Abdominal and pubic collateral veins as indicators of deep venous obstruction

Unveiling absent inferor vena cava in young patients: Case reports and clinical insights

INTRODUCTION

Inferior vena cava agenesis (IVCA), a rare congenital anomaly, contributes to approximately 5 % of deep venous thrombosis (DVT) cases lacking other risk factors. It can lead to chronic venous insufficiency and DVT when collateral circulation is insufficient, presenting diagnostic challenges due to its rarity.

CASE PRESENTATION

We present two cases of Absent IVC (AIVC) in young males. Case 1: a 22-year-old developed bilateral lower limb DVT post-appendectomy. Imaging revealed AIVC with azygos continuation. Treatment included Heparin and Rivaroxaban, achieving symptom resolution. Case 2: a 41-year-old with recurrent DVT and chronic venous insufficiency was diagnosed with AIVC via venography. Managed with warfarin and compression therapy, his symptoms stabilized.

CLINICAL DISCUSSION

These cases underscore the importance of recognizing AIVC in young patients presenting with unexplained DVT. Diagnosis often requires advanced imaging techniques like CT venography. Management typically involves long-term anticoagulation and compression therapy to mitigate the risk of recurrence and chronic venous complications.

CONCLUSION

Early identification of AIVC in young adults presenting with recurrent DVT is essential for appropriate management and prevention of long-term complications.

Inferior and Superior Vena Cava Reconstruction

Obstructions of the superior and inferior vena cava are prevalent etiologies of deep venous obstruction, presenting a spectrum of clinical manifestations ranging from life-threatening conditions to asymptomatic states. The etiological diversity inherent to these central venous obstructions necessitates a subtle approach to their diagnosis and management. This discrepancy in clinical presentations emphasizes the importance of a differentiated diagnostic and therapeutic strategy, tailored to the specific form of vena cava obstruction encountered. This article aims to delineate the various manifestations of vena cava obstruction and encourages specific diagnostic and treatment pathways.

Symptomatic Chronic Severe Stenosis of the Iliac Vein Successfully Treated Endovascularly Using an Interventional Radiology Computed Tomography System

We report a woman with chronic severe stenosis of the left common and external iliac veins and severe post-thrombotic syndrome symptoms. We successfully recanalized the stenotic segment via interventional radiology, which immediately relieved the symptoms. The interventional radiology computed tomography system was helpful for the safe and precise performance of endovascular treatments.

Clinical impact of assessing thrombus age using magnetic resonance venography prior to catheter-directed thrombolysis

Objectives

Magnetic resonance venography (MRV) is underutilized in the evaluation of thrombus properties prior to endovascular treatment but may improve procedural outcomes. We therefore investigated the clinical impact of using a dedicated MRV scoring system to assess thrombus characteristics prior to endovascular intervention for iliofemoral deep vein thrombosis (DVT).

Methods

This is a post hoc analysis of data from the CAVA trial (Clinicaltrials.gov:NCT00970619). MRV studies of patients receiving ultrasound-accelerated catheter-directed thrombolysis (CDT) for iliofemoral DVT were reviewed. Thrombus age-related imaging characteristics were scored and translated into an overall score (acute, subacute, or old). MRV scores were compared to patient-reported complaints. MRV-scored groups were compared for CDT duration and success rate.

Results

Fifty-six patients (29 men; age 50.8 ± 16.4 years) were included. Using MRV, 27 thrombi were classified acute, 17 subacute, and 12 old. Based on patient-reported complaints, 11 (91.7%) of these old thrombi would have been categorized acute or subacute, and one (3.7%) of the acute thrombi as old. Average duration of CDT to > 90% restored patency differed significantly between groups (p < 0.0001): average duration was 23 h for acute thromboses (range: 19–25), 43 h for subacute (range: 41–62), and 85 h for old thromboses (range: 74–96). CDT was almost eleven times more successful in thromboses characterized as acute and subacute compared to old thromboses (OR: 10.7; 95% CI 2.1–55.5).

