Effect of junctional reflux on the venous clinical severity score in patients with insufficiency of the great saphenous vein (JURY study)

OBJECTIVE

Effective treatment options are available for chronic venous insufficiency associated with superficial venous reflux. Although many patients with C2 and C3 disease based on the CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification have combined great saphenous vein (GSV) and saphenofemoral junction (SFJ) reflux, some may not have concomitant SFJ reflux. Several payors have determined that symptom severity in patients without SFJ reflux does not warrant treatment. In patients planned for venous ablation, we tested whether Venous Clinical Severity Scores (VCSS) are equivalent in those with GSV reflux alone compared with those with both GSV and SFJ reflux.

METHODS

This cross-sectional study was conducted at 10 centers. Inclusion criteria were: candidate for endovenous ablation as determined by treating physician; 18 to 80 years of age; GSV reflux with or without SFJ reflux on ultrasound; and C2 or C3 disease. Exclusion criteria were prior deep vein thrombosis; prior vein ablation on the index limb; ilio-caval obstruction; and renal, hepatic, or heart failure requiring prior hospitalization. An a priori sample size was calculated. We used multiple linear regression (adjusted for patient characteristics) to compare differences in VCSS scores of the two groups at baseline, and to test whether scores were equivalent using a priori equivalence boundaries of +1 and -1. In secondary analyses, we tested differences in VCSS scores in patients with C2 and C3 disease separately.

RESULTS

A total of 352 patients were enrolled; 64.2% (n = 226) had SFJ reflux, and 35.8% (n = 126) did not. The two groups did not differ by major clinical characteristics. The mean age of the cohort was 53.9 ± 14.3 years; women comprised 74.2%; White patients 85.8%; and body mass index was 27.8 ± 6.1 kg/m2. The VCSS scores in patients with and without SFJ reflux were found to be equivalent; SFJ reflux was not a significant predictor of VCSS score; and mean VCSS scores did not differ significantly (6.4 vs 6.6, respectively, P = .40). In secondary subset analyses, VCSS scores were equivalent between C2 patients with and without SFJ reflux, and VCSS scores of C3 patients with SFJ reflux were lower than those without SFJ reflux.

CONCLUSIONS

Symptom severity is equivalent in patients with GSV reflux with or without SFJ reflux. The absence of SFJ reflux alone should not determine the treatment paradigm in patients with symptomatic chronic venous insufficiency. Patients with GSV reflux who meet clinical criteria for treatment should have equivalent treatment regardless of whether or not they have SFJ reflux.

Chameleon™ PTA balloon catheter: A single device in managing thrombosed AV access

Thrombectomy is a common procedure for maintenance of arteriovenous (AV) access and is critical to prolong access life. Techniques for performing thrombectomy are incredibly diverse, ranging from open surgical procedures to percutaneous interventions. Percutaneous interventions include a combination of thrombectomy devices to clear the thrombus and balloon angioplasty to treat the underlying lesion. In this case report we describe a novel technique using a single device, the Chameleon™ PTA balloon catheter (Medtronic, Minneapolis, MN) balloon catheter, to safely and efficiently perform a percutaneous intervention.

Immediate and Delayed Complications of IVC Filters

OBJECTIVE

Inferior vena cava (IVC) filter placement has increased dramatically in the past two decades. However, literature supporting the efficacy of these devices has been limited and controversial. In the present study, we have evaluated the predictors and rates of technical complications after IVC filter insertion in a large national database.

METHODS

The Vascular Quality Initiative registry was explored (January 2013 to December 2020). Immediate complications were defined as venous injury requiring treatment, filter misplacement (failure to open, deployed >20 mm from intended site or in wrong vein, embolized to the heart), angulation >20°, and insertion site complications. Delayed complications were defined as migration, angulation >15°, fracture, caval and/or iliac thrombosis, filter thrombus, fragment embolization, and perforation. The Pearson χ² test was used to compare the baseline characteristics between the patients who had developed immediate and/or delayed complications and those who had not. The predictors of these complications were evaluated using multivariable logistic regression, Cox proportional hazard regression, and Kaplan-Meier survival analysis.

RESULTS

A total of 14,784 patients were included in the present analysis, with a median follow-up of 11 months (interquartile range, 4-16 months). The rate of immediate and delayed complications was 1.8% and 3.1%, respectively. Angulation (1.2%) was the most common immediate complication, and filter thrombosis (1.6%) was the most common delayed complication. Compared with the patients with no immediate complications, those with immediate complications were more likely to have had abnormal anatomy (6.0% vs 1.7%; P < .001) and a landing zone other than infrarenal (7.0% vs 4.2%; P = .02). Compared with their counterparts, those with delayed complications were less likely to have received statins (21.0% vs 29.5%; P = .006) and were more likely to have a family history of venous thromboembolism (8.0% vs 5.1%; P = .047). Logistic regression analysis revealed that renal vein visualization was associated a 50% reduction (adjusted odds ratio [aOR], 0.50; 95% confidence interval [CI], 0.27-0.92; P = .027) in the odds of immediate complications and female sex and abnormal anatomy were associated with a 41% (aOR, 1.41; 95% CI, 1.08-1.85; P = .013) and 244% (aOR, 3.44; 95% CI, 1.66-7.16; P < .001) increase in the odds of immediate complications, respectively. Immediate (P = .21) and delayed (P = .51) complications did not result in increased mortality.

