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Dwivedi A, Singh SN, Sharma A, Sharma R, Mishra T. A Systematic Review of Radiological Diagnosis and Management of May-Thurner Syndrome. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2024; 16:S1012-S1016. [PMID: 38882842 PMCID: PMC11174332 DOI: 10.4103/jpbs.jpbs_1135_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/10/2023] [Accepted: 11/17/2023] [Indexed: 06/18/2024] Open
Abstract
May-Thurner syndrome (MTS) is an anatomical condition of external luminal compression of common iliac vein due to a partial obstruction of the common iliac vein between common iliac artery and lumbar vertebra causes deep-vein thrombosis, venous hypertension, and chronic venous insufficiencies. In this article, we review present evidence of the clinical diagnosis and management of MTS. Here, we conducted a literature review of studies on MTS. We also reviewed different clinical features, presentation, diagnostic methods, and therapeutic procedure for this condition. Most studies mentioned the diagnosis of this condition is performed by color Doppler, computed tomographic angiography, venography, and problem-solving cases by intravascular ultrasound technique. Nonsurgical methods of management are first line, and vascular surgery is reserved for refractory cases. Multiple modalities are required to reach the diagnosis of MTS, and noninvasive intervention radiology methods are the first line of management. This review highlights the presentations of MTS and outlines diagnostic procedure and management.
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Affiliation(s)
- Abhishek Dwivedi
- Department of Radiodiagnosis, FH Medical College and Hospital, Agra, Uttar Pradesh, India
| | - Satyender N Singh
- Department of Radiology, Tata Memorial Centre, Varanasi, Uttar Pradesh, India
| | - Ankur Sharma
- Department of Radiodiagnosis, FH Medical College and Hospital, Agra, Uttar Pradesh, India
| | - Rachit Sharma
- Department of Radiology, Military Hospital, Jaipur, Rajasthan, India
| | - Tanu Mishra
- Department of Radiology, Autonomous State Medical College, Basti, Uttar Pradesh, India
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Jiang L, Zhuang H, Song T, Li XQ. Clinical Outcomes at 3 Years After Stenting for Thrombotic and Non-thrombotic Iliac Vein Compression Syndrome Patients. Clin Appl Thromb Hemost 2024; 30:10760296231220053. [PMID: 38213124 PMCID: PMC10787525 DOI: 10.1177/10760296231220053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Iliac vein stenting for the treatment of iliac vein compression syndrome (IVCS) has been gradually developed. This article investigated the long-term patency and improvement of clinical symptoms after endovascular stenting for iliac vein obstruction patients. From 2020 to 2022, 83 patients at a single institution with IVCS underwent venous stent implantation and were divided into two groups: non-thrombotic IVCS (n = 55) and thrombotic IVCS (n = 28). The main stent-related outcomes include technical success, long-term patency, and thrombotic events. The technical success rate of all stent implantation was 100%. The mean length of hospital stay and cost were higher in the thrombotic IVCS group than in the non-thrombotic ICVS group, as well as the length of diseased vessel segment and the number of stents implanted were higher than in the control non-thrombotic group. The 1-, 2-, and 3-year patency rates were 85.4%, 80% and 66.7% in the thrombosis group, which were lower than 93.6%, 88.7%, and 87.5% in the control group (P = .0135, hazard ratio = 2.644). In addition, patients in both groups had a foreign body sensation after stent implantation, which resolved spontaneously within 1 year after surgery. Overall, there were statistically significant differences in long-term patency rate outcome between patients with thrombotic and non-thrombotic IVCS, the 1-, 2-, and 3-year patency rates in non-thrombotic IVCS patients were higher than those in thrombotic IVCS patients.
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Affiliation(s)
- Lei Jiang
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of General Surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Hao Zhuang
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Tao Song
- Department of General Surgery, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui, China
| | - Xiao-Qiang Li
- Department of Vascular Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of Vascular Surgery, Affiliated Nanjing Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
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Zhou Y, Chen Y, Xue M, Zheng X, Guan Y. Pregnancy outcomes in 16 women with previous catheter-directed thrombolysis and stenting for acute left iliofemoral deep vein thrombosis. Phlebology 2023; 38:445-450. [PMID: 37345252 DOI: 10.1177/02683555231183782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
BACKGROUND Whether iliac vein stents affect pregnancy or whether they will be affected by pregnancy was rarely reported in the literature. The aim of this study was to report our experience of pregnancy in women who received thrombolysis and stenting for a previous deep vein thrombosis (DVT). METHODS 16 patients with previous stenting for treatment of acute left iliofemoral DVT who had subsequent pregnancies were identified. Patient demographic information and outcomes were recorded. Duplex scanning and venography were performed as scheduled to evaluate the patency of stents in perinatal period and at 12 months after delivery. RESULTS None of the patients had a hemorrhagic complication and recurrent venous thromboembolism during their pregnancies and postpartum. No stent compression/occlusion and structural damage occurrence in all patients during follow-up. CONCLUSION Pregnancy managed with prophylactic dalteparin resulted in no re-thrombotic events or structural damage to the iliac stents and did not appear to negatively affect pregnancy outcomes.
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Affiliation(s)
- Yadong Zhou
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yingying Chen
- Department of Pediatric Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ming Xue
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xuexun Zheng
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yunbiao Guan
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou, China
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Cherfan P, Zaghloul MS, Abdul-Malak OM, Saadeddin Z, Go C, Hager E, Chaer RA, Avgerinos ED. Stenting across inferior vena cava filters can be a safe and effective alternative to complex retrieval. J Vasc Surg Venous Lymphat Disord 2023; 11:302-309. [PMID: 35995330 PMCID: PMC10805110 DOI: 10.1016/j.jvsv.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 06/20/2022] [Accepted: 07/06/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVE Venous stenting for acute and chronic venous disease has been increasingly used as more evidence has accumulated on the efficacy and durability of these interventions for symptomatic patients. Inferior vena cava (IVC) filters that could have been present for years will often be implicated in the obstructive pathology and removal can be challenging. The purpose of the present study was to evaluate whether stenting across an indwelling IVC filter is a safe and effective alternative to removal. METHODS Consecutive patients who had undergone iliocaval stenting at our institution from 2007 to 2020 were identified and divided into groups stratified by the presence of an IVC filter. The operative notes, venography findings, and the electronic health records were queried to obtain the operative details, patient characteristics, postoperative outcomes, stent patency, and survival outcomes. The primary end point was iliocaval stent patency. The patients were divided into two groups according to the presence of an IVC filter with or without overstenting. We used the χ2 test and survival analysis as appropriate. RESULTS A total of 224 consecutive patients were identified, of whom 71 were found to have undergone iliocaval stenting (age, 48 ± 18 years; 47.9% male; body mass index, 31 ± 9 kg/m2). Of the 71 patients, 15 had had stents placed across an indwelling IVC filter (overstented group) and 56 had not had an IVC filter present (non-overstented group). No differences were found in presentation between the overstented group (acute occlusion, 4 of 15 [26.7%]; chronic occlusion, 8 of 15 [53.3%]; and nonocclusive lesions, 3 of 15 [20%]) and the non-overstented group (acute occlusion, 29 of 56 [52%]; chronic occlusion, 18 of 56 [32%]; nonocclusive lesions, 9 of 56 [16%]; P = .2). Comparisons between the two groups revealed no differences in the baseline characteristics except for age (overstented, 57 ± 15 years; non-overstented, 46 ± 18 years; P = 0.03), preoperative anticoagulation therapy (overstented, 66.6%; non-overstented, 26.9%; P = .01), and bilateral leg symptoms (overstented, 86.7%; non-overstented, 23.2%; P < .001). Primary patency at 30 months was 85.6% in the overstented group and 86.1% in the non-overstented group (P = .78). At follow-up, no adverse events related to filter crushing were reported, and no differences were found in 30-month survival. CONCLUSIONS In our single-center, retrospective study of iliocaval stenting, patients who had undergone overstenting across an indwelling IVC filter had had patency rates similar to those whose stents had been placed with no IVC filter in place. Thus, complex IVC filter removal, when not possible or when the risk of operative complications is too high, can be forgone in favor of stenting across the IVC filter, with no implications on midterm patency or adverse events.
