The TOPOS study

Background: We aimed to study the long-term safety and efficacy of oblique venous stents for post-thrombotic syndrome (PTS) with iliac vein compression. Patients and methods: In the multinational, prospective, single-arm TOPOS study, PTS patients scheduled for endovascular therapy with the sinus-Obliquus® stent and optional distal extension with the sinus-Venous® or sinus-XL Flex® stent were enrolled at eight European vascular centres between October 2016 and December 2020. The primary outcome was primary stent patency at 24 months, and secondary outcomes included the clinical course of PTS (Villalta score, revised Venous Clinical Severity Score [rVCSS], Visual Analog Scale [VAS] of pain), quality of life changes (Chronic Venous Insufficiency Quality of Life Questionnaire, CIVIQ-20), and device-related complications. Results: We enrolled 60 patients (mean age 46±15 years, 68% women, 13% active ulcers): 80% required stent extension (70% below the inguinal ligament). The primary patency rate at 24 months was 80.7% (95%CI 68.1-90.0%); it was higher in patients without vs. those with stent extension (90.9% vs. 78.3%, p=.01). Compared to baseline, the Villalta, rVCSS, pain VAS, and CIVIQ-20 decreased by a median of 8 (interquartile range (IQR): 4-11), 5 (IQR: 3-7), 3 (IQR: 2-5), and 17 (IQR: 6-22) points, respectively; p<.001 for all parameters. Overall, 9 events of acute stent occlusion, 4 symptomatic stent stenosis, and 1 pulmonary embolism occurred. We did not observe major bleeding events or contralateral thrombosis. Conclusions: Endovascular treatment with the oblique stent and optional stent extension was safe and resulted in high patency rates at 24 months. The reduction in PTS severity was substantial and persisted over 2-year follow-up.

Graduated elastic compression stockings in the prevention of post-thrombotic syndrome: A systematic review and meta-analysis

BACKGROUND

The effect of graduated elastic compression stockings (ECS) in the prevention of post-thrombotic syndrome (PTS) has been questioned since a large randomized trial found no prophylactic effect of ECS.

OBJECTIVE

To assess the effect of the wearing time of ECS on the incidence of post-thrombotic syndrome (PTS) after proximal deep venous thrombosis, we performed a meta-analysis of the incidence of PTS across randomized and observational studies.

METHOD

PubMed, Embase and Cochrane databases were searched until 12 June 2023 for studies on the effect of ECS on PTS. References of eligible studies were also screened in order to identify other potential studies that might have been missed during the search.

RESULTS

Four studies comprising a total of 1467 patients met our inclusion criteria for early initiation and consistent use of ECS in patients with acute proximal DVT. ECS significantly reduced the incidence of mild-moderate PTS (OR: 0.48; 95% CI: 0.36-0.63) as well as severe PTS (OR: 0.44; 95% CI: 0.28-0.58).

Long-Term Efficacy and Safety of Direct Oral Anticoagulants at Reduced Doses in the Secondary Prevention of Venous Thromboembolism and Post-Thrombotic Syndrome

Background: Anticoagulation for venous thromboembolism (VTE) is required for at least three to six months; however, it is advisable to extend the duration in certain cases, in which case a reduced dose of Direct Oral Anticoagulants (DOACs) may be an option. Our objective was to investigate the efficacy and safety of reduced-dose DOACs in extended anticoagulation treatment compared to full doses. Methods and Results: This retrospective single-centre study included 185 patients treated with DOACs for at least 6 months who were divided into two groups: (1) the Full Dose (FD) group (n = 113) and (2) the Reduced Dose (RD) group (n = 72), which included patients treated with Apixaban at 2.5 mg bis in die (BID) and Rivaroxaban at 10 mg once daily (OD). Post-thrombotic syndrome (PTS) and its progression were evaluated. During an overall follow-up of 48.32 ± 29.49 months, no VTE occurred, and no patients experienced major bleeding; clinically relevant non-major bleeding occurred in three patients in each group (2.7% vs. 4.2% in FD vs. RD, respectively, p = 0.57). From baseline to follow-up, the prevalence of PTS was not significantly decreased in either group (FD: 54.9% vs. 51.3%, p = 0.29; RD 51.4% vs. 44.4%, p = 0.12); conversely, the Villalta score values were significantly decreased at the last follow-up (FD: 5.51 ± 4.18 vs. 5.51 ± 4.18, p < 0.001; RD 5.49 ± 4.06 vs. 5.11 ± 3.73, p = 0.006). Conclusion: In this real-world retrospective registry, very long-term extended anticoagulant therapy with DOACs at full or reduced doses showed comparable efficacy, safety, and impact on PTS progression. Larger studies are needed.

Pharmacomechanical thrombectomy of iliofemoral deep vein thrombosis is associated with a low incidence of post-thrombotic syndrome and perioperative complications

BACKGROUND

Iliofemoral deep venous thrombosis (IFDVT) is associated with an incidence of post-thrombotic syndrome (PTS) of up to 50%. PTS is associated with high morbidity, impaired quality of life and a significant economic burden. The aim of the current study was to assess the impact of a single session pharmacomechanical thrombectomy (PMT), dedicated venous stents and a risk mitigation protocol on the rate of PTS.

METHODS

Between 2015 and 2022, patients presenting with acute or subacute IFDVT treated with the same protocol of single session PMT, dedicated venous stents, and risk-mitigation measures were included. Procedural success rate, complications, stent patency and incidence of PTS were determined.

RESULTS

Of 60 patients (58 ± 19 years; 65% male), the procedural success rate was 93%, with 7% of patients experiencing complications but no long-term sequelae or mortality. Most (n = 52; 87%) patients were stented, including 46% across the inguinal ligament. At 3 months post-procedure, primary, assisted primary and secondary stent patency rates were 89%, 93% and 98%, respectively, with no loss of patency or re-interventions after that. At latest follow-up of a median 48 months (n = 32), stent patency rate was 97%, with only three patients (9%) experiencing symptoms of PTS.

CONCLUSION

Single session PMT, dedicated venous stents and a risk-mitigation protocol results in high success rate, excellent long-term stent patency and low incidence of PTS without compromising safety. These results support early intervention for iliofemoral DVT.

Femoral vein stenting versus endovenectomy as adjuncts to iliofemoral venous stenting in extensive chronic iliofemoral venous obstruction

PURPOSE

To compare femoral endovenectomy with the creation of an arteriovenous fistula (FE + AVF), versus iliofemoral endovenous stenting with the concurrent extended femoral vein (FV-S) stenting in patients with chronic iliofemoral venous obstruction (IFVO).

MATERIALS AND METHODS

In a randomized prospective single-center study, 48 received (FV-S), while the other 54 had (FE + AVF).

RESULTS

There were no statistically significant differences in the primary outcomes between the two groups (FV-S) and (FE + AVF) (59% vs 56.8%, 75% vs 79.1%, respectively). At a median of 13 months after the treatment. However, the FV-S group's patients experienced fewer postoperative problems (p = .012), shorter procedures (p = .001), and shorter stays in the hospital (p = .025).

CONCLUSION

There is no difference between the efficacy and symptomatic resolution of the FV-S group and the FE + AVF group at the same time, FV-S has lower postoperative complications and a shorter procedure duration and hospital stay.

Closure of Post-thrombotic Iliac Arteriovenous Fistulas by Iliac Vein Recanalization

PURPOSE

The purpose of this study was to report the closure of iliac arteriovenous fistulas associated with a post-thrombotic iliac vein occlusion by iliac venous stent recanalization.

CASE REPORT

An 80-year-old woman presented with a worsening painful swelling of her left leg after an iliofemoral deep vein thrombosis 6 months ago. Duplex ultrasound and magnetic resonance venography revealed a post-thrombotic obstruction of her iliac veins as well as several arteriovenous fistulas between branches of her left external and internal iliac arteries and adjacent diseased venous segments. In a first attempt, coil embolization did not sustainably close these iliac arteriovenous fistulas. Direct stent recanalization of the chronically diseased iliofemoral venous segment, however, resulted in an immediate closure of arteriovenous shunt flow and subsequent improvement of clinical symptoms. Six months after iliac vein stent recanalization, still no fistulas could be detected any more, venous stents were fully patent, and the patient was free of symptoms.

CONCLUSION

Post-thrombotic iliofemoral obstructions might be associated with the development of arteriovenous fistulas. Direct stent recanalization of the chronically occluded veins results in closure of related arteriovenous fistulas.

CLINICAL IMPACT

This case suggests that the combined occurrence of post-thrombotic venous obstructions with arteriovenous fistulas, which are related to aforementioned venous lesions, should be evaluated for primary venous stent recanalization rather than fistula embolization.

Durometry for the Assessment of Severity of Post-thrombotic Syndrome and Possible Clinical Applications

BACKGROUND

Post-thrombotic syndrome (PTS) impacts the patient's quality of life. Available scales to determine its severity remain controversial, therefore, it is of importance to identify new auxiliary methods for the assessment of this sequelae. Measurement of skin hardness (MSH) might be decisive in tracking PTS. The purpose of this study is to assess if the use of durometry is an objective measure to evaluate prognosis of affected limbs in patients with PTS. We compared MSH of extremities with PTS vs healthy limbs, as well as their variation after 3 months of medical treatment to evaluate if durometry can be used to find differences. We strongly believe that measuring and keeping track of skin changes specifically skin hardness can be a useful factor in the prognosis and treatment of PTS.