CONCLUSIONS

The immediate and delayed IVC filter complication rates were 1.8% and 3.1%, respectively, but the occurrence of complications was not associated with increased mortality. Female sex was associated with an increase in the development of immediate complications. The incidence of immediate complications might be mitigated if advanced imaging were used for renal vein visualization before IVC filter deployment. Delayed complications might be avoided if IVC filter retrieval were performed in a timely fashion and institutional retrieval protocols were optimized.

The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment

BACKGROUND

Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology.

METHODS

In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved.

RESULTS

The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment.

CONCLUSION

This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders

This Practice Guidelines document has been co-published in Phlebology [DOI: 10.1177/0268355521999559] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.12.084]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal’s style. The contribution has been published under a Attribution-Non Commercial 4.0 International (CC BY-NC 4.0), (https://creativecommons.org/licenses/by-nc/4.0/)

With the support of the American College of Obstetricians and Gynecologists, the American Vein & Lymphatic Society, the American Venous Forum, the Canadian Society of Phlebology, the Cardiovascular and Interventional Radiology Society of Europe, the European Venous Forum, the International Pelvic Pain Society, the International Union of Phlebology, the Korean Society of Interventional Radiology, the Society of Interventional Radiology, and the Society for Vascular Surgery

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology (“SVP”) classification for PeVD, includes three domains—Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient’s disease. An individual patient’s classification is designated as SVP_A,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVP_A,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Diagnostic approach to lower limb edema

Patients with lower limb edema are frequently referred to vascular specialists for evaluation. Multiple etiologies must be considered and often more than one cause may be present. Notably, the role of lymphatic system regardless of the underlying pathology has been underestimated. A thorough history and physical examination and a carefully considered laboratory and imaging evaluation are critical in differentiating causes. In this opinion article, we propose a diagnostic algorithm that incorporates a systematic approach to the patient with leg swelling and provides an efficient pathway for the differential diagnosis for this problem.

A standardized ultrasound approach to pelvic congestion syndrome

Pelvic congestion syndrome is one of the many causes of chronic pelvic pain and is often diagnosed based on exclusion of other pathologies. Over the past decades, pelvic congestion syndrome was recognized to be a more common cause of chronic pelvic pain. Multiple diagnostic modalities including pelvic duplex ultrasonography, transvaginal ultrasonography, computed tomography, and magnetic resonance were studied. In the current literature, selective ovarian venography, an invasive imaging approach, is believed to be the gold standard for diagnosing pelvic congestion syndrome.

Cerebral Oximetry Monitoring During Carotid Endarterectomy: Effect of Carotid Clamping and Shunting

Cerebral oximetry is a simple method of measuring regional cerebral oxygen saturation (rSO2). One promising application is its use during carotid endarterectomy (CEA) to help minimize the risk of perioperative stroke. The authors used the INVOS-4100 cerebral oximeter at several steps during CEA to measure the effect of carotid clamping and shunting on rSO2. The authors prospectively evaluated 42 consecutive CEAs in 40 patients. All had CEA under general anesthesia with the routine use of a Javid shunt. The INVOS-4100 oximeter was used to measure rSO2 before clamping (t1), after clamping but before shunting (t2), 5 minutes after shunt insertion (t3), and after patch closure with reestablished flow (t4). The Wilcoxon signed-rank and rank-sum tests were used for analysis. Clamping of the internal carotid artery (t1 vs t2) resulted in a drop of ipsilateral rSO2 by –12.3% (p<0.001). Shunt insertion (t2 vs t3) increased rSO2 by 10.9% (p< 0.001). Contralateral rSO2 for the same time periods was insignificant. Patients with preoperative neurologic symptoms had a greater decrease in rSO2 after clamping (–18.4%) compared with a decrease of –10.4% in asymptomatic patients (p=0.037). Cerebral oximetry monitoring is simple and inexpensive. The study showed statistically significant changes in rSO2 as a result of clamping and shunting of the carotid artery. Symptomatic patients had a greater drop in rSO2.

Adventitial Cystic Disease of the External Iliac Vein Presenting with Deep Venous Thrombosis

Adventitial cystic disease of the venous system is a rare occurrence with only 8 reported cases in the world literature. The most commonly involved segment has been the common femoral vein, resulting in luminal compromise and presenting with extremity swelling. Painless swelling of the right lower extremity in a 37-year-old man was diagnosed as iliofemoral thrombosis by duplex examination. Thrombolysis revealed smooth luminal defects of the external iliac vein, which prompted surgical exploration. Iliofemoral thrombectomy exposed multiloculated adventitial cysts of the distal external iliac vein. The preferred surgical intervention in the literature has been transadventitial or transluminal evacuation of the mucoid cysts with removal of cystic wall. These are excellent options when there is no associated venous thrombosis, wall thickening, or persistent venous stenosis after drainage. This is the first reported case associated with deep venous thrombosis. In this situation resection of the involved segment followed by venous reconstruction might be the preferred option.