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Affiliation(s)
- Patrick Cherfan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohamed S Zaghloul
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Othman M Abdul-Malak
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Zein Saadeddin
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Catherine Go
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Williams DM, Nicklas JM, Obi A, Gordon D. Pathologic characteristics of human venous in-stent stenosis and stent occlusion. J Vasc Surg Venous Lymphat Disord 2023; 11:109-118.e2. [PMID: 35961633 DOI: 10.1016/j.jvsv.2022.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/13/2022] [Accepted: 07/02/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The objective of this study was to determine the pathologic features of venous in-stent stenosis over time occurring in bare metal stents. METHODS Endovascular biopsy samples were obtained prospectively from venous bare metal stents implanted in 2009 through 2018. All samples were formalin-fixed, paraffin-embedded and stained with hematoxylin and eosin. Samples were examined by a cardiovascular pathologist to estimate the amount of its constituent components, which included fresh thrombus, organizing thrombus, old thrombus, or diffuse intimal thickening (DIT), and pathologic features including calcification, neovascularization, and hemosiderin deposition. This pathologic characterization was correlated with time following stent implantation to discern time-dependence of pathologic evolution of in-stent stenosis using both descriptive statistics and binary logistic regression. RESULTS A total of 254 post-stent venograms with biopsies of in-stent contents from 148 unique patients were studied. Fresh thrombus and organizing thrombus were both present across all studied time intervals. Old thrombus was seen beginning at approximately 2 weeks and DIT at approximately 4 weeks. Calcification was a rare finding encountered at later time intervals. The prevalence of each component varied with time: the probability of encountering fresh thrombus (P = .010) and organizing thrombus (P = .008) decreased over time. By contrast, the probability of finding DIT (P = .002) and calcifications (P < .001) increased over time. The presence of old thrombus, neovascularization, or hemosiderin did not demonstrate time dependence. Diffuse intimal thickening was frequently seen along with organizing thrombus as well as independently, and in many instances, these two features were directly merged. CONCLUSIONS The evolution of human venous in-stent restenosis appears to follow a time-dependent course, suggesting a possible progressive evolution from fresh and organizing thrombus to DIT. Contrasted with the literature on arterial in-stent restenosis, vein in-stent restenosis may have an increased thrombus prevalence (both organizing and old thrombus). DIT is a primary feature of late in-stent stenosis and may explain in part why many of these lesions may not respond to thrombolytic or anticoagulant treatment alone.
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Affiliation(s)
- David M Williams
- Section of Interventional Radiology, Department of Radiology, University of Michigan Medical School, Ann Arbor, MI
| | | | - Andrea Obi
- Conrad Jobst Vascular Research Laboratories, Department of Surgery, Section of Vascular Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - David Gordon
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI.
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Schrufer-Poland TL, Florio K, Grodzinsky A, Borsa JJ, Schmidt L. Management of May Thurner Syndrome in Pregnant Patients. J Cardiovasc Dev Dis 2022; 9:jcdd9120410. [PMID: 36547407 PMCID: PMC9784684 DOI: 10.3390/jcdd9120410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/12/2022] [Accepted: 11/14/2022] [Indexed: 11/24/2022] Open
Abstract
May Thurner Syndrome contributes to thromboembolic disease and can cause significant morbidity in pregnant patients secondary to exaggerated anatomic relationships and physiologic changes in the hematologic system favoring thrombogenesis. Because this condition is both underrecognized and underreported, management in pregnant and postpartum patients is based on expert opinion without any formal evidence-based guidance. Herein, we review five pregnancies in four patients with May Thurner Syndrome and general management strategies. Through collaborative and multidisciplinary care, patients with May Thurner Syndrome can be safely and successfully managed during pregnancy and the postpartum period with appropriate anticoagulation.
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Affiliation(s)
- Tabitha L. Schrufer-Poland
- Maternal and Fetal Medicine, Saint Luke’s Health System, Kansas City, MO 64111, USA
- Cardiovascular Outcomes Research Department, Saint Luke’s Health System, Kansas City, MO 64111, USA
- Correspondence:
| | - Karen Florio
- Maternal and Fetal Medicine, Saint Luke’s Health System, Kansas City, MO 64111, USA
- Cardiovascular Outcomes Research Department, Saint Luke’s Health System, Kansas City, MO 64111, USA
| | - Anna Grodzinsky
- Cardiovascular Outcomes Research Department, Saint Luke’s Health System, Kansas City, MO 64111, USA
| | - John J. Borsa
- Department of Radiology, Saint Luke’s Health System, Kansas City, MO 64111, USA
- Department of Radiology, University of Missouri Kansas City, Kansas City, MO 64108, USA
| | - Laura Schmidt
- Cardiovascular Outcomes Research Department, Saint Luke’s Health System, Kansas City, MO 64111, USA
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Nana P, Avgerinos E, Spanos K, Giannoukas A, Labropoulos N. Gaps arising from randomized controlled trials on thrombolysis for proximal deep vein thrombosis of the lower limb. J Vasc Surg Venous Lymphat Disord 2021; 10:196-199.e2. [PMID: 34920845 DOI: 10.1016/j.jvsv.2021.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/23/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Petroula Nana
- Division of Vascular Surgery, University of Thessaly, Larissa, Greece
| | - Efthymios Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | | | - Nicos Labropoulos
- Division of Vascular Surgery, Stony Brook Medicine, Stony Brook, NY.
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Zaghloul MS, Abdul-Malak OM, Cherfan P, Go C, Saadeddin Z, Al-Khoury GE, Chaer RA, Avgerinos ED. Female Gender is a Predictor of Lower Iliac Vein Stenting Patency Rates. Ann Vasc Surg 2021; 78:247-256. [PMID: 34464730 DOI: 10.1016/j.avsg.2021.06.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/29/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Iliac venous stenting (IVS) for thrombotic and nonthrombotic venous disease is increasingly used as evidence of the safety, efficacy and durability of these interventions increases. Female gender has been implicated as a predictor of failure in arterial endovascular interventions. We hypothesize that female gender could be predictive of patency rates of iliac vein stenting. METHODS Consecutive patients who underwent IVS for thrombotic or nonthrombotic venous disease at our institution from 2007 until 2019 were identified and divided into groups based on gender. Operative notes, venograms, and the electronic health record were then queried to obtain operative details, co-morbid conditions, postoperative outcomes and stent patency. Study outcome was long term patency rate. The data was analyzed using chi-square, logistic regression, and Kaplan-Meier analysis as appropriate. RESULTS A total of 200 consecutive patients (231 limbs) were identified in our retrospective analysis, with a mean age of 48.8 ± 17.3, and BMI of 31.6 ± 8.6. Of those, 119 (59.5%) patients, (131 [56.8%] limbs) were female. Comparisons between the gender groups revealed no difference in age, BMI, or preoperative comorbidities. There was no difference in type of venous disease between male (85% thrombotic, 15% nonthrombotic) and female (84% thrombotic, 16% nonthrombotic), P= 0.830. The male cohort was more likely to present with leg ulceration (17% vs. 4.6%, P = 0.002), and the female cohort was more likely to present with leg edema (98.5% vs. 93.0%, P= 0.03). The male cohort had a higher rate of caval (48% vs. 33.6%, P= 0.027) and infrainguinal stent extension. (11% vs. 6.9%, P= 0.02). Females had a higher rate of left sided stenting (80.9% vs. 66/0%, P= 0.010). There was no difference in the median stent diameter used between the cohorts. Primary patency at 5 years was significantly higher for the male cohort (94.1% vs. 74.4%, P= 0.01) On adjusted multivariable cox regression female gender was a predictor of loss of primary patency within 5 years (HR, 4.04; P= 0.007). CONCLUSIONS In this single center retrospective analysis of IVS, male patients were found to have better primary stent patency compared to female.
