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Kolluri R, Fukaya E, Krishna S, Dean S. Venous leg ulcers: A review of clinical variability and differential diagnosis. Vasc Med 2025; 30:218-237. [PMID: 40079722 DOI: 10.1177/1358863x251319243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2025]
Abstract
Venous hypertension due to anatomical venous insufficiency (superficial or deep venous valvular reflux and venous obstruction) and/or functional venous insufficiency (calf dysfunction, dependent edema, lymphatic dysfunction, elevated central venous pressures, etc.) leads to chronic venous insufficiency (CVI) and its sequelae. The most severe clinical manifestation of CVI is venous leg ulcer (VLU), which leads to substantial morbidity and disability. VLUs can present in both typical and atypical forms. However, several other types of leg ulcers can mimic VLUs. Therefore, vascular and wound care specialists must recognize the variability in VLU presentation and understand the differential diagnoses to deliver an accurate diagnosis and optimal care of atypical VLUs and conditions that resemble VLUs. Herein, we review and discuss the broad differential diagnosis of VLUs, supported by illustrative examples.
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Affiliation(s)
- Raghu Kolluri
- OhioHealth Heart and Vascular, Columbus, OH, USA
- Syntropic Corelab, Columbus, OH, USA
| | - Eri Fukaya
- Department of Surgery, Division of Vascular Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Surith Krishna
- Syntropic Corelab, Columbus, OH, USA
- College of Arts and Sciences, The Ohio State University, Columbus, OH, USA
| | - Steven Dean
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Paladugu SV, Savlania A, Hari G, Singla T, Gorsi U, Kaman L. Impact of static foot disorder and ankle range of motion in chronic venous insufficiency patients. Phlebology 2025:2683555251326046. [PMID: 40094513 DOI: 10.1177/02683555251326046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2025]
Abstract
ObjectiveChronic venous insufficiency (CVI) is a progressive disease, leading to calf muscle pump dysfunction and reduced range of ankle motion (ROAM). A full ROAM increases venous return decreasing venous hypertension. The dysfunction of foot pump in static foot disorder (SFD) further contributes to chronic venous insufficiency. In present study we studied the effect of ROAM and SFD on CVI.MethodsA prospective observational study was conducted from July 2022 to June 2023, with Institute Ethical clearance (INT/2022/MS-533). A total of 402 legs were included, of which 368 legs of the study group had CVI and 34 legs were in control C0 group. Patients were divided into control C0, mild C1-C3 and advanced C4-C6 disease group based on the severity of CVI. SFD and ROAM were evaluated from X-rays by Djian-Annonier angle and goniometry respectively. The primary objective was to study, impairment of ROAM in patients from C1-C6 and its comparison with control C0 group and impact of static foot disorders on ROAM.ResultsROAM was highest in controls and decreased towards the lowest value in progression to advanced stages of CEAP classification (87° in C0, 71° in mild CVI and 45° in advanced CVI, p < .001). Controls had just nine % legs afflicted with SFD whereas 62.3% and 68.6% with mild and advanced disease had SFD, p < .001. ROAM was highest in those without SFD (68.9°) and least in hollow feet (58.3°), p < .001. ROAM was lower in the symptomatic C2 disease (80°) than asymptomatic type (69°) (p < .001).ConclusionThis study showed that poor ROAM is associated with higher rate of advance CVI. In addition patients with SFD had advance CVI and poor ROAM. So, it is important to consider treatment of SFD and physical rehabilitation to improve ROAM and break vicious cycle of progression to severe CVI.
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Affiliation(s)
- Sree Vani Paladugu
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Savlania
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gokulkrishnan Hari
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tanuj Singla
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Lileswar Kaman
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Hupperetz RD, Iding AFJ, van Laanen J, Brans R, Notten P, Tick LW, Vleming LJ, Jie A, Planken N, Wittens CHA, Cate HT, Ten Cate-Hoek AJ. Patency and reflux in relation to postthrombotic syndrome: a subanalysis of the Ultrasound-Accelerated Catheter-Directed Thrombolysis Versus Anticoagulation for the Prevention of Post-Thrombotic Syndrome trial. J Thromb Haemost 2024; 22:3552-3561. [PMID: 39299612 DOI: 10.1016/j.jtha.2024.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 07/29/2024] [Accepted: 08/19/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Adjunctive catheter-directed thrombolysis shows variable efficacy in preventing postthrombotic syndrome (PTS), despite restored patency. OBJECTIVES This Ultrasound-Accelerated Catheter-Directed Thrombolysis Versus Anticoagulation for the Prevention of Post-Thrombotic Syndrome (CAVA) trial subanalysis investigated the effect of ultrasound-accelerated catheter-directed thrombolysis (UACDT) on patency, reflux, and their relevance in PTS development. METHODS This multicenter, randomized, single-blind trial enrolled patients (aged 18-85 years) with a first iliofemoral deep vein thrombosis and symptom duration ≤14 days. Patency and reflux were assessed by duplex ultrasound at 12 months (T12) and long-term (LT) follow-up (median, 39.5 months; IQR, 24.0-63.0 months). PTS was diagnosed using the Villalta score. RESULTS UACDT significantly improved patency in all vein segments at T12 (60.3% UACDT vs 25.9% standard treatment [ST]; P = .002) and LT (45.2% UACDT vs 11.9% ST; P < .001). Popliteal patency, however, was similar between groups (87.9% UACDT vs 83.3% ST; P = .487). Reflux was similar between groups at T12 and LT; only popliteal reflux was significantly reduced in the UACDT group at LT (22.6% UACDT vs 44.8% ST; P = .010). Absent iliac patency at T12 was associated with increased PTS risk in the ST group only (odds ratio [OR], 10.84; 95% CI, 1.93-60.78; P = .007). In the UACDT group, popliteal reflux at T12 was associated with moderate-to-severe PTS at T12 (OR, 4.88; 95% CI, 1.10-21.57; P = .041) and LT (OR, 5.83; 95% CI, 1.44-23.63; P = .009). Combined popliteal reflux and absent iliac patency significantly amplified PTS risk (OR, 10.79; 95% CI, 2.41-48.42; P < .001). CONCLUSION UACDT improved patency and reduced popliteal reflux. Iliac patency and popliteal reflux are independently associated with moderate-to-severe PTS and contribute synergistically to its development. However, a proportion of moderate-to-severe PTS cases lacks an evident underlying cause.
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Affiliation(s)
- Ruben D Hupperetz
- Thrombosis Expertise Center, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands.
| | - Aaron F J Iding
- Thrombosis Expertise Center, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | | | - Rutger Brans
- Department of Radiology, MUMC+, Maastricht, the Netherlands
| | - Pascale Notten
- Department of Vascular Surgery, MUMC+, Maastricht, the Netherlands
| | - Lidwine W Tick
- Department of Internal Medicine, Maxima Medical Centre, Eindhoven, the Netherlands
| | | | - Asiong Jie
- Department of Internal Medicine, Zuyderland Medical Centre, Sittard, the Netherlands
| | - Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | | | - Hugo Ten Cate
- Thrombosis Expertise Center, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of internal Medicine, MUMC+, Maastricht, the Netherlands; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Arina J Ten Cate-Hoek
- Thrombosis Expertise Center, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
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de Moraes Silva MA, Nelson A, Bell-Syer SE, Jesus-Silva SGD, Miranda F. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev 2024; 3:CD002303. [PMID: 38451842 PMCID: PMC10919450 DOI: 10.1002/14651858.cd002303.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND Up to 1% of adults will have a leg ulcer at some time. Most leg ulcers are venous in origin and are caused by high pressure in the veins due to blockage or damaged valves. Venous ulcer prevention and treatment typically involves the application of compression bandages/stockings to improve venous return and thus reduce pressure in the legs. Other treatment options involve removing or repairing veins. Most venous ulcers heal with compression therapy, but ulcer recurrence is common. For this reason, clinical guidelines recommend that people continue with compression treatment after their ulcer has healed. This is an update of a Cochrane review first published in 2000 and last updated in 2014. OBJECTIVES To assess the effects of compression (socks, stockings, tights, bandages) for preventing recurrence of venous leg ulcers. SEARCH METHODS In August 2023, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, three other databases, and two ongoing trials registries. We also scanned the reference lists of included studies and relevant reviews and health technology reports. There were no restrictions on language, date of publication, or study setting. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated compression bandages or hosiery for preventing the recurrence of venous ulcers. DATA COLLECTION AND ANALYSIS At least two review authors independently selected studies, assessed risk of bias, and extracted data. Our primary outcome was reulceration (ulcer recurrence anywhere on the treated leg). Our secondary outcomes included duration of reulceration episodes, proportion of follow-up without ulcers, ulceration on the contralateral leg, noncompliance with compression therapy, comfort, and adverse effects. We assessed the certainty of evidence using GRADE methodology. MAIN RESULTS We included eight studies (1995 participants), which were published between 1995 and 2019. The median study sample size was 249 participants. The studies evaluated different classes of compression (UK class 2 or 3 and European (EU) class 1, 2, or 3). Duration of follow-up ranged from six months to 10 years. We downgraded the certainty of the evidence for risk of bias (lack of blinding), imprecision, and indirectness. EU class 3 compression stockings may reduce reulceration compared with no compression over six months (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.27 to 0.76; 1 study, 153 participants; low-certainty evidence). EU class 1 compression stockings compared with EU class 2 compression stockings may have little or no effect on reulceration over 12 months (RR 1.70, 95% CI 0.67 to 4.32; 1 study, 99 participants; low-certainty evidence). There may be little or no difference in rates of noncompliance over 12 months between people using EU class 1 stockings and people using EU class 2 stockings (RR 1.22, 95% CI 0.40 to 3.75; 1 study, 99 participants; low-certainty evidence). UK class 2 hosiery compared with UK class 3 hosiery may be associated with a higher risk of reulceration over 18 months to 10 years (RR 1.55, 95% CI 1.26 to 1.91; 5 studies, 1314 participants; low-certainty evidence). People who use UK class 2 hosiery may be more compliant with compression treatment than people who use UK class 3 hosiery over 18 months to 10 years (RR for noncompliance 0.69, 95% CI 0.49 to 0.99; 5 studies, 1372 participants; low-certainty evidence). There may be little or no difference between Scholl UK class 2 compression stockings and Medi UK class 2 compression stockings in terms of reulceration (RR 0.77, 95% CI 0.47 to 1.28; 1 study, 166 participants; low-certainty evidence) and noncompliance (RR 0.97, 95% CI 0.84.1 to 12; 1 study, 166 participants; low-certainty evidence) over 18 months. No studies compared different lengths of compression (e.g. below-knee versus above-knee), and no studies measured duration of reulceration episodes, ulceration on the contralateral leg, proportion of follow-up without ulcers, comfort, or adverse effects. AUTHORS' CONCLUSIONS Compression with EU class 3 compression stockings may reduce reulceration compared with no compression over six months. Use of EU class 1 compression stockings compared with EU class 2 compression stockings may result in little or no difference in reulceration and noncompliance over 12 months. UK class 3 compression hosiery may reduce reulceration compared with UK class 2 compression hosiery; however, higher compression may lead to lower compliance. There may be little to no difference between Scholl and Medi UK class 2 compression stockings in terms of reulceration and noncompliance. There was no information on duration of reulceration episodes, ulceration on the contralateral leg, proportion of follow-up without ulcers, comfort, or adverse effects. More research is needed to investigate acceptable modes of long-term compression therapy for people at risk of recurrent venous ulceration. Future trials should consider interventions to improve compliance with compression treatment, as higher compression may result in lower rates of reulceration.
