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Cardoso DL, de Macedo BA, Neto RM, Cardoso MTL, Marciano L, de Pádua Gomes de Farias L, Araújo Filho JAB, Cerri GG, Azambuja RL, Vieira TDR. Abdominal vascular compression syndromes: A pictorial review. Eur J Radiol 2025; 189:112169. [PMID: 40393099 DOI: 10.1016/j.ejrad.2025.112169] [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: 01/23/2025] [Revised: 04/16/2025] [Accepted: 05/13/2025] [Indexed: 05/22/2025]
Abstract
Abdominal vascular compression syndromes (AVCS) refer to the entrapment of blood vessels between surfaces in a restricted space, a phenomenon that may cause clinical manifestations and can be identified using imaging methods. Although uncommon, their hemodynamic repercussions may lead to potential morbidity and should therefore be recognized by radiologists, who play a crucial role in diagnosing these conditions. Contrast-enhanced computed tomography (CECT) is the imaging modality of choice, primarily valued for its precision in identifying anatomical abnormalities, thereby facilitating appropriate management and reducing the risk of subsequent complications. Follow-up may range from conservative to invasive approaches, including surgical and endovascular procedures. This pictorial review focuses on the main imaging patterns of AVCS. Our objective is to enhance radiologists' ability to discern abdominal vascular anatomy, its interrelations with neighboring structures and its variants, and assist in the analysis of potential etiologies and pathophysiological mechanisms associated with these anomalies.
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Affiliation(s)
- Daniel L Cardoso
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 115 - Bela Vista, São Paulo, SP 01308-050, Brazil.
| | - Beatriz A de Macedo
- São Camilo Hospital, R. Costa Barros, 833 - Centro, Fortaleza, CE 60160-280, Brazil
| | - Roddie M Neto
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 115 - Bela Vista, São Paulo, SP 01308-050, Brazil
| | - Maria Tereza L Cardoso
- Department of Medicine, Unichristus, Rua João Adolfo Gurgel, 133 - Cocó, Fortaleza, CE 60190-180, Brazil
| | - Larissa Marciano
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 115 - Bela Vista, São Paulo, SP 01308-050, Brazil
| | | | - José A B Araújo Filho
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 115 - Bela Vista, São Paulo, SP 01308-050, Brazil
| | - Giovanni G Cerri
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 115 - Bela Vista, São Paulo, SP 01308-050, Brazil
| | - Rodrigo L Azambuja
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 115 - Bela Vista, São Paulo, SP 01308-050, Brazil
| | - Thiago D R Vieira
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 115 - Bela Vista, São Paulo, SP 01308-050, Brazil
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Wang Z, Zhu J, Jiang M, Zhong X, Cheng Y, Chen G, Sheng Y, Wu J, Gao J, Wang W, Xu Y. Preliminary Study of Noncontrast-Enhanced Magnetic Resonance Imaging for the Diagnosis and Management Iliac Venous Compression Syndrome. Ann Vasc Surg 2025; 121:57-64. [PMID: 40441428 DOI: 10.1016/j.avsg.2025.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2025] [Revised: 03/27/2025] [Accepted: 05/10/2025] [Indexed: 06/16/2025]
Abstract
BACKGROUND The purpose of this study was to determine the technical feasibility and safety of noncontrast-enhanced magnetic resonance imaging (MRI) in the diagnosis and management of iliac vein compression syndrome (IVCS) compared with 3-dimensional rotational venography (3D-RV). METHODS The general epidemiological data (including age and gender), clinical manifestations (including major symptom; affected extremity; clinical, etiology, anatomy, and pathophysiology classification; comorbidity; stenosis rate; and Valletta score), and intraoperative findings (collateral vessels present or absent) of 39 IVCS patients who were assessed by both noncontrast-enhanced MRI and 3D-RV between January 2018 and January 2022 were obtained and analyzed. RESULTS The iliac vein stenosis rate determined by noncontrast-enhanced MRI and 3D-RV was 79.09 ± 1.57% vs. 80.06 ± 1.62%, respectively (P = 0.13). With the aggravation of Villalta score, the detection rate of both noncontrast-enhanced MRI and 3D-RV for collateral vessels present increased significantly. Compared with 3D-RV, noncontrast-enhanced MRI is more sensitive for the detection of collateral vessels present in early chronic venous disease (P = 0.03). Of these patients, 20 patients were treated with MR images fusion navigation, and 19 patients were treated with 3D venography images fusion navigation during endovascular management. Significant differences were observed between the noncontrast-enhanced MRI and 3D-RV groups concerning X-ray dose (1,695 ± 36.01 mGy vs. 2,820 ± 23.06 mGy; P < 0.001) and contrast agent dosage (49.25 ± 1.02 mL vs. 83.79 ± 2.75 mL; P < 0.001). CONCLUSION Noncontrast-enhanced MRI is a quick, efficient, and accurate noninvasive technique for the evaluation and diagnosis of IVCS. In addition to providing the required anatomic information to make the diagnosis of IVCS, it also provides all this intraoperative "roadmap" for possible endovascular management of IVCS.
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Affiliation(s)
- Zhu Wang
- Binzhou Medical University Hospital, Binzhou City, P.R. China
| | - Jiahao Zhu
- Binzhou Medical University Hospital, Binzhou City, P.R. China; School of Medical Imaging (Binzhou Medical University), Binzhou City, P.R. China
| | - Mengxin Jiang
- Binzhou Medical University Hospital, Binzhou City, P.R. China
| | - Xiaofei Zhong
- Binzhou Medical University Hospital, Binzhou City, P.R. China
| | - Yongjia Cheng
- Binzhou Medical University Hospital, Binzhou City, P.R. China
| | - Gang Chen
- Binzhou Medical University Hospital, Binzhou City, P.R. China
| | - Yuguo Sheng
- Binzhou Medical University Hospital, Binzhou City, P.R. China
| | - Jian Wu
- Binzhou Medical University Hospital, Binzhou City, P.R. China
| | - Jianwei Gao
- Binzhou Medical University Hospital, Binzhou City, P.R. China
| | - Wenming Wang
- Binzhou Medical University Hospital, Binzhou City, P.R. China
| | - Yingjiang Xu
- Binzhou Medical University Hospital, Binzhou City, P.R. China.
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Chen L, Li DL, Zheng HF, Qiu CZ. Deep learning and radiomics-driven algorithm for automated identification of May-Thurner syndrome in Iliac CTV imaging. Front Med (Lausanne) 2025; 12:1526144. [PMID: 40365495 PMCID: PMC12069258 DOI: 10.3389/fmed.2025.1526144] [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: 11/11/2024] [Accepted: 03/24/2025] [Indexed: 05/15/2025] Open
Abstract
Objective This research aimed to create a dataset of Iliac CTV scans for automated May-Thurner syndrome (MTS) detection using deep learning and radiomics. In addition, it sought to establish an automated segmentation model for Iliac Vein CTV scans and construct a radiomic signature for MTS diagnosis. Methods We collected a dataset of 490 cases meeting specific inclusion and exclusion criteria, anonymized to comply with HIPAA regulations. Iliac Vein CTV scans were prepared with contrast agent administration, followed by image acquisition and evaluation. A deep learning-based segmentation model, UPerNet, was employed using 10-fold cross-validation. Radiomic features were extracted from the scans and used to construct a diagnostic radiomic signature. Statistical analysis, including Dice values and ROC analysis, was conducted to evaluate segmentation and diagnostic performance. Results The dataset consisted of 201 positive cases of MTS and 289 negative cases. The UPerNet segmentation model exhibited remarkable accuracy in identifying MTS regions. A Dice coefficient of 0.925 (95% confidence interval: 0.875-0.961) was observed, indicating the precision and reliability of our segmentation model. Radiomic analysis produced a diagnostic radiomic signature with significant clinical potential. ROC analysis demonstrated promising results, underscoring the efficacy of the developed model in distinguishing MTS cases. The radiomic signature demonstrated strong diagnostic capabilities for MTS. Within the training dataset, it attained a notable area under the curve (AUC) of 0.891, with a 95% confidence interval ranging from 0.825 to 0.956, showcasing its effectiveness. This diagnostic capability extended to the validation dataset, where the AUC remained strong at 0.892 (95% confidence interval: 0.793-0.991). These results highlight the accuracy of our segmentation model and the diagnostic value of our radiomic signature in identifying MTS cases. Conclusion This study presents a comprehensive approach to automate MTS detection from Iliac CTV scans, combining deep learning and radiomics. The results suggest the potential clinical utility of the developed model in diagnosing MTS, offering a non-invasive and efficient alternative to traditional methods.
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Affiliation(s)
- Lufeng Chen
- Department of Thoracic and Cardiovascular Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Dong-Lin Li
- Department of Thoracic and Cardiovascular Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Hua-Feng Zheng
- Department of Thoracic and Cardiovascular Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Cheng-Zhi Qiu
- Department of General Surgery, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
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Lecoq S, Petit Q, Cronier N, Henni S, Noury B, Abraham P. Extreme variability of vascular responses to slightly different abduction angles during abduction and external rotation tests, in patients with suspected thoracic outlet syndrome. Physiol Meas 2025; 46:045003. [PMID: 40101358 DOI: 10.1088/1361-6579/adc239] [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: 10/24/2024] [Accepted: 03/18/2025] [Indexed: 03/20/2025]
Abstract
Objective.Patients may not always perform a perfect 90° upper limb abduction when doing an abduction, external rotation test for the evaluation of thoracic outlet syndrome (TOS). We aimed to study the vascular responses to three slightly different abduction angles.Approach.We recorded fingertip arterial (A-PPG) and forearm venous (V-PPG) photo-plethysmography in 111 patients referred for suspicion or follow up of TOS. The measurements were made bilaterally during a 30 s surrender position, followed by moving elbows in the frontal plane without changing elbow and hand level to open the costo-clavicular angle (prayer position) to standardize venous results, either: slightly below (<90°), at the same level of (∼90°), or slightly above (>90°) the shoulder level, in a random order.Main results.With abnormal results defined as A-PPG <5%rest and V-PPG < 70%max in the surrender position, 54 of the 222 upper limbs were normal at all three tests. The proportion of abnormal tests decreased with the increase in abduction angle (CochranQ< 0.05), 135 upper limbs showed impaired venous outflow for one (n= 74), two (n= 47) or the three angles (n= 14) without arterial inflow impairment at any of the three tests.Significance.Slight changes from a 'perfect' 90° abduction angle gave unreliable results during elevation, abduction, external rotation stress tests. A venous outflow impairment should probably be considered a physiologic response at <90° abduction.