METHODS

Prospective cohort study from January 2021 to February 2022 in patients with unilateral PTS. The MSH of the affected limb was compared to the healthy limb. A calibrated durometer was used, 4 measurements were completed at the time of diagnosis and subsequent follow-up were carried out after 3 months of treatment. The percentage of healing (in case of ulcers) and adherence to treatment was carefully monitored. The statistical program R was used.

RESULTS

A total of 1088 durometric measurements were performed on 17 patients, and 34 limbs. The MSH in limbs with PTS was 39.09 and in the control limbs (19.8) (P = <.00001). After 3 months of treatment, the MSH in PTS varied in PTS limbs (39.09 to 30.4) (P = <.000012). Adherence to treatment was 70.5%.

CONCLUSIONS

MSH varied between healthy limbs and the ones with PTS, before and after treatment. Durometry might represent a method for assessing skin changes in patients with PTS.

The effectiveness of adalimumab as an add-on therapy in two cases with leg ulcers in Behçet's disease resistant to conventional immunosuppressive therapy alone and a review of the literature

The current report presents two cases with leg ulcers related to Behçet's disease (BD) resistant to conventional immunosuppressive therapy (CIST) but successfully treated with adalimumab (ADA). BD, which can affect vessels of any size and type, is a systemic vasculitis. In the vascular system, veins are the most predominantly affected blood vessels, with deep vein thrombosis and recurrent superficial vein thrombophlebitis being the most common vascular signs of the disease in the lower extremities. Leg ulcers, commonly associated with vasculitis or deep vein thrombosis, are rare in patients with BD. Conventional immunosuppressive therapy is very critical to prevent relapses and diminish the risk of post-thrombotic syndrome. In patients with BD-associated venous thrombosis (deep vein thrombosis or superficial vein thrombophlebitis) resistant to these treatments, tumour necrosis factor-α inhibitors can be used alone or in combination with traditional disease-modifying antirheumatic drugs. In view of such information, add-on adalimumab treatment was considered appropriate for both patients. Response to this intervention was highly satisfying for the patients at the end of the 6-month treatment. Nonetheless, it warrants further studies directly evaluating the efficacy of tumour necrosis factor-α inhibitors alone in leg ulcers in BD.

Biomarkers and the post-thrombotic syndrome: A systematic review of biomarkers associated with the occurrence of the post-thrombotic syndrome after lower extremity deep venous thrombosis

INTRODUCTION

Post-thrombotic syndrome (PTS) is a frequent chronic complication of deep venous thrombosis (DVT). Biomarkers are potentially valuable clinical tools for handling PTS. The purpose of this review was to examine which biomarkers are associated with the development of PTS in adults with lower extremity DVT.

METHODS

We performed a systematic review of all English language prospective studies of biomarkers and PTS published in PubMed and EMBASE. Studies were included if diagnosing DVT by diagnostic imaging and assessing PTS by clinical scales, for example, the Villalta scale. Biomarkers of thrombophilia and pathological clot properties were not assessed. Data was reported qualitatively.

RESULTS

15 prospective studies were included. Studies varied widely in study design and methods of data analysis. Forty-six different biomarkers were examined, with seven being measured in two or more studies. The most frequently studied biomarkers were D-dimer, CRP, and IL-6. Associations between PTS and D-dimer were predominantly significant, while results on CRP and IL-6 were inconsistent. ICAM-1 was consistently associated with PTS in all studies and at all timepoints. IL-10 was significantly related to PTS development in the largest study and at all time points. Adiponectin, tPA, HRG and TAFI, MMP-1 and -8, and TIMP-1 and -2 were significantly associated with PTS in single studies.

CONCLUSION

(1) Further research on biomarkers and PTS is clearly warranted. (2) Significant differences in study designs made it difficult to draw reliable conclusions regarding individual biomarkers. We suggest the implementation of a standardized framework for the study of biomarkers and PTS, to make comparison of future studies more feasible. (3) D-dimer, ICAM-1, IL-10, MMP-1 and 8, TIMP-1, TIMP-2, and adiponectin are clinical biomarkers of particular interest to include in future studies of PTS. Large scale systemic quantitative proteomic analyses of DVT patients could help identify novel biomarkers of interest in PTS-patients.

Epidemiology and Diagnosis of Post-Thrombotic Syndrome: Qualitative Synthesis with a Systematic Review

Background: Post-thrombotic syndrome (PTS) is a common and debilitating sequela of lower limb deep vein thrombosis (DVT). There is significant heterogeneity in reported PTS incidence due to lack of standardised diagnostic criteria. This review aimed to develop diagnostic criteria for PTS and subsequently refine the reported incidence and severity. Methods: PRISMA principles were followed; however, the review was not registered. The Cochrane CENTRAL database, MEDLINE, Embase, the NHS NICE Healthcare Databases Advanced Search interface, and trial registers including isrctn.com and clinicaltrials.gov were searched for studies addressing areas of interest (PTS definition, epidemiology, assessment). An experienced Clinical Librarian undertook the systematic searches, and two independent reviewers agreed on the relevance of the papers. Conflicts were resolved through panel review. Evidence quality was assessed using a modified Coleman scoring system and weighted according to their relevance to the aforementioned areas of interest. Results: A total of 339 abstracts were retrieved. A total of 33 full-text papers were included in this review. Following qualitative analysis, four criteria were proposed to define PTS: (1) a proven thrombotic event on radiological assessment; (2) a minimum 24-month follow-up period after an index DVT; (3) assessment with a validated score; and (4) evidence of progression of venous insufficiency from baseline. Four papers conformed to our PTS definition criteria, and the incidence of mild to moderate PTS ranged from 7 to 36%. On reviewing the studies which utilised the recommended Villalta scale, PTS incidence narrowed further to 23-36%. Incidence and severity reached a plateau at 24 months. Conclusions: Four diagnostic criteria were developed from qualitative synthesis. When these criteria were applied to the literature, the range of reported PTS incidence narrowed. These four criteria may standardise PTS diagnosis in future studies, facilitating the pooling of data for meta-analysis and synthesis of higher levels of evidence.

Inflammasome Signaling, Thromboinflammation, and Venous Thromboembolism

Venous thromboembolism (VTE) remains a major health burden despite anticoagulation advances, suggesting incomplete management of pathogenic mechanisms. The NLRP3 (NACHT-, LRR- and pyrin domain-containing protein 3) inflammasome, interleukin (IL)-1, and pyroptosis are emerging contributors to the inflammatory pathogenesis of VTE. Inflammasome pathway activation occurs in patients with VTE. In preclinical models, inflammasome signaling blockade reduces venous thrombogenesis and vascular injury, suggesting that this therapeutic approach may potentially maximize anticoagulation benefits, protecting from VTE occurrence, recurrence, and ensuing post-thrombotic syndrome. The nonselective NLRP3 inhibitor colchicine and the anti-IL-1β agent canakinumab reduce atherothrombosis without increasing bleeding. Rosuvastatin reduces primary venous thrombotic events at least in part through lipid-lowering independent mechanisms, paving the way to targeted anti-inflammatory strategies in VTE. This review outlines recent preclinical and clinical evidence supporting a role for inflammasome pathway activation in venous thrombosis, and discusses the, yet unexplored, therapeutic potential of modulating inflammasome signaling to prevent and manage VTE.

Clinical efficacy of ZelanteDVT™ catheter rheolytic thrombectomy in the single-session treatment of patients with subacute deep venous thrombosis

OBJECTIVE

To evaluate the clinical efficacy and safety of novel ZelanteDVT™ catheter rheolytic thrombectomy in the single-session endovascular management of subacute deep venous thrombosis (DVT).

METHODS

A retrospective study was performed on 31 patients with subacute DVT who underwent ZelanteDVT™ catheter rheolytic thrombectomy. Procedure data, associated complications, and venous patency score were recorded. The deep venous patency and post-thrombotic syndrome (PTS) rate were assessed in all patients during follow-up visits.

RESULTS

After procedure, 19.4% (6/31) patients improved to grade III thrombus removal, while the remaining patients improved to grade II. Significant iliac vein compression syndrome was identified in 54.8% (17/31) patients, and 82.4% (14/17) of them received stent implantation. No serious procedure-related complications occurred. The median follow-up time was 13 months. The primary patency rate at 12 months was 83.87%, and the incidence of PTS was 19.35%.

CONCLUSION

This novel rheological thrombectomy catheter seems to have a promising application prospect for single-session treatment of subacute DVT.

A systematic evaluation and meta-analysis of early prediction of post-thrombotic syndrome

Objective

Post-thrombotic syndrome (PTS) is the most common long-term complication in patients with deep venous thrombosis, and the prevention of PTS remains a major challenge in clinical practice. Some studies have explored early predictors and constructed corresponding prediction models, whereas their specific application and predictive value are controversial. Therefore, we conducted this systematic evaluation and meta-analysis to investigate the incidence of PTS and the feasibility of early prediction.

Methods

We systematically searched databases of PubMed, Embase, Cochrane and Web of Science up to April 7, 2023. Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the included articles, and the OR values of the predictors in multi-factor logistic regression were pooled to assess whether they could be used as effective independent predictors.