Conclusion

A dedicated MRV scoring system can safely discriminate between acute, subacute, and old thromboses. MRV-based selection is predictive of procedural duration and success rate and can help avoid unnecessary complications.

Key Points

• Thrombus age, characterized by MRV as acute, subacute, and old, can predict CDT duration and probability of success.

• Accurate pre-interventional MRV-based thrombus aging has the potential to facilitate identification of eligible patients and may thus prevent CDT-related complications.

Non-contrast-enhanced magnetic resonance imaging: Objective figures in differentiation between acute and chronic deep venous thrombosis in the lower extremities

BACKGROUND

Deep vein thrombosis is a severe health problem. Treatment options may differ between acute and chronic deep vein thrombosis. Thus, distinguishing acute from chronic deep vein thrombosis is essential for patients with deep vein thrombosis.Triggered angiography non-contrast enhanced is an innovative magnetic resonance imaging protocol that may provide objective evidence in differentiating acute from chronic deep vein thrombosis.

METHOD

We prospectively collected information on consecutive patients who had been evaluated through triggered angiography non-contrast enhanced magnetic resonance imaging for venous pathology in their lower extremities at a vascular wound care center in a tertiary hospital between April 2017 and January 2020. Patients included were divided into two groups with the onset time cutoff point of 21 days. All were undergone non-contrast-enhanced magnetic resonance imaging evaluation. Non-contrast-enhanced magnetic resonance imaging images were evaluated by a radiologist, and lower extremity venous thrombosis, collateral-vein development, and subcutaneous honeycombing were emphasized. Cohen's kappa coefficient was used to measure interrater agreement between the development of collateral veins, subcutaneous honeycombing, and symptom onset over 21 days.

RESULTS

Interrater agreement analysis revealed that the development of collateral veins was substantially correlated with the onset of symptoms over 21 days (Table 1). Additionally, the development of subcutaneous honeycombing detected through triggered angiography non-contrast enhanced magnetic resonance imaging also substantially agreed with the onset of symptoms over 21 days (Table 2).

CONCLUSION

The diagnostic power of triggered angiography non-contrast enhanced magnetic resonance imaging in deep vein thrombosis is rival to current gold standard, color Doppler sonography. Triggered angiography non-contrast enhanced magnetic resonance imaging provides objective information on onset timing in patients with deep vein thrombosis that could differentiate acute from chronic deep vein thrombosis and provides guidance for treatment planning.

Evaluation of incidence and clinical significance of obturator hook sign as a marker of chronic iliofemoral venous outflow obstruction in computed tomography venography

OBJECTIVE

The aim of this paper was to describe the obturator hook sign (OHS), a distinctive dilated angled vein similar to a hook, by computed tomography venography (CTV). It is identified mainly on direct CTV (DCTV) as opposed to indirect CTV (ICTV), evidencing obturator vein engorgement as a marker of hemodynamically significant collateralization and representing an indirect sign for chronic iliac vein outflow obstruction.

METHODS

All CTV studies of lower limbs performed from January 2014 to August 2018 in Galway University Hospital and the Galway Clinic were retrospectively reviewed. Data were analyzed using SPSS software (version 25.0; IBM Corp, Armonk, NY).