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Affiliation(s)
- Simon Lecoq
- Vascular Medicine, University Hospital, Angers, France
- Sports and exercise Medicine, University Hospital, Angers, France
| | - Quentin Petit
- Sports and exercise Medicine, University Hospital, Angers, France
- APCoSS, Université catholique de l'ouest-Institut de Formation en Education Physique et Sport d'Angers, Angers, France
| | - Nathan Cronier
- Sports and exercise Medicine, University Hospital, Angers, France
- APCoSS, Université catholique de l'ouest-Institut de Formation en Education Physique et Sport d'Angers, Angers, France
| | - Samir Henni
- Vascular Medicine, University Hospital, Angers, France
- LUNAM University, Angers, France
- UMR CNRS 1083 INSERM 6214, Angers, France
| | - Benedicte Noury
- APCoSS, Université catholique de l'ouest-Institut de Formation en Education Physique et Sport d'Angers, Angers, France
| | - Pierre Abraham
- Vascular Medicine, University Hospital, Angers, France
- Sports and exercise Medicine, University Hospital, Angers, France
- LUNAM University, Angers, France
- UMR CNRS 1083 INSERM 6214, Angers, France
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Sekiryu T, Sugano Y, Itagaki K, Honjo J, Kato Y, Mukai R. Three-Dimensional Characteristics of Choroidal Vasculature Associated With Filling Delay in Central Serous Chorioretinopathy. Invest Ophthalmol Vis Sci 2025; 66:33. [PMID: 40232714 PMCID: PMC12007680 DOI: 10.1167/iovs.66.4.33] [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: 05/21/2024] [Accepted: 02/09/2025] [Indexed: 04/16/2025] Open
Abstract
Purpose The purpose of this study was to investigate circulatory disorders in central serous chorioretinopathy (CSC), we analyzed the three-dimensional (3D) structure of the choroidal vessels in filling delays seen on indocyanine green angiography (ICGA) images. Methods We conducted structural optical coherence tomography (structural OCT) and OCT angiography (OCTA) with swept-source OCT (SS-OCT) and ICGA in 30 eyes with CSC. We aligned the en face z-projection images of structural OCT with the venous-phase ICGA images by incorporating deformation adjustments. Image-enhancement processes, including attenuation correction and local contrast enhancement, were applied to the structural OCT and OCTA images to improve visibility of deep choroidal structures. We used public-domain 3D image analysis software to examine choroidal structures in venous-phase filling delays. Results In the inner Haller's layer, structural OCT images showed occult vessels, that is, dilated blood vessels not delineated by ICGA in the filling delay region in 22 eyes (73%). These vessels had lower signal intensity than the surrounding blood vessels in both structural OCT and OCTA images. In the outer Haller's layer of the filling delay area, the entry points of penetrating vessels were detected in 29 eyes (97%), and direct intersections with penetrating vessels were seen in 7 (33%) of 22 eyes showing occult vessels. Late-phase ICGA images showed hyperpermeability corresponding to the filling delays. Angle and mean curvature at the entry point of the penetrating vessel increased in CSC, especially in the filling delay (P < 0.001). Conclusions In CSC, dilated vessels not visible on ICGA are present in areas with venous-phase filling delays. Alterations in the choroidal arterioles may contribute to the formation of these vessels.
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Affiliation(s)
- Tetsuju Sekiryu
- Department of Ophthalmology, Fukushima Medical University, Fukushima, Japan
| | - Yukinori Sugano
- Department of Ophthalmology, Fukushima Medical University, Fukushima, Japan
| | - Kanako Itagaki
- Department of Ophthalmology, Fukushima Medical University, Fukushima, Japan
| | - Junichiro Honjo
- Department of Ophthalmology, Fukushima Medical University, Fukushima, Japan
| | - Yutaka Kato
- Department of Ophthalmology, Fukushima Medical University, Fukushima, Japan
| | - Ryo Mukai
- Department of Ophthalmology, Fukushima Medical University, Fukushima, Japan
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Gavrilov S, Bredikhin R, Akhmetzyanov R, Grishenkova A, Apkhanova T, Burenchev D, Efremova O, Ilyukhin E, Kamaev A, Konchugova T, Kulchitskaya D, Mishakina N, Pryadko S, Rachin A, Seliverstov E, Sonkin I, Soroka V, Fomina E, Shimanko A, Tsukanov Y, Kirienko A, Sazhin A, Stoyko Y, Suchkov I, Zolotukhin I. Pelvic Varicose Veins in Women. Russian Experts Consensus. JOURNAL OF VENOUS DISORDERS 2025; 19:63. [DOI: 10.17116/flebo20251901163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2025]
Abstract
Pelvic Varicose Veins in Women. Russian Experts Consensus.
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Quadri RS. Central Venous Recanalization and Right Atrial Thrombectomy Using IVUS. Tech Vasc Interv Radiol 2025; 28:101024. [PMID: 40287263 DOI: 10.1016/j.tvir.2025.101024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2025]
Abstract
Central venous occlusions (CVOs) of the systemic circulation are highly morbid, causing significant symptoms from venous congestion, venous thromboembolism (VTE) and impaired vascular access. Endovascular recanalization (EVR) has emerged as the treatment of choice for medically refractory nonthrombotic and thrombotic CVOs with Intravascular Ultrasound (IVUS) playing a pivotal role. Radial and side-firing IVUS catheters are used during central venous recanalization in the chest, abdomen and pelvis. The intraluminal ultrasonic view of a CVO shows dynamic details of pathology not obtained with conventional venography or cone-beam CT, allowing for a more accurate evaluation of clot burden, wall integrity, tumor invasion, occlusion length and luminal caliber. IVUS is also superb for guiding treatment of CVOs involving blunt and sharp recanalization, stenting, and mechanical thromboembolectomy (MTE) of VTE, especially high-risk free-floating thrombi (FFT) and clot in-transit (CIT) in the right atrium (RA). It most accurately assesses procedural endpoints, including successful intravascular traversal across an occlusion, adequate luminal gain after venoplasty and stenting, and complete clot extraction during thrombectomy. Moreover, this is all done without added contrast or radiation, which is paramount to reduce exposure during a challenging recanalization, especially in the aging hemodialysis population. Long-term data is now available that shows IVUS can enhance technical and clinical success and reduce complications during EVR. To achieve these benefits with IVUS interventionalists must be familiar with the available catheters and how to optimize and interpret the intraluminal images obtained. This paper will review the patient evaluation, indications, equipment, steps, challenges, complications, and outcomes for central venous recanalization (CVR) and RA thrombectomy with IVUS.
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Affiliation(s)
- Rehan Syed Quadri
- UT Southwestern Department of Radiology, Division of Vascular and Interventional Radiology, University of Texas Southwestern, Dallas, TX; Cleveland Clinic Imaging Institute, Department of Interventional Radiology, Cleveland Clinic Foundation, Cleveland, OH.
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Chen H, Wang C, Ye S, Wang L, Li X, Kong L, Zhu X, Du X, Hu N. One-stop endovenous laser ablation leads to superior outcomes for varicose veins and iliac vein compression. Sci Rep 2025; 15:1313. [PMID: 39779899 PMCID: PMC11711424 DOI: 10.1038/s41598-025-85306-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 01/01/2025] [Indexed: 01/11/2025] Open
Abstract
To retrospectivly investigate the short-term clinical outcomes of one-stop and two-staged endovenous laser ablation (EVLA) procedures for treatment of varicose veins (VVs) and iliac vein compression syndrome (IVCS). In this study, 424 patients were treated for VVs and IVCS from June 2017 to June 2020, 91 underwent one-stop stent angioplasty (SA) and EVLA, 132 underwent two-staged SA and EVLA, 104 underwent one-stop balloon angioplasty (BA) and EVLA, and 97 underwent two-staged BA and EVLA. Clinical outcomes and complications were recorded at 3 and 12 months post-intervention. Quality of life (QoL) was assessed with the venous clinical severity score (VCSS) and Villalta scale. Patients in the SA groups were older (p < 0.05) with higher BMI values (p < 0.05). The incidences of iliac vein stenosis (p < 0.001) and recurrent VVs (p < 0.01) were lower in the one-stop SA group. The VCSS was significantly improved (p < 0.05) at 12 months after the one-stop SA procedure. The one-stop SA procedure effectively relieved symptoms, decreased symptom recurrence, and improved the QoL of patients with VVs and severe IVCS. The two-staged BA procedure is recommended for patients with longer life expectancy.
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Affiliation(s)
- Hong Chen
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, 210009, China
| | - Chuang Wang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, 210009, China
| | - Shenglin Ye
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, 210009, China
| | - Lulu Wang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, 210009, China
| | - Xiaoqiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, 210009, China
| | - Lingshang Kong
- Department of Vascular Surgery, the Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, Anhui, 230601, China
| | - Xian Zhu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, 210009, China.
| | - Xiaolong Du
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, 210009, China.
| | - Nan Hu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, 210009, China.
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Wei L, Hu K, Wang J, Zhang S, Yang X, Chen Y, Li C, Lu X, Ye K, Qiu P, Zhan Y. Validation of the efficacy of the porous medium model in hemodynamic analysis of iliac vein compression syndrome. Front Bioeng Biotechnol 2025; 12:1481336. [PMID: 39834641 PMCID: PMC11743948 DOI: 10.3389/fbioe.2024.1481336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2024] [Accepted: 12/12/2024] [Indexed: 01/22/2025] Open
Abstract
Iliac Vein Compression Syndrome (IVCS) is a common risk factor for deep vein thrombosis in the lower extremities. The objective of this study was to investigate whether employing a porous medium model to simulate the compressed region of an iliac vein could improve the reliability and accuracy of Computational Fluid Dynamics (CFD) analysis outcomes of IVCS. Pre-operative Computed Tomography (CT) scan images of patients with IVCS were utilized to reconstruct models illustrating both the compression and collateral circulation of the iliac vein. A porous medium model was employed to simulate the compressed region of the iliac vein. The agreements of times to peak between discrete phase particles in CFD analysis and contrast agent particles in Digital Subtraction Angiography (DSA) were compared. Furthermore, comparisons were made between the CFD analysis results that incorporated the porous media and those that did not. The results revealed that in the CFD analysis incorporating the porous media model, more than 80% of discrete phase particles reached the inferior vena cava via collateral circulation. Additionally, the concentration variation curve of discrete phase particles demonstrated a high concordance rate of 92.4% compared to that obtained in DSA. In comparison to CFD analysis conducted without the porous medium model, the incorporation of the porous medium model resulted in a substantial decrease in blood flow velocity by 87.5% within the compressed region, a significant increase in pressure gradient of 141 Pa between the inferior vena cava and left iliac vein, and a wider distribution of wall shear stress exceeding 2.0 Pa in collateral vessels rather than in the compressed region. The study suggests that the introduction of a porous medium model improves the hemodynamic analysis of patients with IVCS, resulting in a closer alignment with clinical observations. This provides a novel theoretical framework for the assessment and treatment of patients with IVCS.
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Affiliation(s)
- Lingling Wei
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Anhui Provincial International Science and Technology Cooperation Base for Major Metabolic Diseases and Nutritional Interventions, School of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Ke Hu
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Anhui Provincial International Science and Technology Cooperation Base for Major Metabolic Diseases and Nutritional Interventions, School of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Jiaqiu Wang
- School of Engineering, London South Bank University, London, United Kingdom
| | - Shuang Zhang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Anhui Provincial International Science and Technology Cooperation Base for Major Metabolic Diseases and Nutritional Interventions, School of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Xiaoxiao Yang
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Anhui Provincial International Science and Technology Cooperation Base for Major Metabolic Diseases and Nutritional Interventions, School of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Yuanli Chen
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Anhui Provincial International Science and Technology Cooperation Base for Major Metabolic Diseases and Nutritional Interventions, School of Food and Biological Engineering, Hefei University of Technology, Hefei, China
| | - Chenshu Li
- Department of Vascular Surgery, The Affiliated Chuzhou Hospital of Anhui Medical University, Chuzhou, China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kaichuang Ye
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peng Qiu
- Department of Vascular Surgery, Shanghai Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanqing Zhan
- Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Department of General Surgery, Anhui Public Health Clinical Center, Hefei, China
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10
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Ferrante MA. The diagnostic role of magnetic resonance neurography in the neurological subtypes of thoracic outlet syndrome: Some answers and some additional questions. Muscle Nerve 2025; 71:6-8. [PMID: 39535327 DOI: 10.1002/mus.28295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2024] [Revised: 10/23/2024] [Accepted: 10/28/2024] [Indexed: 11/16/2024]
Affiliation(s)
- Mark Anthony Ferrante
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Jreij G, Dunlap E, Fitzpatrick S, Nagarsheth K. Popliteal Vein Entrapment as a Rare Form of Popliteal Entrapment Syndrome. Vasc Endovascular Surg 2025; 59:84-88. [PMID: 39178294 DOI: 10.1177/15385744241276689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2024]
Abstract
Popliteal entrapment syndrome (PES) describes a cluster of symptoms related to the compression of the neurovascular bundle in the popliteal fossa, most commonly involving the popliteal artery. In approximately 10-15% of the cases of popliteal entrapment syndrome, the popliteal vein is compressed. Symptoms of popliteal vein entrapment can mimic venous insufficiency or deep venous thrombosis, causing the diagnosis to be missed or delayed. Diagnosis of popliteal vein entrapment can be done with duplex imaging with flexion and extension maneuvers; however, venography is the gold standard for diagnosis. While popliteal vein entrapment is commonly associated with younger individuals, it may also be an underdiagnosed condition in older patients. We describe two cases of successful diagnosis and treatment of late-onset presentation of popliteal vein entrapment.
