Bilateral Iliac Veins Research Articles

3:36 PM Abstract No. 86 Predictors of iliocaval in-stent restenosis

Chronic venous disease (CVD) occurs in 1-5% of adults. Iliocaval obstructive lesions play a significant role in the development of CVD. Iliocaval stenting is a mainstay treatment for CVD. However, in-stent restenosis (ISR) occurs in 5-23% and is related to recurrence of symptoms and possible decreased patency. We sought to evaluate risk factors associated with ISR. Patients who underwent successful iliocaval stenting were compiled from a departmental database of all lower extremity venous stents from 1996-2018. In total, 760 iliocaval stents were placed in 160 patients (47.5% female, 52.5% male), mean age 48.7 years. Median follow-up was 332 days (range, 0-5627 days). ISR was defined as >50% reduction in luminal diameter. Risk factors examined for ISR included age, gender, type of stent (Wallstent, Boston Scientific, Natick MA) vs. SMART stent (Cordis, Santa Clara, CA), diameter and length of stent, and diameter of angioplasty balloon. Veins included were the inferior vena cava (IVC), bilateral common iliac veins (CIV), and bilateral external iliac veins (EIV). Median and mean time to ISR was 177 and 422 days respectively (range, 11-3985 days). Neither age nor gender were significantly associated with ISR. Location of stent was not associated with increased risk of ISR. ISR occurred in 15.1% of IVC stents, 15.2% of CIV stents, and 18.4% of EIV stents. In both the CIV and EIV, Wallstents had a decreased risk of restenosis when compared to SMART stents (CIV: HR -3.0, P <0.005; EIV: HR -2.4, P = 0.02). Stent brand was not a risk factor for IVC ISR. Angioplasty balloon diameter following stent deployment was a significant risk factor for ISR as increased balloon diameter was associated with a decreased risk of IVC ISR (HR -2.7, P = 0.01). Balloon diameter did not affect ISR for CIV or EIV stents. Our study had clinically acceptable and similar rates of ISR for the IVC, CIV and EIV. Wallstents may decrease ISR in iliac veins but are similar to SMART stents when placed in the IVC. Some literature suggests that over dilation of stents may help long-term patency (4); however, we found that use of larger balloons decrease ISR in IVC stents only.

Abstract No. 658 Exercise intolerance caused by chronic iliocaval venous occlusion: non-invasive quantitative assessment

Patients with chronic inferior vena cava (IVC) and bilateral iliac vein postthrombotic occlusion often report subjective decreased exercise tolerance that improves after stent reconstruction. We report preliminary results of the use of quantitative exercise testing to assess change in exercise tolerance occurring after venous reconstruction. The Institutional Review Board approved this retrospective study. Exercise testing before and after intervention was conducted in the Human Performance Laboratory (HPL): resting blood pressure, heart rate, body mass index (BMI), body composition, standard pulmonary function tests, and incremental maximal exercise testing (VO2 max test). Maximal exercise was defined as a plateau in the oxygen uptake, a respiratory exchange ratio (RER) greater than 1.1, or voluntarily termination of exercise. The VO2 max (mL/kg/min), maximum work (W) and total exercise time were analyzed. Percutaneous venous reconstruction was performed using standard techniques and stents. Results were reported as simple averages and percentages. Three male patients with chronic postthrombotic IVC and bilateral iliac venous occlusions were studied. Mean age 63 ± 8 years, mean duration of occlusion 36 ± 12 months. The interval between reconstruction and testing ranged from 2.5 to 11 months. All patients had stents in the infra-renal IVC to bilateral common femoral veins. No exercise instructions were provided to patients after stent reconstruction. Following venous reconstruction, the V02 max increased an average of 38.7%, the total work increased 74.4%, and the total exercise time increased 18.7%. Each individual lost weight, with an average decrease of 7.5%. Subjectively, all patients reported an increased exercise tolerance and decreased shortness of breath with exertion. Subjective impairment in exercise tolerance and improvement after venous reconstruction was quantitated in three patients with chronic postthrombotic occlusion of the IVC and bilateral iliac veins. HPL testing may be a useful additional objective tool in the study of patients with chronic ilio-caval occlusions.