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Affiliation(s)
- Melissa Andreia de Moraes Silva
- Interdisciplinary Surgical Science Program, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
- Vascular Surgery, Hospital de Clinicas de Itajuba - MG, Itajuba, Brazil
| | - Andrea Nelson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | | | | | - Fausto Miranda
- Division of Vascular and Endovascular Surgery, Department of Surgery, Paulista School of Medicine - Federal University of São Paulo, São Paulo, Brazil
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Vedantham S, Weinberg I, Desai KR, Winokur R, Kolli KP, Patel S, Nelson K, Marston W, Azene E. Society of Interventional Radiology Position Statement on the Management of Chronic Iliofemoral Venous Obstruction with Endovascular Placement of Metallic Stents. J Vasc Interv Radiol 2023; 34:1643-1657.e6. [PMID: 37330211 DOI: 10.1016/j.jvir.2023.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 06/08/2023] [Indexed: 06/19/2023] Open
Abstract
PURPOSE To state the position of the Society of Interventional Radiology (SIR) on the endovascular management of chronic iliofemoral venous obstruction with metallic stents. MATERIALS AND METHODS A multidisciplinary writing group with expertise in treating venous disease was convened by SIR. A comprehensive literature search was conducted to identify studies on the topic of interest. Recommendations were drafted and graded according to the updated SIR evidence grading system. A modified Delphi technique was used to achieve consensus agreement on the recommendation statements. RESULTS A total of 41 studies, including randomized trials, systematic reviews and meta-analyses, prospective single-arm studies, and retrospective studies were identified. The expert writing group developed 15 recommendations on the use of endovascular stent placement. CONCLUSIONS SIR considers the use of endovascular stent placement for chronic iliofemoral venous obstruction to be likely to help selected patients, but the risks and benefits have not been fully quantified in well-designed randomized studies. SIR recommends urgent completion of such studies. In the meantime, careful patient selection and optimization of conservative therapy are recommended prior to stent placement, with attention to appropriate stent sizing and quality procedural technique. The use of multiplanar venography with intravascular ultrasound is suggested in diagnosing and characterizing obstructive iliac vein lesions and in guiding stent therapy. After stent placement, SIR recommends close patient follow-up to ensure optimal antithrombotic therapy, durable symptom response, and early identification of adverse events.
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Affiliation(s)
- Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri.
| | - Ido Weinberg
- Cardiology Division, Vascular Medicine Section, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Kush R Desai
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ronald Winokur
- Department of Radiology, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York
| | - Kanti Pallav Kolli
- Department of Radiology & Biomedical Imaging, University of California, San Francisco
| | - Sheena Patel
- Society of Interventional Radiology, Fairfax, Virginia
| | - Kari Nelson
- Department of Radiology, Orange Coast Medical Center, Fountain Valley, California
| | - William Marston
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Ezana Azene
- Gundersen Health System, La Crosse, Wisconsin
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Shao MY, Harlin S, Chan B, Santangelo K, Fukaya E, Stoughton J, Kolluri R. VIEW-VLU observational study of the effect of Varithena on wound healing in the treatment of venous leg ulcers. J Vasc Surg Venous Lymphat Disord 2023; 11:692-699.e1. [PMID: 36972751 DOI: 10.1016/j.jvsv.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Chronic venous hypertension, triggered by venous reflux and/or obstruction, leads to skin changes and venous leg ulcers (VLUs). Compression therapy is the standard of care, but many wounds remain unhealed. The objectives of this study were to observe the effects of endovenous chemical ablation with commercially available 1% polidocanol injectable microfoam on VLU healing and recurrence rates. METHODS The VIEW VLU study was a multicenter, open-label, phase IV registry of patients with active VLUs resulting from venous insufficiency of the great saphenous vein and/or anterior accessory saphenous vein systems who underwent ablation with 1% polidocanol microfoam. Primary outcomes included wound healing rate (change in wound perimeter), wound closure at 12 weeks after treatment, and time to wound closure. Secondary outcomes included VLU recurrence, numeric pain score at the ulcer location, EuroQol five-dimension five-level questionnaire quality-of-life index, and the Venous Clinical Severity Score. Patients were followed for 12 months. RESULTS We enrolled 76 patients (80 ulcers) from 14 sites across the United States and Canada (mean age 63.6 ± 13.7 years, 39.5% female, mean body mass index 36.3). Of the enrollees, 96.3% presented with great saphenous vein incompetence. The mean baseline wound perimeter was 117.2 ± 107.4 mm and 26.3% of wounds (21/80) were circumferential. The mean ulcer age was 34.8 ± 51.8 weeks at first presentation and the mean compression therapy duration was 26.4 ± 35.9 weeks. The median wound perimeter decreased by 16.3% from baseline in the first 2 weeks after the procedure and by 27.0% at 12 weeks. By 12 weeks, 53.8% of wounds (43/80) were healed. The median time to ulcer closure by Kaplan-Meier analysis was 89 days (95% confidence interval, 62.0-117.0). In a Kaplan-Meier analysis of initially healed wounds, 88.9% (95% confidence interval, 76.9-94.8) remained closed at 12 weeks after closure. The mean numeric pain scores (ulcer site) improved by 41.0% and 64.1% at 12 weeks and 12 months after the procedure, respectively. The health-related quality-of-life index (scale of 0-1) improved from 0.65 ± 0.27 at baseline to 0.72 ± 0.28 at 12 weeks and 0.73 ± 0.30 at 12 months. By 12 weeks after treatment, the mean target leg Venous Clinical Severity Score had significantly decreased by 5.8 points, and by 12 months it had decreased by 10.0 points. CONCLUSIONS Treatment with 1% polidocanol microfoam was associated with promising wound healing rates and low recurrence rates for VLUs, despite a challenging patient population with recalcitrant ulcers, a large percentage of which were circumferential, in patients with high body mass indexes.
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Affiliation(s)
- Michael Y Shao
- Swedish Hospital, Northshore University HealthSystem, Chicago, IL.
| | - Stuart Harlin
- University of Texas Health Sciences Center at Houston, Houston, TX
| | - Beverly Chan
- Vascular Health Bronte, Oakville, Ontario, Canada
| | | | - Eri Fukaya
- Stanford University School of Medicine, Palo Alto, CA
| | | | - Raghu Kolluri
- Ohio Health Heart and Vascular Columbus, Columbus, OH
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Vedantham S, Gloviczki P, Carman TL, Zelman Lewis S, Schneider PA, Sabri SS, Kolluri R. Delphi Consensus on Reporting Standards in Clinical Studies for Endovascular Treatment of Acute Iliofemoral Venous Thrombosis and Chronic Iliofemoral Venous Obstruction. Circ Cardiovasc Interv 2023; 16:e012894. [PMID: 37340977 PMCID: PMC10348641 DOI: 10.1161/circinterventions.123.012894] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 05/09/2023] [Indexed: 06/22/2023]
Abstract
Acute iliofemoral deep vein thrombosis and chronic iliofemoral venous obstruction cause substantial patient harm and are increasingly managed with endovascular venous interventions, including percutaneous mechanical thrombectomy and stent placement. However, studies of these treatment elements have not been designed and reported with sufficient rigor to support confident conclusions about their clinical utility. In this project, the Trustworthy consensus-based statement approach was utilized to develop, via a structured process, consensus-based statements to guide future investigators of venous interventions. Thirty statements were drafted to encompass major topics relevant to venous study description and design, safety outcome assessment, efficacy outcome assessment, and topics specific to evaluating percutaneous venous thrombectomy and stent placement. Using modified Delphi techniques for consensus achievement, a panel of physician experts in vascular disease voted on the statements and succeeded in reaching the predefined threshold of >80% consensus (agreement or strong agreement) on all 30 statements. It is hoped that the guidance from these statements will improve standardization, objectivity, and patient-centered relevance in the reporting of clinical outcomes of endovascular interventions for acute iliofemoral deep venous thrombosis and chronic iliofemoral venous obstruction in clinical studies and thereby enhance venous patient care.
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Affiliation(s)
| | | | | | | | | | - Saher S. Sabri
- MedStar Georgetown University Hospital, Washington, DC (S.S.S.)
| | - Raghu Kolluri
- OhioHealth Heart and Vascular, Riverside Methodist Hospital, Columbus (R.K.)
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Cavadas PC, Padial B. Circumferential Radical Debridement and Omental Free Flap in the Treatment of Severe Chronic Venous Ulcers. Ann Plast Surg 2023; 90:568-574. [PMID: 37157147 DOI: 10.1097/sap.0000000000003540] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Chronic venous leg ulcers are a significant health care burden with a difficult and unreliable treatment. Free flaps may be needed for wound coverage in severe cases. Incomplete removal of dermatoliposclerosis (DLS) area and/or not addressing the underlying venous dysfunction may contribute to the reported modest long-term results. METHODS A series of 5 patients with severe chronic venous ulcers of the leg, resistant to conservative treatment and superficial venous surgery, were treated with radical, circumferential, subfascial resection of the DLS skin and coverage with omental free flaps. Delayed arteriovenous (AV) loops were used as recipients. All patients had previous superficial venous surgery and multiple skin grafts. Mean follow-up was 8 years (4-15 years). RESULTS One hundred percent of flaps survived completely. No major complications occurred. One patient developed ulceration of the flap at 2 years and healed with basic wound care. At a mean follow-up of 8 years, all patients were ulcer-free. One patient died 15 years after the surgery for unrelated causes. CONCLUSIONS Radical circumferential resection of DLS area in severe chronic venous leg ulcers and coverage with a free omental flap using staged AV loop provided durable coverage in a series of 5 patients. Complete resection of DLS area, addressing the underlying venous pathology, and draining the flap to a healthy competent vein graft (AV loop) may contribute to these favorable results.