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Affiliation(s)
- Georges Jreij
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Eleanor Dunlap
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Suzanna Fitzpatrick
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Khanjan Nagarsheth
- Division of Vascular Surgery, Department of Surgery, University of Maryland, Baltimore, MD, USA
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Gunabushanam G, Chaubal R, Scoutt LM. Doppler Ultrasound of the Renal Vasculature. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1543-1562. [PMID: 38654477 DOI: 10.1002/jum.16466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024]
Abstract
Ultrasound is the first-line imaging modality used in patients with suspected renovascular disease. Common indications include renovascular hypertension and unexplained renal dysfunction. We review the ultrasound imaging findings of various pathologies involving the renal vessels, including the renal arteries (atherosclerotic stenosis, fibromuscular dysplasia, dissection, arteriovenous fistula, and aneurysm) and veins (tumor and bland thrombus as well as vascular compression syndromes). The current role of renal artery stent placement for atherosclerotic stenosis is also discussed.
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Affiliation(s)
- Gowthaman Gunabushanam
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Leslie M Scoutt
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
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13
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Jayaraj A, Rossi FH, Lurie F, Muck P. Diagnosis of chronic iliac venous obstruction. J Vasc Surg Venous Lymphat Disord 2024; 12:101744. [PMID: 38242206 PMCID: PMC11523300 DOI: 10.1016/j.jvsv.2023.101744] [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: 08/10/2023] [Revised: 12/05/2023] [Accepted: 12/12/2023] [Indexed: 01/21/2024]
Abstract
Stenting has become the first line of treatment for symptomatic chronic iliofemoral venous obstruction in patients with quality-of-life-impairing clinical manifestations who have failed conservative therapy. Patient selection for such intervention is, however, dependent on clear identification of relevant clinical manifestations and subsequent testing to confirm the diagnosis. In this regard, the physician engaged in management of such patients needs to be well-aware of symptoms and signs of chronic iliofemoral venous obstruction, and instruments used to grade chronic venous insufficiency and determine quality of life, in addition to diagnostic tests available and their individual roles. This review serves to provide an overview of the diagnosis of chronic iliofemoral venous obstruction and patient selection for stenting.
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Affiliation(s)
- Arjun Jayaraj
- RANE Center for Venous and Lymphatic Diseases, St Dominic Hospital, Jackson, MS.
| | - Fabio H Rossi
- Dante Pazzanese Cardiovascular Institute, Sao Paulo, Brazil
| | - Fedor Lurie
- Jobst Vascular Institute, Toledo, OH; Division of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Patrick Muck
- Division of Vascular Surgery, Department of Surgery, Good Samaritan Hospital, Cincinnati, OH
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14
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Sarikaya S, Altas O, Ozgur MM, Hancer H, Ozdere BA, Ozer T, Aksut M, Rabus MB, Topcu KO, Bas T, Kirali K. Outcomes of conservative management in patients with nutcracker syndrome. Phlebology 2024; 39:403-413. [PMID: 38452734 DOI: 10.1177/02683555241238772] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
OBJECTIVE This study aims to evaluate outcomes in nutcracker syndrome patients with tolerable symptoms and treated conservatively without invasive interventions. METHODS This prospective study included patients treated conservatively. Promoting weight gain, the endpoint of the study was spontaneous resolution of symptoms. RESULTS Sixteen patients (75% female and mean age 24.4 ± 3.5 years) underwent conservative management. Over a mean follow-up of 27.3 months [13-42, interquartile range (IQR)], the diameter ratio (5.5 [5-6.5, IQR] vs 4.3 [4.1-6], p = NS), the peak velocity ratio (6 [5-7, IQR] vs 4.8 [4.8-5.8], p = NS), beak angle (27° [24-30, IQR] vs 29° [24-32]; p = NS), and aortomesenteric angle (26° [23-29, IQR] vs 28° [24-30]; p = NS) exhibited no statistically significant changes. Complete resolution and improvement of symptoms were 28.5% and 31.4%, respectively, while 68.5% remained unchanged. CONCLUSIONS This study shows that a conservative approach contributes to the spontaneous improvement or complete resolution in young adult patients with mild symptoms.
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Affiliation(s)
- Sabit Sarikaya
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Ozge Altas
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Mert Ozgur
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Hakan Hancer
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Betul Ayca Ozdere
- Department of radiology department, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Tanil Ozer
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Aksut
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Murat Bulent Rabus
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Kamile Ozeren Topcu
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Tolga Bas
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Kaan Kirali
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
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15
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Young VA, Obi C, Oladini LK, Josephs SC, Hofmann LV. Venous Compressive Disorders. Tech Vasc Interv Radiol 2024; 27:100964. [PMID: 39168547 DOI: 10.1016/j.tvir.2024.100964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024]
Abstract
Venous compressive disorders are a heterogenous group of vascular syndromes characterized by extrinsic venous compression that can lead to complications of venous hypertension or venous thrombosis. Endovascular damage secondary to deep venous thrombosis (DVT) can result in post-thrombotic syndrome (PTS), a potentially debilitating condition that can be associated with significant morbidity in the pediatric population. Here we discuss 4 venous compressive disorders: iliac vein compression (May-Thurner syndrome [MTS]); subclavian vein compression at the venous thoracic inlet (Paget-Schroetter syndrome); left renal vein compression (nutcracker syndrome); and popliteal vein compression (popliteal entrapment syndrome) with a focus on clinical evaluation and diagnostic methods. Where endovascular therapy is appropriate, specific procedural considerations including procedure indications, equipment, procedural steps, technical challenges, complications, clinical follow-up and expected outcomes are discussed.
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Affiliation(s)
- Victoria A Young
- Department of Radiology, Division of Pediatric Radiology, Stanford University School of Medicine, Palo Alto, CA.
| | - Chrystal Obi
- Department of Radiology, Division of Pediatric Radiology, Stanford University School of Medicine, Palo Alto, CA
| | - Lola K Oladini
- Department of Radiology, Division of Pediatric Radiology, Stanford University School of Medicine, Palo Alto, CA
| | - Shellie C Josephs
- Department of Radiology, Division of Pediatric Radiology, Stanford University School of Medicine, Palo Alto, CA
| | - Lawrence V Hofmann
- Department of Radiology, Division of Pediatric Radiology, Stanford University School of Medicine, Palo Alto, CA
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16
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Sarikaya S, Altas O, Ozgur MM, Hancer H, Yilmaz F, Karagoz A, Ozer T, Aksut M, Ozen Y, Kirali K. Treatment of Nutcracker Syndrome with Left Renal Vein Transposition and Endovascular Stenting. Ann Vasc Surg 2024; 102:110-120. [PMID: 38296038 DOI: 10.1016/j.avsg.2023.11.036] [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: 09/12/2023] [Revised: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 02/26/2024]
Abstract
BACKGROUND Nutcracker syndrome is a rare condition that occurs as a result of the entrapment of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It is typically associated with symptoms such as left flank pain, hematuria, proteinuria, and pelvic congestion. The current treatment approach may be conservative in the presence of tolerable symptoms, and surgical or hybrid and stenting procedures in the order of priority in the presence of intolerable symptoms. The aim of this study is to review our experiences to evaluate the results of both methods in this series in which we have a greater tendency toward surgery instead of stenting. METHODS The clinical data of consecutive patients with nutcracker syndrome who underwent LRV transposition and LRV stenting between July 2019 and October 2023 were retrospectively reviewed. The patients were divided into 2 groups based on the methods of treatment: surgical and stenting. For procedure selection, LRV transposition was primarily recommended, with stenting offered to those who declined. Primary end points were morbidity and mortality. Secondary end points included late complications, patency, freedom from reintervention, and resolution of symptoms. Standard basic statistics and survival analysis methods were employed. RESULTS Nineteen patients with nutcracker syndrome (female: 100%) were treated with LRV stentings (n = 5) and LRV transposition (n = 14). The mean age was 24 (20-27, interquartile range [IQR]) years. The mean follow-up was 23 (9-32, IQR) months. There were no major complications and mortality after both procedures. The most frequent sign and symptom associated with LRV entrapment were left flank pain 100% (n = 19), proteinuria 88% (n = 15), and hematuria 47% (n = 9). The mean peak velocity ratio on Doppler ultrasound was 6.13 (6-6.44, IQR). Aortomesenteric angle, beak angle (beak sign), and mean diameter ratio on computed tomography were 26° (22.6-28.5, IQR), 25° (23.9-28, IQR), and 5.3 (5-6, IQR), respectively. Venous pressure measurements were only used to confirm the diagnosis in 5 patients in the stenting group. The measured renocaval gradient was 4 (3.9-4.4, IQR) mm Hg. After both procedures, the classical symptoms, including left flank pain, proteinuria, and hematuria, resolved in 89.5% (n = 17), 57.8% (n = 11), and 82.3% (n = 15) of the cases, respectively. A total of 4 patients required reintervention, 3 patients after LRV transposition (occlusion, n = 2; stenosis, n = 1), and 1 patient after stenting (occlusion, n = 1). The 1-year and 3-year primary patency for the 19 patients was 87% and 80%, respectively. Three-year primary-assisted patency was 100%. Similarly, the 1-year and 3-year freedom from reintervention rate was 83% and 72%, respectively. Additionally, the 1-year and 3-year primary patency for the surgical group was 91% and 81%, respectively, and the 1-year and 3-year primary patency for the stenting group was 75%. CONCLUSIONS Nutcracker syndrome should be kept in mind in cases where flank pain and hematuria cannot be associated with kidney diseases. Radiographic evidence must be accompanied by serious symptoms to initiate the treatment of nutcracker syndrome with LRV transposition and endovascular stenting procedures. Both procedures, along with their respective advantages and disadvantages, can be preferred as primary treatments for nutcracker syndrome. Our study demonstrates that both procedures can be safely and effectively performed, yielding good outcomes.
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Affiliation(s)
- Sabit Sarikaya
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey.
| | - Ozge Altas
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Mert Ozgur
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Hakan Hancer
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Fatih Yilmaz
- Department of Cardiology, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Ali Karagoz
- Department of Cardiology, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Tanıl Ozer
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Aksut
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Yucel Ozen
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
| | - Kaan Kirali
- Department of Cardiovascular Surgery, Kosuyolu Heart Training and Research Hospital, Istanbul, Turkey
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17
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Cagir Y, Yuksel I. RIGHT ILIAC VEIN COMPRESSION CAUSED BY TERMINAL ILEUM PENETRATION OF THE PSOAS IN A PATIENT WITH CROHN'S DISEASE. Gastroenterol Nurs 2024; 47:213-216. [PMID: 38847431 DOI: 10.1097/sga.0000000000000765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Accepted: 05/26/2024] [Indexed: 07/27/2024] Open
Affiliation(s)
- Yavuz Cagir
- Yavuz Cagir, MD, is at Department of Gastroenterology, Ankara Bilkent City Hospital, Ankara, Turkey
- Ilhami Yuksel, MD, is at Department of Gastroenterology, Ankara Bilkent City Hospital, Ankara, Turkey; and Department of Gastroenterology, School of Medicine, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Ilhami Yuksel
- Yavuz Cagir, MD, is at Department of Gastroenterology, Ankara Bilkent City Hospital, Ankara, Turkey
- Ilhami Yuksel, MD, is at Department of Gastroenterology, Ankara Bilkent City Hospital, Ankara, Turkey; and Department of Gastroenterology, School of Medicine, Ankara Yildirim Beyazit University, Ankara, Turkey
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18
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Betancourt A, Benrashid E, Gupta PC, McGinigle KL. Current concepts in clinical features and diagnosis of thoracic outlet syndrome. Semin Vasc Surg 2024; 37:3-11. [PMID: 38704181 DOI: 10.1053/j.semvascsurg.2024.01.005] [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: 10/21/2023] [Revised: 12/14/2023] [Accepted: 01/19/2024] [Indexed: 05/06/2024]
Abstract
The diagnosis and clinical features of thoracic outlet syndrome have long confounded clinicians, owing to heterogeneity in symptom presentation and many overlapping competing diagnoses that are "more common." Despite the advent and prevalence of high-resolution imaging, along with the increasing awareness of the syndrome itself, misdiagnoses and untimely diagnoses can result in significant patient morbidity. The authors aimed to summarize the current concepts in the clinical features and diagnosis of thoracic outlet syndrome.