Results

We systematically included 20 articles involving 8,512 subjects, with a predominant onset of PTS between 6 and 72 months, with a 2-year incidence of 37.5% (95% CI: 27.8-47.7%). The results for the early predictors were as follows: old age OR = 1.840 (95% CI: 1.410-2.402), obesity or overweight OR = 1.721 (95% CI: 1.245-2.378), proximal deep vein thrombosis OR = 2.335 (95% CI: 1.855-2.938), history of venous thromboembolism OR = 3.593 (95% CI: 1.738-7.240), history of smoking OR = 2.051 (95% CI: 1.305-3.224), varicose veins OR = 2.405 (95% CI: 1.344-4.304), and baseline Villalta score OR = 1.095(95% CI: 1.056-1.135). Meanwhile, gender, unprovoked DVT and insufficient anticoagulation were not independent predictors. Seven studies constructed risk prediction models. In the training set, the c-index of the prediction models was 0.77 (95% CI: 0.74-0.80) with a sensitivity of 0.75 (95% CI: 0.68-0.81) and specificity of 0.69 (95% CI: 0.60-0.77). In the validation set, the c-index, sensitivity and specificity of the prediction models were 0.74(95% CI: 0.69-0.79), 0.71(95% CI: 0.64-0.78) and 0.72(95% CI: 0.67-0.76), respectively.

Conclusions

With a high incidence after venous thrombosis, PTS is a complication that cannot be ignored in patients with venous thrombosis. Risk prediction scoring based on early model construction is a feasible option, which helps to identify the patient's condition and develop an individualized prevention program to reduce the risk of PTS.

Patient-Reported Outcomes of Endovascular Treatment of Post-Thrombotic Syndrome: Ancillary Study of a French Cohort

Excellent outcomes of angioplasty/stenting for the post-thrombotic syndrome (PTS) have been reported, notably regarding objective criteria in the vast French SFICV cohort. Differences may exist between patient-reported and objective outcomes. We investigated this possibility by using validated scales because significative correlations are discordant in the literature between patency and patient-reported characteristics. Patient-reported outcomes seem to be a more consistent tool than radiologic patency for the diagnosis and follow-up of patients displaying PTS. We retrospectively reviewed the Villalta scale and 20-item ChronIc Venous dIsease quality-of-life Questionnaire (CIVIQ-20) scores recorded after endovascular stenting for PTS at 14 centres in France in 2009-2019. We also collected patency rates, pre-operative post-thrombotic lesion severity, and the extent of stenting. We performed multivariate analyses to identify factors independently associated with improvements in each of the two scores. The 539 patients, including 324 women and 235 men, had a mean age of 44.7 years. The mean Villalta scale improvement was 7.0 ± 4.7 (p < 0.0001) and correlated with the thrombosis sequelae grade and time from thrombosis to stenting. The CIVIQ-20 score was available for 298 patients; the mean improvement was 19.2 ± 14.8 (p < 0.0001) and correlated with bilateral stenting, single thrombosis recurrence, and single stented segment. The objective gains demonstrated in earlier work after stenting were accompanied by patient-reported improvements. The factors associated with these improvements differed between the Villalta scale and the CIVIQ-20 score. These results proved that clinical follow-up with validated scores is gainful in patients treated for PTS thanks to a mini-invasive procedure.

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.

Do treatment methods for deep vein thrombosis have different effects on post-thrombotic syndrome and the quality of life?

OBJECTIVE

This study aimed to compare the effects of interventional methods and medical therapy in patients with acute proximal deep vein thrombosis (DVT) on the risk of development of post-thrombotic syndrome (PTS) and the quality of life during the follow-up period.

PATIENTS AND METHODS

Clinical statuses of the patients who were treated medical therapy alone or medical therapy and endovascular treatment for acute proximal (iliofemoral-popliteal) DVT between 1st January 2014 and 1st November 2022 were reviewed retrospectively. The study included 128 patients who received interventional treatment (Group I) and 120 patients who received medical therapy alone (Group M). The mean age of the patients was 52.98 ± 12.45 years in Group I and 55.60 ± 16.15 years in Group M. Patients were classified as provoked or unprovoked and by LET scale (lower extremity thrombosis level scale). Patients were followed-up for 1 year using Villalta scores and VEINES-QoL/Sym questionnaire. LET scale was evaluated based on the results of lower extremity venous Doppler ultrasound (DUS).

RESULTS

No early acute phase mortality was observed. LET classification showed that there is higher proximal involvement in Group I (Table 1[Table: see text]). Recurrence rate was 6.25% (8 patients) in Group I and 21.66% (26 patients) in Group M (p < .001). Pulmonary embolism was not observed in either group. At 12-month follow-up, the number of patients with a Villalta score of ≥5 was 8 (6.25%) in Group I and 81 (67.5%) in Group M (p < .001), while the mean VEINES-QoL/Sym scale score was found to be 72.5 ± 6.35 in Group I and 40.2 ± 9.31 in Group M (p < .001). The rates of anticoagulant-associated bleeding were 3.12% (4 patients) in Group I and 6.66% (8 patients) in Group M. The mean complete recanalization rates calculated using DUS at year 1 was found to be 63.28% (81 patients) in Group I and 9.16% (11 patients) in Group M (p < .001).

CONCLUSION

When deep vein thrombosis is treated using interventional methods, lower Villalta scores are detected after 1 year of follow-up. Development of post-thrombotic syndrome is reduced substantially. According to VEINES-QoL/Sym quality of life (QoL) scale, QoL is higher in patients who underwent interventional procedures. Interventional treatment provides persistent benefit in the short and medium terms especially in DVT with proximal involvement.

Video-capillaroscopy, a promising tool for the clinical evaluation of patients with chronic venous insufficiency

Background

The cutaneous microangiopathy plays a key role in the development of the skin clinical lesions of venous insufficiency. Capillaroscopy allows a non-invasive observation of the superficial skin capillaries of the lower leg, which have previously been shown to be altered in patients with advanced venous disease. As it is now available in a friendly, easy to handle way through modern video devices, we report our findings in a short series of patients with C3-C5 chronic venous disorders using this technique.

Methods

A total of 21 patients with venous insufficiency (C3-C5 on at least one leg) underwent a capillaroscopic examination of both legs and pictures recorded from the sites of the most severe venous skin lesions. This was performed with a CapXview handheld video-capillaroscope (×100 magnification), allowing easy manual measurement of maximum capillary bulk diameter and capillary density.

Results

Dramatic changes in capillary density, size, and shape were easily observed at the site of the venous skin lesions. A significant negative linear relationship was found between capillary density and the "C" classes (r = -0.45; P < 0.001). A significant negative correlation was also found between capillary density and bulk diameter (r = -0.52; P < 0.001). The area under the ROC curve for the mathematical prediction of venous skin changes by capillary density was 0.842, which shows the strength of the link between the microvascular and the clinical status.

Conclusion

Video-capillaroscopy allows a direct observation of the cutaneous venous microangiopathy and provides the possibility to measure capillary density which allows its quantification. This simple to use technique shows the potential for a more precise follow-up and treatment evaluation of the cutaneous consequences of venous disease, which remains to be further investigated.

Role of statins in the prevention of post-thrombotic syndrome after a deep vein thrombosis event: a systematic review and meta-analysis

BACKGROUND

Post-thrombotic syndrome (PTS) is the most frequent long-term complication of deep vein thrombosis. Apart from anticoagulation, there are no medications, procedures, devices, or lifestyle changes that effectively prevent PTS. There is a growing interest in the potential protective effects of statins for the prevention of PTS.

OBJECTIVE

To conduct a systematic review and meta-analysis on the role of statins to prevent PTS after a DVT event.

METHODS

We searched the MEDLINE(R) ALL, Embase, Cochrane Central Register of Controlled Trials, and Scopus from inception to April 5, 2022. The main concepts searched were "statins" and "post thrombotic syndrome." There was no language restriction. The main outcome measure was the incidence rate ratio (IRR) for PTS associated with exposure to statins.

RESULTS

Of 1971 screened records, 5 studies were included in the meta-analysis (2 retrospective cohorts and 3 randomized controlled trials [RCTs]). The pooled incidence of PTS was 34.8% per patient-year (95% CI, 9.5-127.4) in patients receiving a statin and 41.6% per patient-year (95% CI, 13.2-132) in controls. Exposure to statins was associated with a significantly decreased risk of PTS (IRR, 0.78; 95% CI, 0.63-0.96, I² = 0%). Meta-analysis of the 2 retrospective cohorts found a significant reduction in the risk of developing PTS (IRR, 0.68; 95% CI, 0.51-0.91), whereas meta-analysis of RCTs showed no reduction in PTS occurrence (IRR, 0.92; 95% CI, 0.68-1.25).

CONCLUSIONS

Although this systematic review suggests that statins may reduce PTS incidence by 22% after deep vein thrombosis, meta-analysis of RCTs showed no risk reduction. Confirmation of the efficacy of statins on the prevention of PTS should be assessed in larger RCTs.