Visceral Patch Rupture after Repair of Thoracoabdominal Aortic Aneurysm

This is a unique case of a visceral patch rupture in a Marfan patient after a repair of a thoracoabdominal aneurysm. The patient presented with abdominal pain and in shock 6 years after repair. The retained aortic wall containing the origins of the celiac, mesenteric, and renal arteries was aneurysmal and had ruptured. Clinical presentation, diagnosis, and operative modalities are discussed.

A multicenter, randomized, placebo-controlled trial of endovenous thermal ablation with or without polidocanol endovenous microfoam treatment in patients with great saphenous vein incompetence and visible varicosities

Objectives

*

Varithena 017 Investigator Group: Michael Vasquez, MD, Venous Institute of Buffalo, Amherst, NY; Antonios Gasparis, MD, Stony Brook University Medical Center, Stony Brook, NY; Kathleen Gibson, MD, Lake Washington Vascular, Bellevue, WA; James Theodore King, MD, Vein Clinics of America, Oakbrook Terrace, IL; Nick Morrison, MD, Morrison Vein Institute, Scottsdale, AZ; Girish Munavalli, MD, Dermatology, Laser & Vein Specialists of the Carolinas, Charlotte, NC; Eulogio J. Sanchez, MD, Batey Cardiovascular Center, Bradenton, FL. Varithena® is a trademark of Provensis Ltd, a BTG International group company.

To determine the efficacy and safety of polidocanol endovenous microfoam (PEM 0.5%, 1.0%) and placebo each administered with endovenous thermal ablation.

Methods

A multicenter, randomized, placebo-controlled, blinded study was conducted in patients with great saphenous vein incompetence and symptomatic and visible superficial venous disease. Co-primary endpoints were physician-assessed and patient-assessed appearance change from Baseline to Week 8.

Results

A total of 117 patients received treatment (38 placebo, 39 PEM 0.5%, 40 PEM 1%). Physician-rated vein appearance at Week 8 was significantly better with PEM (p = 0.001 vs. placebo); patient-assessed appearance trended similarly. Polidocanol endovenous microfoam provided improvements in clinically meaningful change in patient-assessed and physician-assessed appearance (p < 0.05), need for additional treatment (p < 0.05), saphenofemoral junction reflux elimination, symptoms, and QOL. In PEM recipients, the most frequent adverse event was superficial thrombophlebitis (35.4%)

Conclusions

Endovenous thermal ablation + PEM significantly improved physician-assessed appearance at Week 8, increased the proportion of patients with a clinically meaningful change in appearance, and reduced need for additional treatment. www.clinicaltrials.gov (NCT01197833)

Morbidity and mortality after thermal venous ablations

BACKGROUND

The treatment of saphenous vein reflux has evolved over the years with the development of thermal ablation techniques. This study was designed to analyze the complications of endovenous ablation (EVA) using data from an open, voluntary national database.

METHODS

We analyzed 349 adverse events of endovenous laser (EVLT) and radiofrequency ablation (RFA) reported in the Manufacturer and User Facility Device Experience (MAUDE) database from January 2000 to June 2012. Outcomes of interest were pulmonary embolism (PE), deep vein thrombosis (DVT), death, and device failures (i.e. broken laser tip, broken sheath).

RESULTS

Two hundred and three (58%) reports were patient-related injuries and the other 146 (42%) device-related failures. More complications were related to RFA compared to EVLT (216 vs. 133 procedures). Thirty (8%) non-fatal PEs and 123 (35%) DVTs were described. There were 7 (2%) periprocedural deaths, all from PE. Of the 135 device failure reports, 41(30%) required surgical intervention. Despite an increasing number of procedures, reported events peaked around 2008 and stabilized since then. Over the past 5 years, the incidence of adverse events reported for EVLT and RFA were 1 and 2 per 10,000 procedures. The complication ratio over the years was <1:2500 for DVT, <1:10,000 for PE, <1:50,000 for death.

CONCLUSION

EVA has gained high acceptance worldwide but the risks tend to be overlooked. Despite a very low complication rate, mortality has been reported. The complications found in MAUDE represent only a fraction as the majority of the practitioners are not aware of this database. Further investigation by a large national registry is warranted to better define the real magnitude of EVA complications.

Long-term follow-up for percutaneous transluminal angioplasty in renal artery fibromuscular dysplasia

AIM

Percutaneous transluminal angioplasty (PTA) is an effective treatment for renal artery stenosis secondary to fibromuscular dysplasia (FMD). This study aimed to evaluate the short-and long-term outcomes of percutaneous transluminal angioplasty in patients with hypertension and renal artery fibromuscular dysplasia (FMD). Additionally, we sought to identify specific patient factors that may affect outcomes.