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Affiliation(s)
- Alexis Betancourt
- Division of Vascular Surgery, University of North Carolina at Chapel Hill, Burnett Womack Building, 3(rd) Floor, Campus Box 7212, Chapel Hill, NC, 27599
| | - Ehsan Benrashid
- University Surgical Associates, University of Tennessee at Chattanooga, Chattanooga, TN
| | - Prem Chand Gupta
- Department of Vascular and Endovascular Surgery, Care Hospital, Banjara Hills, Hyderabad, India
| | - Katharine L McGinigle
- Division of Vascular Surgery, University of North Carolina at Chapel Hill, Burnett Womack Building, 3(rd) Floor, Campus Box 7212, Chapel Hill, NC, 27599.
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19
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Fitzpatrick S, Dunlap E, Schweitzer E, Phelan M, Nagarsheth K. Surgical treatment of nutcracker syndrome results in improved pain and quality of life. JOURNAL OF VASCULAR NURSING 2023; 41:235-239. [PMID: 38072578 DOI: 10.1016/j.jvn.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 09/06/2023] [Accepted: 10/01/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Left renal vein (LRV) compression, or nutcracker phenomenon, describes the compression of the LRV, most commonly between the aorta and the superior mesenteric artery. The outflow obstruction that occurs from the compression causes venous hypertension leading to the development of pelvic collaterals, lumbar vein engorgement and gonadal vein reflux. The symptoms associated with LRV compression include abdominal pain, left flank pain, back pain, headache, pelvic pain/pressure, and hematuria. Symptomatic LRV compression can cause chronic pain and disability that impedes activities of daily living. Left renal auto transplantation (LR-AT) is one mode of treatment, leading to decreased pain with no significant vascular or urological complications. Herein we present a five patient case series with symptomatic LRV compression who underwent LR-AT with improved pain and quality of life after surgery. METHODS Five patients underwent LR-AT between June 2020-December 2020 to resolve their symptomatic LRV compression. These patients were given three validated surveys pre- and post- intervention, then again at their three month follow up visit to assess their pain and health-related quality of life. RESULTS The five patients were all female with the average age of 36.8 years old (36-41) and underwent LR-AT to treat their symptomatic LRV compression. The average Numeric Rating Scale (NRS) pain score pre intervention was 8.3 (range 6.7 to 10) which improved to pain rating 5.22 (range 2.7 to 6) post intervention, p-value = 0.013. The average pain NRS score at 3 month follow up was 3.86 (range 1.3-6), p-value = 0.006 when compared to pre-intervention pain scores. The average pain intensity pre intervention was 4.5 (4 to 5) and 2.7 (1 to 4.3) post intervention, p-value = 0.024. The average pain intensity score at 3 month follow up was 2.24 (range 1.3-3.3), p-value = 0.002 when compared to pre-intervention. The VascuQoL-6 survey score pre intervention averaged score of 9.6 (range 7-12) which improved to an average score of 20.6 (range 18-24), p-value = 0.001. The average VascuQoL score at 3 month follow up was 22.6 (range 22-24), p-value = < 0.001 when compared to pre intervention QoL scores all showing a statistically significant improvement of health-related quality of life. CONCLUSION The diagnosis of LRV compression can be challenging due to the non-descript symptoms and overall lack of awareness. Understanding venous tributary pathways and drainage can help clarify why patients present with unusual symptoms. Surgical treatment of LRV compression through LR-AT can improve patients' pain and improve vascular quality of life.
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Affiliation(s)
- Suzanna Fitzpatrick
- University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, United States
| | - Eleanor Dunlap
- University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, United States.
| | - Eugene Schweitzer
- University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, United States
| | - Michael Phelan
- University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, United States
| | - Khanjan Nagarsheth
- University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, United States
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20
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Kim JH, Lee SK, Kim EH, Kim JY. Acute left iliofemoral vein thrombosis: Comparison between simple and bony May-Thurner syndrome in CT venography. Vascular 2023; 31:1230-1239. [PMID: 35762344 DOI: 10.1177/17085381221111010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To explore the etiology of May-Thurner syndrome (MTS) with acute iliofemoral deep vein thrombosis (DVT) regarding imaging findings and clinical features. METHODS We retrospectively analyzed 57 patients with acute left iliofemoral DVT from 2015 to 2020. The diameter of left common iliac vein (LCIV) at the maximal compression site and its percent compression regarding the average diameter of the uncompressed iliac vein were recorded in central and distal portions of the LCIV according to the location in the quadrant of lumbar vertebral body. Compression was categorized into simple and bony MTS; Simple MTS as LCIV compressed by the right common iliac artery (RCIA) versus Bony MTS as LCIV by lower lumbar degenerative changes regardless of RCIA compression. Initial computed tomographic venography (CTV) regarding chronic change of LCIV such as fibrotic atrophy or cordlike obliteration, extent of thrombus, and lumbar degenerative changes were evaluated. Therapeutic effect after initial therapy was assessed in follow-up CTVs after 3-6 months. RESULTS All patients showed LCIV compression with 19 simple MTS (mean age, 42.8 ± 14.1 years [23-67 years]; 12 females; symptom for 4.4 ± 5.5 days) and 38 bony MTS (mean age, 73.0 ± 10.2 years [49-85 years]; 26 females; symptom for 5.5 ± 4.8 days). There was significant difference in age (p < .001) and no significant difference in sex or symptom duration between two groups (p = .691 and 0.415, respectively). All simple MTS showed compression only in the central LCIV and half of bony MTS showed compression in both central and distal LCIV (p < .001). Among the lumbar degenerative changes, symmetric anterolateral osteophyte (p < .001) and asymmetric osteophyte (p < .001) were significantly associated with bony MTS, but not scoliosis (p = .799), compared to simple MTS. Although there was no significant difference in chronic change of LCIV, thrombosis extent, and therapeutic effect between two groups (p > .05), chronic change of LCIV showed significant difference between single and dual compression (23.7% vs. 57.9%, p = .024) and residual thrombus after initial therapy was occurred in 21.1% of single compression and 47.4% in dual compression with non-significant trend (p = .082). CONCLUSION Bony MTS related to lumbar degenerative changes with acute iliofemoral DVT occurs in older patients, presenting more than one stenosis at LCIV, inducing more chronic change with possibly weaker therapeutic effect than simple MTS.
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Affiliation(s)
- Jun-Ho Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea
| | - Seul Ki Lee
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Eu Hyun Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jee-Young Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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21
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Li X, Ruff C, Rafailidis V, Grozinger G, Cokkinos D, Kirksey L, Levitin A, Gadani S, Partovi S. Noninvasive and invasive imaging of lower-extremity acute and chronic venous thrombotic disease. Vasc Med 2023; 28:592-603. [PMID: 37792749 DOI: 10.1177/1358863x231198069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
The spectrum of venous thromboembolic (VTE) disease encompasses both acute deep venous thrombosis (DVT) and chronic postthrombotic changes (CPC). A large percentage of acute DVT patients experience recurrent VTE despite adequate anticoagulation, and may progress to CPC. Further, the role of iliocaval venous obstruction (ICVO) in lower-extremity VTE has been increasingly recognized in recent years. Imaging continues to play an important role in both acute and chronic venous disease. Venous duplex ultrasound remains the gold standard for diagnosing acute VTE. However, imaging of CPC is more complex and may involve computed tomography, magnetic resonance, contrast-enhanced ultrasound, or intravascular ultrasound. In this narrative review, we aim to discuss the full spectrum of venous disease imaging for both acute and chronic venous thrombotic disease.
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Affiliation(s)
- Xin Li
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Christer Ruff
- Department of Diagnostic and Interventional Radiology, University of Tubingen, Tubingen, Germany
- Department of Diagnostic and Interventional Neuroradiology, University of Tubingen, Tubingen, Germany
| | - Vasileios Rafailidis
- Department of Clinical Radiology, AHEPA University Hospital of Thessaloniki, Thessaloniki, Greece
| | - Gerd Grozinger
- Department of Diagnostic and Interventional Radiology, University of Tubingen, Tubingen, Germany
| | | | - Levester Kirksey
- Department of Vascular Surgery, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Abraham Levitin
- Division of Interventional Radiology, The Cleveland Clinic Imaging Institute, Cleveland, OH, USA
| | - Sameer Gadani
- Division of Interventional Radiology, The Cleveland Clinic Imaging Institute, Cleveland, OH, USA
| | - Sasan Partovi
- Division of Interventional Radiology, The Cleveland Clinic Imaging Institute, Cleveland, OH, USA
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22
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Abstract
Anatomic compression of the left renal vein in the angle between the aorta and superior mesenteric artery may be asymptomatic or may result in symptoms, including flank pain, hematuria, or pelvic pain and/or congestion. Patients can be referred to a vascular surgeon due to symptoms and/or radiologic findings. Because symptoms of nutcracker syndrome can be vague and/or nondiagnostic, careful evaluation, assessment, and counseling with patients are required before undertaking intervention, which is often an open surgical procedure. The definitive diagnosis is ideally confirmed with diagnostic venography, including pressure measurements from the left renal vein and inferior vena cava. The optimal treatment includes open decompression of the left renal vein with renal vein transposition or gonadal vein transposition, with or without concomitant management of pelvic varicosities if symptomatic. Because most patients with nutcracker syndrome are young, long-term follow-up with scheduled ultrasound examinations should be maintained.
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Affiliation(s)
- Audra A. Duncan
- Division of Vascular and Endovascular Surgery, Department of Surgery, Western University, Victoria Hospital, London, ON, Canada
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23
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Bahadur A, Mundhra R, Ravi AK, Gill P, Pathak A, Singhvi S, Shah K, Suresh G. May-Thurner Syndrome in a Case of Left Iliofemoral Vein Thrombosis With Contralateral Tubo-Ovarian Abscess in the Post-postpartum Period. Cureus 2023; 15:e49879. [PMID: 38174177 PMCID: PMC10761936 DOI: 10.7759/cureus.49879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2023] [Indexed: 01/05/2024] Open
Abstract
May-Thurner syndrome (MTS) is a rare, yet important, differential diagnosis in reproductive-age women with deep vein thrombosis (DVT). It is characterized by the compression of the left common iliac vein by the right common artery against the lumbar vertebra. The condition is complicated by recurrent DVT with pulmonary thromboembolism (PTE). Here is a case of multiparous women in early puerperium with right tubo-ovarian abscess and left lower limb DVT likely due to MTS. The diagnosis was further complicated by the presence of persistent thrombocytosis but a myeloproliferative neoplasm was ruled out by genetic mutation testing. She was given anticoagulants, and laparotomy was done for the excision of the tubo-ovarian mass in view of the persistent fever not responding to injectable antibiotics. PTE in the postoperative period was managed by anticoagulants followed by an inferior vena cava (IVC) filter for the risk of recurrent DVT and/or PTE in an MTS case.