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Affiliation(s)
- Mohamed S Zaghloul
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Othman M Abdul-Malak
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick Cherfan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Catherine Go
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Zein Saadeddin
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Georges E Al-Khoury
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Al Sinani A, Al Saadi W, Al Harthi S, Al Hajriy M. May-Thurner Syndrome: A Case Report and a Concise Review. Cureus 2021; 13:e16256. [PMID: 34373817 PMCID: PMC8346263 DOI: 10.7759/cureus.16256] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2021] [Indexed: 11/18/2022] Open
Abstract
We report a case of a 31-year-oldman who presented to the hospital with extensive deep vein thrombosis (DVT) complicated by pulmonary embolism (PE) after a recent trauma and prolonged immobilization. He underwent contrast venography that revealed features of May-Thurner syndrome (MTS). He was managed with therapeutic anticoagulation, inferior vena cava filter placement, mechanical clot aspiration, catheter-directed thrombolytic therapy, and left common iliac vein stenting. MTS is a vascular condition caused by the compression of the left common iliac vein by an overlying right common iliac artery against a vertebral body. This results in indolent endothelial changes secondary to the pulsating nearby artery as well as the compression increasing the susceptibility to venous thrombosis. Females are thought to be more prone to the condition due to the nature of their pelvic anatomy. Most patients are asymptomatic or present with unspecific symptoms, rendering the condition underdiagnosed. The gold standard diagnostic modality is contrast venography that reveals collaterals and a pressure gradient greater than 2 mmHg at rest across the stenotic region. Treatment is revolved around the removal of the thrombus along with the correction of the anatomical defect through interventional or surgical treatment to prevent a recurrence. Untreated MTS complicated with DVT carries a risk of potentially life-threatening complications, such as PE, iliac vein rupture, retroperitoneal hematoma, or refractory DVT that is difficult to treat. Due to the chronicity of this syndrome, its management plan differs from that of other causes of DVT. Proper identification of MTS carries a positive outcome in treating DVT secondary to MTS. Here we are going to discuss a case diagnosed with MTS complicated by saddle PE outlying the possible pathophysiology, clinical manifestation, diagnostic tools, and management of complicated MTS.
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Affiliation(s)
| | - Waleed Al Saadi
- Internal Medicine, Oman Medical Specialty Board, Muscat, OMN
| | - Salma Al Harthi
- Internal Medicine, Oman Medical Specialty Board, Muscat, OMN
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Charisis N, Harb H, Harb M, Labropoulos N. A systematic review on long-term clinical impact in patients with iliofemoral deep vein thrombosis. Phlebology 2021; 36:710-718. [PMID: 34098805 DOI: 10.1177/02683555211020596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this systematic review was to investigate the long-term clinical impact of iliofemoral (IF) deep vein thrombosis (DVT) based on patient reported outcomes, physician administered test measures and compare medical to interventional treatment. METHODS This study was conducted according to the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Criteria for inclusion were patients with thrombus involving the common femoral vein or more proximal veins, ≥5-year follow-up and physician assessment. Data quality was assessed using the Robins-I tool and Cochrane tool. RESULTS Eight studies that fulfilled our criteria were deemed eligible and provided data for 499 patients. There were 230 patients who received medical treatment and 269 interventional. Two studies were randomized controlled trials and six observational. Venous claudication, where reported, was found in 7.7% (1/13) of interventionally treated patients and 21% (13/62) of medically treated patients. Long term symptom resolution was reported in 58% (18/31) and 24% (12/50) of interventionally and medically treated patients, respectively. Venous ulcers were seen in 5.5% (7/126) of medically treated patients and 5% (5/100)of interventionally treated patients. CONCLUSION A wide range of signs and symptoms was reported at long-term. Interventional treatment appeared to be better than medical one but the evidence was weak. Given the significant lack of patient reported outcomes, objective testing and use of validated instruments, the results should be interpreted in context with these limitations. Data on long-term outcomes after IF DVT have been poorly reported and outcome criteria should be better defined in future studies.
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Affiliation(s)
| | | | | | - Nicos Labropoulos
- Department of Vascular Surgery, Stony Brook University, New York, USA
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11
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Zhou Y, Guan Y, Xue M, Zheng X, Chen X. Clinical Outcomes of Stenting Extending Below the Inguinal Ligament for Treatment of Chronic Iliofemoral Venous Obstruction. Ann Vasc Surg 2021; 75:259-266. [PMID: 33823261 DOI: 10.1016/j.avsg.2021.01.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 12/27/2020] [Accepted: 01/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with chronic iliofemoral venous obstructive lesions that often require stenting extending below the inguinal ligament. However, the issue of stents crossing the inguinal ligament is currently controversial. Some guidelines suggest that it should be avoided, and some guidelines suggest that in order to ensure adequate flow, the inguinal ligament can be crossed if necessary. The aim of this study was to evaluate the technical aspects and examine patency rates of stent placement across the inguinal ligament for managing iliofemoral venous obstruction. METHODS A retrospective analysis of 127 patients with chronic iliofemoral venous obstruction were treated with interventional surgery in a single institution from January 2012 to January 2018 was conducted. All patients underwent balloon dilatation and placement of at least 2 stents extending below inguinal ligament. Inflow condition, technical success, operation duration, stent patency rates, anticoagulant selection and duration, and complications were recorded after the interventions. RESULTS The technical success rate was 100%. No major perioperative complications occurred. The mean number of stents was 2.14 ± 0.37. Follow up periods ranged from 12 to 60 months (28.79 ± 10.90 months). Overall cumulative primary, assisted primary, and secondary stent patency rates were 81.9%, 90.5%, and 92.9% at 12 months and 70.4%, 80.9%, and 86.0% at 24 months, and 64.2%, 72.3%, and 74.3% at 36months, respectively. Cumulative patency rates at 12 months, 24 months and 36 months were significantly greater in the patients with "good" inflow as compared to "fair" inflow. The symptoms of all patients improved. None of the stents were compressed, fractured or migrated. CONCLUSIONS Stenting across the inguinal ligament for treatment of the patients with chronic iliofemoral venous obstruction was a feasible and safe treatment with good patency and clinical results in short and midterm follow up, and stents with good inflow have better patency.
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Affiliation(s)
- Yadong Zhou
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Yunbiao Guan
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China.
| | - Ming Xue
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Xuexun Zheng
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
| | - Xingsheng Chen
- Department of Vascular Surgery, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, China
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Tang A, Lakhter V, Zack CJ, Comerota AJ, Shah N, Zhao H, Bashir R. Contemporary nationwide trends and in-hospital outcomes of adjunctive stenting in patients undergoing catheter-directed thrombolysis for proximal deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2020; 9:62-72.e1. [PMID: 32522616 DOI: 10.1016/j.jvsv.2020.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/15/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Outflow venous stenting as an adjunct to catheter-directed thrombolysis (CDT) is performed to prevent recurrent thrombosis and to reduce the risk of post-thrombotic syndrome. Historical data show that stenting improves outcomes of surgical thrombectomy in patients with iliofemoral deep venous thrombosis (DVT), and recent observational data suggest that stenting improves long-term outcomes of CDT. However, the impact of stenting during CDT on acute safety outcomes is unknown. We sought to investigate the contemporary trends, safety outcomes, and resource utilization of adjunctive stent placement in patients undergoing CDT. METHODS Patients with proximal lower extremity and caval DVT were identified within the National Inpatient Sample from January 2005 to December 2013. From this data set, we stratified our patients into three groups: patients who received CDT alone, patients who received CDT plus angioplasty, and patients who received CDT plus angioplasty with stenting. We used an inverse probability treatment weighting algorithm to create three weighted cohorts. Cochran-Armitage test was used to evaluate the trends of stent placement among patients treated with CDT. The primary outcome was a composite end point of all-cause mortality, gastrointestinal bleed, or intracranial hemorrhage. RESULTS A total of 138,049 patients were discharged with a principal diagnosis of proximal and caval DVT; 7097 of these patients received CDT (5.1%). From this group, 2854 (40.2%) were treated with CDT alone, 2311 (32.6%) received adjunctive angioplasty alone, and 1932 (27.2%) received adjunctive angioplasty and stent. Adjunctive stenting had a significantly lower rate of primary composite outcome compared with CDT alone (2.7% vs 3.8%; P = .04). Stent placement was associated with a similar length of stay compared with angioplasty and CDT alone groups (6.8 vs 6.9 vs 7.1 days, respectively; P = .94) and higher in-hospital charges ($115,164.01 ± $76,985.31 vs $98,089.82 ± $72,921.94 vs $80,441.63 ± $74,024.98; P < .001). CONCLUSIONS This nationwide study suggests that one in four patients undergoing CDT is treated with adjunctive stent placement in the United States. This observational study showed that adjunctive stenting does not adversely affect the acute safety outcomes of CDT; however, it was associated with increased hospital charges.