METHODS

This study prospectively enrolled 29 patients with uncontrolled hypertension and renal artery FMD diagnosed by duplex ultrasound and angiography. All patients underwent PTA with the goal of cure or improvement of hypertension. Follow-up was at one-month, 6 months, 12 months and then yearly with minimum follow-up of 2 years and maximum of 5 years.

RESULTS

Technical success from the intervention was 100%. 21 patients were included in the final analysis. Short-term outcomes: One month after PTA mean systolic blood pressure (138.1 mmHg), diastolic blood pressure (78.6 mmHg), and number of anti-hypertensive medications (1.4) were significantly reduced. Blood pressure improvement was driven by 14/21 (67%) patients who had significant improvement in blood pressure, while 7/21 (33%) did not. These two groups (improved vs. not improved) differed significantly in mean age at intervention (40.6 vs. 58.3 years), duration of hypertension (3.1 vs. 15.4 years), systolic blood pressure (150.4 mmHg vs. 162.1 mmHg), diastolic blood pressure (86.4 mmHg vs. 95.7 mmHg), number of anti-hypertensive medications (2.2 vs. 3.0), serum creatinine (0.82 vs. 1.45), and renal resistive index (0.59 vs. 0.74) prior to intervention. Long-term outcomes: Mean follow-up was 3.86 years. Improvements in blood pressure and anti-hypertensive medications remained significant at five-year follow-up.

CONCLUSION

PTA is effective at reducing blood pressure in patients with renal artery FMD. Age at intervention, duration of hypertension, and renal function may be used to predict outcomes prior to intervention.

Accuracy of venous thromboembolism assessment and compliance to prophylaxis in a tertiary care center

BACKGROUND

Proper assessment of venous thromboembolism (VTE) risk level in hospitalized patients is vital to providing adequate prophylaxis. Clinical decision support (CDS) tools with electronic medical record (EMR) have been used by institutions to improve assessment and prophylaxis. As such, this study was conducted after implementing such a system to compare admitting service (AS) assessment of VTE risk level to the VTE consult service (CS) assessment. In addition, compliance of ordered prophylaxis based on AS assessment was evaluated.

METHODS

At a tertiary care center, we performed a review of randomly selected patients assessed within 18 h of admission for VTE risk over a five-month period. A total of 104 patients were evaluated, four of which were excluded because of VTE presence on admission. Patients were assessed for VTE risk independently, first by the AS, followed by the VTE CS. Prophylaxis orders were then reviewed based on AS assessment compliance to CDS recommendations for prophylaxis based on ACCP guidelines.

RESULTS

All 100 patients underwent VTE risk assessment within 18 h from admission. The mean age was 63 years. Comparing AS to CS assessment, 13 patients had incorrect assessments (p < .001). Of these, six patients were under-assessed (p = .029), and seven patients were over-assessed (p = .014). Based on AS assessment there were eight patients who had incorrect prophylaxis ordered. Unnecessary exposure to complications due to inappropriate prophylaxis occurred in five patients.

CONCLUSION

Despite the use of EMR CDS tools, there continues to be a significant number of patients that are being under-assessed and under-prophylaxed for VTE resulting in exposing patients to potential harm. Quality programs need to be instituted to further improve VTE assessment and prophylaxis.

The natural history and treatment outcomes of symptomatic ovarian vein thrombosis

BACKGROUND

Information on ovarian vein thrombosis (OVT) is limited to some retrospective studies. The purpose of this prospective study was to evaluate the natural history and treatment outcomes of OVT.

METHODS

Patients with documented symptomatic OVT who were treated with anticoagulation and had at least 3 months of follow-up were included. Outcomes of interest were recanalization rates, pain resolution, pelvic congestion syndrome, recurrent deep venous thrombosis (DVT), and mortality. All patients underwent clinical examination and duplex ultrasound; computed tomography venography was selectively performed.

RESULTS

There were 23 women with a mean age of 44 years (range, 23-68 years). Fifteen (65%) right, 5 (22%) left, and 3 (23%) bilateral OVTs were detected. The median follow-up was 27 months (range, 3 months-7 years). The most common presentation was abdominal pain in nine patients (39%), followed by flank pain in six (26%). Two patients (9%) presented with dyspnea due to pulmonary embolism. The most prevalent condition was the puerperium (n = 9; 39%). Complete recanalization occurred in 16 veins (61%), partial recanalization in four veins (15%), and occlusion in six veins (24%) while patients were receiving anticoagulation. Four patients (17%) had lower extremity DVT during follow-up after the interruption of anticoagulation. Three patients (13%) developed pelvic congestion syndrome. All four deaths (17%) were due to cancer-related complications.

CONCLUSIONS

Symptomatic OVT is rare. Patients fare well with anticoagulation; complete recanalization occurs in about two thirds of the patients. Recurrent DVT is found in lower extremity veins after the interruption of anticoagulation in 17% of patients; mortality was seen only in cancer patients.