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Affiliation(s)
- Anupama Bahadur
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Rajlaxmi Mundhra
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Anoosha K Ravi
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Poonam Gill
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Anjali Pathak
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Shreya Singhvi
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Komal Shah
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
| | - Gayatri Suresh
- Obstetrics and Gynecology, All India Institute of Medical Sciences, Rishikesh, Rishikesh, IND
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24
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Hamdan A, Homsy S, Rashid G, Rehman A, Al-Jamal M. Anterior Nutcracker syndrome in a young male patient: a case report and review of literature. Ann Med Surg (Lond) 2023; 85:5056-5059. [PMID: 37811088 PMCID: PMC10553089 DOI: 10.1097/ms9.0000000000001182] [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: 03/13/2023] [Accepted: 08/04/2023] [Indexed: 10/10/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The left renal vein (LRV) is affected by a venous compression syndrome called Nutcracker syndrome (NCS). This syndrome is characterized by extrinsic compression of the LRV, which usually occurs between aorta and superior mesenteric artery. It is a rare and under-diagnosed condition, more prevalent in females and that, if left untreated, can lead to severe problems. There are no clear guidelines regarding management. Therefore, the authors report this rare case and its symptoms in male patient and they display current management options. CASE PRESENTATION NCS was observed during computer tomography in a male patient presented with persistent left flank pain and associated haematuria. Ultrasound for left scrotum demonstrated left moderate-sized varicocele. The left varicocele testis unit was 1.6 mm and during the Valsalva manoeuvre in the supine position the testis unit was 2 mm. LRV compression between abdominal aorta and superior mesenteric artery was identified by computer tomography imaging and therefore, diagnosis of NCS was confirmed. CLINICAL DISCUSSION The actual prevalence is unclear, and incidence rates have been observed to fluctuate among age group and more prevalent in women. Main symptoms include haematuria, left flank discomfort, varicocele in men, proteinuria and anaemia. Depending on severity of symptoms, management might range from conservative care to surgery. CONCLUSION This treatment strategy was effective in reducing the symptoms of the patients. In young patients, conservative treatment is advised for a fair amount of time. However, more studies on how much the authors should wait before considering surgery is important.
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Affiliation(s)
- Alaa Hamdan
- Department of Neurosurgery, Hamdan’s Research Lab
| | | | | | - Andleeb Rehman
- Department of Biotechnology, Shri Mata Vaishno Devi University, Jammu
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Kim JH, Lee SK, Kim JY. Iliac vein compression syndrome by lumbar degenerative changes is associated with deep vein thrombosis after total knee arthroplasty. Arch Orthop Trauma Surg 2023; 143:5833-5842. [PMID: 36799994 DOI: 10.1007/s00402-023-04811-3] [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] [Received: 09/18/2022] [Accepted: 02/04/2023] [Indexed: 02/18/2023]
Abstract
INTRODUCTION This study aimed to identify whether iliac vein compression syndrome(IVCS) is associated with deep vein thrombosis(DVT) after total knee arthroplasty(TKA) and whether lower lumbar degenerative changes were risk factors for IVCS. MATERIALS AND METHODS A total of 259 consecutive patients who underwent TKA from January 2019 to March 2022 was retrospectively reviewed. Preoperative plain radiographs of lumbar spines and CT venography (CTV) for DVT diagnosis at postoperative 7 days were performed in all patients. Imaging findings of lower lumbar degenerative changes were analyzed on plain radiograph including lateral osteophytes, scoliosis, lateralolisthesis, retrolisthesis, anterolisthesis, and lower lumbar lordosis angle (LLLA). Percent compression at the left common iliac vein (LCIV) and right common iliac vein (RCIV) as well as DVT were evaluated on CTV. Moreover, IVCS was defined as greater than 50% of compression of the iliac vein on CTV. RESULTS DVT occurred in 79 patients (30.5%) after TKA. The overall occurrence of DVT was significantly higher in patients with IVCS of LCIV (52.8%) than those without (18.8%, P < 0.001). When DVT was further subdivided, compared to non-IVCS, IVCS of LCIV was significantly associated with bilateral DVT (P < 0.001, both), especially distal DVT (P < 0.001, both), and IVCS of RCIV was significantly associated with right-side DVT (P = 0.031), especially popliteal (P = 0.008) and distal DVT(P = 0.011). Female patients (OR: 3.945, P = 0.039), presence of left osteophyte (OR: 2.348, P = 0.006), and higher LLLA (OR: 1.082, P < 0.001) were significantly associated with IVCS of LCIV, and presence of right osteophyte (OR: 3.494, P = 0.017) was significantly associated with IVCS of RCIV. CONCLUSION IVCS was significantly associated with DVT after TKA and lumbar degenerative changes with lateral osteophytes and hyperlordosis were significant risk factors for IVCS.
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Affiliation(s)
- Jun-Ho Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, 05278, Seoul, Republic of Korea
| | - Seul Ki Lee
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 06591, Seoul, Republic of Korea.
| | - Jee-Young Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 06591, Seoul, Republic of Korea
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Rajendran S, Brown KGM, Solomon MJ. Oncovascular surgery for advanced pelvic malignancy. Br J Surg 2023; 110:144-149. [PMID: 36427187 DOI: 10.1093/bjs/znac414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/22/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND The number of units with experience in extended radical resections for advanced pelvic tumours has grown substantially in recent years. The use of complex vascular resections and reconstructive techniques in these units is expected to increase with experience. This review aimed to provide a cutting-edge overview of this evolving surgical approach to complex pelvic tumours with vascular involvement. METHODS This was a narrative review of published data on major vascular resection and reconstruction for advanced pelvic tumours, including preoperative evaluation, techniques used, and outcomes. Advice for treatment decisions is provided, and based on current literature and the personal experience of the authors. Current controversies and future directions are discussed. RESULTS Major vascular resection and reconstruction during surgery for advanced pelvic tumours is associated with prolonged operating time (510-678 min) and significant blood loss (median 2-5 l). R0 resection can be achieved in 58-82 per cent at contemporary specialist units. The risk of major complications is similar to that of extended pelvic resection without vascular involvement (30-40 per cent) and perioperative mortality is acceptable (0-4 per cent). Long-term survival is achievable in approximately 50 per cent of patients. CONCLUSION En bloc resection of the common or external iliac vessels during exenterative pelvic surgery is a feasible strategy for patients with advanced tumours which infiltrate major pelvic vascular structures. Oncological, morbidity, and survival outcomes appear comparable to more central pelvic tumours. These encouraging outcomes, combined with an increasing interest in extended pelvic resections globally, will likely lead to more exenteration units developing oncovascular experience.
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Affiliation(s)
- Saissan Rajendran
- Department of Vascular Surgery, Concord Repatriation General Hospital, Sydney, Australia.,Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia
| | - Kilian G M Brown
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Solomon
- Surgical Outcomes Research Centre (SOuRCe), Sydney, Australia.,The Institute of Academic Surgery at RPA, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
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Shin HM, Lee J, Lee DH, Kim SH. CT Evaluation of the Findings of Nutcracker Syndrome in Patients with Bladder Cancer after Radical Cystectomy and Ileal Neobladder Formation: A Correlation with Hematuria. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2023; 84:409-417. [PMID: 37051384 PMCID: PMC10083630 DOI: 10.3348/jksr.2022.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/05/2022] [Accepted: 07/28/2022] [Indexed: 02/21/2023]
Abstract
Purpose Patients with bladder cancer may show hematuria after radical cystectomy with ileal neobladder formation, causing anxiety regarding tumor recurrence. Here, we aim to show that the nutcracker syndrome (NCS) can be a cause of hematuria post-operation, and is a common, rather than a rare syndrome. Materials and Methods A retrospective review of contrast-enhanced abdominopelvic CT (CE-APCT) and urine analysis (UA) findings of 255 patients with bladder cancer who underwent radical cystectomy and ileal neobladder formation between 2011 and 2016 was performed. In the CE-APCT review, the left renal vein flow patterns were evaluated to determine the presence of NCS findings. In the UA review, patients were classified according to the percentage of UA tests with positive hematuria among the total number of UA tests. Results CT findings of NCS were present in 31.9% of the 135 patients. In the positive hematuria group, there were 26% more patients with NCS findings than those without. Conclusion NCS findings are prevalent even for bladder cancer patients after surgery, and there is a strong correlation between NCS findings and hematuria. Furthermore, the prevalence of NCS findings is much higher than urinary tract recurrence after the surgery.
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Affiliation(s)
- Hae Min Shin
- Department of Radiology, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Joongyub Lee
- Department of Preventive Medicine, Seoul National University Hospital, Seoul National University, Seoul, Korea
| | - Dong Hyeon Lee
- Department of Urology, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Seung Hyup Kim
- Department of Radiology, Ewha Womans University Mokdong Hospital, College of Medicine, Ewha Womans University, Seoul, Korea
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MISHIMA H, AYABE J, TAKADERA M, TSUCHIYA Y, KAWASAKI T, OKANO M, ISODA M, TANAKA Y. Spinal Epidural Hematoma Due to Venous Congestion Caused by Nutcracker Syndrome. NMC Case Rep J 2022; 9:209-212. [PMID: 35974955 PMCID: PMC9339261 DOI: 10.2176/jns-nmc.2022-0066] [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: 03/07/2022] [Accepted: 05/09/2022] [Indexed: 11/20/2022] Open
Abstract
The causes of spinal epidural hematoma (SEH) have been attributed to coagulopathy, trauma, vascular anomalies, and so forth. The incidence of vascular anomalies shown by digital subtraction angiography has been reported to be 15%, and most cases have been reported to be spinal epidural arteriovenous fistulae. SEH has rarely been caused by venous congestion. We report a case of SEH in a 78-year-old male who presented to our emergency department with sudden-onset back pain, followed by complete paraplegia with bladder and rectal disturbance. Magnetic resonance imaging revealed a dorsally placed extradural hematoma extending from T10 to L1. An urgent laminectomy from T11 to L2 was performed. Computed tomography angiography (CTA) performed 1 week after the operation showed compression of the left renal vein between the aorta and superior mesenteric artery with dilation of the surrounding veins, including the spinal epidural venous plexus, at the same level as the hematoma. This was diagnosed as Nutcracker syndrome (NCS), which was consistent as a cause of SEH. The patient's symptoms gradually improved, and after 6 months, he regained normal strength in his lower extremities, but bladder and rectal disturbance remained and required intermittent self-catheterization. We chose conservative treatment for NCS, and SEH did not recur until the patient died of a cause unrelated to SEH or NCS. SEH could occur secondary to venous congestion including NCS. We emphasize the importance of investigating venous return to evaluate the etiology of SEH, which can be clearly visualized using CTA.
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Aortosternal Venous Compression: A Review of Two Cases. Case Rep Med 2022; 2022:4591024. [PMID: 36247652 PMCID: PMC9556204 DOI: 10.1155/2022/4591024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 09/21/2022] [Indexed: 11/20/2022] Open
Abstract
Aortosternal venous compression (AVC) is a rare venous compression syndrome that involves brachiocephalic venous compression due to its positioning between the sternum and the aorta. One of the features of AVC involves compression of the left innominate vein with variability in luminal caliber on inspiration and expiration. Imaging modalities such as computed tomography (CT) examination can aid in initial diagnosis; however, venography can be utilized for confirmatory diagnosis due to its higher specificity during the inspiratory and expiratory phases. Through findings demonstrated during venography, we herein present two cases of confirmed AVC secondary to an aberrant right subclavian artery. Characteristic imaging features in the diagnosis of AVC and its etiology are discussed.
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Altuwaijri TA. Comparison of duplex ultrasound and hemodynamic assessment with computed tomography angiography in patients with arterial thoracic outlet syndrome. Medicine (Baltimore) 2022; 101:e30360. [PMID: 36086770 PMCID: PMC10980469 DOI: 10.1097/md.0000000000030360] [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] [Received: 12/02/2021] [Accepted: 07/20/2022] [Indexed: 11/26/2022] Open
Abstract
Thoracic outlet syndrome (TOS) presents with a variety of neurovascular symptoms, and its diagnosis cannot be established purely on the basis of clinical assessments. Computed tomography angiography (CTA) is currently the most useful investigative modality for patients with suspected vascular TOS. However, CTA facilities are limited, and CTA itself is an expensive and a resource-intensive technique associated with risks such as radiation exposure and contrast toxicity. Therefore, a screening test to identify the need for CTA may facilitate clinical management of patients with suspected TOS. Data for patients with suspected arterial TOS who underwent duplex ultrasound with arterial hemodynamic assessment (HDA) (pulse-volume recording and Doppler arterial pressure measurement) at King Saud University Medical City Vascular Lab between 2009 and 2018 were collected. The sensitivity, specificity, positive and negative predictive values (NPV), and area under the curve for duplex ultrasound and arm arterial HDA with CTA were reviewed. The data for 49 patients (mean age, 31 ± 14 years) were reviewed, of which 71% were female. The sensitivity, specificity, positive predictive value, and NPV of duplex ultrasound were 86.7%, 49.3%, 26.5%, and 94.6%, respectively. For arm arterial HDA, these values were 73.3%, 78.9%, 42.3%, and 93.3%, respectively. The combination of arm arterial HDA with duplex ultrasound scores yielded sensitivity, specificity, positive predictive value, and NPV of 93.3%, 42.3%, 25.5%, and 96.8%, respectively. The combination of duplex ultrasound with arm arterial HDA showed higher sensitivity and NPV than either test alone. The specificity of arm arterial HDA was significantly higher than that of the other measurements. When suspected, arterial TOS could be ruled out using duplex ultrasound and arm arterial HDA. These 2 investigations may help determine the need for CTA.