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Raju S, Lucas M, Thaggard D, Saleem T, Jayaraj A. Plethysmographic features of calf pump failure in chronic venous obstruction and reflux. J Vasc Surg Venous Lymphat Disord 2023; 11:262-269. [PMID: 36400423 DOI: 10.1016/j.jvsv.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Calf pump failure (CPF) is a common concept in chronic venous disease. Dorsal vein pressures were originally used to define the pathophysiology. More recently, an abnormal ejection fraction (EF) and residual volume fraction (RVF) with air plethysmography (APG) have been substituted for its diagnosis. The relationship between reflux and calf pump function has been studied extensively. Reflux is thought to be the main cause of CPF, although other mechanisms may play a secondary role. Data mining in our dataset revealed that CPF is frequently found in nonrefluxive limbs-an unexpected finding. We analyzed the APG features of CPF in nonrefluxive limbs of a large cohort of patients investigated for chronic venous disease in our clinic. Data from refluxive limbs (control) seen over the same period was included for comparison. Venous obstructive pathology was variably present in both subsets. Iliac vein stent outcome in CPF limbs from both subsets is included. The role of obstruction in CPF is currently unknown. METHODS Records of 13,234 limbs in 8813 patients evaluated for suspected chronic venous disease over a 22-year period were analyzed. Prestent and poststent data in 406 CPF limbs (129 nonrefluxive; 277 refluxive) that underwent iliac vein stenting to correct associated stenosis are included. This is a single-center retrospective analysis of prospectively collected data. Duplex and APG data were available for included limbs. A RVF of more than 50% was defined as CPF. A reflux time of greater than 1 second elicited with automated cuffs in the erect position was defined as reflux. RESULTS There were 7780 (59%) limbs with reflux and 5454 (41%) that were nonrefluxive. Supine venous pressure, an index of venous obstruction, was elevated in both subsets. The incidence of CPF was 25% in refluxive limbs and 16% in nonrefluxive limbs totaling 2790 limbs. Venous volume and venous filling index were significantly elevated (P = .0001) in refluxive limbs compared to nonrefluxive limbs. The EF was diminished (<50%) in all CPF limbs except in a small fraction (n = 427 [3%]). Stent correction of iliac vein stenosis corrected CPF, normalizing the RVF in both subsets. CONCLUSIONS CPF frequently occurs in nonrefluxive limbs with incidence only slightly less than in refluxive limbs. An RVF of more than 50% seems to be a practical definition of a CPF; an EF of less than 50% is associated with a RVF of greater than 50% in 97% of analyzed limbs. Prospective identification of CPF in limbs with chronic venous disease may allow more detailed investigation of its cause (preload, afterload, neuromuscular pathology or joint immobility, etc) and direct more targeted treatment than currently practiced.
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Affiliation(s)
- Seshadri Raju
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS.
| | - Michael Lucas
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
| | - David Thaggard
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
| | - Taimur Saleem
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
| | - Arjun Jayaraj
- The RANE Center for Venous & Lymphatic Diseases, Jackson, MS
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Attaran RR, Carr JG. Chronic Venous Disease of the Lower Extremities: A State-of-the Art Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100538. [PMID: 39132527 PMCID: PMC11307564 DOI: 10.1016/j.jscai.2022.100538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/26/2022] [Accepted: 10/07/2022] [Indexed: 08/13/2024]
Abstract
Chronic venous disease is a common disease, the prevalence of which increases with age, and can cause debilitating symptoms that adversely affect the quality of life. The risk factors include family history, female sex, obesity, pregnancy, parity, and history of deep vein thrombosis. Moreover, it is associated with venous obstruction, reflux, or both, which, in turn, leads to ambulatory venous hypertension. Chronic venous disease is the leading cause of leg ulcers, which place a significant cost burden on the health care system. Compression therapy remains the cornerstone of treatment, particularly for more advanced disease. Superficial saphenous vein reflux can be associated with significant symptoms. Catheter techniques, both thermal and nonthermal, have demonstrated efficacy and safety in successful closure and symptom improvement. Deep vein obstruction can be broadly divided into thrombotic and nonthrombotic and can lead to symptomatic chronic venous disease. Recanalization using balloons and stents has been increasingly used and studied in such patients. It is critical to develop training opportunities and guidelines to improve evidence-based and appropriate care for cardiologists treating chronic venous disease.
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Affiliation(s)
- Robert R. Attaran
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Jeffrey G. Carr
- CardiaStream at Tyler Cardiac and Endovascular Center, Tyler, Texas
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Kumar P, Khan IA, Das A, Shah H. Chronic venous insufficiency: Part 1 Pathophysiology and Clinical features. Clin Exp Dermatol 2022; 47:1228-1239. [PMID: 35167156 DOI: 10.1111/ced.15143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/12/2022] [Accepted: 02/13/2022] [Indexed: 11/28/2022]
Abstract
Chronic venous disease (CVD) is a commonly encountered disease in dermatology out-patient department and if untreated, may progress to chronic leg ulcer causing serious morbidity to the patient. Also, it affects the quality of life of the affected patient and contributes to the loss of work productivity. The range of clinical manifestations is myriad, ranging from asymptomatic varicose veins and pigmentation to ulceration and scarring. The awareness of spectrum of clinical presentations is required to identify, diagnose and manage CVD. Long standing cases may develop ankle joint stiffness, significant fibrosis causing fixed flexion deformity, periostitis and even, Marjolin's ulcer. Increased venous hypertension, thought to result from incompetent valve and failure of calf muscle pump, is central to the pathophysiology of the development of CVD. Tissue edema, hypoxia and subsequent fibrosis are major immediate contributing factors responsible for the clinical manifestations of CVD. Localized, chronic inflammation is now increasingly being recognized as a key player, directly responsible for stasis dermatitis and hypercoagulable state. The complete ramifications of persistent inflammation in CVD is yet to be understood and serious systemic morbidities like arterial and cardiac disease are increasingly been recognized in association with CVD.
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Affiliation(s)
| | - Ismat Ara Khan
- Department of Dermatology, Venereology, and Leprosy; Medical College & Hospital, Kolkata, India
| | - Anupam Das
- Department of Dermatology, Venereology, and Leprosy; KPC Medical College & Hospital, Kolkata, India
| | - Hiral Shah
- Department of Dermatology, Venereology, and Leprosy; Baroda Medical College, Vadodara, India
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12
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Ashrafi M, Ahmad SB, Antoniou SA, Khan T, Antoniou GA. Treatment Strategies for Proximal Deep Vein Thrombosis: A Network Meta-analysis of Randomised Controlled Trials. Eur J Vasc Endovasc Surg 2022; 63:323-334. [PMID: 35086761 DOI: 10.1016/j.ejvs.2021.10.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 09/27/2021] [Accepted: 10/31/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the outcomes of treatment strategies for proximal and iliofemoral deep vein thrombosis (DVT). METHODS Randomised controlled trials (RCTs) investigating outcomes of catheter directed thrombolysis (CDT), ultrasound assisted CDT (USCDT), percutaneous aspiration thrombectomy (PAT), and best medical therapy (BMT) for proximal DVT from 2000 onwards were considered. MEDLINE, EMBASE, and CINAHL were searched using the Healthcare Databases Advanced Search interface developed by the National Institute for Health and Care Excellence. The primary outcome was the rate of post-thrombotic syndrome (PTS), which was defined using the Villalta scoring system (score of ≥5). Secondary outcomes included vessel patency, recurrence, bleeding, and mortality. The network of evidence was summarised using network plots, and random effects network meta-analyses were performed. The certainty of evidence was assessed using the Certainty In Network Meta-Analysis (CINeMA) approach. RESULTS Seven RCTs meeting the inclusion criteria were identified. There were direct comparisons between medical therapy, CDT, and USCDT across outcomes, except for patency. There were no direct comparisons between medical therapy and PAT (except for patency), and USCDT and PAT. There was no significant difference observed in PTS between the treatment modalities for proximal and iliofemoral DVT (low certainty). There was a significant difference in patency rates between medical therapy and USCDT (odds ratio [OR] 9.46, 95% confidence interval [CI] 3.05 - 29.35; low certainty) and CDT (OR 2.03, 95% CI 1.46 - 2.80; low certainty) in favour of USCDT and CDT, respectively, for proximal DVT. USCDT significantly improved patency rates compared with CDT (OR 4.67, 95% CI 1.58 - 13.81; very low certainty) for proximal DVT. There was no significant difference in DVT recurrence, bleeding, or mortality between treatment groups for proximal and iliofemoral DVT (low to moderate certainty for most comparisons). CONCLUSION USCDT may improve patency rates compared with BMT and the other interventional treatment modalities used for the management of proximal DVT. However, no treatment modality showed superiority with regard to a reduction in PTS, and overall, the quality of available evidence is poor.
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Affiliation(s)
- Mohammed Ashrafi
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Saad B Ahmad
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - Stavros A Antoniou
- Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus
| | - Taha Khan
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, Manchester University NHS Foundation Trust, Manchester, UK; Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK.
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13
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Ito T, Ota T, Kono R, Miyaoka Y, Ishibashi H, Komori M, Yasukawa A, Kanno Y, Miki N. Pump-Free Microfluidic Hemofiltration Device. MICROMACHINES 2021; 12:mi12080992. [PMID: 34442614 PMCID: PMC8401791 DOI: 10.3390/mi12080992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 11/16/2022]
Abstract
Hemofiltration removes water and small molecules from the blood via nanoporous filtering membranes. This paper discusses a pump-free hemofiltration device driven by the pressure difference between the artery and the vein. In the design of the filtering device, oncotic pressure needs to be taken into consideration. Transmembrane pressure (TMP) determines the amount and direction of hemofiltration, which is calculated by subtracting the oncotic pressure from the blood pressure. Blood pressure decreases as the channels progress from the inlet to the outlet, while oncotic pressure increases slightly since no protein is removed from the blood to the filtrate in hemofiltration. When TMP is negative, the filtrate returns to the blood, i.e., backfiltration takes place. A small region of the device with negative TMP would thus result in a small amount of or even zero filtrates. First, we investigated this phenomenon using in vitro experiments. We then designed a hemofiltration system taking backfiltration into consideration. We divided the device into two parts. In the first part, the device has channels for the blood and filtrate with a nanoporous membrane. In the second part, the device does not have channels for filtration. This design ensures TMP is always positive in the first part and prevents backfiltration. The concept was verified using in vitro experiments and ex vivo experiments in beagle dogs. Given the simplicity of the device without pumps or electrical components, the proposed pump-free hemofiltration device may prove useful for either implantable or wearable hemofiltration.