Overall Hemostatic Potential Assay Detects Risk of Progression to Post-Thrombotic Syndrome in Anticoagulated Patients following Deep Vein Thrombosis

Deep vein thrombosis (DVT) frequently leads to post-thrombotic syndrome (PTS) which is challenging to predict and prevent. Identifying those at high risk of developing PTS may help to focus preventative strategies. Adults were recruited within 3 months of DVT diagnosis. Blood was sampled during the therapeutic anticoagulation phase. Overall hemostatic potential (OHP) assay, a spectrophotometric assay, was performed on platelet-poor plasma (PPP). In this assay, fibrin formation is triggered by small amounts of thrombin and termed the overall coagulation potential (OCP). Simultaneously, thrombin and tissue plasminogen activator are added to PPP and the resulting fibrin aggregation curve is the overall hemostatic potential (OHP). Fibrinolysis is expressed by the parameter overall fibrinolytic potential (OFP%). Patients were followed up at regular intervals. PTS was diagnosed if the Villalta score was ≥5 at least 3 months after the DVT diagnosis. Results were obtained from 190 patients (53.7% male, mean age 56.9 years). PTS developed in 62 (32.6%) patients. Patients with PTS displayed significantly higher median OCP (45.8 vs. 38.8 units, p = 0.010), OHP (12.8 vs. 9.2 units, p = 0.005) and significantly lower OFP (74.1 vs. 75.6%, p = 0.050). PTS patients had higher neutrophil/lymphocyte ratios (NLR) (2.3 vs. 1.9, p = 0.007). After multivariate analysis, proximal DVT location, history of varicose veins, NLR ≥ 2.6, OHP > 13.0 units and weight >108 kg were independent predictors for PTS. The c-statistic of the multivariate model was 0.77. This pilot study suggests that OHP testing while patients are still anticoagulated may assist in the prediction of PTS development and could assist in prognostication and targeting of preventative measures. However, larger prospective studies are needed to confirm these findings.

Idiopathic upper extremity deep vein thrombosis: A systematic review

BACKGROUND

Idiopathic upper extremity deep vein thrombosis (UEDVT) management is controversial and ranges from anticoagulation alone to the addition of further interventions such as thrombolysis and decompressive surgery.

OBJECTIVES

The objective of this systematic review was to assess the effects of anticoagulation alone compared to anticoagulation with additional interventions such as thrombolysis or decompressive surgery on the incidence of recurrent UEDVT and post-thrombotic syndrome (PTS) in patients with idiopathic UEDVT (including those associated with the oral contraceptive pill).

PATIENTS/METHODS

A systematic search was conducted for studies which focused on acute UEDVT treatment defined as therapies starting within 4 weeks of symptom onset. We limited studies to those that recruited 10 or more subjects and involved at least 6 weeks to 12 months anticoagulation alone or together with additional interventions with at least 6-month follow-up. Primary outcomes were symptomatic recurrent radiologically confirmed UEDVT and PTS. Secondary outcomes were symptomatic venous thromboembolism, bleeding and mortality.

RESULTS

We found seven studies which reported recurrent UEDVT rates and five that reported PTS rates. All studies were retrospective or cross-sectional. None compared anticoagulation alone to anticoagulation with additional intervention. Study heterogeneity precluded meta-analysis and risk of bias was moderate to serious. Recurrent UEDVT occurred in 0% to 12% post-anticoagulation alone and 0% to 23% post-additional interventions. PTS rates varied from 4% to 32% without severe PTS. Only limited studies reported on our secondary outcomes.

CONCLUSION

There is limited evidence behind idiopathic UEDVT management. Prospective comparative studies in this area are essential.

Post-thrombotic syndrome after upper extremity deep vein thrombosis: An international Delphi consensus study

OBJECTIVES

Primary deep vein thrombosis of the upper extremity (UEDVT) is a rare condition but up to 60% of patients may develop post-thrombotic syndrome in the upper extremity (UE-PTS) with significant morbidity and decreased quality of life. However, there is no universally accepted method to diagnose and classify UE-PTS, hampering scientific research on UEDVT treatment. Through this international Delphi consensus study we aimed to determine what a clinical score for diagnosing UE-PTS should entail.

METHODS

An online focus group survey among 20 patients treated for UEDVT was performed to provide clinical parameters before the start of a four round electronic Delphi consensus study among 25 international experts. The CREDES recommendations on Conducting and Reporting Delphi Studies were applied. Open text questions, multiple selection questions, and 9-point Likert scales were used. Consensus was set at 70% agreement.

RESULTS

After four rounds, agreement was reached on a composite score of five symptoms and three clinical signs, combined with a functional disability score. The signs and symptom will each be scored on a severity scale of 0-3 and the total score expressed as an ordinal variable; no/mild/moderate/or severe PTS. The functional disability portion measures the impact of the signs and symptoms on the functionality of the patient's arm.

CONCLUSION

Consensus was reached on a composite score of signs and symptoms of UE-PTS combined with a functional disability score. Clinical validation of the UE-PTS score in a large patient cohort is mandatory to facilitate application in future research.

Interim Outcomes of Mechanical Thrombectomy for Deep Vein Thrombosis from the All-Comer CLOUT Registry

OBJECTIVES

The multicenter, prospective, single arm CLOUT registry assesses the safety and effectiveness of the ClotTriever System (Inari Medical, Irvine, CA) for the treatment of acute and non-acute lower extremity deep vein thrombosis (DVT) in all-comer patients. Reported here are the outcomes of the first 250 patients.

METHODS

All-comer patients with lower extremity DVT were enrolled, including those with bilateral DVT, those with previously failed DVT treatment, and regardless of symptom duration. The primary effectiveness endpoint is complete, or near-complete (≥75%) thrombus removal determined by independent core laboratory-adjudicated Marder scores. Safety outcomes include serious adverse events (SAEs) through 30 days and clinical outcomes include PTS severity, symptoms, pain, and quality of life through 6 months.

RESULTS

The median age was 62 years and 40% of patients had contraindications to thrombolytics. A range of thrombus chronicity (33% acute, 35% subacute, 32% chronic) was observed. No patients received thrombolytics and 99.6% were treated in a single session. Median thrombectomy time was 28 minutes. The primary effectiveness endpoint was achieved in 86% of limbs. Through 30 days, one device-related SAE occurred. At 6 months, 24% of patients had PTS. Significant and sustained improvements were observed in all clinical outcomes including rVCSS, NPRS, and EQ-5D.

CONCLUSIONS

6-month outcomes from the all-comer CLOUT registry with a range of thrombus chronicity demonstrate favorable effectiveness, safety, and sustained clinical improvements.

Impact of the Post-Thrombotic Syndrome on the Arterial Wall of the Lower Limbs

OBJECTIVE

Deep vein thrombosis of the lower limbs is a common disease in vascular surgery. Approximately 20-50% of deep vein thrombosis patients develop post-thrombotic syndrome, which can severely affect the patient's quality of life. However, the precise science of the pathophysiology of the progression of the post-thrombotic syndrome remains unclear. Studies have demonstrated that patients with post-thrombotic syndrome of the lower limbs have impaired arterial wall endothelial function. Nevertheless, there is little research on the different impacts of post-thrombotic syndrome on the arterial wall endothelial function between the affected limbs and the healthy limbs. This study aims to assess this difference.

METHODS

A total of 60 patients treated for the post-thrombotic syndrome of the lower limbs were included. The flow-mediated dilation (FMD%) and nitroglycerin-mediated dilation (NMD%) were measured to assess the different endothelial function alterations of the common femoral arterial wall between the affected limb and the healthy limb.

RESULTS

No significant differences in the common femoral artery diameter between the affected limbs and the healthy limbs were discovered (8.94  ±  0.92 mm vs 8.75  ±  1.0 mm, P = 0.710). The flow-mediated dilation of the common femoral artery of the affected limbs were significantly lower compared to the healthy limbs (FMD%: 3.21  ±  1.07% vs 5.19  ±  1.35%, P  =  0.001). However, there was no significant difference in the nitroglycerin-mediated dilation of the common femoral artery between the affected limbs and the healthy limbs（ NMD%: 13.37  ±  1.78% versus 14.45  ±  2.14%, P = 0.083).

CONCLUSIONS

Our results demonstrated the association between post-thrombotic syndrome and deteriorated endothelial functional properties of the arterial wall of the lower limbs. Endothelial dysfunction of the arteries wall was more severe in the affected lower limbs with the post-thrombotic syndrome than in the healthy limbs. The mentioned findings may partly explain the pathophysiology of the progression post-thrombotic syndrome of the lower limbs.

HIGHLIGHTS

tudies have demonstrated that patients with post-thrombotic syndrome of the lower limbs have impaired arterial wall endothelial function. Our results demonstrated the endothelial dysfunction of the arteries wall was more severe in the affected lower limbs with the post-thrombotic syndrome than in the healthy limbs. Our findings may partly explain the pathophysiology of the progression post-thrombotic syndrome of the lower limbs.

Compression garments for the management of pediatric post-thrombotic syndrome: A prospective longitudinal study

BACKGROUND

Graduated compression garments (CG) are a standard form of management of post-thrombotic syndrome (PTS) in adults, but data in children are lacking.

OBJECTIVES

We aimed to study the attitudes toward CG and change in PTS severity score in children who were prescribed CG for PTS management.