RESULTS

In total, 531 CTV studies were reviewed, of which 122 (23%) were performed for acute deep venous thrombosis, 183 (35%) for follow-up after iliac stenting, and 109 (21%) for etiologic study of chronic venous disease. For the purpose of analysis for the presence of OHS, only first-time CTV studies were included in patients who were never submitted to venous intervention (n = 296), of which 40 were DCTV (14%) and 256 were ICTV (86%). Two groups were defined according to whether OHS was present, and significant predictors were identified: female sex (P = .038), younger age (P < .0001), DCTV (P < .0001), nonthrombotic iliac vein lesion (P < .001), past history of iliofemoral deep venous thrombosis (P < .0001), and dilated pelvic veins (P < .0001). OHS was significantly more common in chronic occlusions compared with chronic stenosis or acute occlusion (P < .0001). Findings from DCTV and ICTV were compared with results from ascending venography as the "gold standard," and the sign proved to have high specificity and positive predictive value (100% for both tests), whereas sensitivity and negative predictive value were low for both DCTV (65% [95% confidence interval (CI), 43%-84%] and 11% [95% CI, 7%-18%], respectively) and ICTV (8% [95% CI, 4%-14%] and 6% [95% CI, 9%-20%], respectively). From analysis of the remaining CTVs, particularly follow-up after iliac stenting, an interesting fact was recognized: successful venous stenting was associated with OHS disappearance, and stent occlusion was also sometimes associated with OHS reappearance or appearance de novo.

CONCLUSIONS

The identification of hemodynamically significant lesions in patients with clinically significant chronic venous disease is the aim of any form of imaging. In this study, we have depicted a previously undescribed sign that is straightforward to identify, particularly in DCTV, immediately pointing us toward hemodynamically significant chronic iliac venous outflow obstruction diagnosis. It is too early to call it pathognomonic, but perhaps comparative analysis involving data from additional centers could lead to this conclusion.

En bloc resection of the external iliac vein along with broad ligament leiomyosarcoma: A case report

Outcomes following the excision of the external iliac vein during gynaecological oncology surgery are poorly documented. This is because most gynaecological oncologists consider tumours with vascular involvement inoperable. We describe a patient whose right external iliac vein was transected during the removal of a large broad ligament leiomyosarcoma invading the right external iliac vein. The patient's recovery following surgery was uneventful, and she remained disease-free 6 months postoperatively, with minimal morbidity. In describing this case, we hope to educate and inform other gynaecological oncologists facing a similar surgical challenge. We also propose that resection of the external iliac vessels in such cases is safe and feasible, and summarise the anatomical course of venous collaterals, which develop when the external iliac veins are obstructed.

Autologous sapheno-saphenous bypass collateral development in the setting of chronic unilateral iliac vein occlusion

Background

Chronic iliac vein occlusion can result in the development of a variety of collateral venous drainage pathways. While several drainage pathways have been well documented, autologous sapheno-saphenous bypass collateral drainage has not been described. This novel collateral drainage pathway is readily visible on cross sectional imaging, may serve as a diagnostic indicator of chronic obstructive venous pathology, and may hint at the underlying etiology.

Case presentation

This brief report depicts findings and technical considerations in two cases of venous recanalization of sapheno-saphenous collaterals in the setting of chronic unilateral iliac vein occlusion. In both cases at one-month follow-up, the patients’ pain had resolved, edema had improved, and computed tomographic venography demonstrated stent patency.

Conclusions

Identification of a sapheno-saphenous collateral can provide an important clue to the underlying venous obstructive pathology, therefore guiding corrective intervention.

Venous stent patency may be affected by collateral vein lumen size

Purpose

Deep venous thrombosis causes blood flow deviation. It is hypothesized that with stent placement, developed collateral veins become redundant. This article evaluates the relation between the surface area of the collaterals and stent patency.

Methods

The azygos and hemiazygos veins were identified and the largest surface area was measured at thoracic level. Patency rates of stented tracts were evaluated and related to collateral vein lumen size.

Results

The vena cava occlusion and the azygos and hemiazygos vein surface area measurements were positive and statistically significant related (OR 1.01, 95% CI 1.003−1.019, p = 0.004) respectively (and OR 1.007, 95% CI 1.001−1.013, p = 0.004). An azygos surface area measurement of 23 (p<0.001) and hemiazygos surface area measurement of 40 (p = 0.008) was shown as cut-off point related to higher occlusion rates.

Conclusions

The surface area of major venous collateral pathways seems to be related to stent occlusion in deep venous interventions.

