%]). Patency was confirmed in 32 of 35 patients (91%) over a median follow-up of 98 months. Both losses in patency were at 4 months and did not require an operation. One patient underwent left colon resection on postoperative day 9 because of ischemia. (Patency could not be confirmed.) No statistically significant predictor of patency was noted. Incidence of colonic ischemia was 1.4% in patients undergoing IMAR. The overall mortality was 51% in patients undergoing IMAR over the median follow-up period. The overall 10-year survival was 30% in patients undergoing IMAR for aortic aneurysmal disease. The nature of aneurysm (juxtarenal or higher juxta renal abdominal aortic aneurysm [JRAAA]) was associated with mortality, with a hazard ratio of 1.8 (P = 0.08) approaching significance. Ten-year survival was worse if IMAR was performed for intraoperative colonic ischemia (26% vs 34%) or in JRAAA (19.0% vs 38%; P = 0.03). Age per year at the time of repair was the only statistically significant predictor of survival (P Conclusion IMAR for AAA remains necessary for select patients. Reimplantation is associated with excellent long-term patency and low risk of colonic ischemia.

The objective of this study was to investigate changes in health-related quality of life (QOL) in patients treated for pararenal aortic aneurysms (PAAs) and thoracoabdominal aortic aneurysms (TAAAs) with fenestrated-branched endovascular aneurysm repair (F-BEVAR).A total of 159 consecutive patients (70% male; mean age, 75 ± 7 years) were enrolled in a prospective, nonrandomized single-center study using manufactured F-BEVAR (2013-2016). All patients were observed for at least 12 months (mean follow-up time, 27 ± 12 months). Patients' health-related QOL was assessed using the 36-Item Short Form Health Survey questionnaire at baseline (N = 159), 6 to 8 weeks (n = 136), 6 months (n = 129), and 12 months (n = 123). Physical component scores (PCSs) and mental component scores (MCSs) were compared with historical results of patients enrolled in the endovascular aneurysm repair (EVAR) 1 trial who were treated by standard EVAR for simple infrarenal abdominal aortic aneurysms.There were 57 patients with PAAs and 102 patients with TAAAs (50 extent IV and 52 extent I-III TAAAs). There were no 30-day deaths, in-hospital deaths, conversions to open surgery, or aorta-related deaths. Survival was 96% at 1 year and 87% at 2 years. Major adverse events occurred in 18% of patients, and 1-year reintervention rate was 14%. There were no statistically significant differences between the groups in 30-day outcomes. Patients treated for TAAAs had lower baseline scores compared with those treated for PAAs (P .05). PCS declined significantly 6 to 8 weeks after F-BEVAR in both groups and returned to baseline values at 12 months in the PAA group but not in the TAAA group. Patients with TAAAs had significantly lower PCSs at 12 months compared with those with PAAs (P .001). There was no decline in mean MCS. Major adverse events were associated with decline in PCS assessed at 6 to 8 weeks (P = .021) but not in the subsequent evaluations. Reinterventions had no effect on PCS or MCS. Overall, patients treated by F-BEVAR had similar changes in QOL measures as those who underwent standard EVAR in the EVAR 1 trial, except for lower PCS in TAAA patients at 12 months.Patients treated for TAAAs had lower scores at baseline in their physical aspect of health-related QOL. F-BEVAR was associated with significant decline in PCSs in both groups, which improved after 2 months and returned to baseline values at 12 months in patients with PAAs but not in those with TAAAs. Patients treated for PAAs had similar changes in QOL compared with those treated for infrarenal aortic aneurysms with standard EVAR.

Few areas of venous disease provide a more satisfying experience for both the patient and the vascular specialist than reconstruction for superior vena cava (SVC) syndrome. Relief from severe, frequently incapacitating symptoms of venous congestion of the head and neck is almost instantaneous, and benefit after reconstruction is generally long lasting. This article reviews the etiologic factors, clinical presentation, and diagnostic evaluation of SVC syndrome, and current techniques and results for the endovascular and open surgical treatment of SVC occlusion.

Chronic lymphedema continues to be a challenge both in diagnosis and treatment. Physical therapy remains the first line of treatment, and interventions traditionally have been reserved for those who do not significantly benefit from physical therapy or fail nonoperative management. Indications are slowly changing, however, since preventive microsurgery and reconstruction in the early stages of lymphedema, before fibrosis and obstruction of the major lymph vessels occur, have been recommended by multiple authors. The goal of reconstructive lymphatic surgery is to improve lymphatic outflow by restoring lymphatic drainage of the affected limb. Lymphatic reconstructions using microsurgical or supermicrosurgical techniques have been around for decades, but recent progress has been significant. The three main techniques include lymphovenous anastomoses (LVA), lymphatic grafting, and vascularized lymph node autotransplantation (VLNT). This introductory chapter provides a general overview of these microsurgical techniques and helps the readers to make decisions on patient’s selection and appropriate treatment. The senior author’s personal experience of 40 years in this field helps to focus attention to the most promising procedures.