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Affiliation(s)
- Alice Tang
- Lewis Katz School of Medicine, Temple University, Philadelphia, Pa
| | - Vladimir Lakhter
- Department of Cardiovascular Diseases, Temple University Hospital, Philadelphia, Pa
| | - Chad J Zack
- Department of Cardiology, Pennsylvania State University Milton S. Hershey Medical Center, Hershey, Pa
| | - Anthony J Comerota
- Inova Heart and Vascular Institute, Inova Alexandria Hospital, Alexandria, Va
| | - Neal Shah
- Department of Internal Medicine, Temple University Hospital, Philadelphia, Pa
| | - Huaqing Zhao
- Department of Clinical Sciences, Lewis Katz School of Medicine, Temple University, Philadelphia, Pa
| | - Riyaz Bashir
- Department of Cardiovascular Diseases, Temple University Hospital, Philadelphia, Pa.
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Zaldivar-Jolissaint JF, de Schlichting E, Haller C, Morard M. Foot Drop After Iliocaval Vein Stenting: Radicular Syndrome from Stent Misplacement in Spinal Canal. World Neurosurg 2020; 137:43-45. [DOI: 10.1016/j.wneu.2020.01.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 11/30/2022]
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14
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Farsad K, Kapoor BS, Fidelman N, Cain TR, Caplin DM, Eldrup-Jorgensen J, Gupta A, Higgins M, Hohenwalter EJ, Lee MH, McBride JJ, Minocha J, Rochon PJ, Sutphin PD, Lorenz JM. ACR Appropriateness Criteria® Radiologic Management of Iliofemoral Venous Thrombosis. J Am Coll Radiol 2020; 17:S255-S264. [PMID: 32370969 DOI: 10.1016/j.jacr.2020.01.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 01/30/2020] [Indexed: 11/16/2022]
Abstract
Iliofemoral venous thrombosis carries a high risk for pulmonary embolism, recurrent deep vein thrombosis, and post-thrombotic syndrome complicating 30% to 71% of those affected. The clinical scenarios in which iliofemoral venous thrombosis is managed may be diverse, presenting a challenge to identify optimum therapy tailored to each situation. Goals for management include preventing morbidity from venous occlusive disease, and morbidity and mortality from pulmonary embolism. Anticoagulation remains the standard of care for iliofemoral venous thrombosis, although a role for more aggressive therapies with catheter-based interventions or surgery exists in select circumstances. Results from recent prospective trials have improved patient selection guidelines for more aggressive therapies, and have also demonstrated a lack of efficacy for certain conservative therapies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Khashayar Farsad
- Charles T. Dotter Department of Interventional Radiology, Portland, Oregon.
| | | | - Nicholas Fidelman
- Panel Vice-Chair, University of California San Francisco, San Francisco, California
| | - Thomas R Cain
- Desert Regional Medical Center, Palm Springs, California
| | - Drew M Caplin
- Zucker School of Medicine at Hofstra Northwell, Hempstead, New York
| | - Jens Eldrup-Jorgensen
- Tufts University School of Medicine, Boston, Massachusetts; Society for Vascular Surgery
| | - Amit Gupta
- Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | | | | | - Margaret H Lee
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Jeet Minocha
- University of California San Diego, San Diego, California
| | - Paul J Rochon
- University of Colorado Denver Anschutz Medical Campus, Aurora, Colorado
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15
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Toh MR, Tang TY, Lim HHMN, Venkatanarasimha N, Damodharan K. Review of imaging and endovascular intervention of iliocaval venous compression syndrome. World J Radiol 2020; 12:18-28. [PMID: 32226586 PMCID: PMC7061234 DOI: 10.4329/wjr.v12.i3.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/04/2020] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
Iliocaval venous compression syndrome (ICS) is the extrinsic compression of the common iliac vein by the overlying iliac artery against the vertebra. Chronic compression can lead to venous stenosis and stasis, which manifests as chronic venous disease and treatment resistance. Therefore, early recognition of ICS and prompt treatment are essential. Clinical presentations of ICS can be ambiguous and diagnosis requires a high index of suspicion with the relevant imaging studies. The initial imaging test is typically a Duplex ultrasound for vessel assessment and pelvic ultrasound to exclude a compressive mass, which is followed by computed tomography (CT) or magnetic resonance (MR) venography. CT and MRI can identify the anatomical causes for venous compression. In patients with high clinical suspicion for ICS, negative findings on CT and MR venography would still warrant further investigations. Definitive diagnosis can be established using catheter-based venography complemented with intravascular ultrasonography but the nature of their invasiveness limits its utility as a routine imaging modality. In this review paper, we will discuss the evidence, utility and limitations of the existing imaging modalities and endovascular intervention used in the management of ICS.
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Affiliation(s)
- Ming Ren Toh
- Duke-NUS Medical School, Singapore 544886, Singapore
| | - Tjun Yip Tang
- Department of Vascular surgery, Singapore General Hospital, Singapore 169608, Singapore
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16
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Salahuddin T, Armstrong EJ. Intervention for Iliofemoral Deep Vein Thrombosis and May-Thurner Syndrome. Interv Cardiol Clin 2020; 9:243-254. [PMID: 32147124 DOI: 10.1016/j.iccl.2019.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
May-Thurner syndrome, also known as iliac vein compression syndrome, may cause symptoms of venous hypertension and is a predisposing factor for the development of iliofemoral deep vein thrombosis (DVT). Iliofemoral DVT is associated with high rates of development of postthrombotic syndrome, a potentially debilitating condition associated with development of symptoms related to venous outflow obstruction and resulting in reduced quality of life. In this Clinics article, we review procedural intervention with catheter-directed thrombolysis and stenting for iliofemoral DVT and iliac vein compression.
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Affiliation(s)
- Taufiq Salahuddin
- Cardiology Section, Rocky Mountain Regional VA Medical Center, 1700 North Wheeling Street, Aurora, CO 80045, USA
| | - Ehrin J Armstrong
- Cardiology Section, Rocky Mountain Regional VA Medical Center, 1700 North Wheeling Street, Aurora, CO 80045, USA; Interventional Cardiology, Vascular Laboratory, Rocky Mountain Regional VA, Division of Cardiology, University of Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
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17
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Harbin MM, Lutsey PL. May-Thurner syndrome: History of understanding and need for defining population prevalence. J Thromb Haemost 2020; 18:534-542. [PMID: 31821707 DOI: 10.1111/jth.14707] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/13/2019] [Accepted: 12/04/2019] [Indexed: 12/17/2022]
Abstract
Patients with May-Thurner syndrome (MTS) are at elevated risk of developing an extensive left iliofemoral deep vein thrombosis (DVT; localized blood clot) due to an anatomical variant where the right common iliac artery compresses the left common iliac vein against the lumbar spine. While MTS was initially presumed to be rare when it was first anatomically defined in 1957, case reports of this syndrome have recently become more frequent, perhaps due to improved imaging techniques allowing for enhanced visualization of the iliac veins. Still, the population burden of this condition is unknown, and there is speculation it may be higher than generally perceived. In the present review, we (a) review history of how MTS became recognized, (b) describe practical challenges of studying MTS in population-based settings due to the specialized imaging required for diagnosis, (c) discuss why the contribution of MTS to DVT may be underestimated, (d) describe uncertainty regarding the degree of venous compression which leads to DVT, and (e) outline future research needs. Our goal is to raise awareness of MTS and spark additional research into the epidemiology of this condition, which may be an underappreciated causative venous thromboembolism risk factor.
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Affiliation(s)
- Michelle M Harbin
- Laboratory of Integrative Human Physiology, School of Kinesiology, University of Minnesota, Minneapolis, MN, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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18
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Barge TF, Wilton E, Wigham A. Endovascular Treatment of an Extensive Iliocaval and Renal Vein Thrombosis Secondary to Inferior Vena Cava Stenosis and May-Thurner Type Iliac Vein Compression: A Case Report. Vasc Endovascular Surg 2020; 54:297-300. [PMID: 31950885 DOI: 10.1177/1538574419900613] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 23-year-old presenting with an acute history of back pain, leg swelling, and claudication was diagnosed with an extensive iliocaval thrombosis, extending from the popliteal veins into the inferior vena cava (IVC) and left renal vein. He was treated with a combination of endovascular techniques, including EKOS and AngioJet. An underlying congenital IVC stenosis and May-Thurner type iliac vein compression were subsequently treated with venoplasty and stenting. To our knowledge, this is the first report of the use of EKOS for renal vein thrombosis and we highlight the complementary nature of different endovascular techniques for managing complex venous thrombotic disease.