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Affiliation(s)
- Takahiro Ito
- Department of Mechanical Engineering, Keio University, 3-14-1 Hiyoshi, Kohoku-ku, Yokohama 223-8522, Kanagawa, Japan; (T.I.); (T.O.); (R.K.)
| | - Takashi Ota
- Department of Mechanical Engineering, Keio University, 3-14-1 Hiyoshi, Kohoku-ku, Yokohama 223-8522, Kanagawa, Japan; (T.I.); (T.O.); (R.K.)
| | - Rei Kono
- Department of Mechanical Engineering, Keio University, 3-14-1 Hiyoshi, Kohoku-ku, Yokohama 223-8522, Kanagawa, Japan; (T.I.); (T.O.); (R.K.)
| | - Yoshitaka Miyaoka
- Department of Nephrology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan; (Y.M.); (Y.K.)
| | - Hidetoshi Ishibashi
- Pre-Clinical Research Center, Tokyo Medical University, 6-1-1 Shinjuku, Shinjuku-ku, Tokyo 160-8492, Japan;
| | - Masaki Komori
- Japanese Small Animal Hemodialysis Association, 63-2-7 Nihonbashi-Hongokucho, Chuo-ku, Tokyo 103-0021, Japan;
| | - Akio Yasukawa
- Kamishakujii Animal Hospital, 1-4-13 Sekimachi-Higashi, Nerima-ku, Tokyo 177-0052, Japan;
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan; (Y.M.); (Y.K.)
| | - Norihisa Miki
- Department of Mechanical Engineering, Keio University, 3-14-1 Hiyoshi, Kohoku-ku, Yokohama 223-8522, Kanagawa, Japan; (T.I.); (T.O.); (R.K.)
- Correspondence: ; Tel.: +81-455-661-430
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Agrawal Y, Ponna P, Zoltowska DM, Halabi AR. A case report of successful intravascular shockwave lithotripsy and ad hoc directional venous atherectomy of extensive chronic femoral deep venous thrombosis. Eur Heart J Case Rep 2021; 5:ytab107. [PMID: 34124557 PMCID: PMC8189304 DOI: 10.1093/ehjcr/ytab107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 09/29/2020] [Accepted: 02/28/2021] [Indexed: 11/21/2022]
Abstract
Background Conventional treatment for chronic deep venous thrombosis (DVT) is anticoagulation. However, limited interventional endovascular options exist for patients with non-healing venous ulcers secondary to chronic DVT. Case summary We present a case of 67-year-old man with severely symptomatic post-thrombotic syndrome (PTS) with persistent high-grade femoral DVT despite prior compressive therapy and chronic oral anticoagulation. It has been successfully treated with intravascular shockwave lithotripsy and ad hoc directional venous atherectomy facilitating subsequent mechanical thrombectomy and venoplasty. The procedure was without complication and resulted in significant clinical improvement. Discussion We believe our novel endovascular interventional approach represents a unique modality of intervention for patients with chronic DVT and PTS resistant to conventional venoplasty.
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Affiliation(s)
| | - Pramod Ponna
- St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA
| | - Dominika M Zoltowska
- University of Florida College of Medicine, Cardiovascular Disease Fellowship, Jacksonville, FL 32209, USA
| | - Abdul R Halabi
- St. Joseph Mercy Oakland Hospital, Pontiac, MI 48341, USA
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15
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Reduced calf muscle pump function is a risk factor for venous thromboembolism: a population-based cohort study. Blood 2021; 137:3284-3290. [PMID: 33657212 DOI: 10.1182/blood.2020010231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 01/29/2021] [Indexed: 12/14/2022] Open
Abstract
The calf muscle pump is a major determinate of venous return in the legs but has not been studied as a risk factor for venous thromboembolism (VTE). A population-based cohort study of Olmsted County, Minnesota residents was performed using calf pump function (CPF) measurements from venous plethysmography studies from 1998 to 2015. Patients with a history of VTE were excluded. Nursing validated VTE outcomes from the Rochester Epidemiology Project were identified after the index study date, and patients with reduced CPF (rCPF) were compared with patients with normal CPF. A total of 1532 patients with recorded CPF (28% air and 72% strain gauge plethysmography) were included; 591 (38.5%) had normal CPF, 353 (23.0%) had unilateral rCPF, and 588 (38.3%) had bilateral rCPF. Any VTE occurred in 87 patients (5.7%) after a median follow-up of 11.7 years (range, 0-22.0 years). Comparing patients with bilateral reduced to bilateral normal CPF, the unadjusted hazard ratio (HR) for incident VTE was 2.0 (95% confidence interval [CI], 1.2-3.4) and after adjusting for age, BMI, and Charlson Comorbidity Index, the HR was 1.68 (95% CI, 0.98-2.89). The adjusted HR for ipsilateral deep vein thrombosis was evaluated in 3064 legs comparing legs with reduced to normal CPF and was 1.71 (95% CI, 1.03-2.84). Mortality was significantly higher in both the bilateral (P < .001) and unilateral (P < .001) rCPF groups compared with normal CPF. Our results demonstrate that CPF is a risk factor for VTE in an otherwise low-risk ambulatory population and might be a useful component in risk stratification models.
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16
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Gifre-Renom L, Jones EAV. Vessel Enlargement in Development and Pathophysiology. Front Physiol 2021; 12:639645. [PMID: 33716786 PMCID: PMC7947306 DOI: 10.3389/fphys.2021.639645] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
From developmental stages until adulthood, the circulatory system remodels in response to changes in blood flow in order to maintain vascular homeostasis. Remodeling processes can be driven by de novo formation of vessels or angiogenesis, and by the restructuration of already existing vessels, such as vessel enlargement and regression. Notably, vessel enlargement can occur as fast as in few hours in response to changes in flow and pressure. The high plasticity and responsiveness of blood vessels rely on endothelial cells. Changes within the bloodstream, such as increasing shear stress in a narrowing vessel or lowering blood flow in redundant vessels, are sensed by endothelial cells and activate downstream signaling cascades, promoting behavioral changes in the involved cells. This way, endothelial cells can reorganize themselves to restore normal circulation levels within the vessel. However, the dysregulation of such processes can entail severe pathological circumstances with disturbances affecting diverse organs, such as human hereditary telangiectasias. There are different pathways through which endothelial cells react to promote vessel enlargement and mechanisms may differ depending on whether remodeling occurs in the adult or in developmental models. Understanding the molecular mechanisms involved in the fast-adapting processes governing vessel enlargement can open the door to a new set of therapeutical approaches to be applied in occlusive vascular diseases. Therefore, we have outlined here the latest advances in the study of vessel enlargement in physiology and pathology, with a special insight in the pathways involved in its regulation.
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Affiliation(s)
- Laia Gifre-Renom
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium
| | - Elizabeth A V Jones
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, KU Leuven, Leuven, Belgium.,Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
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17
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Rusinovich Y, Rusinovich V. Respiratory changes in biometry of suprarenal inferior vena cava in patients with varicose veins of lower extremities. Phlebology 2020; 36:313-321. [PMID: 33201763 DOI: 10.1177/0268355520974135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM This study examines respiratory biometry of inferior vena cava in patients with varicose veins of lower extremities. MATERIAL AND METHODS We performed retrospective analysis of clinical and ultrasound data of 67 patients with primary varicose veins. RESULTS The largest expiratory (mean 16.2 mm, p-value 0.09) and inspiratory (mean 8.2 mm, p-value 0.02) inferior vena cava diameters were in C3 Clinical Etiological Anatomical Pathophysiological clinical class; the smallest expiratory diameters (mean 13.1 mm, p-value 0.5) were in C6 class; the smallest inspiratory diameters (mean 4.6 mm, intercept) were in C2 class. C2 class was associated with highest inferior vena cava collapsibility index (mean 68.2%, intercept); C6 class was associated with lowest collapsibility index (mean 48.3%, p-value 0.04).Recurrent varices in comparison with previously untreated were associated with smaller inspiratory diameters of inferior vena cava (mean 4.4 mm, p-value 0.005), smaller expiratory diameters (mean 13.4 mm, p-value 0.06) and higher collapsibility index (mean 68.5%, p-value 0.005). Patients with recurrent and bilateral varicose veins had identical respiratory biometry of inferior vena cava.Older age was associated with smaller inferior vena cava diameters (p-value <0.01). CONCLUSION Clinical presentation of varicose veins is associated with different respiratory biometry of suprarenal inferior vena cava. C6 clinical class in comparison with C2 clinical class is associated with lower central venous compliance possible due to the narrowing of inferior vena cava. Smaller inferior vena cava diameters and higher collapsibility index in recurrent subgroup in comparison with previously untreated can be a sign of the significantly altered pressure gradient between the systemic capillaries and the right heart and impaired peripheral venous return. Narrowing of inferior vena cava with age can be a sign of more profound changes in systemic venous return with age in patients with varicose veins in comparison to those without chronic venous disease.
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Affiliation(s)
- Yury Rusinovich
- Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany.,Department of Vascular Surgery, Krankenhausgesellschaft Sankt Vincenz GmbH, Limburg, Germany
| | - Volha Rusinovich
- Institute of Hygiene and Environmental Medicine, University Hospital Leipzig, Leipzig, Germany
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18
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Midulla M, Chevallier O, Comby PO, Giordano G, Pescatori LC, Falvo N, van den Berg JC, Cariati M, Loffroy R. Endovascular management of the deep venous thrombosis: A new challenging role for the endovascular specialist in 2020. Catheter Cardiovasc Interv 2020; 98:748-755. [PMID: 33185318 DOI: 10.1002/ccd.29375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 10/02/2020] [Accepted: 10/26/2020] [Indexed: 11/11/2022]
Abstract
Over the last years, the endovascular approach to the management of the acute and chronic deep vein thrombosis (DVT) has gained more and more attention from the scientific community. DVT is the third most common cardiovascular disease after coronary heart disease and stroke, with classic treatment based on anticoagulation. Recent evidences have highlighted the risk of postthrombotic syndrome as high as 30%-50% in proximal ilio-femoral lesions, with irreversible clinical symptoms and impact on the quality of life of the population. Since 2000s, the new concept of thrombus removal in the acute phase has been supported by the introduction of different techniques based on the endovascular ablation of the clot by in-situ fibrinolysis and, more recently, fragmentation and aspiration. In the chronic phase, recanalization of the thrombosed segment is recommended by stent placement to remove the obstruction and eventually reduce the congestion. Immediate technical success of these procedures is widely satisfying, whereas the long-term clinical benefits are still debated. This paper presents an overview of the modern management of the DVT by endovascular approach with regard to the clinical contexts, interventional strategies and clinical outcomes. Endovascular specialist needs to be aware of this incoming challenge, as local expertise is demanded for the modern management of these patients in multidisciplinary theaters.