Reporting the impact of inferior vena cava perforation by filters

Background

Perforation of the inferior vena cava by filters struts is a known complication. The goal of our review is to assess the impact of inferior vena cava perforation by filters based on an open, voluntary national database.

Methods

We reviewed 3311 adverse events of inferior vena cava filters reported in Manufacturer and User Facility Device Experience database from January 2000 to June 2011. Outcomes of interest were incidence of inferior vena cava perforation, type of filter, clinical presentation, and management of the perforation, including retrievability rates.

Results

Three hundred ninety-one (12%) cases of inferior vena cava perforation were reported. The annual distribution of inferior vena cava perforation was 35 cases (9%), varying from seven (2%) to 70 (18%). A three-fold increment in the number of adverse events related to inferior vena cava filters has been noted since 2004. Wall perforation as an incidental finding was the most common presentation ( N = 268, 69%). Surrounding organ involvement was found in 117 cases (30%), with the aorta being the most common in 43 cases (37%), followed by small bowel in 36 (31%). Filters were retrieved in 97 patients (83%) regardless of wall perforation. Twenty-five (26%) cases required an open procedure to remove the filter. Neither major bleeding requiring further intervention nor mortality was reported.

Conclusions

Inferior vena cava perforation by filters remains stable over the studied years despite increasing numbers of adverse events reported. The majority of filters involved in a perforation were retrievable. Filter retrieval, regardless of inferior vena cava wall perforation, is feasible and must be attempted whenever possible in order to avoid complications.

Prospective analysis of incidence, extent and chronicity of lower extremity venous thrombosis

OBJECTIVE

This study was designed to determine all variables related to lower extremity deep venous thrombosis (DVT) to be used as reference in patients examined in a hospital setting.

METHODS

Consecutive patients presented with signs and symptoms of venous thromboembolism over a one-year period, examined in our university hospital. Patients' demographics and clinical characteristics in a data base organized to answer all the pertinent questions.

RESULTS

There were 2594 patients. Thrombosis was found in 348 (13.4%) of which 249 were acute and 72 had chronic luminal changes. Unilateral thrombosis was found in 268 and bilateral in 80. Acute DVT and/or chronic changes were more common on the left limb. Chronic thrombosis was more prevalent in the proximal veins. Acute thrombosis was more often found in the inpatients. Both acute DVT and chronic changes were found in 27 patients (7.8%) of whom 15 were bilateral.

CONCLUSIONS

Various patterns of thrombosis are found in both inpatients and outpatients with the former having a higher incidence of acute events. Acute, chronic and recurrent thrombosis are very frequent and very important to report as they could change the management of the patients.

pharmacomechanical Thrombectomy for Early Thrombus Removal

Objectives:

To review the current literature on the outcomes of pharmacomechanical thrombectomy (PMT) for early thrombus removal in patients with venous thromboembolism (VTE).

Methods:

We searched the MEDLINE database and performed a manual search of the references of selected articles to select reports reporting the outcomes of PMT alone and PMT compared to catheter-direct thrombolysis (CDT). Outcomes of interest included clot lysis rate, incidence of pulmonary embolism, major bleeding, recurrent deep vein thrombosis, number of venograms needed and amount of lytic utilized.

Results

We found nine articles that reported outcomes of PMT. Three devices were utilized for PMT, the Angiojet, Trellis and Helix. Different thrombolytics were used to facilitate thrombus removal including urokinase, reteplase, tecneteplase, and tissue plasminogen activator (t-PA). Complete and partial thrombus removal were achieved in up to 84% and 64% and 81% and 59% of the limbs treated with PMT and CDT alone, respectively. Data on PE and bleeding risk after PMT compared to CDT are scarce. The duration of the thrombolysis process, amount of lytics and number of venograms were substantially reduced in the patients who had PMT compared to those who underwent CDT alone. Two articles evaluated the obstacles that limit the indication of PMT in patients with VTE.

Conclusion:

VTE is a prevalent burden in Western societies. The rationale of early thrombus is to reduce valvular damage and improve venous patency in order to reduce the risk of PTS. PMT is a feasible, safe and faster alternative to expedite the thrombolysis process in patients with VTE.

Results of a New Human Recombinant Thrombin for the Treatment of Arterial Pseudoaneurysm

Objective: To evaluate the results of a new thrombin sealant (Recothrom) for the treatment of arterial pseudoaneurysms (PDAs). Methods: We reviewed 47 consecutive patients prospectively entered in a dedicated data set who underwent ultrasound-guided percutaneous thrombin injection to treat PDA. End points were PDA recurrence, need for reintervention, and related complications such as limb ischemia or allergic reactions. Results: Twenty-six patients were females (55%) and the median age of the entire group was 71 years (range, 45-87). The mean size of the PDA was 2.3 ± 0.9 cm. The mean injected volume was 2.4 ± 1.4 mL containing 500 ± 320 units. Recurrence of the PDA occurred in 4 (8.5%) patients and was not related to anticoagulation status, body habitus, platelets levels, or use of antiplatelets. All recurred PDAs were successfully sealed with a second (n = 3) and a third injection (n = 1). There was no distal embolization or allergic reactions and no surgical intervention was required. Conclusion: The new human recombinant thrombin (Recothrom) is a safer nonimmunogenic option with similar success rates of other fibrin glue sealants.