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Affiliation(s)
- Thomas Frederick Barge
- Department of Interventional Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Emma Wilton
- Department of Vascular Surgery, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Andrew Wigham
- Department of Interventional Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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19
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May-Thurner Syndrome with Large Abdominal Varicosity, Treated Successfully Using Multiple Approaches. Case Rep Vasc Med 2019; 2019:7079307. [PMID: 31183243 PMCID: PMC6515053 DOI: 10.1155/2019/7079307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 04/12/2019] [Accepted: 04/18/2019] [Indexed: 11/22/2022] Open
Abstract
May-Thurner syndrome (MTS) is a venous outflow obstruction disorder characterized by compression of the left common iliac vein by an overriding right common iliac artery. MTS primarily affects young to middle-aged women, although many patients remain entirely asymptomatic. Anatomic variations of MTS, while uncommon, have been described. Treatment usually involves endovascular management, including thrombolysis and/or thrombectomy with or without inferior vena cava filter placement, followed by angioplasty and stenting of the left common iliac vein. We report a unique case of a 31-year-old woman who presented with MTS-related deep vein thrombosis accompanied by symptomatic abdominal and pelvic varicosities. The varicosities were treated successfully using multiple procedures, resulting in complete resolution of all symptoms. Our case discusses a treatment approach for an unusual presentation of MTS-related postthrombotic syndrome, and provides a brief literature review of MTS complications and management.
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20
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Mid-and long-term efficacy of endovascular-based procedures for Cockett syndrome. Sci Rep 2018; 8:12145. [PMID: 30108228 PMCID: PMC6092402 DOI: 10.1038/s41598-018-29756-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 07/12/2018] [Indexed: 12/21/2022] Open
Abstract
To investigate the mid- and long-term results of endovascular-based procedures for Cockett syndrome. The clinical data of 412 patients with Cockett syndrome treated between January 2003 and September 2017 were retrospectively analyzed. In these patients, 231 cases were acute left iliac femoral vein thrombosis (group A), and 181 cases were chronic venous insufficiency (group B), and different endovascular procedures and/or hybrid procedures were performed. In group A, the technique success rate was 100% (231/231); the left iliac vein in 5 patients showed no stenosis or occlusion, and the incidence of pathological changes in the left iliac vein was 97.8% (226/231); a total of 182 stents were implanted. In group B, the technique success rate was 99.4% (180/181); the average pressure difference between the proximal and distal portion of the pathological left iliac veins decreased from preoperative (18 ± 4.45) cmH2O to postoperative (4 ± 3.02) cmH2O (P < 0.01); 89 patients, complicated with valvular incompetence in the left superficial femoral vein, underwent a second-stage femoral valve repair. Follow-up ranged from 3 months to 8 years, with an average of 35.6 months, and intrastent thrombosis occurred in 15 cases of group A and in 2 cases of group B. Endovascular-based procedures offer favorable mid- and long-term results in treatment of Cockett syndrome, which in combination with Fogarty catheter thrombectomy or catheter-directed thrombolysis is a beneficial complementary treatment for patients with acute iliac femoral vein thrombosis.
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21
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Stent implantation for May–Thurner syndrome with acute deep venous thrombosis: acute and long-term results from the ATOMIC (AcTive stenting for May–Thurner Iliac Compression syndrome) registry. Cardiovasc Interv Ther 2018; 34:131-138. [DOI: 10.1007/s12928-018-0532-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 05/31/2018] [Indexed: 01/27/2023]
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22
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Abstract
Lower extremity deep venous thrombosis is a leading cause of morbidity and mortality. The mainstay of therapy is medical. However, anticoagulation does not remove the thrombus and restore venous patency. In select patients, early thrombus removal and anticoagulation can restore venous patency, preserve venous valve function, and may reduce the incidence of postthrombotic syndrome. Catheter-directed therapies are minimally invasive with low complication rates. However, in patients with a contraindication to thrombolytic agents who can receive anticoagulation, open thrombectomy should be considered if indications for thrombus removal are met and patients are good operative risks.
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23
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van Vuuren TM, Kurstjens RL, de Wolf MA, van Laanen JH, Wittens CH, de Graaf R. Stent extension into a single inflow vessel is a valuable option after endophlebectomy. Phlebology 2017; 33:610-617. [PMID: 29113541 PMCID: PMC6131728 DOI: 10.1177/0268355517739766] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Venous stenting with an endophlebectomy and arteriovenous fistula can be
performed in patients with extensive post-thrombotic changes. However, these
hybrid procedures can induce restenosis, sometimes requiring stent
extension, into a single inflow vessel. This study investigates the
effectiveness of stenting into a single inflow vessel. Methods All evaluated patients had temporary balloon occlusion of the arteriovenous
fistula to evaluate venous flow into the stents. When stent inflow was
deemed insufficient, AVF closure was postponed and additional stenting was
performed. Patency rates and clinical outcomes were evaluated. Results Twenty-four (38%) of 64 patients had additional stenting. The primary,
assisted primary and secondary patency were 60 %, 70% and 70% respectively.
Villalta score reduced by 6.1 points (p < 0.001), and
venous clinical severity score by 2.7 points
(p = 0.034). Conclusion Stenting through the femoral confluence into a single inflow vessel is a
feasible bailout option if primary hybrid intervention fails with relative
high patency rates and clinical improvement.
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Affiliation(s)
- Timme Maj van Vuuren
- 1 Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,2 Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Ralph Lm Kurstjens
- 1 Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,2 Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands.,3 Department of Obstetrics and Gynaecology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Mark Af de Wolf
- 1 Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,2 Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands.,4 Department of Radiology, Maasstad Hospital, Rotterdam, the Netherlands
| | - Jorinde Hh van Laanen
- 1 Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Cees Ha Wittens
- 1 Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,2 Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands.,5 Department of Vascular Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Rick de Graaf
- 6 Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
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Abstract
Venous compression syndromes occur due to extrinsic compression causing complications of venous hypertension or venous thrombosis. This review focuses on 4 venous compression syndromes involving the left common iliac vein, subclavian vein, left renal vein, and popliteal vein. Clinical presentation, diagnostic methods, and management options are reviewed. When properly diagnosed and treated, long-term consequences can be avoided.
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Affiliation(s)
- Joseph M White
- 1 The Department of Surgery, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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25
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Outcomes of iliac vein stents after pregnancy. J Vasc Surg Venous Lymphat Disord 2017; 5:353-357. [DOI: 10.1016/j.jvsv.2017.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/25/2017] [Indexed: 11/23/2022]
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26
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Rodríguez LE, Aponte-Rivera F, Figueroa-Vicente R, Bolanos-Avila GE, Martínez-Trabal JL. Symptomatic iliofemoral deep venous thrombosis treated with hybrid operative thrombectomy. J Vasc Surg Venous Lymphat Disord 2016; 3:438-441. [PMID: 26992622 DOI: 10.1016/j.jvsv.2015.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 02/09/2015] [Indexed: 11/27/2022]
Abstract
During the past 15 years, strategies that promote immediate and complete thrombus removal have gained popularity for the treatment of acute-onset iliofemoral deep venous thrombosis. In this case report, we describe a novel operative approach to venous thrombus removal known as hybrid operative thrombectomy. The technique employs a direct inguinal approach with concomitant retrograde advancement of a balloon catheter by femoral venotomy. Moreover, it provides effective thrombus removal through a single incision, with or without stent placement, and has the advantage of a completion venogram.