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Affiliation(s)
- Marco Midulla
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
| | - Olivier Chevallier
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
| | - Pierre-Olivier Comby
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
| | - Giuseppe Giordano
- Diagnostic and Interventional Radiology, ARNAS Garibaldi-Nesima, Catania, Italy
| | - Lorenzo Carlo Pescatori
- Department of Radiology, CHU Henri-Mondor, Assistance publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France
| | - Nicolas Falvo
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
| | - Jos C van den Berg
- Service of Interventional Radiology, Centro Vascolare Ticino, Ospedale Regionale di Lugano, Lugano, Switzerland.,Inselspital, Universitätsspital Bern Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie, Bern, Switzerland
| | - Maurizio Cariati
- Department of Radiology, Ospedale Universitario Santi Carlo e Paolo, Milan, Italy
| | - Romaric Loffroy
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Centre Hospitalier Universitaire de Dijon; Université de Bourgogne Franche-Comté, France
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19
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Rodoplu O, Yildiz CE, Oztas DM, Beyaz MO, Ulukan MO, Unal O, Conkbayir C, Ugurlucan M. The efficacy of rotational pharmaco-mechanical thrombectomy in patients with acute iliofemoral deep vein thrombosis: Is the standard treatment of deep vein thrombosis changing? Phlebology 2020; 36:119-126. [PMID: 33092483 DOI: 10.1177/0268355520966880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
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.
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Affiliation(s)
- Orhan Rodoplu
- Cardiovascular Surgery Clinic, Kadikoy Medicana Hospital, Istanbul, Turkey
| | - Cenk Eray Yildiz
- Department of Cardiovascular Surgery, Istanbul University Cerrahpasa, Institute of Cardiology, Istanbul, Turkey
| | - Didem Melis Oztas
- Cardiovascular Surgery Clinic, Bagcilar Education and Research Hospital, Istanbul, Turkey
| | - Metin Onur Beyaz
- Department of Cardiovascular Surgery, Istanbul Medipol University Medical Faculty, Istanbul, Turkey
| | - Mustafa Ozer Ulukan
- Department of Cardiovascular Surgery, Istanbul Medipol University Medical Faculty, Istanbul, Turkey
| | - Orcun Unal
- Cardiovascular Surgery Clinic, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
| | - Cenk Conkbayir
- Department of Cardiology, Near East University, North Nicosia, North Cyprus
| | - Murat Ugurlucan
- Department of Cardiovascular Surgery, Istanbul Medipol University Medical Faculty, Istanbul, Turkey
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20
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Kalinin RE, Suchkov IA, Laut MV, Mzhavanadze ND, Shanaev IN. Varicose Veins: A Local or Systemic Hemodynamic Disorder? JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2020; 36:328-334. [DOI: 10.1177/8756479320912683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2024]
Abstract
Objective: To determine the capabilities of a sonographic examination to evaluate local and systemic hemodynamic disorders in patients with varicose disease. Materials and Methods: This study included 583 patients with varicose veins, among whom 348 had trophic disorders. All subjects underwent lower limb duplex sonography and superficial, perforator, and deep venous diameter measurements, as well as had a calculated velocity for antegrade and reflux flow. Peripheral resistive index (RI) in the arteries, accompanying perforator veins (PVs), was analyzed. In addition, echocardiography was performed on 46 of the participants. Results: A statistically significant difference in the diameter of the great saphenous vein was obtained between class C2 and C4 varicose veins ( P < .05). Similar findings were obtained for the diameter of the PVs and the velocity reflux flow through PVs. Arteries in the perforator bundles demonstrated low RI, which may be attributed to the presence of arteriovenous shunts. Varicose veins were associated with an increased incidence of nonrestrictive type of blood flow through the tricuspid valve. Conclusions: Sonography demonstrated that additional factors rather than hemodynamics may be attributable to the development of venous ulcers. The most informative parameters of cardiac function, in a patient with varicose veins, are the indicators of diastolic function in both ventricles.
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Affiliation(s)
| | | | - Marina V. Laut
- Ryazan Regional Clinical Cardiologic Dispensary, Ryazan, Russia
| | | | - Ivan N. Shanaev
- Ryazan State Medical University, Ryazan, Russia
- Ryazan Regional Clinical Cardiologic Dispensary, Ryazan, Russia
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21
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Toh MR, Tang TY, Lim HHMN, Venkatanarasimha N, Damodharan K. Review of imaging and endovascular intervention of iliocaval venous compression syndrome. World J Radiol 2020; 12:18-28. [PMID: 32226586 PMCID: PMC7061234 DOI: 10.4329/wjr.v12.i3.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/04/2020] [Accepted: 01/13/2020] [Indexed: 02/06/2023] Open
Abstract
Iliocaval venous compression syndrome (ICS) is the extrinsic compression of the common iliac vein by the overlying iliac artery against the vertebra. Chronic compression can lead to venous stenosis and stasis, which manifests as chronic venous disease and treatment resistance. Therefore, early recognition of ICS and prompt treatment are essential. Clinical presentations of ICS can be ambiguous and diagnosis requires a high index of suspicion with the relevant imaging studies. The initial imaging test is typically a Duplex ultrasound for vessel assessment and pelvic ultrasound to exclude a compressive mass, which is followed by computed tomography (CT) or magnetic resonance (MR) venography. CT and MRI can identify the anatomical causes for venous compression. In patients with high clinical suspicion for ICS, negative findings on CT and MR venography would still warrant further investigations. Definitive diagnosis can be established using catheter-based venography complemented with intravascular ultrasonography but the nature of their invasiveness limits its utility as a routine imaging modality. In this review paper, we will discuss the evidence, utility and limitations of the existing imaging modalities and endovascular intervention used in the management of ICS.
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Affiliation(s)
- Ming Ren Toh
- Duke-NUS Medical School, Singapore 544886, Singapore
| | - Tjun Yip Tang
- Department of Vascular surgery, Singapore General Hospital, Singapore 169608, Singapore
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Rusinovich Y, Rusinovich V. Association between right heart diastolic function and clinical presentation of chronic venous disease and primary varicose veins of lower extremities. Phlebology 2020; 35:513-519. [DOI: 10.1177/0268355520901903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim This study examines the association between right heart diastolic function and clinical presentation of chronic venous disease and primary varicose veins of lower extremities. Material and methods We performed retrospective analysis of clinical, peripheral venous Duplex and tricuspid Doppler (early diastolic inflow E-wave, late diastolic inflow A-wave, ratios of E to A waves, early diastolic annular e′-wave, late diastolic annular a′-wave and systolic annular s′- wave) data of 85 patients, 133 legs with primary varicose veins. Results We found following significant (p-value < 0.05) associations between tricuspid Doppler and clinical presentation of chronic venous disease and primary varicose veins: Clinical Etiological Anatomical Pathophysiological clinical class influenced late diastolic inflow velocities (C6 class A-wave +11.2 cm/s or +27% in comparison with C2), late diastolic annular velocities (C6 class a′-wave +3.3 cm/s or +22% in comparison with C2), systolic annular velocities (C6 class s′-wave +3.7 cm/s or +27% in comparison with C2) and E/A ratios (C6 class E/A ratio −0.22 or −21% in comparison with C2). Recurrent varices in comparison with previously untreated are associated with significantly lower late diastolic inflow velocities (A-wave −4.4 cm/s or −9%) and preserved E/A ratios. Age significantly influenced tricuspid Doppler (E-, A-, e′-, a′-waves and E/A ratios) in patients with chronic venous disease. Conclusion Clinical presentation of primary varicose veins and chronic venous disease can be associated with the right heart diastolic function: C6 Clinical Etiological Anatomical Pathophysiological class in comparison with C2 is associated with increased right ventricular filling and impaired ventricular relaxation – right heart diastolic dysfunction; recurrent varices in comparison with previously untreated are associated with reduced right ventricular filling and preserved right heart diastolic function. Older age is the most important risk factor for varicose veins and chronic venous disease possible due to significant changes in right ventricular filling and in right heart diastolic function with age.
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Affiliation(s)
- Yury Rusinovich
- Department of Vascular Surgery, Krankenhausgesellschaft Sankt Vincenz GmbH, Limburg, Germany
- Department of Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Volha Rusinovich
- Department of Postgraduate Medical Education, Biermann Verlag GmbH, Koln, Germany
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Raju S, Walker W, May C. Measurement of ambulatory venous pressure and column interruption duration in normal volunteers. J Vasc Surg Venous Lymphat Disord 2020; 8:127-136. [DOI: 10.1016/j.jvsv.2019.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 06/07/2019] [Indexed: 10/26/2022]
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Cuen-Ojeda C, Anaya-Ayala JE, Laparra-Escareno H, García-Alva R, Lizola R, Arzola LH, Luna L, Hinojosa CA. Measurement of transcutaneous oxygen pressure in patients with post-thrombotic syndrome: Findings and possible clinical applications. Vascular 2019; 28:172-176. [PMID: 31584353 DOI: 10.1177/1708538119881347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives Post-thrombotic syndrome is the commonest long-term sequela of deep venous thrombosis. Severe post-thrombotic syndrome reduces importantly the quality of life of patients and tissue hypoxia is associated with ulceration. Transcutaneous oxygen pressure (tcPO2) provides information on the delivery of oxygen through the microvascular circulation and measuring tcPO2 might detect values at which patients with post-thrombotic syndrome might ulcerate. The aim of our study is to determine tcPO2 in post-thrombotic syndrome patients and compare the values with a control group. Methods A cross-sectional study was performed. Periflux 5000 monitor (Perimed) was used to measure tcPO2 in patients with mild-moderate, severe post-thrombotic syndrome and control groups. In patients with ulceration, two measurements were obtained, the first around the ulcer and the second 10 cm away from the lesion. Categorical data were analyzed with Fisher’s exact test and a p value <0.05 was considered statistically significant. Results Twelve patients with post-thrombotic syndrome and 13 patients (control group) were enrolled. Post-thrombotic syndrome patients’ mean age was 58 years (47–72 years) and eight (67%) patients were males. The overall mean tcPO2 measurement in post-thrombotic syndrome group was 35.5 mm Hg (SD ± 11), while in the severe post-thrombotic syndrome was 23.2 mm Hg (SD ± 9). All severe post-thrombotic syndrome patients had measurements <40 mm Hg, tcPO2 value in control group was >50 mm Hg (SD ± 4) in all patients, with a mean value of 58.2 mm Hg. During comparison of severe post-thrombotic syndrome subgroup versus control group, we found that patients with venous ulcers had <40 mm Hg in tcPO2 measurement and all control group patients had >50 mm Hg ( p < 0.0001). Conclusions Our results demonstrate that severe post-thrombotic syndrome patients have significantly lower TcPO2 values compared to a healthy control group and non-severe post-thrombotic syndrome ( p = 0.0001). Further research is necessary to establish cut-off point values of tcPO2 in this debilitating disease for possible clinical applications and determination of ulcer healing predictors.