Review of indications and practices of vena caval filters at a large university hospital

BACKGROUND

Vena caval filter (VCF) use has been increasing in recent years. Prophylactic VCF placement has been applied liberally in high-risk patients.

METHODS

Consecutive patients with VCF placement over a 2-year period at a university hospital were reviewed.

RESULTS

A total of 244 patients underwent VCF placement in 2 years. Of all, 54% of the patients had the VCF placed for an absolute indication, 14% for a relative indication, and 32% for prophylaxis. Only 14 (9%) of the retrievable filters were removed. Eight patients had a complication of VCF placement; there were no complications of filter retrieval. Vena caval filter placement for prophylaxis alone was 57% from the division of trauma and surgical critical care, 18.3% from interventional radiology department, and 5.2% from the division of vascular surgery.

CONCLUSIONS

This study indicates that many VCFs are placed for prophylaxis. A low percentage of VCFs was retrieved. This may be the practice at many other large university-based hospitals, necessitating strategies for reducing their placement.

How to diagnose giant cell arteritis

AIM

Current debate on how to diagnose giant cell arteritis (GCA) has strayed from the traditional approach of temporal artery biopsy and has instead explored the effectiveness of alternative imaging modalities.

METHODS

We have reviewed the literature and pooled published results for temporal artery imaging including magnetic resonance imaging (MRI), Duplex ultrasound, positron emission tomography-computed tomography (PET-CT) scan.

RESULTS

The results of this review show that ultrasound and MRI both represent viable options for evaluation of GCA; however utilizing ultrasound first may be the best first option in diagnostic tools. In 1990 the American College of Rheumatology offered criteria for positive pathology in GCA.

CONCLUSION

In this study, we propose a risk stratification criteria as well as an algorithm for the best diagnostic approach when GCA is suspected.

Impact and clinical significance of recurrent venous thromboembolism

Background

The purpose of this review was to analyse current knowledge and controversies associated with the diagnosis, treatment and prevention of recurrent venous thromboembolism (VTE).

Methods

MEDLINE and manual searches were performed to select prospective papers on the diagnosis, treatment and prevention of recurrent VTE for their relevance and quality.

Results

The cumulative incidence of recurrent VTE increases from 11 per cent at 1 year to 40 per cent at 10 years. The incidence of recurrence is higher in unprovoked thrombosis compared with provoked VTE. Patients with unprovoked deep vein thrombosis also have a greater number of multiple recurrences. Ultrasonography or D-dimer monitoring may have an impact on the duration of anticoagulation but further refinements are needed. The incidence of skin damage is higher in ipsilateral recurrence compared with contralateral or no recurrence. Legs with ipsilateral recurrence more often have both reflux and obstruction.

Conclusion

The role and weight of the predictive factors for recurrent VTE and its sequelae, and the type and optimal duration of anticoagulation have not been studied adequately. Fatality associated with pulmonary embolism and rates of recurrent VTE remain unacceptably high.

Prospective determination of candidates for thrombolysis in patients with acute proximal deep vein thrombosis

PURPOSE

To prospectively determine the distribution, extent, and age of venous thrombosis in patients presenting with acute signs and symptoms of venous thromboembolism and identify candidates for thrombolysis.

MATERIALS AND METHODS

Five hundred seventy-six consecutive patients (281 male, 295 female; mean age 58) referred for lower extremity deep vein thrombosis (DVT) assessment between November 2007 and April 2008 were included in the study. Documented cases of DVT were categorized by age (acute, chronic, and acute on chronic), anatomic location, and extent. Patients with iliofemoral and femoropopliteal DVT were evaluated for thrombolysis using standard criteria.

RESULTS

DVT was found in 19% of patients (112/576). Of these, 31 patients (27.7%, 31/112) had isolated calf DVT, 61 patients (54.5%, 61/112) had proximal vein thrombosis extending into the femoropopliteal venous segments, and 20 patients (17.9%, 20/112) presented with iliofemoral DVT. Using standard criteria, 12 patients were selected as potential candidates for pharmacomechanical thrombolysis (PhMT). This equated to an incidence of 2% (12/576) in the population studied, 11% of patients (12/112) with DVT, 26.1% of patients (12/46) presenting with acute proximal DVT, and 20% of patients (4/20) with iliofemoral DVT.

CONCLUSION

The incidence of potential candidates for thrombolysis is low. These data should be considered when recruiting centers to participate in ongoing clinical trials assessing the efficacy of these techniques.

Secondary chronic venous disease progresses faster than primary

PURPOSE

To compare the progression rate of primary with secondary chronic venous disease (CVD).