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Affiliation(s)
- Limael E Rodríguez
- Vascular Surgery Division, Department of Surgery, St. Luke's Memorial Hospital, Ponce School of Medicine and Health Sciences, "Ponce School of Medicine and Health Sciences", Ponce, Puerto Rico.
| | - Francisco Aponte-Rivera
- Vascular Surgery Division, Department of Surgery, St. Luke's Memorial Hospital, Ponce School of Medicine and Health Sciences, "Ponce School of Medicine and Health Sciences", Ponce, Puerto Rico
| | - Ricardo Figueroa-Vicente
- Vascular Surgery Division, Department of Surgery, St. Luke's Memorial Hospital, Ponce School of Medicine and Health Sciences, "Ponce School of Medicine and Health Sciences", Ponce, Puerto Rico
| | - Guillermo E Bolanos-Avila
- Vascular Surgery Division, Department of Surgery, St. Luke's Memorial Hospital, Ponce School of Medicine and Health Sciences, "Ponce School of Medicine and Health Sciences", Ponce, Puerto Rico
| | - Jorge L Martínez-Trabal
- Vascular Surgery Division, Department of Surgery, St. Luke's Memorial Hospital, Ponce School of Medicine and Health Sciences, "Ponce School of Medicine and Health Sciences", Ponce, Puerto Rico
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27
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Alkhouli M, Morad M, Narins CR, Raza F, Bashir R. Inferior Vena Cava Thrombosis. JACC Cardiovasc Interv 2016; 9:629-43. [PMID: 26952909 DOI: 10.1016/j.jcin.2015.12.268] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 11/22/2015] [Accepted: 12/17/2015] [Indexed: 01/20/2023]
Abstract
Thrombosis of the inferior vena cava (IVC) is an under-recognized entity that is associated with significant short- and long-term morbidity and mortality. In absence of a congenital anomaly, the most common cause of IVC thrombosis is the presence of an unretrieved IVC filter. Due to the substantial increase in the number of IVC filters placed in the United States and the very low filter retrieval rates, clinicians are faced with a very large population of patients at risk for developing IVC thrombosis. Nevertheless, there is a paucity of data and societal guidelines with regards to the diagnosis and management of IVC thrombosis. This paper aims to enhance the awareness of this uncommon, but morbid, condition by providing a concise, yet comprehensive, review of the etiology, diagnostic approaches, and treatment strategies in patients with IVC thrombosis.
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Affiliation(s)
- Mohamad Alkhouli
- Division of Cardiovascular Disease, University of Rochester Medical Center, Rochester, New York.
| | - Mohammad Morad
- Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania
| | - Craig R Narins
- Division of Cardiovascular Disease, University of Rochester Medical Center, Rochester, New York; Department of Surgery, Section of Vascular Surgery, University of Rochester Medical Center, Rochester, New York
| | - Farhan Raza
- Division of Cardiovascular Disease, Temple University Hospital, Philadelphia, Pennsylvania
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Temple University Hospital, Philadelphia, Pennsylvania
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Mumme A, Hummel T. Rekanalisierende Therapie der tiefen Bein-/Beckenvenenthrombose. GEFÄSSCHIRURGIE 2016. [DOI: 10.1007/s00772-016-0119-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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29
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O'Sullivan GJ, Waldron D, Mannion E, Keane M, Donnellan PP. Thrombolysis and iliofemoral vein stent placement in cancer patients with lower extremity swelling attributed to lymphedema. J Vasc Interv Radiol 2015; 26:39-45. [PMID: 25541444 DOI: 10.1016/j.jvir.2014.10.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 10/08/2014] [Accepted: 10/12/2014] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To assess the effects of iliofemoral vein stent placement on symptomatic lower extremity swelling (LES), presumed to be lymphedema, in patients with cancer. MATERIALS AND METHODS During the period 2005-2013, 62 patients (38 female; age, 60.4 y ± 15.4) with histology-proven metastatic disease and LES resistant to standard therapies were evaluated and found to have venous outflow obstruction. Stents were placed in the iliofemoral veins or inferior vena cava, or both, and evaluated by color Doppler ultrasound or contrast-enhanced computed tomography during the follow-up period. Patient symptoms were assessed using the Venous Disability Score (VDS) and the Galway Limb Swelling score, a patient-directed, 5-question symptom scoring system. RESULTS Stents were successfully placed in all patients. During the follow-up period, in-stent thrombosis occurred in 13 patients, and additional stents were placed in 3 patients to treat luminal narrowing. The mean VDS improved significantly (P < .05): from 3.0 ± 0 on the day of the procedure to 2.95 ± 0.22 on day 3, 2.0 ± 0.33 on day 7, and 1.87 ± 0.34 on day 30. The mean Galway Limb Swelling score also improved significantly (P < 0.001): from 3.6 ± 0.74 on the day of the procedure to 1.96 ± 0.91 on day 3, 1.06 ± 0.78 on day 7, and 0.6 ± 0.66 on day 30. During the follow-up period, 60 patients died as a result of their underlying malignancy (mean, 230 d; range, 5-1,080 d). CONCLUSIONS Iliofemoral or iliocaval venous stent placement may have a valuable role in patients with metastatic disease and symptomatic LES associated with venous obstruction.
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Affiliation(s)
- Gerard J O'Sullivan
- Department of Interventional Radiology, Galway University Hospitals, Newcastle Road, Galway, Ireland..
| | - Dymphna Waldron
- Department of Palliative Medicine, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Eileen Mannion
- Department of Palliative Medicine, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Maccon Keane
- Department of Oncology, Galway University Hospitals, Newcastle Road, Galway, Ireland
| | - Paul P Donnellan
- Department of Oncology, Galway University Hospitals, Newcastle Road, Galway, Ireland
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Abstract
Advances in image-guided, catheter-based interventions have shown great potential to improve outcomes in patients with venous thromboembolism. Catheter-directed thrombolysis has been shown in one randomized controlled trial to reduce the risk of post-thrombotic syndrome in patients with acute lower extremity deep vein thrombosis; data from a larger national institute of health trial are expected in early 2017. The use of catheter-directed thrombolysis is also being increasingly considered for patients with submassive or massive pulmonary embolism. Preliminary studies suggest that endovascular stent placement and ablative therapies may be used to reduce symptoms and improve quality of life in severely affected patients with established post-thrombotic syndrome. In this article, we summarize the risks and benefits of endovascular venous thromboembolism therapies as currently understood, highlight clinical situations where their benefit may outweigh risks, and describe ongoing and upcoming pivotal research initiatives with multidisciplinary participation.
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Affiliation(s)
- S Vedantham
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
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31
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Abstract
The conservative treatment of deep leg and pelvic vein thrombosis leads to permanent damage of recanalised veins, which in cases of long distance clots as well as involvement of the pelvic level, increase the risk of developing a postthrombotic syndrome. Such subsequent damage of the deep veins can only be avoided if occluded veins are rapidly recanalised and the function of the valves is successfully reestablished. Recanalisation may consist of surgical, fibrolytic and interventional methods and aims to minimize any subsequent damage; however no potential benefit of recanalisation versus standard treatment has yet been proven by means of methodologically adequate comparative studies. Thus, the indications for recanalisation must remain strict and be founded on a thorough risk-benefit assessment.
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Affiliation(s)
- A Mumme
- Klinik für Gefäßchirurgie, Katholisches Klinikum der Ruhr-Universität Bochum, Gudrunstr. 56, 44791, Bochum, Deutschland,
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Alkhouli M, Zack CJ, Zhao H, Shafi I, Bashir R. Comparative Outcomes of Catheter-Directed Thrombolysis Plus Anticoagulation Versus Anticoagulation Alone in the Treatment of Inferior Vena Caval Thrombosis. Circ Cardiovasc Interv 2015; 8:e001882. [DOI: 10.1161/circinterventions.114.001882] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Mohamad Alkhouli
- From the Division of Cardiovascular Diseases (M.A., I.S., R.B.), Department of Medicine (C.J.Z.), and Department of Clinical Sciences (H.Z.), Temple University School of Medicine, Philadelphia, PA
| | - Chad J. Zack
- From the Division of Cardiovascular Diseases (M.A., I.S., R.B.), Department of Medicine (C.J.Z.), and Department of Clinical Sciences (H.Z.), Temple University School of Medicine, Philadelphia, PA
| | - Huaqing Zhao
- From the Division of Cardiovascular Diseases (M.A., I.S., R.B.), Department of Medicine (C.J.Z.), and Department of Clinical Sciences (H.Z.), Temple University School of Medicine, Philadelphia, PA
| | - Irfan Shafi
- From the Division of Cardiovascular Diseases (M.A., I.S., R.B.), Department of Medicine (C.J.Z.), and Department of Clinical Sciences (H.Z.), Temple University School of Medicine, Philadelphia, PA
| | - Riyaz Bashir
- From the Division of Cardiovascular Diseases (M.A., I.S., R.B.), Department of Medicine (C.J.Z.), and Department of Clinical Sciences (H.Z.), Temple University School of Medicine, Philadelphia, PA
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Birn J, Vedantham S. May-Thurner syndrome and other obstructive iliac vein lesions: meaning, myth, and mystery. Vasc Med 2014; 20:74-83. [PMID: 25502563 DOI: 10.1177/1358863x14560429] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Acute and chronic venous disorders of the lower extremities affect millions of people and cause substantial disability. Long ago, surgeons and pathologists identified the presence of 'spur-like' abnormalities of the left common iliac vein; these abnormalities were hypothesized to result from compression and/or irritation from the adjacent crossing right common iliac artery. In the 1990s, physicians, starting to perform catheter-directed thrombolysis to treat extensive deep vein thrombosis (DVT), observed that about 50% of patients had an iliac vein stenosis. Vascular physicians have become aware of the occasional patient with otherwise-unexplained extremity swelling and/or pain but without a DVT history who is subsequently found to have an iliac vein abnormality. These 'lesions' have been hypothesized to elevate ambulatory venous pressures and thereby produce lower-extremity symptoms, increase the risk of initial and recurrent DVT episodes, and increase the risk of treatment failure with medical and endovascular therapies for thrombotic and non-thrombotic venous conditions. As a result, many practitioners now actively seek iliac venous obstructive 'lesions' when evaluating patients with known or suspected venous disease. However, for many patients, it continues to be unclear what degree of obstruction to venous blood flow is being caused by such lesions, how clinically significant they are, how much emphasis should be placed on identifying them, and when they should be treated. This article seeks to improve the knowledge base of vascular practitioners who make clinical decisions about the diagnosis and treatment of obstructive iliac vein lesions.