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Affiliation(s)
- Cesar Cuen-Ojeda
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Javier E Anaya-Ayala
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Hugo Laparra-Escareno
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ramón García-Alva
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rene Lizola
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luis H Arzola
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Lizeth Luna
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carlos A Hinojosa
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Taha MA, Lane T, Shalhoub J, Davies AH. Endovenous stenting in chronic venous disease secondary to iliac vein obstruction. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2019. [DOI: 10.23736/s1824-4777.18.01398-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Cuen-Ojeda C, Bobadilla-Rosado LO, Garcia-Alva R, Arzola LH, Anaya-Ayala JE, Hinojosa CA. Left Common Femoral to Right Common Iliac Venous Bypass Through a Retroperitoneal Exposure. Vasc Specialist Int 2019; 34:117-120. [PMID: 30671421 PMCID: PMC6340695 DOI: 10.5758/vsi.2018.34.4.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 10/06/2018] [Accepted: 11/05/2018] [Indexed: 11/20/2022] Open
Abstract
The endovascular recanalization of the iliocaval system has replaced venous surgical reconstructions as the primary treatment option in severe post-thrombotic syndrome (PTS). We herein present a 51-year-old female with previous deep venous thrombosis, complicated with PTS with a large and complex circumferential calf ulcer measuring 25 cm of length in the left lower extremity. Venogram revealed a complete and extensive occlusion in the left iliofemoral system. A surgical bypass from the left common femoral vein to the right common iliac vein was performed. Patient recovered well and after 12 months postoperation her large wound is healing favorably with a clean and well granulated bed. Iliofemoral venous bypass is a feasible treatment for non-healing ulcer of lower extremity.
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Affiliation(s)
- Cesar Cuen-Ojeda
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Luis O Bobadilla-Rosado
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Ramon Garcia-Alva
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Luis H Arzola
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Javier E Anaya-Ayala
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Carlos A Hinojosa
- Department of Surgery, Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Medicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
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Milic DJ, Zivic SS, Bogdanovic DC, Golubovic MD, Lazarevic MV, Lazarevic KK. A randomized trial of class 2 and class 3 elastic compression in the prevention of recurrence of venous ulceration. J Vasc Surg Venous Lymphat Disord 2018; 6:717-723. [DOI: 10.1016/j.jvsv.2018.06.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/17/2018] [Indexed: 10/28/2022]
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Talaie T, Hansraj N, Werter C, Nagarsheth K, Monahan TS, Toursavadkohi S. Surgical Scarring after Arterial Bypass, an Etiology of Venous Hypertension. Ann Vasc Surg 2018; 52:315.e7-315.e10. [PMID: 29886209 DOI: 10.1016/j.avsg.2018.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/01/2018] [Accepted: 04/02/2018] [Indexed: 11/19/2022]
Abstract
Venous ulcers can be a chronic debilitating condition with a high rate of recurrence. Herein, we describe a case of a patient who successfully underwent an arterial bypass for rest pain but returned with lower extremity swelling and venous ulcers. Venography demonstrated a focal common femoral vein stenosis due to scarring from the surgical exposure. This was treated with endovenous stenting and resulted in resolution of the swelling and ulceration.
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Affiliation(s)
- Tara Talaie
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Natasha Hansraj
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.
| | - Christopher Werter
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Khanjan Nagarsheth
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Thomas S Monahan
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Surgery, Baltimore Veterans Affairs Medical Center, Baltimore, MD
| | - Shahab Toursavadkohi
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD; Department of Surgery, Baltimore Veterans Affairs Medical Center, Baltimore, MD
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Sanford DA, Kelly D, Rhee SJ, Stoughton J, Cantelmo NL. Importance of Phasicity in Detection of Proximal Iliac Vein Thrombosis with Venous Duplex Examination. ACTA ACUST UNITED AC 2018. [DOI: 10.1177/154431671103500305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Superficial venous reflux is commonly the cause of symptomatic venous disease, but proximal venous obstruction may also play a role. A duplex ultrasound evaluating bilateral common femoral veins can detect differences in phasicity, which may be due to pelvic venous obstruction. We report a case of a patient with recurrent symptomatic varicose veins after treatment of superficial venous reflux. Based the duplex ultrasound results of damped respiratory phasicity, the patient was diagnosed with deep venous obstruction which was confirmed on MRV.
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Affiliation(s)
| | - Donna Kelly
- Veinsolutions of North Suburban Boston, Stoneham, Massachusetts
| | - Soo J. Rhee
- Veinsolutions of North Suburban Boston, Stoneham, Massachusetts
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How I use catheter-directed interventional therapy to treat patients with venous thromboembolism. Blood 2018; 131:733-740. [PMID: 29295847 DOI: 10.1182/blood-2016-11-693663] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/19/2017] [Indexed: 12/18/2022] Open
Abstract
Patients who present with severe manifestations of acute venous thromboembolism (VTE) are at higher risk for premature death and long-term disability. In recent years, catheter-based interventional procedures have shown strong potential to improve clinical outcomes in selected VTE patients. However, physicians continue to be routinely faced with challenging decisions that pertain to the utilization of these risky and costly treatment strategies, and there is a relative paucity of published clinical trials with sufficient rigor and directness to inform clinical practice. In this article, using 3 distinct clinical scenario presentations, we draw from the available published literature describing the natural history, pathophysiology, treatments, and outcomes of VTE to illustrate the key factors that should influence clinical decision making for patients with severe manifestations of deep vein thrombosis and pulmonary embolism. The results of a recently completed pivotal multicenter randomized trial are also discussed.
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Vedantham S. Thrombectomy and thrombolysis for the prevention and treatment of postthrombotic syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:681-685. [PMID: 29222321 PMCID: PMC6142606 DOI: 10.1182/asheducation-2017.1.681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Postthrombotic syndrome (PTS) is a frequent complication of lower-extremity deep vein thrombosis (DVT), occurring in approximately 40% of patients despite the use of anticoagulant therapy. PTS causes significant impairment of patients' health-related quality of life, and no evidence-based therapies have been consistently effective. Catheter-directed thrombolysis and thrombectomy have been shown to remove acute thrombus, and it has been hypothesized they could prevent or reduce PTS. However, because these procedures can be associated with complications, mainly bleeding, randomized trial data are needed to determine when they should be used. In this article, I summarize the current status of thrombus removal procedures for DVT to provide contemporary guidance to clinicians seeking to individualize treatment decisions for their patients.
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Affiliation(s)
- Suresh Vedantham
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO
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Catheter-directed thrombolysis to avoid late consequences of acute deep vein thrombosis. Thromb Res 2017; 164:125-128. [PMID: 28844445 DOI: 10.1016/j.thromres.2017.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/12/2017] [Accepted: 08/17/2017] [Indexed: 11/22/2022]
Abstract
The application of catheter-based methods to treat acute deep vein thrombosis (DVT) has increased in recent years. Catheter-directed thrombolysis (CDT), introduced during the early 1990s, has shown the ability to rapidly eliminate thrombus and is used in many centers as a salvage therapy for DVT patients who exhibit a poor initial response to anticoagulant therapy. However, CDT has disadvantages in terms of safety and resource use. Although CDT methods have evolved substantially to try to address these issues, for most of the last 25years there was little high-quality data on CDT outcomes upon which to base patient care decisions. The paucity of evidence was particularly problematic for long-term outcomes such as recurrent venous thromboembolism (VTE) and the post-thrombotic syndrome (PTS). Fortunately, rigorous studies of CDT are now being completed. Accordingly, the purpose of this article is to: 1) state the known and unknown factors influencing risk and benefit with use of CDT and related methods to treat acute DVT; 2) summarize emerging evidence showing the patient outcomes that occur when CDT is used for first-line management of DVT; and 3) suggest clinical parameters for CDT utilization in light of the available evidence.
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Abstract
Venous thromboembolism (VTE) is a common disease (~700 per 100 000) that is associated with significant risk of recurrence, chronic complications, and substantial mortality, with reported death rates of up to 40% at 10 years. The development of novel anticoagulants has revolutionized the treatment of acute VTE, while strategies for prevention and treatment of chronic complications still seek for such a landmark change. Impaired thrombus resolution is the common denominator behind VTE complications, which are postthrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (CTEPH). PTS and CTEPH are associated with substantial morbidity and high healthcare expenses. While PTS occurs in up to 50% of patients after symptomatic deep vein thrombosis, only a small and poorly defined number of patients are diagnosed with CTEPH after pulmonary embolism. This review is a comprehensive summary of VTE-related chronic complications, their epidemiology, diagnosis, and treatment.
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Affiliation(s)
- M-P Winter
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - G H Schernthaner
- Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - I M Lang
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Lester RM, Johnson K, Khalil RE, Khan R, Gorgey AS. MRI analysis and clinical significance of lower extremity muscle cross-sectional area after spinal cord injury. Neural Regen Res 2017; 12:714-722. [PMID: 28616021 PMCID: PMC5461602 DOI: 10.4103/1673-5374.206634] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2017] [Indexed: 12/11/2022] Open
Abstract
Shortly after spinal cord injury (SCI), the musculoskeletal system undergoes detrimental changes in size and composition, predominantly below the level of injury. The loss of muscle size and strength, along with increased immobility, predisposes persons with SCI to rapid and severe loss in bone mineral density and other health related consequences. Previous studies have highlighted the significance of measuring thigh muscle cross-sectional area, however, measuring the size and composition of muscles of the lower leg may provide insights on how to decrease the risk of various comorbidities. The purpose of the current review was to summarize the methodological approach to manually trace and measure the muscles of the lower leg in individuals with SCI, using magnetic resonance imaging. We also intend to highlight the significance of analyzing lower leg muscle cross-sectional area and its relationship to musculoskeletal and vascular systems in persons with SCI.
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Affiliation(s)
- Robert M. Lester
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veterans Administration Medical Center (VAMC), Richmond, VA, USA
| | - Kori Johnson
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veterans Administration Medical Center (VAMC), Richmond, VA, USA
| | - Refka E. Khalil
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veterans Administration Medical Center (VAMC), Richmond, VA, USA
| | - Rehan Khan
- Radiology Service, Hunter Holmes McGuire Veterans Administration Medical Center (VAMC), Richmond, VA, USA
| | - Ashraf S. Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veterans Administration Medical Center (VAMC), Richmond, VA, USA
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
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The value of near-infrared spectroscopy for the assessment of calf muscle function in venous patients. J Vasc Surg Venous Lymphat Disord 2017; 5:244-253. [PMID: 28214493 DOI: 10.1016/j.jvsv.2016.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 01/14/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Near-infrared spectroscopy (NIRS) is a noninvasive technique with the potential to determine the degree of tissue oxygenation. The aim of the current study was to investigate the use of NIRS as a reliable method of detecting calf muscle pump dysfunction in groups of patients with venous disease. METHODS Patients with superficial venous insufficiency (SVI) or history of deep venous thrombosis (DVT) were classified according to the comprehensive classification system for chronic venous disorders (clinical class, etiology, anatomy, and pathophysiology) and compared with controls (GROUP variable). A 10-stage evaluation of ambulatory venous function was performed, and corresponding values of calf regional oxygen saturation (crSaO2, %) at each phase were recorded (TIME variable). Thereafter, the percentage changes of crSaO2 values (Δ scores, %) between a given phase and the reference phase were estimated. Differences among groups and phases were evaluated using analysis of variance. Subgroup analysis between C0-C2 and C3-C6 patients was performed. The receiver operating characteristic curve analysis was used to detect the best predictive capability for SVI and DVT. RESULTS A total of 30 patients with SVI, 31 patients with DVT, and 34 controls were included in the study. A statistically significant effect of TIME (F = 382.4; P < .001) and TIME × GROUP interaction (F = 6.3; P < .001) was recorded. Concerning prediction, we found a statistically significant area under the curve (AUC) for SVI (AUC = 0.72; 95% confidence interval, 0.58-0.83; P = .003) and for DVT (AUC = 0.83; 95% confidence interval, 0.71-0.92; P < .0001) patients. CONCLUSIONS The measurement of crSaO2 using NIRS detected alterations in calf muscle pump oxygenation during exercise and differences in tissue oxygenation among SVI patients, DVT patients, and controls. NIRS may represent a reliable noninvasive tool for the study of calf muscle dysfunction in venous disease and a useful vehicle for generating testable hypotheses in the laboratory setting.