METHODS

Patients with a first episode of proximal deep vein thrombosis (DVT), diagnosed by duplex ultrasound (DU) were included in group A - secondary CVD (41 patients, 46 limbs). DU was performed at least once, 1 year after the diagnosis, and repeated at 5 years. Group B - primary CVD (41 patients, 50 limbs) included age- and sex-matched patients with primary CVD and duration of 5 to 10 years to be comparable with that of group A. They had no history of DVT and were referred for reflux evaluation. All their veins were free of postthrombotic signs upon DU examination. Group C (15 patients, 30 limbs) had no signs and symptoms of CVD and were examined at baseline and 5 years later. This group of patients was also matched for age and sex. Clinic examinations were performed at 3, 6, and 12 months and yearly thereafter. The CEAP system was used to grade disease severity. The proximal veins were divided in the CFV, FV, and POPV segments for analysis. Thrombosed veins were subsequently graded as complete, partial, and fully recanalized. Recurrent DVT cases were also recorded.

RESULTS

At 5-year follow-up, the prevalence of skin damage was significantly higher in group A (11/46 vs group B 3/50, P = .019 and vs group C 0/30, P < .01). The progression to skin damage in group A was faster as it changed from 4% (2/46) at 1 year (P = 0.014) compared with the two other groups. In group A, 22 limbs had reflux, three had obstruction, 19 had combine reflux and obstruction, and two were normal. In group B, superficial, deep, and perforator vein reflux were seen in 50, 4, and 15 limbs, respectively. In group C, five limbs in four patients developed superficial reflux in which only two had symptoms. The CEAP class in this group was C0N = 25, C1 = 3, and C2 = 2. In group A, skin damage was significantly higher in limbs with combined proximal and distal obstruction as well as in limbs with combined reflux and obstruction (P = .012 and P = 0.013, respectively). DVT was found in 108 segments (25 CFV, 40 FV, and in 43 POPV), 82 at the first episode and 26 as an ipsilateral recurrence. Ipsilateral and contralateral recurrences were seen in 21.9% and 9.8% of patients, respectively. Complete recanalization occurred in 43 segments, partial in 55, and none in 10. Reflux occurred in 85.5% and 60.5% of the partially and completely recanalized segments, respectively (P = .006).

CONCLUSIONS

The progression of CVD is more rapid in postthrombotic limbs when compared with those with primary CVD. The incidence of CVD in normal individuals is small and its progression is slow. Poor prognostic factors for progression to advanced CVD include the combination of reflux and obstruction, ipsilateral recurrent DVT, and multi-segmental involvement.

Venous Outflow Obstruction With Retroperitoneal Kaposi's Sarcoma and Treatment With Inferior Vena Cava Stenting

A 26-year-old man presented with acute renal insufficiency, and severe lower extremity swelling. Computed tomographic scan revealed retroperitoneal lymphadenopathy encasing both ureters and the inferior vena cava. He underwent placement of ureteral stents to relieve the obstruction and afterward underwent lymph node biopsy, which revealed Kaposi's sarcoma. He subsequently was diagnosed with acquired immunodeficiency syndrome. Abdominal and lower extremity venous duplex ultrasound did not show any evidence of deep vein thrombosis. The inferior vena cava measured 3.5 mm in diameter and was encased by retroperitoneal lymphadenopathy. Bilateral transfemoral venography and intravascular ultrasound demonstrated significant compression of the inferior vena cava below the renal veins. Endovascular treatment was followed with primary stenting under intravascular ultrasound guidance. His symptoms improved with reduction in swelling. At 1-year follow-up, the patient was ambulatory with mild symptoms, and on venography the iliac vein and inferior vena cava stents were widely patent.

Midterm Follow-up After Pharmacomechanical Thrombolysis for Lower Extremity Deep Venous Thrombosis

Objective: To provide follow-up in patients treated with pharmacomechanical thrombolysis (PhMT) for lower extremity deep venous thrombosis (DVT). Methods: Retrospective analysis of prospectively collected data. Patients underwent clinical evaluation, duplex ultrasound, venous clinical severity scoring, venous segmental disease scoring, and venous disability scoring. Results: Fourteen patients were available for evaluation. Median age was 40 years (19—58). Median follow-up was 24 months (13—69 months). Thirteen of 14 patients (93%) had a venous disability score < 1 and 13 of 14 patients (93%) had a venous clinical severity scoring < 5. In all but 1 patient the venous segmental disease scoring score was < 5. All iliac segments were patent, all but 3 patients had partial infrainguinal obstruction and 5 of 14 (36%) had reflux. Conclusions: Our data demonstrate that the good early clinical results after PhMT can be sustained on longer follow-up and may prevent the development of advanced postthrombotic syndrome.