CT variants of the caudal vena cava in 121 small breed dogs.

Computed tomography is increasingly used as a treatment planning method in canine patients with diseases of the retroperitoneum, however, published information on normal variations in the caudal vena cava (CVC) are currently lacking. The objectives of this retrospective descriptive study were to characterize CVC variants using CT angiography in a sample of small breed dogs and localize the CVC bifurcations for each variant. Inclusion criteria were small breed dogs (weight≤15) that underwent contrast-enhanced CT scans of the CVC, abdominal aorta, and CVC tributaries. A total of 121 small breed dogs were sampled. Four right-sided and one left-sided CVC variations were identified: normal (88/121, 72.7%), caudal-partial split (17/121, 14.0%), partial duplication (8/121, 6.6%), complete duplication (7/121, 5.8%), and left-sidedness (1/121, 0.8%). The mean lumbar vertebral levels of the CVC bifurcation were L6.39 ± 0.41, L5.70 ± 0.35, L4.39 ± 0.42, L2.74 ± 0.38, and L6.4 in the normal, caudal-partial split, partial duplication, complete duplication, and left-sidedness types, respectively. The location of the CVC bifurcation, the relationship between the aortic trifurcation and the CVC bifurcation, and the location of the bilateral deep circumflex iliac veins with respect to the CVC bifurcation were significantly different among the right-sided types (P ≤ .001). Bilateral deep circumflex iliac veins joined to the ipsilateral common iliac veins and the CVC in the caudal-partial split and duplication types, respectively. The results of this study indicated that canine CVC variants may be frequent and should be considered during surgery or diagnostic imaging of the retroperitoneum.

Anatomical Variations of Iliac Vein Tributaries and Their Clinical Implications During Complex Pelvic Surgeries.

During high sacrectomies and lateral pelvic compartment exenterations, isolating the external and internal iliac veins within the presacral area is crucial to avoid inadvertent injury and severe hemorrhage. Anatomical variations of external iliac vein tributaries have not been previously described, whereas multiple classifications of internal iliac vein tributaries exist. We sought to clarify the iliac venous system anatomy using soft-embalmed cadavers. This is a descriptive study. This study was conducted in Chulalongkorn University, Thailand. We examined 40 iliac venous systems from 20 human cadavers (10 males, 10 females). Blue resin dye infused into the inferior vena cava highlighted the iliac venous system, which was meticulously dissected and traced to their draining organs. Iliac vein tributaries and their valvular system were documented and analyzed. The external iliac vein classically receives 2 tributaries (inferior epigastric and deep circumflex iliac) near the inguinal ligament. However, external iliac vein tributaries in the presacral area were found in 20 venous systems among 15 cadavers (75%). The mean diameter of each tributary was 4.0 ± 0.35 mm, with 72% arising laterally. We propose a simplified classification for internal iliac vein variations: pattern 1 in 12 cadavers (60%) where a single internal iliac vein joins a single external iliac vein to drain into the common iliac vein; pattern 2 in 7 cadavers (35%) where the internal iliac vein is duplicated; and pattern 3 in 1 cadaver (5%) where bilateral internal iliac veins drain into a common trunk before joining the common iliac vein bifurcation. This study is limited by the number of cadavers included. A comprehensive understanding of previously unreported highly prevalent external iliac vein tributaries in the presacral region is vital during complex pelvic surgery. A simplified classification of internal iliac vein variations is proposed. See Video Abstract at http://links.lww.com/DCR/A900.

Bilateral iliac vein stenting reduces great and small saphenous venous reflux.