METHODS

Children with PTS were enrolled in this longitudinal prospective study at the time of CG prescription. PTS severity was measured at baseline and follow-up using CAPTSure© ; attitude toward CG was registered at follow-up.

RESULTS

Forty-five patients were enrolled (median age 13 years, 25th-75th percentile 8-15 years; 53% male patients); 71% were prescribed socks and 29% sleeves; pressure was 15-20 mmHg in 84% of CG. Median baseline PTS CAPTSure© score was 31 points (25th-75th percentile 21-45 points). At follow-up, 49% of patients found CG helpful, 27% found CG not helpful, and 16% did not buy or wear the CG. Eight percent of enrolled patients did not return for study follow-up. Ninety-five percent of the children who found CG helpful wore them for ≥3 days/week. Hours of CG wear at the time of follow-up were associated with lower PTS scores at follow-up in a non-linear manner (e.g., wearing 12 vs. 0 h/day was associated with a 16-point reduction in PTS scores at follow-up, 95% CI -29 to -2 points).

CONCLUSION

Nearly half the patients who were prescribed CG found them helpful. We observed non-linear improvement in PTS severity with the use of low-pressure CG for 8-12 h/day and ≥3 days/week, providing guidance in their prescription.

Catheter-directed thrombolysis for deep vein thrombosis: 2021 update

Catheter-directed thrombolysis (CDT) has been utilized as an adjunct to anticoagulant therapy in selected patients with deep vein thrombosis (DVT) for approximately 30 years. CDT used to be limited to patients with DVT causing acute limb threat and those exhibiting failure of initial anticoagulation, but has expanded over time. Randomized trials evaluating the first-line use of CDT for proximal DVT have demonstrated that CDT does not produce a major reduction in the occurrence of post-thrombotic syndrome (PTS) and that it is poorly suited for elderly patients and those with limited thrombus extent or major risk factors for bleeding. However, CDT does offer selected patients with acute iliofemoral DVT improvement in reducing early DVT symptoms, in achieving reduction in PTS severity, and in producing an improvement in health-related quality of life (QOL). Clinical practice guidelines from medical and surgical societies are now largely aligned with the randomized trial results. This review offers the reader an update on the results of recently completed clinical trials, and additional guidance on appropriate selection of patients with DVT for catheter-directed thrombolytic therapy.

Post-thrombotic syndrome in patients with venous thromboembolism treated with dabigatran or warfarin: A long-term cross-sectional follow-up of RE-COVER study patients

BACKGROUND

Studies suggest that the direct factor Xa inhibitor rivaroxaban compared to warfarin reduces the risk of post-thrombotic syndrome (PTS) after deep vein thrombosis (DVT), but this has not been evaluated for oral direct thrombin inhibitors.

OBJECTIVES

To compare the long-term prevalence of PTS, recurrent venous thromboembolism (VTE), and health-related quality of life (HRQoL) in patients with acute DVT and/or pulmonary embolism (PE), randomized to treatment with dabigatran or warfarin in the phase III RE-COVER studies.

METHODS

We conducted a cross-sectional follow-up study of patients randomized in Canada, Norway, and Sweden. PTS was assessed by the patient-reported Villalta scale (PRV) and HRQoL by EQ-5D and VEINES-QOL/Sym.

RESULTS

We included 349 patients between December 2015 and November 2018; 166 were treated with dabigatran and 183 with warfarin. DVT (+/- PE) was index event in 255 patients, whereas 94 patients had PE only. Mean time from index event was 8.7 (standard deviation 1.4) years. PTS was diagnosed in 63% of patients with DVT and in 46% of patients with PE only, and did not differ between the treatment groups; the crude odds ratio (OR) for PTS in patients treated with dabigatran compared with warfarin was 1.1 (95% confidence interval [CI] 0.6-1.8) after DVT and 1.2 (95% CI 0.5-2.6) after PE only. The prevalence of recurrent VTE was 21% in both treatment groups. HRQoL scores did not differ between groups.

CONCLUSION

In this long-term cross-sectional study, the prevalence of PTS, recurrent VTE, and HRQoL were similar in patients treated with dabigatran and warfarin.

First-in-human experience of the Bashir Endovascular Catheter in the treatment of iliocaval deep vein thrombosis

Deep vein thrombosis (DVT) is a common disorder affecting approximately 900,000 new patients in the United States each year. Although the mainstay of treatment of DVT patients is therapeutic anticoagulation, some patients remain significantly symptomatic and therefore require more advanced interventions such as catheter-directed thrombolysis (CDT). We describe a case series of 13 patients with acute symptomatic inferior vena cava (IVC) and iliofemoral DVT that were treated with CDT using the Bashir Endovascular Catheter (BEC). We report the first-in-human use of BEC, which is a novel pharmacomechanical thrombolysis device. All the treated patients had complete and rapid resolution of their symptoms with excellent venous outflow. Despite initial promising results, larger studies using this catheter design will be needed to assess the role of BEC-directed therapy on rates of post-thrombotic syndrome and bleeding complications.

Delay between clinical presentation and treatment of deep venous thrombosis in the lower limbs and regression of thrombosis

INTRODUCTION

The objective was to investigate the delay between the onset of DVT symptoms and start of anticoagulation in common practice, assess whether this has any impact on the recanalization of venous thrombosis over one year follow up.

METHODS

A prospective observational study on 76 consecutive patients (39 men, 51.3%) with DVT diagnosed using compression ultrasound (CUS). Timing was classified as very early treatment ≤72 hours, early treatment ˂7 days and late treatment ≥7 days from onset of symptoms. Further development of the disease was monitored by CUS in scheduled visits 1, 3, 6 and 12 months after the start of treatment.

RESULTS

Mean delay from symptom onset to the start of anticoagulation was 11.1 days (median 7 days, range 1-42 days) with significant difference (p˂0.05) between proximal (12.9 days, median 30 days) and distal DVT (6.5 days, median 2 days). In less than 25% of all patients, with both proximal and distal DVT, treatment was started very early (≤72 hours), 40 patients (52.6%) received late treatment ≥7 days. There was a positive correlation between delay, average time of complete recanalization (≤72 hours 4.2 months, ≥7 days 5.3 months, p˂0.05) and rate of incomplete recanalization (≤72 hours 7.3%, ≥7 days 30.9%, p˂0.01) in proximal DVT, not in distal DVT.

CONCLUSIONS

There was a delay of ≥7 days in treating in more than half of our patients. The mean interval between clinical onset and start of treatment was significantly shorter and a delay ≥7 days significantly less frequent in patients with distal DVT compared to patients with proximal DVT. A very significant positive correlation between delay in treatment and rate of incomplete recanalization of proximal and distal thrombosis indicates that delayed anticoagulation could be a signal risk factor for the incomplete recanalization and development of PTS.

Intraoperative completion cone-beam computed tomography for the assessment of residual lesions after primary treatment of proximal venous outflow obstructions

OBJECTIVE

Report the usefulness of completion cone-beam computed tomography (CBCT) as an adjunct tool during femoro-ilio-caval recanalization post stent placement.

METHODS

Data from patients who underwent complex endovenous recanalization for chronic proximal outflow obstruction from January 2018 to May 2020 were analyzed. Two groups of patients were obtained based on the execution or not of completion CBCT. Outcomes, radiation, and contrast doses in the two groups were compared.

RESULTS

Fifteen patients (9 female, mean age 46.9 ± 13.3) in the control group and ten patients (7 female, 58.3 ± 14) in the CBCT group were included. In the CBCT group, one patient underwent an intraprocedural revision due to a residual lesion. The median total kerma area product (KAP_total) and the total volume of contrast injected were not statistically different in the two groups.

CONCLUSIONS

Completion CBCT after endovenous procedures might identify residual stenosis or stent malposition without a significant increase of total contrast injected and KAP_total.

Early and Mid-Term Outcomes of Femoro-Ilio-Caval Vein Stent Implantation

OBJECTIVE

We sought to investigate mid-term clinical outcomes and identify risk factors in one of the largest comprehensive series reported of femoro-ilio-caval (FIC) vein stent placement.

BACKGROUND

Endovascular intervention with balloon angioplasty and stenting of the iliac and common femoral veins has become first-line treatment for symptomatic deep venous outflow obstruction.

METHODS

We conducted a single-center, retrospective analysis of 180 patients who underwent FIC stent implantation between May 2017 and May 2019; 327 procedures were performed. Our primary objective was to evaluate a composite of stent thrombosis and stent restenosis. Secondary outcomes included individual predictors of in-stent restenosis (ISR) and in-stent thrombosis (IST), primary and secondary patency, access-site complications, major bleeding, pulmonary embolism, cardiovascular death, any death, intracranial bleeding, all-cause mortality, and components of major adverse cardiac and cerebrovascular events (MACCE) in a 24-month period.

RESULTS

A total of 327 procedures were performed for 180 patients. At 2-year follow up, 78.3% of cases remained free of any complication. Primary outcome occurred in 53 procedures (16.2%) and was highest at early (<30 days) follow-up. Primary patency at 2-year follow-up was 78.43%. There were no deaths, 1 patient (0.3%) had a subdural hematoma, and 3 patients (0.9%) had MACCE. Age and post-thrombotic syndrome (PTS) were significant predictors of primary outcome. PTS and Venous Clinical Severity score (VCSS) ≥10 were found to have higher rates of thrombosis. Active smokers, the elderly, history of deep vein thrombosis (DVT), and VCSS ≥10 had a statistically significant elevated risk of ISR.