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Affiliation(s)
- Jeffrey Birn
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Suresh Vedantham
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
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34
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Mathur M, Shafi I, Alkhouli M, Bashir R. Surgical hardware-related iatrogenic venous compression syndrome. Vasc Med 2014; 20:162-7. [PMID: 25425626 DOI: 10.1177/1358863x14559093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Deep vein thrombosis related to immobilization is a common and extensively studied disorder, particularly in hospitalized patients. However, the phenomenon of iatrogenic venous compression (IAVC) and related deep venous thrombosis (DVT) is under-recognized and under-reported. In the absence of relieving the compressive pathology, the recanalization rates are expected to be very low - thereby putting patients at a significant risk for the development of post-thrombotic syndrome (PTS). In this report, we describe two cases of DVT related to IAVC, and review similar cases that have been previously reported in the literature. With advancements in catheter-based technology, patients with IAVC (with or without DVT) may now be offered advanced endovascular treatment options such as catheter-directed pharmacomechanical thrombolysis (PMT) and percutaneous venoplasty and/or stenting. Hence, timely recognition and treatment is essential in the prevention of disabling PTS or life-threatening pulmonary embolism.
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Affiliation(s)
- Moses Mathur
- Temple University Hospital, Department of Medicine, Section of Cardiovascular Diseases, Philadelphia, PA, USA
| | - Irfan Shafi
- Temple University Hospital, Department of Medicine, Section of Cardiovascular Diseases, Philadelphia, PA, USA
| | - Mohamad Alkhouli
- Temple University Hospital, Department of Medicine, Section of Cardiovascular Diseases, Philadelphia, PA, USA
| | - Riyaz Bashir
- Temple University Hospital, Department of Medicine, Section of Cardiovascular Diseases, Philadelphia, PA, USA
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35
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Igari K, Kudo T, Toyofuku T, Jibiki M, Inoue Y. Surgical Thrombectomy and Simultaneous Stenting for Deep Venous Thrombosis Caused by Iliac Vein Compression Syndrome (May-Thurner Syndrome). Ann Thorac Cardiovasc Surg 2014; 20:995-1000. [DOI: 10.5761/atcs.oa.13-00213] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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36
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Matsuda A, Yamada N, Ogihara Y, Tsuji A, Ota S, Ishikura K, Nakamura M, Ito M. Early and Long-Term Outcomes of Venous Stent Implantation for Iliac Venous Stenosis After Catheter-Directed Thrombolysis for Acute Deep Vein Thrombosis. Circ J 2014; 78:1234-9. [DOI: 10.1253/circj.cj-13-1247] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akimasa Matsuda
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | | | - Satoshi Ota
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Ken Ishikura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Mashio Nakamura
- Clinical Cardiovascular Research, Mie University Graduate School of Medicine
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
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37
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Mumme A, Hummel T. Die multimodale operative Therapie der tiefen Beinvenenthrombose. GEFÄSSCHIRURGIE 2013. [DOI: 10.1007/s00772-013-1211-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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38
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Mousa AY, AbuRahma AF. May–Thurner Syndrome: Update and Review. Ann Vasc Surg 2013; 27:984-95. [DOI: 10.1016/j.avsg.2013.05.001] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 05/07/2013] [Accepted: 05/08/2013] [Indexed: 01/27/2023]
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de Wolf MAF, Arnoldussen CWKP, Wittens CHA. Indications for endophlebectomy and/or arteriovenous fistula after stenting. Phlebology 2013; 28 Suppl 1:123-8. [PMID: 23482547 DOI: 10.1177/0268355513477063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovenous recanalization with percutaneous transluminal angioplasty and stenting in post-thrombotic syndrome patients with iliocaval obstruction is a treatment modality quickly gaining popularity. Studies show good patency and clinical success rates. If the obstruction extends distally, below the inguinal ligament, stenting remains controversial. Without adequate inflow, the patency of stented iliocaval segments drops dramatically. This suggests that treatment of diseased common femoral, femoral and profunda femoral veins is required to ensure adequate inflow. Endophlebectomy, the removal of synechiae and septae from the common femoral vein, is a viable option in these cases. Another option, which can be done concurrently with the endophlebectomy, is the creation of an arteriovenous fistula. Selecting patients for these interventions however remains difficult, as precise preoperative prediction of inflow into the stented segments is difficult. In this paper we describe our experience in using duplex ultrasonography, magnetic resonance venography and conventional venography to assess the patency of the inflow trajectory. We believe this approach is essential in dealing with cases of complex post-thrombotic disease extending below the inguinal ligament. There is a great need to establish criteria to accurately assess pre- and postinterventional flow through treated vein segments.
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Affiliation(s)
- M A F de Wolf
- Department of General Surgery, Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
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40
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Park JY, Ahn JH, Jeon YS, Cho SG, Kim JY, Hong KC. Iliac vein stenting as a durable option for residual stenosis after catheter-directed thrombolysis and angioplasty of iliofemoral deep vein thrombosis secondary to May–Thurner syndrome. Phlebology 2013; 29:461-70. [DOI: 10.1177/0268355513491724] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Introduction This study aims to evaluate the primary patency and clinical outcomes after stenting for residual iliac venous stenosis during catheter-directed thrombolysis treatment of acute iliofemoral deep vein thrombosis arising from May–Thurner syndome. Methods A retrospective study was done for the all patients who underwent iliac vein stenting after catheter-directed thrombolysis treatment of acute iliofemoral deep vein thrombosis due to May–Thurner syndrome from January 2005 to April 2011 in Inha University Hospital. Patient information was assembled from the electronic medical records, imaging and interview. The patency of iliac vein stent was evaluated with serial computed tomography. Results Fifty-one patients were enrolled. The median age was 70 years (range 44–86). There were 37 females (72.5%). The duration of symptoms of acute deep vein thrombosis before catheter-directed thrombolysis treatment was 6 days (median, range 1–33). Self-expanding stent was used for iliac vein stenting. Initial technical success rate was 94.1%. There were two complications (3.9%): an arteriovenous fistula formation in left popliteal area and a right inguinal hematoma. Mean follow-up was 15.6 months (range 6 days–80.8 months). Primary patency rate after iliac vein stenting was 95.8% at 6 months, 87.5% at 12 months and 84.3% at 24 months. Four patients had recurrent thrombotic occlusion (7.8%) during the follow-up. Conclusion Iliac vein stenting showed good primary patency rate with few complications. Iliac vein stenting is a durable option for residual stenosis after catheter-directed thrombolysis treatment of acute deep vein thrombosis in May–Thurner syndrome.