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Potério-Filho J, Silveira SAF, Potério GMB, Fecuri RJ, de Almeida FHM, Menezes FH. The Effect of Walking With High-Heeled Shoes on the Leg Venous Pressure. Angiology 2016; 57:424-30. [PMID: 17022377 DOI: 10.1177/0003319706290744] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
It is common belief that the use of high-heeled shoes is deleterious to venous return, by impairing the efficiency of the muscular calf pump. Ambulatory venous pressure obtained with dorsal foot venipuncture is the gold standard in the evaluation of venous pressure during walking, but it is not routinely used in clinical practice. The objective of the present study was to determine the variations in leg venous pressure obtained with a new noninvasive method, in individuals without venous disease, walking without shoes and wearing high-heeled shoes. A new method of evaluation of the venous pressure by means of air plethysmography was applied to 10 volunteers (20 limbs). The patients were evaluated while standing, with ortho-static flexion and extension foot movements, and while walking on a treadmill barefooted and wearing high-heeled shoes. It was found that the variation on the cuff pressure during walking with high-heeled shoes was higher than the variation on the cuff pressure walking barefooted (52.2 ±8.89 x 26.65 ±6.7 mm Hg, p<0.0001), and the final hydrostatic venous pressure was lower (51.5 ±12.78 x 61.5 ±8.44 mm Hg). The use of high-heeled shoes increases muscular effort during walking and diminishes the leg venous pressure compared with barefooted.
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Labropoulos N, Patel PJ, Tiongson JE, Pryor L, Leon LR, Tassiopoulos AK. Patterns of Venous Reflux and Obstruction in Patients With Skin Damage Due to Chronic Venous Disease. Vasc Endovascular Surg 2016; 41:33-40. [PMID: 17277241 DOI: 10.1177/1538574406296246] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Identified were characteristics of individuals with skin damage related to chronic venous disease. Patients with chronic venous disease (n = 164) were evaluated with duplex ultrasound imaging and were placed in classes 4, 5, and 6 according to the CEAP classification. Their findings were compared with 100 class 2 controls. The prevalence of deep venous thrombosis was higher in the study group (23.7%) versus controls (5.1%; P < .0001), as was the prevalence of deep, perforator, and combined patterns of disease ( P < .0001, P < .0007, and P < .0001). The mean duration of disease in controls 2 was shorter compared with the study group ( P = .0019). The prevalence of reflux and obstruction within the study group was higher than in controls ( P = .0021). Skin changes accurately reflect severity of chronic venous disease. Superficial and perforator vein reflux is the major cause of disease.
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Affiliation(s)
- Nicos Labropoulos
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA.
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Matsuda H, Ota T, Okada M. Foot Venous Pressure Measurement in Patients with Varicose Veins. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/153857449402800702] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
For the evaluation of the severity of varicose veins, foot venous pressure (FVP) measurements utilizing manual calf compression were applied to 52 limbs with varicose veins (group V) and 12 limbs of healthy volunteers (group C). Group V was divided into three groups: group V1 comprising 37 limbs without stasis syndrome, group V2 comprising 9 limbs with pigmentation, and group V3 comprising 6 limbs with preulcerative or ulcerative skin change. First, comparison of manual calf compression with the toe-stand test was performed, wherein a higher reproducibility was revealed for subjects undergoing manual calf compression. Also, a lower ambulatory venous pressure (AVP) and a higher percentage of FVP drop (%drop = [pressure at rest-AVP]/pressure at rest) was obtained with manual calf compression, confirming that this method apparently emptied the calf venous pool. Based on these findings, FVP at four seconds after compression (4SP) and its ratio of increase (4SR% = [4SP - AVP] / [pressure at rest - AVP]) were instituted by use of this method, in addition to AVP, % drop, and 50%/90% of calf-refilling times (RT50/RT90). When the values of the four groups were compared, differences were insignificant between groups C and V1, while significant differences were found between groups V2 (continued on next page) (Abstract continued) or V3 and groups C or V1 in all parameters examined. The number of abnormal limbs that had values beyond the ranges for group C increased from group V1 to group V3. Such abnormalities were best revealed by 4SR% and RT50. In the postoperative FVP measurements of 17 limbs, all parameters of all limbs were restored to the normal range, except for % drop of 4 limbs, and 4SR%, RT50, and RT90 of 1 limb. Based on these findings, all parameters examined in this study were considered to be sufficient for the evaluation of the severity of varicose veins. In particular, 4SR% and RT50, which reflect venous reflux in the early venous refilling phase, were the best diagnostic parameters. The usefulness of FVP measurement utilizing manual calf compression and the significance of the early phase of venous refilling in the varicose veins limbs were confirmed.
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Affiliation(s)
- Hitoshi Matsuda
- Department of Surgery, Division , Kobe University School of Medicine, Kobe, Japan
| | - Toshiaki Ota
- Department of Surgery, Division , Kobe University School of Medicine, Kobe, Japan
| | - Masayoshi Okada
- Department of Surgery, Division , Kobe University School of Medicine, Kobe, Japan
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Lazarides M, Giannoukas A. The Role of Hemodynamic Measurements in the Management of Venous and Ischemic Ulcers. INT J LOW EXTR WOUND 2016; 6:254-61. [DOI: 10.1177/1534734607306878] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is a need for quantitative investigations in the vascular laboratory to manage lower extremity ulcers. The majority of leg ulcers are of venous (45%-60%) or arterial origin (10%-20%). Despite the increasing complexity of new devices used in vascular surgical practice, the anklebrachial pressure index (ABPI) remains the cornerstone for the differential diagnosis of ischemic ulcers. The toe-brachial pressure index and the pole test represent attractive alternative tests especially in patients with diabetes. Color flow Doppler imaging (CFDI) is advantageous over ABPI in cases in which wounds and ulcers prevent the use of a cuff by virtue of their size or location; additionally CFDI technology can detect nonflow limiting lesions, lesions to nonaxial arteries such as the deep femoral artery, or lesions limited to a single tibial artery. Continued improvements in the accuracy of CFDI have prompted some vascular surgeons to replace contrast arteriography in distal bypass procedures. Transcutaneous partial oxygen tension measurement (TcPO2) is another noninvasive method that is reliable to select the level of amputation and recommended to determine tissue viability in critically ischemic limbs and in the management of the diabetic foot. CFDI has revolutionized the diagnostic approach to venous disorders and it is considered the gold standard for the assessment of the venous system of the lower limb, causes minimal inconvenience to patients, and is easily repeatable, but it is considered highly operator dependent. Various plethysmography techniques are of limited application in ulcer investigations, because of their difficulty to calibrate signal, unless time measurements such as the postexercise refilling time are used.
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Affiliation(s)
- M.K. Lazarides
- Department of Vascular Surgery, Demokritos University,
Alexandroupolis,
| | - A.D. Giannoukas
- Department of Vascular Surgery, University of Thessaly,
Larissa, Greece
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Yamaki T, Nozaki M, Sasaki K. Preliminary Report of a New Approach to Sparing the Greater Saphenous Vein for Grafting: Valvuloplasty Combined with Axial Transposition of a Competent Tributary Vein. J Endovasc Ther 2016; 8:188-96. [PMID: 11357981 DOI: 10.1177/152660280100800215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose: To compare a new vessel-sparing technique combining valvuloplasty with axial transposition of a competent tributary vein versus single valvuloplasty for the treatment of greater saphenous vein (GSV) incompetence. Methods: In 55 patients with GSV incompetence, 29 of 57 limbs were treated by angioscopic valvuloplasty of the subterminal valve alone, whereas the remaining 28 limbs underwent angioscopic valvuloplasty combined with axial transposition of a competent tributary vein identified preoperatively by duplex scanning. After angioscopic valvuloplasty in the latter group, the competent tributary vein was exposed and cut 1.5 cm distal to its insertion point on the GSV. The transected vein was anastomosed end to side to the GSV, which was ligated between the tributary insertion site and the anastomosis. Changes in venous hemodynamics, including venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF), were analyzed by use of air plethysmography. Results: In the 1-year follow-up, no venous thrombosis was detected in either group. In the valvuloplasty-only group, 22 (75.9%) limbs exhibited reflux in the proximal GSV; recurrent varicose veins were detected in 5 (17.2%) limbs. In contrast, only 2 (7.1%) limbs showed reflux in the valvuloplasty + transposition group. There were no significant differences in EF and RVF between the groups before or after the operation, although a significant difference was seen in VFI at 1 year (p = 0.005, Wilcoxon rank sum test). Conclusions: Valvuloplasty combined with tributary vein transposition gives a better result than valvuloplasty alone at 1 year. This new treatment option may be useful for both reducing the rate of varicose veins and sparing the GSV for grafting.
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Affiliation(s)
- T Yamaki
- Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Japan.
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Vayssairat M, Chakkour K, Gouny P, Taccoen A, Cheynel C, Baudot N, Nussaume O. Ambulatory Venous Pressure and Leg Volume Measurements before and after Surgery for Primary Varicose Veins. Phlebology 2016. [DOI: 10.1177/026835559701200303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To compare clinical disability, ambulatory venous pressure (AVP) and leg volume before and after venous surgery, and to relate the changes to those observed after one night preoperative in-hospital rest. Design: Prospective study. Setting: Department of Vascular Surgery, University Hospital, Paris, France. Subjects: Nineteen patients with primary varicose veins and mild chronic venous insufficiency (CVI), scheduled for venous surgery. Main outcome measures: Clinical disability recorded by the analogue scale method, and leg volume and AVP measurements. These evaluations were repeated three times: on the day before surgery, in the afternoon; in the early morning on the day of surgery; and 2 months after surgery, in the afternoon. Results: Varicose vein surgery improved disability ( p = 0.001) and two AVP parameters: recovery time (RT, p = 0.0049) and the calf muscle pump index (CMPI), which rose by 345% (95% confidence intervals: 29, 659). Preoperative supine rest for one night improved disability ( p = 0.0016) and reduced leg volume ( p = 0.0002). The improvements induced by surgery correlated with the changes induced by rest, for disability ( p = 0.016), RT ( p = 0.006) and CMPI ( p = 0.033). Conclusion: Surgery improves venous function in patients with primary varicose veins. AVP remains a standard method of evaluating CVI. Combined with volumetry, it allows sensitive comparisons between different treatments. Because venous function varies greatly with daily activity, it is imperative to standardize the times at which venous function is evaluated.