CONCLUSION

Endovascular treatment with stent implantation for non-thrombotic iliac vein lesion and PTS is safe, with low morbidity, zero mortality, low complications, and persistent improvement of symptoms. Age and PTS were significant predictors of primary outcome.

Risk for post-thrombotic syndrome after lower-limb deep vein thrombosis: location of the thrombus or residual thrombi?

BACKGROUND

Many works aimed to determine factors that influence the onset of postthrombotic syndrome after an acute episode of deep venous thrombosis. We aimed to compare the prognostic value of the most proximal extent of thrombus (proximal and distal DVT) versus the residual thrombosis as identified by venous ultrasonography performed during follow-up.

METHOD

We conducted a retrospective study of prospectively collected 1183 consecutive cohort patients in the RIETE registry after a first episode of deep venous thrombosis and assessed for postthrombotic syndrome after 12 months.

RESULTS

Multivariate analysis revealed that: residual thrombosis (OR 1.40; 95% CI 0,88-2,21), the presence of cancer (OR 1.38; 95% CI: 0,64-2,97), immobility (OR 1.31; 95% CI 0,70-2,43) and estrogen-containing drugs use (OR 2.08, 95% CI 0,63-6,83), all had a predictive value for the occurrence of PTS.

CONCLUSION

Our study results revealed that ultrasound finding of residual thrombosis is more predictive than proximal location of thrombus for postthrombotic syndrome after episode of deep venous thrombosis. Real life data from a large group of patients from the RIETE registry substantiates that.

Timing of Endovascular Interventions for Iliac Vein Compression Syndrome With Thrombus

The aim of this study is to explore the timing and method of endovascular intervention for iliac vein compression syndrome (IVCS) with thrombus. Data from 111 patients with IVCS, complicated acute deep vein thrombosis (DVT), or post-thrombotic syndrome (PTS) who underwent endovascular interventions were analyzed retrospectively. Patients were divided into Group A (DVT group), including 56 patients with IVCS and iliofemoral DVT, with or without femoropopliteal DVT, with sudden lower limb swelling, and Group B (PTS group) included 55 patients with IVCS and PTS, including 18 with lower extremity wet ulcers and 32 with lower limb infections. Interventional therapies were used to treat the thrombus and eliminate stenosis and occlusion of the iliac vein. In both groups, clinical symptoms in the lower limbs after surgery were reduced significantly, and PTS incidence was low during long-term follow-up. The cumulative patency rate was 75.2% in the DVT group and 88.6% in the PTS group. Comprehensive interventional therapies are safe and effective in patients with IVCS and thrombi. Long-term efficacy in the PTS group tended to be better than that in the DVT group.

A clinical guide to Deep venous stenting for chronic iliofemoral venous obstruction

INTRODUCTION

An increase in endovenous interventions for deep venous pathologies has been observed. This article aims to provide an overview of the role of venous stenting in the management of chronic conditions affecting the deep venous system of the lower limbs, with a focus on intervention relating to the vena cava and iliofemoral venous segments.

METHOD

An overview of the literature on the minimally invasive venous stenting procedures that are being increasingly used in the management of chronic conditions affecting the deep venous system of the lower limbs.

RESULTS

We discuss key areas of interest to a venous specialist practicing in this area, including diagnostic imaging in chronic deep venous disease, with a focus on the use of intravascular ultrasound in this context; treatment of chronic venous outflow obstruction, including the rationale and structural indications for stenting, current guidance regarding stent placement, and fundamental points to consider during decision-making (endophlebectomy and stenting, stenting across the inguinal ligament, optimal sizing of venous stents, extension of venous stenting to beyond the common femoral vein confluence, the role of thrombolysis useful in chronic venous disease, and arteriovenous fistulae); outcomes and initial reports of stenting; and the future of venous stents.

CONCLUSION

Deep venous stenting has become a key treatment option for chronic (thrombotic or non-thrombotic) obstructive venous disease. Dedicated venous stents and intravascular ultrasound represent important technological advances in the minimally invasive treatment of symptomatic chronic deep venous obstruction, which previously required open surgical reconstruction.

Braided nitinol stent for chronic iliofemoral venous disease - the real-world BLUEFLOW registry

Background: In patients with iliofemoral chronic venous disease (CVD) secondary to post-thrombotic or non-thrombotic obstruction, venous outflow obstruction after adequate anticoagulation alone is still frequent and post-thrombotic syndrome is a common complication. Thus, we aimed to evaluate mid-term effectiveness and safety of a novel braided venous stent for venous outflow obstruction treatment. Patients and methods: Consecutive patients who underwent venous recanalization with a new braided, closed cell, venous stent for non- or post-thrombotic CVD were eligible for inclusion in our retrospective, observational study. Effectiveness outcomes were primary patency and change in the revised venous clinical severity score (rVCSS) and the clinical score of the comprehensive classification system for chronic venous disease (CEAP) at 6- and 12-month follow-up. Safety outcomes were recurrent DVT, clinically driven target vein revascularization, index limb major amputation, or death. Results: A total of 67 participants (50.7% female, aged 46.7±18.1 years) who underwent blueflow Venous Stent implantation between February 2018 and March 2019 were enrolled. Primary patency of the target segment was present in 91.7% (95%CI: 76.8-97.7) of participants at the 6-month examination and in 79.8% (95%CI: 66.4-93.2) at the 12-month examination. Twelve-month primary patency was 91.7% (95%CI: 76.0-100) in non-thrombotic, and 72.6% (95%CI: 53.9-91.3) in postthrombotic disease (log-rank p=0.14). Median rVCSS improved from 8 (interquartile range [IQR]: 9-7) at baseline to 4 (IQR: 6.3-2.8) at 12 months (p<0.001) with a substantial clinical improvement of ≥2 points in 86.1% (31 of 36 participants). No significant association of rVCSS improvement with thrombotic pathogenesis could be found. Median clinical CEAP score improved from 3 (IQR: 3-3) to 2 (IQR: 3-2), p>0.001. No safety signal occurred. Conclusions: blueflow Venous Stent implantation for the treatment of iliofemoral CVD was associated with promising patency and favorable clinical improvement over the mid-term.

Pediatric May-Thurner Syndrome-Systematic review and individual patient data meta-analysis

BACKGROUND

The outcomes of deep vein thrombosis (DVT) in children with May-Thurner Syndrome (MTS) remain unclear.

OBJECTIVES

This systematic review and patient-level meta-analysis aims to describe the outcomes of children with MTS presenting with DVT.

METHODS

A systematic review of the published literature was performed. Data related to patients <18 years diagnosed with MTS and DVT was extracted. Risk of bias was assessed using the Murad criteria. Outcomes included vessel patency post-treatment, DVT recurrence, and post-thrombotic syndrome (PTS). Predictive and explanatory models were developed for these outcomes.

RESULTS

In total, 109 cases were identified (age range 4-17 years; 77 females) in 28 studies; 75% of patients had ≥1 additional risk factor for DVT. PTS was seen in 61% of patients, DVT recurrence in 38%, and complete vessel patency post-treatment in 65%. The models developed to predict and explain PTS performed poorly overall. Recurrent thrombosis (adjusted for age and patency) predicted PTS (odds ratio [OR] 3.36, 95% confidence interval [CI] 1.28-8.82). DVT management strategies (adjusted for age and DVT characteristics) predicted vessel patency (OR 2.10, 95% CI 1.43-3.08). Lack of complete vessel patency (adjusted for age and thrombophilia) predicted recurrent DVT (OR 2.70, 95% CI 1.09-6.67). Sensitivity analyses showed the same direction of effects for all outcomes.

CONCLUSIONS

PTS and DVT recurrence occur frequently in pediatric MTS. PTS prediction is complex and it was not possible to identify early predictors to guide clinical practice. Use of imaging-guided therapy and thrombus burden predicted venous patency, and lack of patency predicted DVT recurrence.

Catheter-directed thrombolysis and mechanical intervention in deep venous thrombosis: what is the status after the ATTRACT trial?

Deep venous thrombosis (DVT) is a major cause of acute and chronic morbidity, mortality, and increased healthcare costs. Endovascular methods for thrombus removal and reestablishing venous patency are increasing in both scope and usage. The most commonly used method for endovascular thrombectomy is catheter-directed thrombolysis (CDT). Several studies have shown promise for CDT in alleviating acute symptomatology in acute lower extremity DVT as well as mitigating potential long-term consequences of DVT, such as post-thrombotic syndrome (PTS). The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial is the largest and most comprehensive randomized-controlled trial to date evaluating CDT compared to anticoagulation alone for the treatment of acute symptomatic proximal lower extremity DVT. This review discusses the current status of CDT and adjunctive endovascular interventions for DVT, particularly in the context of the ATTRACT trial.

Clinical outcomes and overview of dedicated venous stents for management of chronic iliocaval and femoral deep venous disease

OBJECTIVES

Venous stenting of the lower extremities has grown in popularity and is now considered a key component of the primary treatment strategy for the management of pathologically obstructive or stenotic lesions of the deep venous system. This review aims to provide an overview of the role of venous stenting in the management of chronic conditions affecting the deep venous system of the lower limbs.