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Affiliation(s)
- Jae Young Park
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Jong Hyuk Ahn
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University School of Medicine, Incheon, Korea
| | - Soon Gu Cho
- Department of Radiology, Inha University School of Medicine, Incheon, Korea
| | - Jang Yong Kim
- Division of Vascular Surgery, Department of Surgery, School of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kee Chun Hong
- Department of Surgery, Inha University School of Medicine, Incheon, Korea
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41
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Foit NA, Chen QM, Cook B, Hammerberg EM. Iliofemoral deep vein thrombosis after tibial plateau fracture fixation related to undiagnosed May-Thurner syndrome: a case report. Patient Saf Surg 2013; 7:12. [PMID: 23628366 PMCID: PMC3879220 DOI: 10.1186/1754-9493-7-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 04/02/2013] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND May-Thurner Syndrome (MTS) represents an anatomic variation of the iliac vessels, in which the left common iliac vein is compressed by an overriding iliac artery. Patients with this abnormality are predisposed to the formation of a left-sided iliofemoral deep venous thrombosis (DVT). While DVT is a familiar complication in the setting of lower extremity trauma, there are no previous reports of MTS complicating the care of patients requiring orthopaedic surgery. CASE PRESENTATION We present the case of an extensive limb-threatening DVT in a patient with previously undiagnosed MTS, resulting after internal fixation of a left tibial plateau fracture. Four days after surgery, despite standard prophylactic anticoagulation, the patient developed an extensive occlusive DVT, extending from the common iliac vein to the popliteal vein. Successful diagnosis required a CT venogram in addition to standard lower extremity ultrasound exam. Severe lower extremity edema continued to worsen despite formal anticoagulation. Urgent mechanical thrombolysis was undertaken, followed by staged catheter-directed thrombolysis with recombinant tissue plasminogen activator (rTPA) and intraluminal stenting. Following this treatment, the patient was noted to have gradual but dramatic resolution of his lower extremity edema and swelling. CONCLUSION The present case demonstrates the potential danger that may accompany MTS in the setting of lower extremity trauma. When an extensive left lower extremity DVT complicates the care of a patient with extremity trauma, clinicians should have a low threshold to pursue the diagnosis of MTS with advanced imaging studies. Venography remains the gold standard in diagnosis, but CT and MRI venography are less invasive and should allow for accurate diagnosis. In this case, formal anticoagulation proved to be ineffective, and endovascular intervention was required.
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Affiliation(s)
| | | | | | - Eric Mark Hammerberg
- Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, MC 0188, Denver, CO 80204, USA.
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42
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Dumantepe M, Tarhan IA, Yurdakul I, Ozler A. Ultrasound-accelerated catheter-directed thrombolysis for the management of postpartum deep venous thrombosis. J Obstet Gynaecol Res 2013; 39:1065-9. [PMID: 23379969 DOI: 10.1111/jog.12002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2012] [Accepted: 09/29/2012] [Indexed: 11/29/2022]
Abstract
Pregnancy and the postpartum period are associated with an increased risk of venous thromboembolism, which remains an important cause of maternal morbidity and mortality. Although oral or systemic anticoagulation therapy may minimize thrombus propagation, it remains ineffective in removing thrombus burden and consequently does not prevent post-thrombotic syndrome. A novel technique, ultrasound accelerated catheter directed thrombolysis (UACDT), has been developed to rapidly and completely resolve thrombus. While pregnancy and the postpartum period are generally considered as contraindications for thrombolysis, we demonstrate in this case study the safety and effectiveness of using UACDT to treat symptomatic, postpartum, iliofemoral deep vein thrombosis after only an overnight infusion.
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Affiliation(s)
- Mert Dumantepe
- Departments of Cardiovascular Surgery, Memorial Atasehir Hospital, Istanbul, Turkey.
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43
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Abstract
Patients with acute iliofemoral deep vein thrombosis suffer the most severe post-thrombotic sequelae. The pathophysiology of the post-thrombotic syndrome is ambulatory venous hypertension, and patients with valve dysfunction and luminal obstruction have the highest ambulatory venous pressures. Treatment designed to reduce or eliminate the post-thrombotic syndrome must necessarily remove thrombus to eliminate obstruction. The technique of contemporary venous thrombectomy follows basic vascular surgical principles and offers patients the opportunity for complete or near complete thrombus extraction. The techniques described herein represent the authors' approach to patients with few alternatives to clear their venous system.
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44
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Liu Y, Sun Y, Zhang S, Jin X. Placement of a retrievable inferior vena cava filter for deep venous thrombosis in term pregnancy. J Vasc Surg 2012; 55:1042-7. [DOI: 10.1016/j.jvs.2011.10.107] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Revised: 10/18/2011] [Accepted: 10/19/2011] [Indexed: 11/24/2022]
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45
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Funatsu A, Nakamura S. Stent Implantation for Iliac Compression Syndrome with Acute Deep Venous Thrombosis. ACTA ACUST UNITED AC 2012. [DOI: 10.7134/phlebol.23.283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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46
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Herrera S, Comerota AJ. Embolization during treatment of deep venous thrombosis: incidence, importance, and prevention. Tech Vasc Interv Radiol 2011; 14:58-64. [PMID: 21550507 DOI: 10.1053/j.tvir.2011.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The standard of care for the treatment of acute deep venous thrombosis (DVT) is anticoagulation, which often prevents the formation of new thrombus and reduces the risk of pulmonary embolism (PE) but fails to eliminate the clot burden. Patients who have thrombus remaining in their deep venous system despite therapeutic anticoagulation are at high risk for developing symptoms of the postthrombotic syndrome, a debilitating condition that adversely affects their quality of life. Strategies of thrombus removal for acute DVT, such as operative thrombectomy, catheter-directed thrombolysis, and pharmacomechanical techniques, are designed to avoid postthrombotic morbidity by restoring patency to the deep veins, but there is concern that these techniques may result in fragmentation of clot and pulmonary embolization. Careful patient evaluation before treatment is essential for preventing complications and often reveals asymptomatic pulmonary emboli in as many as 50% of patients. Nonobstructive or free-floating thrombus in the vena cava is a risk factor for procedure-related embolization and is frequently an indication for the use of vena caval filtration. A review of the literature on acute DVT treated by anticoagulation alone or with strategies of thrombus removal reveals that pulmonary embolization is an infrequent occurrence. Treatment with anticoagulation alone, however, increases the risk of patients developing symptoms of the postthrombotic syndrome, whereas thrombus removal strategies reduce postthrombotic morbidity without increasing the risk of embolization.
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Affiliation(s)
- Santiago Herrera
- Jobst Vascular Center, The Toledo Hospital, Toledo, OH 43606, USA
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47
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Karthikesalingam A, Young E, Hinchliffe R, Loftus I, Thompson M, Holt P. A Systematic Review of Percutaneous Mechanical Thrombectomy in the Treatment of Deep Venous Thrombosis. Eur J Vasc Endovasc Surg 2011; 41:554-65. [DOI: 10.1016/j.ejvs.2011.01.010] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 01/10/2011] [Indexed: 12/16/2022]
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48
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Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123:1788-830. [PMID: 21422387 DOI: 10.1161/cir.0b013e318214914f] [Citation(s) in RCA: 1463] [Impact Index Per Article: 112.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is responsible for the hospitalization of >250 000 Americans annually and represents a significant risk for morbidity and mortality. Despite the publication of evidence-based clinical practice guidelines to aid in the management of VTE in its acute and chronic forms, the clinician is frequently confronted with manifestations of VTE for which data are sparse and optimal management is unclear. In particular, the optimal use of advanced therapies for acute VTE, including thrombolysis and catheter-based therapies, remains uncertain. This report addresses the management of massive and submassive pulmonary embolism (PE), iliofemoral deep vein thrombosis (IFDVT),and chronic thromboembolic pulmonary hypertension (CTEPH). The goal is to provide practical advice to enable the busy clinician to optimize the management of patients with these severe manifestations of VTE. Although this document makes recommendations for management, optimal medical decisions must incorporate other factors, including patient wishes, quality of life, and life expectancy based on age and comorbidities. The appropriateness of these recommendations for a specific patient may vary depending on these factors and will be best judged by the bedside clinician.
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49
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Posner C, Owen M, Melhem N, Vidyarthi M, Low D, Renfrew I, MacCallum P, Chowdhury TA. An acutely swollen leg. Clin Med (Lond) 2010; 10:484-6. [PMID: 21117384 PMCID: PMC4952413 DOI: 10.7861/clinmedicine.10-5-484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- C Posner
- Department of Diabetes and Metabolism
| | - M Owen
- Department of Diabetes and Metabolism
| | - N Melhem
- Department of Diabetes and Metabolism
| | | | - D Low
- Department of Interventional Radiology
| | - I Renfrew
- Department of Interventional Radiology
| | - P MacCallum
- Department of Haematology, The Royal London Hospital, London
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50
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Alhadad A, Kölbel T, Herbst A, Holst J, Alhadad H, Gottsäter A. Iliocaval vein stenting: Long term survey of postthrombotic symptoms and working capacity. J Thromb Thrombolysis 2010; 31:211-6. [DOI: 10.1007/s11239-010-0504-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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