Endovascular covered stenting for visceral artery pseudoaneurysm rupture: report of 2 cases and a summary of the disease process and treatment options

We present 2 cases of hemorrhage from a visceral artery pseudoaneurysm, managed successfully with endovascular covered stent placement. The first case was a 59-year-old man, 3 months after a laparoscopic distal pancreatectomy for adenoma, presenting with diffuse abdominal pain. The patient was evaluated with a computed tomography scan revealing a splenic artery pseudoaneurysm (PA) bleeding into a pancreatic pseudocyst. He was emergently taken to the angiography suite where a covered stent was deployed at the level of splenic artery PA. The second case was a 52-year-old woman with recurrent left retroperitoneal mass 5 years after distal pancreatectomy and splenectomy for a nonfunctional neuroendocrine tumor. She underwent resection of the mass in the left upper quadrant. Postoperative course was complicated by hematoma, abscess formation, reexploration, and repair of the duodenotomy and the portal vein. Subsequently, she was noted to have intermittent gastrointestinal hemorrhage, which prompted an angiogram revealing a hepatic artery PA that was repaired with a covered balloon-expandable stent. A completion angiogram was obtained in each case demonstrating exclusion of the PA. Our experience with these 2 cases supports the notion that endovascular covered stenting is a safe and effective therapy for exclusion of visceral artery aneurysm.

Endoluminal retrieval of a dislodged umbilical vein catheter--a case report

Endoluminal retrieval of foreign bodies in the pediatric and infant population is an uncommon and challenging procedure for the endovascular specialist. The alternative is an open exploration of these often-fragile patients. The availability of smaller catheter systems allows retrieval with minimally invasive techniques. We report retrieval of a catheter fragment using an Amplatz loop snare through the umbilical vein and review the literature.

Contemporary management of "high-risk" patients with carotid stenosis

The concept of a "high-risk" carotid endarterectomy patient has been suggested in an effort to justify the application of carotid angioplasty and stenting outside of clinical trials. Contemporary results of carotid endarterectomy in this subgroup of patients would argue against the existence of a high-risk patient. Until randomized prospective trials establish the role of carotid angioplasty and stenting in carotid bifurcation disease, this new technology should be restricted to recurrent and radiation-induced disease.

High-risk carotid endarterectomy: fact or fiction

OBJECTIVE

It has been proposed that patients whose conditions do not meet North American Symptomatic Carotid Endarterectomy Trial inclusion criteria or have anatomic risk factors constitute a "high-risk" group for carotid endarterectomy (CEA) and might be candidates for primary carotid angioplasty stenting. Our objective was to review a consecutive series of isolated CEAs, identify the number of such patients at high risk, and determine whether their operations were associated with increased complication rate.

METHODS

Consecutive isolated CEAs performed between June 1996 and June 2001 were reviewed. High-risk comorbidities included: age 80 years or more (n = 80), New York Heart Association class III/IV angina (n = 16), Canadian class III/IV heart failure (n = 4), myocardial infarct 6 months or less (n = 11), steroid-dependent or oxygen-dependent pulmonary disease (n = 4), and creatinine level of 3 or more (n = 13). Anatomic high risk was defined by: contralateral occlusion (n = 66), lesion above C(2) or requirement of digastric division (n = 53), reoperation (n = 29), and neck radiation (n = 3). Statistical analysis was with chi(2) analysis.

RESULTS

Of 788 patients reviewed, 228 (29%) were classified as high risk by one or more of the previous criteria (63% comorbidity, 28% anatomy, 9% both). Presence of preoperative neurologic symptoms and postoperative results were similar across all patient groups. The total stroke and death rate was 1.1% for all the patients. Six patients had postoperative strokes (0.8%), and three patients died of myocardial infarcts (0.4%). The stroke and death rate was 1.3% in the high-risk group as compared with 1.1% in the normal-risk group (P =.51).

CONCLUSION

The concept of the high-risk CEA must be critically reexamined. Although 29% of patients for CEA were high risk as defined by others, we found no evidence that this influenced the results after CEA. Patients with significant medical comorbidities, contralateral carotid occlusion, and high carotid lesions can undergo operation without increased complications. If a high-risk group exists, it is small and restricted to reoperation or radiated neck (4% in this series). With this possible exception, carotid angioplasty stenting should be restricted to randomized clinical trials.

Distal venous arterialization for limb salvage--a case report

The reperfusion of an ischemic limb in the absence of suitable target artery remains a formidable task. The authors report a case of an ischemic limb in patient whose distal arteries were identified intraoperatively as unsuitable for conventional revascularization. A distal arteriovenous fistula was created between the already arterialized in situ greater saphenous vein conduit and the inframalleolar superficial venous system of the foot. The flow through the superficial venous system salvaged the limb and continues to perfuse the foot 4 years post-operatively with resolution of rest pain.

Nutritional support in the patient with HIV infection

Weight loss and malnutrition are the most common symptoms associated with active infection with human immunodeficiency virus. The origin of the malnutrition is considered multifactorial and broadly includes decreased nutrient intake, nutrient malabsorption, and metabolic alterations. Steady advances have been made in understanding the mechanisms underlying weight loss in these patients. The utility and optimal modes of nutrition support have not yet been fully established.