A case report of thrombosed varicosities of pubic collateral veins: Ideal treatment strategy and contribution of era imaging technologies in diagnosis

Collateral circulation is an alternative path occurring in case of venous or artery obstruction. This path may usually develop after primary recanalization. In our case, a 62-year-old woman presented to our Emergency Department complaining about a suprapubic swelling with a cyanotic discoloration of the overlying skin for the past 10 days for which she had been previously prescribed antibiotics. Investigation with ultrasound and contrast-enhanced computed tomography was performed. An imaging study revealed thrombosed pubic varicose collateral veins due to deep vein obstruction and occlusion of the left external iliac vein. The patient was treated with low-molecular-weight heparin, and swelling subsided gradually. Collateral veins of the abdominal wall and over the pubic tubercle are highly predictive of deep venous obstructive disease proximal to the groin level. These collaterals should never be removed, and the patient should be subjected to a diligent laboratory and imaging investigation.

Patency rates and clinical outcomes in a cohort of 200 patients treated with a dedicated venous stent

OBJECTIVE

Minimally invasive interventions by recanalization, percutaneous transluminal angioplasty, and stenting in post-thrombotic syndrome (PTS) obstructions and iliac vein compression syndrome (IVCS) have shown good results. Until recently, no dedicated venous stents were available, and stent-related issues accounted for a decrease in patency scores. The introduction of dedicated stents with more flexibility and higher radial forces could result in higher patency scores. This study focused on the outcomes of patients treated by a dedicated sinus-Venous stent (OptiMed GmbH, Ettlingen, Germany). Patency rates and clinical evaluation are described for both PTS and IVCS patients.

METHODS

A total of 200 patients treated at a tertiary university referral center were analyzed. A percutaneous procedure was performed in 103 (51%) PTS patients and 48 (24%) IVCS patients. In 49 (25%) patients, a hybrid procedure was executed. Patency rates and complications were analyzed by duplex ultrasound. Clinical improvement was scored by Venous Clinical Severity Score, Villalta scale, and venous claudication rates.

RESULTS

The mean age was 43.2 ± 14.5 (17-81) years, and 66% were female. Mean Villalta score decreased from 10.5 ± 4.2 (3-24) to 5.3 ± 3.8 (0-14) at the latest follow-up (P < .001). Venous Clinical Severity Score decreased by a total of 3 points (P < .001). At baseline, venous claudication was present in 132 patients, which subsided in 115 (87%). Overall patency scores revealed a primary patency of 68%, assisted primary patency of 83%, and secondary patency of 90% with a median follow-up of 12 (11-12) months. Of all included patients, 122 (61%) did not have a complication during follow-up; the most frequent complications were in-stent restenosis (n = 23) and occlusion (n = 25) of the stented tract.

CONCLUSIONS

Short-term clinical results using the sinus-Venous stent are comparable to previous research. Loss of stent patency due to stent-related issues like kinking or tapering is hardly ever seen in this short-term follow-up.

Suprapubic varicose vein formation during pregnancy following pre-pregnancy pelvic vein embolisation with coils, without any residual pelvic venous reflux or obstruction

Suprapubic varicose veins are usually indicative of unilateral iliac vein occlusion and venous collateralisation. We report two cases of suprapubic varicose veins following pelvic vein embolisation and subsequent pregnancy; both presented without residual pelvic venous reflux or pelvic venous obstruction. In both cases, there was no significant flow in the suprapubic veins indicating that they were not acting as a collateral post-pregnancy. One patient had this venous abnormality treated successfully with TRansluminal Occlusion of Perforators, followed by foam sclerotherapy to the main part of the suprapubic vein. This patient has since completed the reminder of her lower limb varicose vein treatment. We suggest that pregnancy may have caused prolonged intermittent compression of the left common iliac vein, and that this, together with the physiological impact of previous embolisation procedures, obstructed venous drainage from the left leg resulting in collateral vein formation within the 9-month gestation period.