METHODS

An overview of venous stents design and current role of stenting procedure in individuals presenting with Chronic Venous Insufficiency (CVI) and presenting the current trials of dedicated venous stenting in management of chronic deep venous lesions. This review provides a focused insight on venous stent design, physical properties and the available dedicated venous stents selected studies with their related patency outcome based on selective literature search of the PubMed database and Cochrane library.

CONCLUSIONS

Dedicated venous stent technology is advancing at a rapid pace alongside the increased undertaking of endovascular deep venous stent reconstruction in the management of iliocaval vein pathologies. The ideal design(s) for venous stents remain unknown, although it is hoped that the presence of new dedicated venous stents in clinical practice will allow the generation of experience and data to advance our understanding in this area.

Compression treatment in acute symptomatic proximal deep venous thrombosis - Results of a worldwide survey

OBJECTIVES

The aim of this study was to illustrate how compression is performed worldwide in proximal DVT and if compression management has changed recently.

METHODS

A global online survey, consisting of 36 questions, was used. The survey was solicited from membership lists of Union Internationale de Phlébologie (UIP) membership societies. For differences between the continents in comparison to Western Europe odds ratios and 95% Confidence Intervals (95%CI) where calculated.

RESULTS

We received 626 answers from 41 countries. Compression is routinely used in proximal DVT in all regions (82.8%). 81.4% start compression immediately after diagnosis. In the acute phase of DVT reduction of pain and swelling (91.7%) and PTS prevention (66.2%) are the main reasons for compression. 33.2% recently changed their compression management with 43.5% starting compression earlier and 7.0% later.

CONCLUSIONS

Compression is still used routinely in proximal DVT in addition to anticoagulation. The changes in international guidelines towards the non-routine use of compression in proximal DVT have not caused significant changes in DVT management.

Single-Session Thrombolysis-Free Treatment of Deep Vein Thrombosis With a Novel Mechanical Thrombectomy Device

Catheter-directed thrombolysis of iliofemoral deep vein thrombosis (DVT) carries an increased risk of major bleeding and may fail to rapidly remove thrombus or prevent post-thrombotic syndrome. We describe an alternative, thrombolysis-free, advanced DVT treatment strategy with rapid single-session percutaneous mechanical thrombectomy using the ClotTriever system. (Level of Difficulty: Intermediate.).

Diagnostic and Technical Challenges in the Care of a Complex Patient With Post-Thrombotic Syndrome

Iliofemoral deep vein thrombosis can lead to post-thrombotic syndrome, a costly and morbid condition. Endovascular treatment is increasingly used for symptomatic relief, but clinical success depends on accurate patient evaluation and selection. This case describes the diagnostic and technical challenges in the care of a complex patient with post-thrombotic syndrome following stroke and extensive deep vein thrombosis. It highlights the multi-disciplinary work-up for a patient with post-thrombotic syndrome presenting with confounding symptoms, as well as the importance of considering alternative access for successful lower extremity venous recanalization.

The role of platelets in thrombus fibrosis and vessel wall remodeling after venous thrombosis

PURPOSE

Platelets are known to play an important role in venous thrombogenesis, but their role in thrombus maturation, resolution, and postthrombotic vein wall remodeling is unclear. The purpose of this study was to determine the role that circulating platelets play in the later phases of venous thrombosis.

METHODS

We used a murine inferior vena cava (IVC) stenosis model. Baseline studies in untreated mice were performed to determine an optimal postthrombotic time point for tissue harvest that would capture both thrombus maturation/resolution and postthrombotic vein wall remodeling. This time point was found to be postoperative day 10. After undergoing IVC ultrasound on day 2 to confirm venous thrombus formation, mice were treated with a daily injection of platelet-depleting antibody (anti-GP1bα) to maintain thrombocytopenia or with control IgG until postoperative day 10, at which time IVC and thrombi were harvested and thrombus length, volume, fibrosis, neovascularization, and smooth muscle cell invasion analyzed. Vein wall fibrosis and intimal thickening were also determined.

RESULTS

Mice that were made thrombocytopenic after venous thrombogenesis had thrombi that were less fibrotic, with fewer invading smooth muscle cells. Furthermore, thrombocytopenia in the setting of venous thrombosis resulted in less postthrombotic vein wall intimal thickening. Thrombus volume did not differ between thrombocytopenic mice and their control peers.

CONCLUSIONS

This work suggests that circulating platelets contribute to venous thrombus maturation, fibrosis, and adverse vein wall remodeling, and that that inhibition of platelet recruitment may decrease thrombus and vein wall fibrosis, thus helping thrombolysis and preventing postthrombotic syndrome.

Surgical and non-surgical approaches in the management of lower limb post-thrombotic syndrome

Introduction: Post-thrombotic syndrome (PTS) is a common lifelong condition affecting up to 50% of those suffering from deep vein thrombosis (DVT). PTS compromises function and quality of life with subsequent venous ulceration in up to 29% of those affected.Areas covered: A literature review of surgical and non-surgical approaches in the prevention and treatment of PTS was undertaken. Notable areas include the use of percutaneous endovenous interventions and the use of graduated compression stockings (GCS) after acute proximal DVT.Expert opinion: In patients with acute iliofemoral DVT, we think it is important to have a frank conversation with the patient about catheter-directed thrombolysis, aiming to reduce the severity of PTS experienced. We advocate ultrasound-accelerated thrombolysis with adjunctive procedures, such as deep venous stenting for proximal iliofemoral DVT. For patients with isolated femoral DVT, we believe that anticoagulation and GCS should be recommended. In patients with established PTS, we recommend GCS for symptomatic relief. We recommend that patients engage in regular exercise where possible with the prospect of gaining symptomatic relief. For those with severe PTS that has a significant effect on quality of life, we discuss the patient's case at a multi-disciplinary team meeting to plan for endovenous intervention.

Ten-year trends in iliofemoral deep vein thrombosis treatment and referral pathways

OBJECTIVES

Iliofemoral deep venous thrombosis is associated with an increased risk of developing post-thrombotic syndrome resulting in reduced quality of life. As there is debate about best management practices, this study aimed to examine the referral and treatment pathways for patients presenting with iliofemoral deep venous thrombosis over an 11-year period at our institution.

METHODS

We conducted a retrospective review of patients diagnosed with lower limb deep vein thrombosis between 2010 and 2020. Ultrasound report findings were reviewed for the presence of iliofemoral deep venous thrombosis with acute, occlusive, or proximal clot. Multiple factors were extracted, including patient demographics, risk factors, diagnostic methods, interventions, referrals, and details of follow-up. The CaVenT and ATTRACT trials studied the benefit of thrombolysis in the early phase of iliofemoral deep venous thrombosis management as compared to anticoagulation alone. An analysis was conducted of patients requiring thrombolysis to determine whether these trials impacted physician practice patterns for thrombolysis. Data were organized and examined by year for trends in treatment and referral pathways.

RESULTS

The review yielded 2792 patients assessed for lower limb deep venous thrombosis by ultrasound. Four hundred and sixty-seven (16.7%) patients were confirmed to have an occlusive iliofemoral deep venous thrombosis. The average age was 62.7 years (18-101 years). Half (50.4%) of the patients were male. The most common etiology for clot was malignancy-induced hypercoagulable state (39.0%). There was no difference in incidence of iliofemoral deep venous thrombosis diagnosed by ultrasound per year, with an average of 42.5 per year and a peak of 61. There was a trend towards increased rates of computed tomography imaging, ranging between 9.1% and 52.9%. The rate thrombolysis per year ranged between 1.8% and 8.9%, with a range of 4.3% (n = 20) to 8.9% (n = 5) in 2018. The use of pharmacomechanical thrombolysis increased, from 25% (n = 1) in 2010-2012 to 87.5% (n = 7) in 2018-2020. The rate of inferior vena cava filter insertion alone decreased from 18.2% in 2010 (n = 4) to 5.9% (n = 1) in 2020. The length of thrombolysis treatment also decreased, from 100% of patients (n = 4) receiving treatment duration greater than 24 h in 2010-2012 to 0% (n = 0) in 2018-2020. About 45% of patients receiving thrombolysis (n = 9) had venous stenting. No difference in treatment outcomes were observed, with greater than 87.5% of patients reaching intermediate to full resolution of clot burden. No patients experienced intracranial hemorrhage.

CONCLUSIONS

The results of this analysis highlight the change in practice in our institution over time. The low rate of intervention likely reflects the current lack of consensus in published guidelines. It is important for future work to elicit the most appropriate management pathways for patients with iliofemoral deep venous thrombosis.

Accuracy of contralateral Villalta score to assess for pre-existing chronic venous insufficiency in patients with unilateral deep vein thrombosis

BACKGROUND

International guidelines recommend using the Villalta score (VS) to diagnose the postthrombotic syndrome (PTS). However, a high proportion of PTS detected with VS could just reflect the presence of preexisting primary venous insufficiency (PVI). Furthermore, it is unclear whether the contralateral VS (cl-VS) can be used to assess for preexisting PVI.

OBJECTIVES

To estimate whether cl-VS can be used to assess for preexisting PVI, and to assess the proportion of PTS that could be attributable to preexisting PVI.