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Affiliation(s)
- Talal A. Altuwaijri
- Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
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Jiang Y, Gan Z, Wang Q, Chen Y, Jiang Y. Bibliometric and visual analysis of research on nutcracker syndrome from 1974 to 2021: A systematic review. Medicine (Baltimore) 2022; 101:e29939. [PMID: 35945728 PMCID: PMC9351850 DOI: 10.1097/md.0000000000029939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND At present, researchers have obtained fruitful results in the study of nutcracker syndrome (NCS), but there is still a lack of systematic research on the overall status of this disease. This article aims to describe the past and current status of research into NCS, and predict future research trends and popular research topics. METHODS Using bibliometric and visualization methods, 552 articles related to NCS collected from the Scopus database from 1974 to 2021 were analyzed from multiple perspectives. RESULTS Overall, the amount of literature related to NCS is on the rise every year, and the number of citations is the turning point in 2006. The United States has the largest number of publications and has the most extensive cooperation with other countries. The main contents of the co-authored study focused on the symptoms, surgical procedures, and concomitant diseases of NCS. Keywords such as peak velocity, ultrasonography, orthostatic proteinuria, etc appeared earlier, whereas diagnosis, chronic pelvic pain, endovascular stents, etc appeared later. CONCLUSIONS The literature utilization rate of NCS is relatively insufficient. The pathogenesis and pathological mechanisms need to be further studied, and the diagnostic criteria and surgical methods will continue to be favored by clinicians.
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Affiliation(s)
- Yuchang Jiang
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Zaili Gan
- Institute of Chinese Medicine Literature, Nanjing University of Chinese Medicine, Nanjing, China
| | - Qinsheng Wang
- Traditional Chinese Medicine Hospital of Jiangbei District, Chongqing, China
| | - Yang Chen
- College of acupuncture and massage, Chengdu University of traditional Chinese Medicine, Chengdu, China
| | - Yong Jiang
- School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China
- *Correspondence: Yong Jiang, School of Basic Medicine, Chengdu University of Traditional Chinese Medicine, No. 37 Shierqiao Road, Jinniu District, Chengdu 610072, China (e-mail: )
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Sheikh AB, Fudim M, Garg I, Minhas AMK, Sobotka AA, Patel MR, Eng MH, Sobotka PA. The Clinical Problem of Pelvic Venous Disorders. Interv Cardiol Clin 2022; 11:307-324. [PMID: 35710285 DOI: 10.1016/j.iccl.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Pelvic venous disorders are inter-related pathologic conditions caused by reflux and obstruction in the pelvic veins. It can present a spectrum of clinical features based on the route of transmission of venous hypertension to either distal or caudal venous reservoirs. Imaging can help to visualize pelvic vascular and visceral structures to rule out other gynecologic, gastrointestinal, and urologic diseases. Endovascular treatment, owing to its low invasive nature and high success rate, has become the mainstay in the management of pelvic venous disorders. This article reviews the pathophysiology, clinical presentations, and diagnostic and therapeutic approaches to pelvic venous disorders.
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Affiliation(s)
- Abu Baker Sheikh
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1021 Medical Arts Avenue NE, Albuquerque, NM 87102, USA
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA.
| | - Ishan Garg
- Department of Internal Medicine, University of New Mexico Health Sciences Center, 1021 Medical Arts Avenue NE, Albuquerque, NM 87102, USA
| | - Abdul Mannan Khan Minhas
- Department of Internal Medicine, Forrest General Hospital, 6051 US 49, Hattiesburg, MS 39401, USA
| | | | - Manesh R Patel
- Division of Cardiology, Duke University Medical Center, 200 Trent Drive, Durham, NC 27710, USA; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, USA
| | - Marvin H Eng
- Division of Cardiology, University of Arizona, Banner University Medical Center, 1111 E McDowell Rd, Phoenix, AZ 85006, USA
| | - Paul A Sobotka
- The Ohio State University, 281 West Lane Avenue, Columbus, OH 43210, USA.
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Diagnostic Value of the Iliac Vein Stenosis Percentage Combined With Indicators of Venous Reflux for Iliac Vein Compression Syndrome With Computed Tomography Venography. J Comput Assist Tomogr 2022; 46:722-728. [PMID: 35759778 DOI: 10.1097/rct.0000000000001348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To identify a cutoff value of iliac vein stenosis in computed tomography venography (CTV) for assisting in the diagnosis of iliac vein compression syndrome (IVCS). Meanwhile, determining whether the inclusion of venous return and collateral imaging findings could further enhance the diagnostic performance. METHODS We conducted a retrospective study on 264 patients suspected of IVCS who underwent both CTV and digital subtraction venography (DSV) from January 2016 to December 2020; they were assigned to either a control group (n = 101) or an IVCS group (n = 163) based on the DSV results. The narrowest anteroposterior diameter of the common iliac vein and the anteroposterior diameter of the distal end were measured to calculate the percentage of iliac vein stenosis. Receiver operating characteristic curve analysis was performed to determine the predictive accuracy of the percentage of iliac vein stenosis for IVCS and whether the inclusion of venous reflux indicators can further improve the diagnostic accuracy. RESULTS With respect to the DSV results, the area under the curve was 0.797 (P < 0.001). The best cutoff value was 46.67%, corresponding to a sensitivity of 83.44% and a specificity of 69.31% for predicting IVCS. Moreover, the combination diagnostic method had higher sensitivity and accuracy (94.48% vs 83.44% [P = 0.01] and 84.85% vs 78.03% [P = 0.04], respectively). CONCLUSIONS The best cutoff percentage of iliac vein stenosis to diagnose IVCS was 46.67% with CTV. The sensitivity and accuracy of the combined diagnostic method were higher than those of the iliac vein stenosis ratio diagnostic method.
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Dhaliwal J, Hecht EM, Roditi G, Douglas P. MR Angiography Series: MR Angiography of the Extremities. Radiographics 2022; 42:E132-E133. [PMID: 35559661 DOI: 10.1148/rg.210221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
MR angiography (MRA) is a powerful tool for imaging of the extremities, allowing a thorough assessment of the arteries and veins in both the upper and lower limbs. Both contrast-enhanced and noncontrast MRA techniques are described in the online presentation, including practical tips and tricks to obtain all necessary information at every examination. This module is the sixth and final segment in a series created on behalf of the Society for Magnetic Resonance Angiography (SMRA), a group of researchers and clinicians who are passionate about the benefits of MRA but understand its challenges. The full digital presentation is available online. ©RSNA, 2022.
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Affiliation(s)
- Javraj Dhaliwal
- From the Department of Radiology, NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow G51 4TF, Scotland (J.D., G.R., P.D.); Department of Radiology, Weill Cornell Medicine, New York, NY (E.M.H.); and Institute of Cardiovascular and Medical Sciences (G.R.) and School of Medicine, Dentistry and Nursing (P.D.), University of Glasgow, Glasgow, Scotland
| | - Elizabeth M Hecht
- From the Department of Radiology, NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow G51 4TF, Scotland (J.D., G.R., P.D.); Department of Radiology, Weill Cornell Medicine, New York, NY (E.M.H.); and Institute of Cardiovascular and Medical Sciences (G.R.) and School of Medicine, Dentistry and Nursing (P.D.), University of Glasgow, Glasgow, Scotland
| | - Giles Roditi
- From the Department of Radiology, NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow G51 4TF, Scotland (J.D., G.R., P.D.); Department of Radiology, Weill Cornell Medicine, New York, NY (E.M.H.); and Institute of Cardiovascular and Medical Sciences (G.R.) and School of Medicine, Dentistry and Nursing (P.D.), University of Glasgow, Glasgow, Scotland
| | - Peter Douglas
- From the Department of Radiology, NHS Greater Glasgow and Clyde, Queen Elizabeth University Hospital, 1345 Govan Rd, Glasgow G51 4TF, Scotland (J.D., G.R., P.D.); Department of Radiology, Weill Cornell Medicine, New York, NY (E.M.H.); and Institute of Cardiovascular and Medical Sciences (G.R.) and School of Medicine, Dentistry and Nursing (P.D.), University of Glasgow, Glasgow, Scotland
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Gonzalez-Urquijo M, Torrealba J, Vargas JF, Mertens R, Mariné L, Valdés F. Extrinsic venous compression secondary to spine osteophytes. Vascular 2022:17085381221084815. [PMID: 35392735 DOI: 10.1177/17085381221084815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE This study aims to report two cases of symptomatic extrinsic compression of the inferior vena cava and left iliac vein caused by vertebral osteophytes. METHODS We present two case reports of extrinsic venous compression by vertebral osteophytes. Both cases were endovascularly treated, with a successful outcome. A review of the literature of this unusual condition is also presented. RESULTS The first patient is an 80-year-old woman who presented to the vascular surgery clinic with bilateral lower extremity edema and pain. A computed-tomography angiography (CTA) revealed extrinsic compression of the inferior vena cava from enlarged osteophytes. Venography and intravascular ultrasound were performed, confirming the diagnosis. A self-expanding venous stent was successfully deployed in the inferior vena cava relieving the extrinsic compression. The edema resolved the following day and was discharged without complications. The second patient is a 61-year-old male that presented to the emergency department with a left iliofemoral deep venous thrombosis. CTA showed left iliac vein compression by a lumbar osteophyte. Percutaneous thrombectomy was successfully achieved and an expanding stent was deployed covering the entire lesion. One month after the procedure the patient died from COVID-19-associated respiratory failure. CONCLUSION Osteophytes must be considered when dealing with extrinsic venous compression, especially in elderly people.
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Affiliation(s)
- Mauricio Gonzalez-Urquijo
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, 28033Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jose Torrealba
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, 28033Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jose Francisco Vargas
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, 28033Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Renato Mertens
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, 28033Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Leopoldo Mariné
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, 28033Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Valdés
- Departamento de Cirugía Vascular y Endovascular, Escuela de Medicina, 28033Pontificia Universidad Católica de Chile, Santiago, Chile
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Farina R, Foti PV, Pennisi I, Vasile T, Clemenza M, Rosa GL, Crimi L, Catalano M, Vacirca F, Basile A. Vascular compression syndromes: a pictorial review. Ultrasonography 2022; 41:444-461. [PMID: 35644605 PMCID: PMC9262661 DOI: 10.14366/usg.21233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 02/23/2022] [Indexed: 12/01/2022] Open
Abstract
Vascular compression syndromes include a group of rare vascular changes due to extrinsic compression of veins or arteries by surrounding structures. These pathologies are often underestimated due to their rarity, clinicians’ poor level of knowledge, and the non-specificity of their symptoms. The best known are Eagle syndrome, thoracic outlet syndrome, nutcracker syndrome, May-Thurner syndrome, Dunbar syndrome, and popliteal entrapment syndrome. This work summarizes the main ultrasonographic characteristics, symptoms, and treatments of choice for these syndromes. Knowledge of these conditions’ characteristic signs is essential for the differential diagnosis. Failure to diagnose these rare diseases can expose patients to serious complications and risks to their health.