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Affiliation(s)
- M. Vayssairat
- Department of Vascular Surgery, Tenon Hospital, Paris, France
| | - K. Chakkour
- Department of Vascular Surgery, Tenon Hospital, Paris, France
| | - P. Gouny
- Department of Vascular Surgery, Tenon Hospital, Paris, France
| | - A. Taccoen
- Department of Vascular Surgery, Tenon Hospital, Paris, France
| | - C. Cheynel
- Department of Vascular Surgery, Tenon Hospital, Paris, France
| | - N. Baudot
- Department of Vascular Surgery, Tenon Hospital, Paris, France
| | - O. Nussaume
- Department of Vascular Surgery, Tenon Hospital, Paris, France
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Neglén P. Chronic Venous Obstruction: Diagnostic Considerations and Therapeutic Role of Percutaneous Iliac Stenting. Vascular 2016; 15:273-80. [DOI: 10.2310/6670.2007.00071] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Iliac venous outflow obstruction has an important role in the expression of symptomatic chronic venous insufficiency. This anatomic obstruction is frequently overlooked, owing in part to diagnostic difficulty. The combination of venous obstruction and reflux leads to more severe clinical disease. Current diagnostic modalities do not allow an definitive assessment of hemodynamically critical venous obstruction. No single invasive or noninvasive study can accurately detect borderline obstruction of potential hemodynamic significance. A high index of suspicion is critical in the initial recognition of chronic venous obstruction. The diagnosis relies on clinical signs and symptoms and radiologic assessment of morphologic venous outflow obstruction. Treatment strategy should be based on the results of morphologic investigations such as transfemoral phlebography or, preferably, intravascular ultrasonography. Percutaneous iliac venous stenting offers a safe and efficient method to correct pelvic venous obstruction. Percutaneous iliac stenting does not preclude subsequent venous bypass or corrective superficial and deep reflux surgery. This article reviews the etiologic factors and diagnostic modalities of iliac venous obstruction. The therapeutic role of percutaneous iliac stenting in the management of venous obstruction is also discussed.
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Classification and Grading of Chronic Venous Disease in the Lower Limbs: A Consensus Statement. Phlebology 2016. [DOI: 10.1177/026835559501000202] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Janssen MCH, Wollersheim H, van Asten WNJC, de Rooij MJM, Nováková IRO, Thien T. The Post-Thrombotic Syndrome: A Review. Phlebology 2016. [DOI: 10.1177/026835559601100302] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: A review of the published data on epidemiology, pathophysiology, diagnostic techniques and prevention of the post-thrombotic syndrome (PTS). Study selection: Studies, published between 1966 and 1996, identified through the medline database, and references cited in identified articles were included. Data synthesis: Deep venous thrombosis (DVT) may cause outflow obstruction and valve incompetence, resulting in venous hypertension. PTS is probably the effect of venous hypertension on the microcirculation. For qualitative anatomical and functional assessment of the venous system, duplex scanning is required, and for quantitative functional assessment, plethysmographic methods are the most suitable. The best treatment of PTS is its prevention by optimizing diagnosis and treatment of DVT and by prescribing and wearing elastic compression stockings. Until valid follow-up studies have been performed, distal DVT should not be neglected when assessing the PTS risk. Conclusions: PTS is a serious problem in terms of prevalence, complications (venous ulcers) and treatment with considerable socio-economic consequences. Duplex and plethysmography are valuable tools in its diagnosis and might be appropriate to identify patients at risk of developing PTS.
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Affiliation(s)
- M. C. H. Janssen
- Department of General Internal Medicine, University Hospital Nijmegen, Nijmegen, The Netherlands
| | - H. Wollersheim
- Department of General Internal Medicine, University Hospital Nijmegen, Nijmegen, The Netherlands
| | - W. N. J. C. van Asten
- Department of Clinical Vascular Laboratory, University Hospital Nijmegen, Nijmegen, The Netherlands
| | - M. J. M. de Rooij
- Department of Dermatology, University Hospital Nijmegen, Nijmegen, The Netherlands
| | - I. R. O. Nováková
- Department of Haematology, University Hospital Nijmegen, Nijmegen, The Netherlands
| | - Th. Thien
- Department of General Internal Medicine, University Hospital Nijmegen, Nijmegen, The Netherlands
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Kurstjens RLM, de Wolf MAF, Konijn HW, Toonder IM, Nelemans PJ, de Graaf R, Wittens CHA. Intravenous pressure changes in patients with postthrombotic deep venous obstruction: results using a treadmill stress test. J Thromb Haemost 2016; 14:1163-70. [PMID: 27061685 DOI: 10.1111/jth.13333] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 04/02/2016] [Indexed: 11/30/2022]
Abstract
UNLABELLED Essentials Little is known about the hemodynamic consequences of deep venous obstructive disease. We investigated pressure changes in 22 patients with unilateral postthrombotic obstruction. Common femoral vein pressure significantly increased after walking, compared to control limbs. Common femoral vein hypertension could explain the debilitating effect of venous claudication. Click to hear Dr Ten Cate's perspective on postthrombotic syndrome SUMMARY Background Little is known about the hemodynamic consequences of deep venous obstructive disease. Objectives The aim of this study was to investigate the hemodynamic effect of postthrombotic obstruction of the iliofemoral veins and to determine what pressure parameters differentiate best between limbs with post-thrombotic obstructive disease of the iliofemoral veins and those without obstruction. Methods Twenty-two participants with unilateral obstruction of the iliac and common femoral veins underwent a standardized treadmill test with simultaneous bilateral invasive pressure measurements in the common femoral vein and dorsal foot vein. Results Mean age was 42.8 ± 11.9 years and 86.4% of participants were female. Postthrombotic limbs showed a mean common femoral vein (CFV) pressure increase of 28.1 ± 21.0 mmHg after walking, compared with 2.1 ± 6.2 mmHg in control limbs (26.0 mmHg difference; 95% confidence interval [CI], 17.1-34.9). Less difference was observed in the dorsal foot vein (net drop of 36.8 ± 22.7 mmHg in affected limbs vs. 48.7 ± 23.1 mmHg in non-affected limbs, 11.9 mmHg difference; 95% CI, -1.3 to 25.0). Change in CFV pressure after walking yielded the best discrimination between affected and non-affected limbs (area under the receiver operated characteristic curve of 0.94 [95% CI, 0.85-1.00], compared with 0.57 [95% CI, 0.37-0.76] in the dorsal foot vein, P < 0.001). Conclusions Common femoral vein pressure significantly increases during ambulation in patients with iliofemoral postthrombotic obstruction, which could explain the debilitating effects of venous claudication. This is an indication that patients with an iliofemoral obstruction may benefit from further treatment that resolves the deep vein obstruction. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov/show/NCT01846780.
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Affiliation(s)
- R L M Kurstjens
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - M A F de Wolf
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - H W Konijn
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - I M Toonder
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - P J Nelemans
- Department of Epidemiology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - R de Graaf
- Department of Radiology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - C H A Wittens
- Department of Vascular Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
- Department of Vascular Surgery, University Hospital Aachen, Aachen, Germany
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Abstract
Abstract
Venous thromboembolism (VTE) continues to represent a major source or mortality and morbidity. Although anticoagulation is the mainstay of therapy, adjunctive catheter-based interventions have shown substantial potential to improve clinically meaningful patient outcomes in patients with deep vein thrombosis (DVT), pulmonary embolism (PE), and the post-thrombotic syndrome (PTS). Catheter-directed thrombolysis (CDT) has been shown in a randomized trial to reduce the risk of PTS in patients with acute proximal DVT; data from a larger NIH trial is expected shortly. The use of CDT is being increasingly used for patients with submassive or massive pulmonary embolism. Preliminary studies suggest that endovascular stent placement and ablative therapies can improve quality-of-life in carefully selected patients with established PTS. In this article, we summarize the current status of thrombus removal and stent placement procedures for VTE and PTS, with the main purpose being to guide clinicians in individualizing treatment decisions for their challenging patients.
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Sista AK, Vedantham S, Kaufman JA, Madoff DC. Endovascular Interventions for Acute and Chronic Lower Extremity Deep Venous Disease: State of the Art. Radiology 2015; 276:31-53. [PMID: 26101920 DOI: 10.1148/radiol.2015132603] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The societal and individual burden caused by acute and chronic lower extremity venous disease is considerable. In the past several decades, minimally invasive endovascular interventions have been developed to reduce thrombus burden in the setting of acute deep venous thrombosis to prevent both short- and long-term morbidity and to recanalize chronically occluded or stenosed postthrombotic or nonthrombotic veins in symptomatic patients. This state-of-the-art review provides an overview of the techniques and challenges, rationale, patient selection criteria, complications, postinterventional care, and outcomes data for endovascular intervention in the setting of acute and chronic lower extremity deep venous disease. Online supplemental material is available for this article.
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Affiliation(s)
- Akhilesh K Sista
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - Suresh Vedantham
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - John A Kaufman
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
| | - David C Madoff
- From the Department of Radiology, Weill Cornell Medical College, 525 E 68th St, P-518, New York, NY 10065 (A.K.S., D.C.M.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.V.); and Dotter Interventional Institute, Oregon Health and Science Center, Portland, Ore (J.A.K.)
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50
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Abstract
Advances in image-guided, catheter-based interventions have shown great potential to improve outcomes in patients with venous thromboembolism. Catheter-directed thrombolysis has been shown in one randomized controlled trial to reduce the risk of post-thrombotic syndrome in patients with acute lower extremity deep vein thrombosis; data from a larger national institute of health trial are expected in early 2017. The use of catheter-directed thrombolysis is also being increasingly considered for patients with submassive or massive pulmonary embolism. Preliminary studies suggest that endovascular stent placement and ablative therapies may be used to reduce symptoms and improve quality of life in severely affected patients with established post-thrombotic syndrome. In this article, we summarize the risks and benefits of endovascular venous thromboembolism therapies as currently understood, highlight clinical situations where their benefit may outweigh risks, and describe ongoing and upcoming pivotal research initiatives with multidisciplinary participation.
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Affiliation(s)
- S Vedantham
- Interventional Radiology Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
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