METHODS

Subanalysis of the SOX multicenter randomized trial focusing on patients with a first unilateral proximal deep vein thrombosis (DVT) followed for up to 2 years. PVI was defined as a baseline cl-VS > 4, and PTS as VS > 4 in the leg ipsilateral to DVT starting 6 months after DVT.

RESULTS

Among 680 patients, mean cl-VS remained stable over time: 1.23 (standard deviation [SD] ±2.49) at baseline and 1.17 (±2.20), 1.59 (±2.81), 1.54 (±2.50), 1.65 (±2.82), and 1.55 (±2.63) at the 1-, 6-, 12-, 18-, and 24-month visits, respectively. Baseline cl-VS and ipsilateral VS measured during follow-up were mildly correlated (Pearson correlation = 0.13-0.25). This association disappeared after subtracting the cl-VS measured at the same visit from the ipsilateral VS. Overall, 48.8% of patients developed PTS of whom 12.8% had baseline cl-VS > 4.

CONCLUSION

In our study of patients with a first unilateral proximal DVT, the proportion of patients with PTS who had a cl-VS > 4 is modest. However, cl-VS appears to be stable over time. Its assessment could constitute a simple way of documenting preexisting PVI and help to classify patients as having PTS.

Bilateral Vein Compression by Popliteal Artery Aneurisms Mimicking Post-Thrombotic Syndrome

PURPOSE

To report a case of a 79-year-old man who presented a bilateral popliteal artery aneurysm compressing both popliteal veins mimicking signs and symptoms of post-thrombotic syndrome.

CASE REPORT

A 79-year-old male patient, was seen in the ambulatory clinic with a 2-year history of bilateral leg swelling, calf pain, chronic ulceration, and hyperpigmentation. Upon physical examination, lower extremities were edematous, with a 3 cm suppurative ulcer on each leg. Image studies showed a popliteal right arterial aneurysm of maximum diameter of 41.7 mm, extrinsically compressing the ipsilateral popliteal vein. Likewise, on the left leg, a popliteal arterial aneurysm of maximum diameter of 47.9 mm was encountered triggering the same phenomenon. Bilateral endovascular treatment deploying stent grafts was auspiciously performed. At 36-months follow up, his symptoms are completely resolved, and his ulcers healed. US follow up showed exclusion of the aneurysms with progressive shrinkage of both residual sacs.

CONCLUSION

Popliteal artery aneurysm compressing and constraining flow in the popliteal vein must be included as a differential diagnosis among the causes of chronic venous syndromes. Prompt diagnosis with its appropriate treatment is needed for reducing severe complications caused by PAA, such as the venous disorder our patient had.

The efficacy of rotational pharmaco-mechanical thrombectomy in patients with acute iliofemoral deep vein thrombosis: Is the standard treatment of deep vein thrombosis changing?

OBJECTIVE

In this study, we aimed to evaluate the efficiency of rotational thrombectomy device in pharmaco-mechanical thrombolysis for symptomatic acute ilio-femoral deep vein thrombosis.

MATERIALS AND METHODS

Between August 2013 and May 2018,82 patients with acute deep vein thrombosis comprising the iliofemoral segment whom underwent Pharmaco-mechanical thrombolysis were evaluated retrospectively. The Cleaner thrombectomy device was used. The resolution of thrombi was examined and graded. Development of post-thrombotic syndrome was assessed with Villalta scores.

RESULTS

75 patients (91.4%) had complete thrombus resolution. Between 50-99% resolution was noted in 6 patients (7.4%) and in one (1.2%) case less than %50 thrombus resolution was obtained. Seventy-five patients (91%) of the cohort could be treated in a single session; 7 patients (8.6%) required reintervention(s). Although improved post-thrombotic syndrome rates were lower at the short term, Villalta scores gradually increased during follow up.

CONCLUSIONS

In conclusion, Pharmaco-mechanical thrombolysis with Cleaner thrombectomy device is a safe and beneficial method for the treatment of acute iliofemoral deep vein thrombosis. Long term follow up data of large volume multicenter studies are warranted.

Predictors of postthrombotic syndrome in pediatric thrombosis: A systematic review and meta-analysis of the literature

BACKGROUND

Postthrombotic syndrome (PTS) is a significant complication of pediatric deep venous thrombosis (DVT). There is a gap in the understanding of the risk factors associated with the development of pediatric PTS preventing the early identification of those patients at greatest risk, and the development of risk-stratified interventions.

OBJECTIVES

To conduct a systematic review and meta-analysis of the literature on prognostic factors for PTS development in pediatric patients.

METHODS

A systematic search of MEDLINE, EMBASE, and the Cochrane Library from 1960 to December 2018 was performed. Eligible studies reported at least one prognostic factor for PTS development in patients < 21 years of age with a radiographically confirmed DVT. To be included in the meta-analysis, prognostic factors had to be reported in at least three published studies.

RESULTS AND CONCLUSIONS

Twelve studies (n = 1160 patients) met criteria for inclusion. Ninety-three percent of patients with an extremity DVT (n = 1076) were assessed for PTS. PTS developed in 40% (n = 434) of these patients. Central venous catheter-associated DVT (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.08-2.98), complete veno-occlusion (OR, 1.89; 95% CI, 1.04-3.46), and incomplete DVT resolution (OR, 2.07; 95% CI, 1.4-3.07) were identified as candidate prognostic factors for pediatric PTS. These findings should be interpreted in the context of the heterogeneity of the included studies and the limitations of current pediatric PTS assessment tools. Further, the predictive value of these prognostic factors will need to be validated in future collaborative prospective multicenter studies that maximize the homogeneity of pediatric DVT patients.

Yield of ultrasonography in patients with or without post-thrombotic syndrome for diagnosis of suspected recurrent ipsilateral deep vein thrombosis

BACKGROUND

The yield of ultrasonography in patients with or without post-thrombotic syndrome (PTS) presenting with a suspected recurrent ipsilateral deep vein thrombosis (DVT) is unknown.

METHODS

Patients with a first unprovoked DVT received standard anticoagulation for 5 to 7 months. Then, they were assessed for PTS using the Villalta scale (score equal or >5) and followed for up to 18 months. Yield of ultrasonography for recurrent ipsilateral DVT was defined as the number of confirmed DVT divided by the number of suspicions. Outcomes were compared between patients without or with PTS.

RESULTS AND DISCUSSION

A total of 452 patients with a symptomatic proximal DVT were included. During follow-up, there were 144 suspicions of recurrent ipsilateral DVT, which were confirmed in 38 patients (26.4%). The confirmation rate of recurrent ipsilateral DVT was 25.6% (23/90) in patients without PTS as compared with 27.8% (15/54) in patients with PTS (P = .84). Our study supports a similar yield of ultrasonography to diagnose recurrent ipsilateral DVT in patients off anticoagulation therapy with or without PTS as defined by 5 or more points on the Villalta scale.

Use of the VENOVO™ and Sinus Obliquus™ venous stents in the treatment of non-thrombotic or post-thrombotic iliac vein lesions - Short-term results from a multi-centre Asian cohort

OBJECTIVES

Deep venous stenting with intravascular ultrasound (IVUS) guidance is gaining favour as the treatment modality of choice for symptomatic ilio-femoral venous occlusive disease. The aim was to determine the short-term patency and symptomatic relief gained using the Bard Venovo™ and Optimed Sinus Obliquus™ stents in the endovascular treatment of non-thrombotic iliac vein lesions (NIVL) and post-thrombotic venous obstruction (PTO) from two Asian tertiary vascular centres.

METHODS

Sixty patients (males = 21/60 (35.0%); median age 67 years (interquartile range 54-77)) who underwent IVUS interrogation and ilio-femoral stenting (June 2018-May 2019) in two Asian centres were prospectively followed. Clinical improvement was determined by the revised Venous Clinical Severity Score (rVCSS), pain using the Visual Analogue Scale (VAS) and ulcer healing rate. Patency rates were evaluated using Duplex ultrasound and computer tomography venogram.

RESULTS

Seventy-one legs were interrogated and stented; 11/60 (18.3%) patients had a bilateral procedure. Indications for surgery were PTO (n = 11/71 (15.5%)) and NIVL (n = 60/71 (84.5%)). Twenty-seven of 71 (38.0%) patients had CEAP 6 disease. The median follow-up was 283 (interquartile range 211-370) days. Technical and procedural success was both 100%. Twenty-one of 71 (29.6%) legs had a combination of Venovo™ and Sinus Obliquus™ stents inserted for concurrent ilio-caval and iliac lesions. There were no major post-operative complications. Six-month primary, assisted primary and secondary patency rates were 94.1, 97.1 and 100%, respectively. There were no stent fractures. Mean rVCSS and VAS improved from 12.26 (±3.31) to 4.33 (±2.78) and 6.97 (±1.38) to 2.03 (±1.65), respectively, at three months (p < 0.01). Complete ulcer healing was seen in 27/27 (100%) patients at three months.

CONCLUSION

Use of Venovo™ and Sinus Obliquus™ stents for symptomatic ilio-femoral venous disease showed excellent six-month primary patency rate with no stent fractures. There were significant clinical improvement and low-device-related complications. Longer follow-up is awaited to see how these dedicated venous stents perform.