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Affiliation(s)
- Renato Farina
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Pietro Valerio Foti
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Isabella Pennisi
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Tiziana Vasile
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Mariangela Clemenza
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Giuliana La Rosa
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Luca Crimi
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Marco Catalano
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Francesco Vacirca
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
| | - Antonio Basile
- Department of Surgical and Medical Sciences, Advanced Technologies GF Ingrassia, University of Catania, Catania, Italy
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Cheng Z, Wang H, Lin S, Yin L, Su J, Lei Y, Lan Y, Yan J, Han T, Ma M, Xie G. Black-blood Venous Imaging (BBVI): A Contrast-Free and High-Resolution Magnetic Resonance Approach for Diagnosing IVCS - a Proof of Concept Study. Clin Appl Thromb Hemost 2022; 28:10760296221127275. [PMID: 36124369 PMCID: PMC9490483 DOI: 10.1177/10760296221127275] [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] [Indexed: 11/29/2022] Open
Abstract
Background Iliac vein compression syndrome (IVCS) diagnosis heavily relies on an imaging test. However, non-invasive and contrast-free imaging test for the diagnosis of IVCS remains a big challenge. To address this issue, this prospective study aimed to assess the image quality and diagnostic performance of a magnetic resonance imaging technique, black-blood venous imaging (BBVI), in detecting IVCS by comparing it with contrast-enhanced computed tomography venography (CTV) and using invasive digital subtraction angiography (DSA) as the reference. Methods We enrolled 105 patients, and all patients underwent BBVI, CTV, and DSA examinations. We compared the consistency of CTV and BBVI image quality and their consistency in diagnosing the rate of iliac vein stenosis in IVCS patients. Using the consensus DSA as a reference, the sensitivity, specificity, positive and negative predictive values, and accuracy of BBVI and CTV and their diagnostic agreement with DSA were calculated. Results BBVI demonstrated high sensitivity, specificity, and accuracy for the diagnosis of IVCS, without contrast agents. BBVI and CTV are quite in diagnosis IVCS. Quite SE (67.8% vs 68.3%), SP (94.8% vs 94.8%), PPV (98.0% vs 98.0%), NPV (46.2% vs 46.9%) and ACC (75.3% vs 75.7%) were obtained by BBVI in comparison with CTV. Conclusion BBVI has comparable diagnostic performance with CTV. It may be a viable alternative to CTV techniques in screening the IVCS without contrast agents and free of ionizing radiation.
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Affiliation(s)
- Zhangbo Cheng
- Department of Cardiovascular Surgery, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Hang Wang
- Department of Cardiovascular Surgery, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Shengmei Lin
- Department of Radiology, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Lei Yin
- Department of Radiology, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Jiawei Su
- Department of Radiology, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Yunhong Lei
- Department of Cardiovascular Surgery, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Yongrong Lan
- Department of Cardiovascular Surgery, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Jun Yan
- Department of Cardiovascular Surgery, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Tao Han
- Department of Cardiovascular Surgery, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Mingping Ma
- Department of Radiology, Fujian Provincial Clinical College of Fujian Medical University, 117861Fujian Provincial Hospital, Fuzhou, China
| | - Guoxi Xie
- Department of Biomedical Engineering of Basic Medical School, 26468Guangzhou Medical University, Guangzhou, China
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Liu Q, Liu F, Lü P, Wu HX, Ye P, You Y, Yao Z. Current Status and Prospect of Stent Placement for May-Thurner Syndrome. Curr Med Sci 2021; 41:1178-1186. [PMID: 34918176 DOI: 10.1007/s11596-021-2481-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 11/18/2021] [Indexed: 11/28/2022]
Abstract
Stent implantation has been proven to be safe and has become the first-line intervention for May-Thurner syndrome (MTS), with satisfactory mid-term patency rates and clinical outcomes. Recent research has demonstrated that catheter-directed thrombolysis is the preferred strategy when MTS is combined with deep vein thrombosis after self-expanding stent placement. However, the stent used for the venous system was developed based on the experience obtained in the treatment of arterial disease. Consequently, relatively common corresponding complications may come along later, which include stent displacement, deformation, and obstruction. Different measures such as adopting a stent with a larger diameter, improving stent flexibility, and increasing stent strength have been employed in order to prevent these complications. The ideal venous stent is presently being evaluated and will be introduced in detail in this review.
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Affiliation(s)
- Qin Liu
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Fang Liu
- Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ping Lü
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Hong-Xiao Wu
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Pin Ye
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yun You
- Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhong Yao
- Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, Ontario, M5S 2E8, Canada
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Hersant J, Ramondou P, Durand S, Feuilloy M, Daligault M, Abraham P, Henni S. Thoracic Outlet Syndrome: Fingertip Cannot Replace Forearm Photoplethysmography in the Evaluation of Positional Venous Outflow Impairments. Front Physiol 2021; 12:765174. [PMID: 34887775 PMCID: PMC8650580 DOI: 10.3389/fphys.2021.765174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/22/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Fingertip photoplethysmography (PPG) resulting from high-pass filtered raw PPG signal is often used to record arterial pulse changes in patients with suspected thoracic outlet syndrome (TOS). Results from venous (low-pass filtered raw signal) forearm PPG (V-PPG) during the Candlestick-Prayer (Ca + Pra) maneuver were recently classified into four different patterns in patients with suspected TOS, two of which are suggestive of the presence of outflow impairment. We aimed to test the effect of probe position (fingertip vs. forearm) and of red (R) vs. infrared (IR) light wavelength on V-PPG classification and compared pattern classifications with the results of ultrasound (US). Methods: In patients with suspected TOS, we routinely performed US imaging (US + being the presence of a positional compression) and Ca + Pra tests with forearm V-PPGIR. We recruited patients for a Ca + Pra maneuver with the simultaneous fingertip and forearm V-PPGR. The correlation of each V-PPG recording to each of the published pattern profiles was calculated. Each record was classified according to the patterns for which the coefficient of correlation was the highest. Cohen’s kappa test was used to determine the reliability of classification among forearm V-PPGIR, fingertip V-PPGR, and forearm V-PPGR. Results: We obtained 40 measurements from 20 patients (40.2 ± 11.3 years old, 11 males). We found 13 limbs with US + results, while V-PPG suggested the presence of venous outflow impairment in 27 and 20 limbs with forearm V-PPGIR and forearm V-PPGR, respectively. Fingertip V-PPGR provided no patterns suggesting outflow impairment. Conclusion: We found more V-PPG patterns suggesting venous outflow impairment than US + results. Probe position is essential if aiming to perform upper-limb V-PPG during the Ca + Pra maneuver in patients with suspected TOS. V-PPG during the Ca + Pra maneuver is of low cost and easy and provides reliable, recordable, and objective evidence of forearm swelling. It should be performed on the forearm (close to the elbow) with either PPGR or PPGIR but not at the fingertip level.
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Affiliation(s)
- Jeanne Hersant
- Vascular Medicine, University Hospital, Angers, France.,UMR CNRS 1083 INSERM 6214, LUNAM University, Angers, France
| | - Pierre Ramondou
- Vascular Medicine, University Hospital, Angers, France.,UMR CNRS 1083 INSERM 6214, LUNAM University, Angers, France.,Sports and Exercise Medicine, University Hospital, Angers, France
| | - Sylvain Durand
- EA 4334 Motricité Interaction Performance, Le Mans University, Le Mans, France
| | - Mathieu Feuilloy
- UMR CNRS 6613 LAUM, Le Mans, France.,School of Electronics (ESEO), Angers, France
| | - Mickael Daligault
- Department of Thoracic and Vascular Surgery, University Hospital, Angers, France
| | - Pierre Abraham
- Vascular Medicine, University Hospital, Angers, France.,UMR CNRS 1083 INSERM 6214, LUNAM University, Angers, France.,Sports and Exercise Medicine, University Hospital, Angers, France
| | - Samir Henni
- Vascular Medicine, University Hospital, Angers, France.,UMR CNRS 1083 INSERM 6214, LUNAM University, Angers, France
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40
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A rare cause of upper extremity deep venous thrombosis: Paget Schroetter syndrome. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.919650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chen CK, Kolber M. Venous popliteal entrapment syndrome. Cardiovasc Diagn Ther 2021; 11:1168-1171. [PMID: 34815968 DOI: 10.21037/cdt-20-292] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 06/29/2020] [Indexed: 11/06/2022]
Abstract
Popliteal entrapment syndrome (PES) describes a set of symptoms related to compression of the neurovascular bundle in the popliteal fossa, with popliteal artery involvement the most widely recognized variation. Popliteal vein entrapment is a rare variation which can easily go undiagnosed. This is most commonly due to an anomaly of the medial head of the gastrocnemius muscle, but other etiologies include excess adipose tissue or cysts within the popliteal fossa, popliteal artery aneurysm, fibrous bands, thickened perivenous fascia, compression by the popliteus muscle or muscular hypertrophy independent of anomalous anatomy, or variant origin of the short saphenous vein. However, with improving awareness, it is a condition which should be increasingly considered in patients presenting with unexplained lower extremity swelling or other symptoms of lower extremity thrombosis. The initial test of choice is typically ultrasound with flexion and extension maneuvers. Venography is the gold standard for diagnosis, but MRI offers a noninvasive option for both diagnosis and evaluation of etiology and should be considered in the work-up of popliteal venous entrapment. Management is based on severity and type of symptoms, ranging from conservative management with compression stockings to surgical management if there is popliteal artery involvement or more severe symptoms. Endovascular therapy such as angioplasty or stenting has also been reported with good results.
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Affiliation(s)
- Christine K Chen
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marcin Kolber
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Poyyamoli S, Mehta P, Cherian M, Anand RR, Patil SB, Kalva S, Salazar G. May-Thurner syndrome. Cardiovasc Diagn Ther 2021; 11:1104-1111. [PMID: 34815961 DOI: 10.21037/cdt.2020.03.07] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/09/2020] [Indexed: 12/26/2022]
Abstract
May-Thurner syndrome (MTS) is a venous compression syndrome in which the left common iliac vein (LCIV) is compressed between the lower lumbar spine and the right common iliac artery (RCIA). Variations are known where in the right lower limb can be affected. While most of the cases are asymptomatic, it can cause severe morbidity in symptomatic individuals, most commonly deep vein thrombosis and post thrombotic sequelae. In this article, we review the key clinical features, multimodality imaging findings and treatment options of this disorder. Our goal is to raise awareness of this under-diagnosed condition among clinicians in order to promote early detection and recognition to enhance positive and expedited outcomes.
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Affiliation(s)
- Santhosh Poyyamoli
- Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Pankaj Mehta
- Department of Radiology, KMCH Institute of Health Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Mathew Cherian
- Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Rinoy R Anand
- Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Santosh B Patil
- Department of Diagnostic and Interventional Radiology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Sanjeeva Kalva
- Division of Interventional Radiology, Massachusetts General Hospital Boston, Harvard University, MA, USA
| | - Gloria Salazar
- Division of Interventional Radiology, Massachusetts General Hospital Boston, Harvard University, MA, USA
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Habibollahi P, Zhang D, Kolber MK, Pillai AK. Venous thoracic outlet syndrome. Cardiovasc Diagn Ther 2021; 11:1150-1158. [PMID: 34815966 DOI: 10.21037/cdt-20-168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/04/2020] [Indexed: 11/06/2022]
Abstract
Venous thoracic outlet syndrome (vTOS) is a spectrum of disease caused by external compression of the subclavian vein as it passes through the costoclavicular space. Paget-Schroetter's Syndrome (PSS) or effort thrombosis is a subtype of vTOS where compression and microtrauma to subclavian vein from repetitive arm movements results in venous thrombosis. PSS or effort thrombosis mostly affects young otherwise healthy active individuals, and this further highlights the importance of this condition. Early diagnosis and aggressive early intervention aimed at complete resolution of acute symptoms and minimizing the risk of recurrence is ultimately important and increases the likelihood of the full restoration of limb function. Several noninvasive imaging techniques are currently available to confirm the initial diagnosis including Doppler ultrasound, contrast-enhanced computed tomography, and magnetic resonance imaging. Following diagnosis, multiple algorithms exist for the management of PSS and almost all require a multidisciplinary approach. Like any other condition involving the thrombosis of deep venous system, initial step in the management is anticoagulation. Catheter-directed therapies (CDT) have also a pivotal role as the initial treatment to resolve the acute thrombosis and establish venous patency. CDT combined with medical anticoagulation and surgical decompression are the components of most treatment algorithms for the management of patients suffering from PSS.
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Affiliation(s)
- Peiman Habibollahi
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dianbo Zhang
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marcin K Kolber
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anil K Pillai
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Armenta Flores R, Armenta-Villalobos D, Ramirez-Centeno E, Harrison-Ragle D, Carrillo LGD. May Thurner syndrome: Sixty years later. Phlebology 2021; 37:5-13. [PMID: 34494483 DOI: 10.1177/02683555211045202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
May-Thurner syndrome (MTS) was described sixty years ago. Once ignored for several years, it is currently a recognized pathology in the vascular surgery community; but not long ago due to several factors, it was underdiagnosed and sub-optimally treated. In the last 20 years, with renewed interest in venous pathology, technical imaging advances and the recent interventional procedures, it has become a better known disease. On the other hand, nowadays the easiness in diagnosis and treatment of the syndrome has lead to overtreatment of such patients. In this article, we do a historical review and describe the significant advances and current management of May-Thurner syndrome.
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Affiliation(s)
- Romulo Armenta Flores
- Hospital Medica Campestre, Department of Cardiovascular Surgery, Leon, Guanajuato, Mexico
| | - Diego Armenta-Villalobos
- Guanajuato University Medical School, Department of Medicine and Nutrition, Leon, Guanajuato, Mexico
| | | | - Derek Harrison-Ragle
- Hospital General del Norte de Puebla SSA, Department of Internal Medicine, Puebla, Puebla, Mexico
| | - Luis G Dominguez Carrillo
- Guanajuato University Medical School, Department of Medicine and Nutrition, Leon, Guanajuato, Mexico
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Yue L, Fu HY, Sun HL. Acute deep venous thrombosis induced by May-Thurner syndrome after spondylolisthesis surgery: A case report and review of literature. World J Clin Cases 2021; 9:7490-7497. [PMID: 34616817 PMCID: PMC8464458 DOI: 10.12998/wjcc.v9.i25.7490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/04/2021] [Accepted: 07/15/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Deep venous thrombosis (DVT) is a serious complication of lumbar spine surgery. Current guidelines recommend pharmacomechanical prophylaxis for patients at high risk of DVT after spine surgery. May-Thurner syndrome (MTS), a venous anatomical variation that may require invasive intervention, is an often overlooked cause of DVT. To date, no case reports of symptomatic MTS caused by isthmic spondylolisthesis or subsequent acute DVT after posterior lumbar surgery have been published. CASE SUMMARY We here present a case of a patient who developed acute DVT 4 h after spondylolisthesis surgery, and MTS was only considered after surgery, during a review of a gynecological enhanced computed tomography image taken before the procedure. CONCLUSION In conclusion, clinicians should consider MTS in the presence of a dangerous triad: spondylolisthesis, elevated D-dimer levels, and sonographically indicated unilateral deep vein dilation. Consultation with a vascular surgeon is also essential to MTS management.
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Affiliation(s)
- Lei Yue
- Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
| | - Hao-Yong Fu
- Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
| | - Hao-Lin Sun
- Department of Orthopedics, Peking University First Hospital, Beijing 100034, China
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46
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Brahmbhatt A, Macher J, Shetty AN, Chughtai K, Baah NO, Dogra VS. Sonographic Evaluation of Pelvic Venous Disorders. Ultrasound Q 2021; 37:219-228. [PMID: 34478419 DOI: 10.1097/ruq.0000000000000576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Pelvic venous disorders are a group of interrelated conditions characterized by venous incompetence. These conditions often manifest with nonspecific symptoms that overlap with many gynecological, gastrointestinal, and urologic diseases. Clinical diagnosis can be difficult, and imaging can play a vital role in differentiating etiology. Sonographic evaluation is often the first step in evaluating these symptoms. Special attention to possible underlying pelvic venous disorders can reveal characteristic findings, support diagnosis, and guide treatment. Here we review pelvic congestion syndrome, nutcracker syndrome, May-Thurner syndrome, and other venous disorders, with a specific focus on sonographic findings and considerations.
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Speranza G, Sadek M, Jacobowitz G. Common iliac vein stenting for May-Thurner syndrome and subsequent pregnancy. J Vasc Surg Venous Lymphat Disord 2021; 10:348-352. [PMID: 34438090 DOI: 10.1016/j.jvsv.2021.07.018] [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: 06/04/2021] [Accepted: 07/30/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND For women with left common iliac vein compression (ie, May-Thurner syndrome) who undergo venous stenting and subsequently become pregnant, concerns have been raised regarding a possible compromise of stent patency due to compression from the gravid uterus and the hypercoagulability induced by pregnancy. Only a small body of literature exists on this subject, and limited management guidelines are available. The present study was designed to evaluate the safety of iliac vein stenting for May-Thurner syndrome (MTS) with subsequent pregnancy. METHODS Female patients who had undergone common iliac vein stenting at our center who were aged 18 to 45 years and had subsequently become pregnant were identified. A retrospective medical record review of eight eligible patients was conducted, recording the demographics, procedural characteristics, and anticoagulation strategies. The primary outcome evaluated was stent patency. RESULTS All eight patients had undergone left common iliac vein stenting for MTS. A total of eight stents were placed, and all demonstrated duplex ultrasound patency throughout pregnancy and postpartum. Seven patients delivered healthy pregnancies, and one experienced a stillbirth. The clinical CEAP (clinical, etiologic, anatomic, pathophysiologic) class remained unchanged or improved from pregnancy to postpartum for all patients. The average age at stent placement was 31 ± 5 years, and the average interval from stent placement to pregnancy was 28 ± 19 months. One patient developed nonobstructive deep vein thrombosis (DVT) of the left femoral vein during pregnancy and was treated with therapeutic enoxaparin. The nonobstructive DVT did not compromise the iliac vein stent. Two patients received low-dose aspirin and prophylactic doses of enoxaparin, one for a history of DVT and factor V Leiden and one for a recent history of fertility treatment. The five remaining patients received no anticoagulation, three received low-dose aspirin, and two received no antiplatelet therapy. CONCLUSIONS Common iliac vein stent patency was not compromised by subsequent pregnancy in our eight patients with MTS. Furthermore, the stents remained patent throughout pregnancy in patients receiving a wide range of anticoagulation and antiplatelet treatments, suggesting that no uniform therapeutic threshold exists and treatment should be individualized. For most patients, low-dose aspirin alone or no treatment was adequate. This could have implications for counseling women who require intervention for MTS and are of child-bearing age.
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Affiliation(s)
| | - Mikel Sadek
- Division of Vascular Surgery, New York University Langone Health, New York, NY
| | - Glenn Jacobowitz
- Division of Vascular Surgery, New York University Langone Health, New York, NY.
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48
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Millen RN, Thomas KN, Versteeg MPT, van Rij AM. Popliteal Vein Compression, Obesity, and Chronic Venous Disease. J Vasc Surg Venous Lymphat Disord 2021; 10:200-208.e2. [PMID: 34343719 DOI: 10.1016/j.jvsv.2021.05.013] [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: 02/14/2021] [Accepted: 05/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Obesity is a known risk factor for the development of chronic venous disease (CVD). However, some obese patients with lower limb skin changes suggestive of venous disease do not demonstrate venous reflux or obstruction. Popliteal vein compression (PVC) caused by knee hyper-extension during standing has been postulated by others to be more common in the obese due to the increased adipose content of the popliteal fossa. This compression may contribute to the development of venous disease. OBJECTIVE To examine the prevalence of PVC in obese and non-obese subjects, with and without venous disease. METHODS Participants were recruited across the range of clinical CEAP classifications and body mass. Those referred for venous studies had full venous ultrasound assessments. To assess for PVC, the popliteal vein was assessed via B-mode ultrasound whilst the subject stood and performed two manoeuvres: knee hyper-extension and a bilateral toe stand. Video clips of each manoeuvre were analysed offline. RESULTS There were 309 limbs (158 subjects), of which 131 were non-obese (BMI 26±3 kg/m2) and 178 obese (BMI 43±8 kg/m2). PVC with toe stand was more common in obese limbs (89% vs. 64%, P<0.001). It occurred mainly in the distal popliteal vein, associated with contraction of the gastrocnemius muscles. PVC with knee hyper-extension was also more frequent in obese limbs (39% vs. 10%, P<0.0001), and was distinct as it occurred more proximally in the popliteal vein. PVC with knee hyper-extension was significantly more frequent in all obese C classes of obese patients, most notably in the obese with C4-6 CVD (41% vs. 4%, P<0.0001) and was associated with more severe VCSS (median 8 (range: 0-19) vs. 5 (0-21), P = 0.034). There were 19 limbs with skin changes (C4-6) with no venous reflux or obstruction on ultrasound; exclusively obese limbs. These limbs, designated CEAP Pn limbs, were in older, shorter participants with a higher BMI than their counterparts demonstrating reflux, and they also had more frequent PVC with knee hyper-extension (63% vs. 37%, P=0.036). CONCLUSIONS PVC with toe stand and knee hyper-extension are both functional effects and more common in obese limbs. PVC(toe stand) is likely associated with normal functioning of the calf muscle pump. While PVC(lock) may contribute to CVD in some obese limbs, the demonstration of PVC(lock) alone is insufficient evidence for direct intervention.
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Affiliation(s)
- Rebecca N Millen
- Department of Surgical Sciences, Otago Medical School - Dunedin Campus, University of Otago, Dunedin, New Zealand
| | - Kate N Thomas
- Department of Surgical Sciences, Otago Medical School - Dunedin Campus, University of Otago, Dunedin, New Zealand
| | - Matthew P T Versteeg
- Department of Surgical Sciences, Otago Medical School - Dunedin Campus, University of Otago, Dunedin, New Zealand; Royal Brisbane and Women's Hospital, Queensland, Australia
| | - Andre M van Rij
- Department of Surgical Sciences, Otago Medical School - Dunedin Campus, University of Otago, Dunedin, New Zealand.
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Srisajjakul S, Prapaisilp P, Bangchokdee S. Imaging features of vascular compression in abdomen: Fantasy, phenomenon, or true syndrome. Indian J Radiol Imaging 2021; 27:216-224. [PMID: 28744083 PMCID: PMC5510320 DOI: 10.4103/ijri.ijri_7_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Vascular structures in the abdomen can compress or be compressed by adjacent structures. Classic imaging findings of vascular compressions, including median arcuate ligament syndrome, superior mesenteric artery syndrome, nutcracker syndrome, portal biliopathy, May-Thurner syndrome, and ureteropelvic junction obstruction will be discussed here. It is important to correlate imaging findings and clinical data to identify asymptomatic vascular compression which requires no treatment, intermittent vascular compression with nonspecific or vague clinical manifestation, and the subset of patients with true syndromes who will benefit from treatment.
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Affiliation(s)
- Sitthipong Srisajjakul
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Patcharin Prapaisilp
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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50
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Speranza G, Hager E. Venous thromboembolism in a patient with an uncommon etiology of May-Thurner syndrome. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:549-552. [PMID: 34401623 PMCID: PMC8358287 DOI: 10.1016/j.jvscit.2021.07.003] [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: 05/18/2021] [Accepted: 07/09/2021] [Indexed: 11/30/2022]
Abstract
May-Thurner syndrome (MTS) consists of common iliac vein compression from an extrinsic source. Patients with MTS can present with a variety of symptoms, potentially making the diagnosis difficult. Classically, MTS will result in left iliac vein compression from the right iliac artery. In rare cases, it can be secondarily caused by compression from other anatomic structures in the pelvis. We present the case of a 43-year-old woman with MTS with iliofemoral deep vein thrombosis and pulmonary embolism caused by a large uterine leiomyoma. Our findings underscore the need to consider various etiologies of venous compression in patients with extensive unilateral venous thromboembolism.
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Affiliation(s)
| | - Eric Hager
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
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