Objective Iliac vein stenting has been an evolving treatment option in the management of CVI secondary to iliac vein obstruction. Historically, treatment of CVI has been focused on the elimination of saphenous vein disease; however, the effect of reduction of iliac vein obstruction on superficial venous reflux remains largely unknown. This study aimed to identify the effect of iliac vein stenting on saphenous vein reflux. Methods In this retrospective study spanning course of five years, we performed 2681 venograms with venoplasties and stenting of the iliac veins. Pre-operative and post-operative venous mapping was performed via duplex ultrasonography. Patients who received any lower extremity vascular intervention between “pre-” and “post-stenting” duplex ultrasonography examination, other than iliac vein stenting, were excluded from analysis. Results One thousand six hundred forty-five patients, of which 63.2% were female, underwent iliac vein stenting; 1033 patients received bilateral intervention, whereas 356 and 259 patients received unilateral left and right stenting, respectively. The average age of the patient cohort was 66 (range 22–100; SD ± 13.9). The distribution CEAP scores of each limb at the time of intervention were: C2 (1%), C3 (25%), C4 (51%), C5 (5%), and C6 (18%). Bilateral iliac vein stenting significantly reduced reflux in the bilateral great saphenous and small saphenous veins by 363.8 ms ( p &lt; 0.0001) and 345.4 ms ( p &lt; 0.0002), respectively, but had no effect on ASV reflux. Unilateral stenting did not produce significant reductions in reflux, besides an average reduction of 573.2 ms ( p = 0.004) in the left great saphenous vein. Conclusion Bilateral iliac vein stenting decreased great saphenous vein and small saphenous vein reflux. Unilateral stenting did not demonstrate a significant reduction in saphenous reflux. Bilateral reduction in stenosis of the iliac veins may influence superficial venous reflux.

PB2437 THROMBOLYTIC THERAPY IN PEDIATRIC PATIENTS; OUTCOME AND COMPLICATIONS OF TISSUE PLASMINOGEN ACTIVATOR

Background:Although tissue plasminogen activator (tPA), is not indicated in patients under 18 years, off‐label administration is increasingly reported in life or limb‐threatening thrombi.Aims:To present experience with tPA administration in pediatric patients.Methods:Between March 2012 and January 2018, hospital records of patients who received thrombolytic therapy were reviewed. Written informed consent forms signed by legal guardians of the patients for off‐lable use of tPA were present in patients’ hospital files. Major bleeding was defined as any intracranial or retroperitoneal bleeding, or bleeding requiring prolonged admission, transfusion or bleeding leading to death. All other bleeding events were classified as minor. Dose modifications were performed with monitorization of clinical findings, imaging studies and bleeding complications.Results:Seven children, 1 day‐17 years underwent thrombolysis with tPA. First patient had acute lymphoblastic leukemia, fungal pneumonia; she had also central venous catheter and developed superior vena cava syndrome due to right juguler vein thrombosis. Second patient had nephrotic syndrome and diffuse pulmonary thrombosis causing hypoxia. Third patient with Kawasaki disease had coronary aneurism and thrombosis. Fourth patient was a newborn with 37 week‐gestation born with left arm cyanosis and had subclavian artery thrombosis. This baby had methylen tethra hydropholate reductase plus phrothrombin 20210 heterozygous mutations. Fifth patient with homozygous antithrombin deficiency had adolescent pregnancy and vaginal delivery; she presented on the post‐partum 10th day with left renal vein, artery and vena cava inferior (VCI) thrombosis. Sixth patient had hypertension and right kidney atrophy developed left renal artery thrombosis. Seventh patient had Behçet's disease and developed right atrium, pulmonary arteries, VCI, vena‐porta, vena hepatica, bilateral iliac vein thrombosis. Administration of tPA was started median 2 days (1‐12) after onset of symptoms. Median initial tPA dose was 0.1 mg/g/h (0.03‐0.4) and the median maximum dose was 0.15 mg/kg/h (0.06‐0.4). Dose escalation or de‐escalation was performed according to monitorization by imaging findings, resolution of clinical findings, and bleeding complication. Median tPA duration was 46 h (12‐72 h). Concomitant heparin was administered in all patients except patient 2 and 3. Outcome was complete resolution was achieved in patients 1,2,6,7, partial resolution in patient 3 and no resolution in patients 4 and 5. There was one organ (kidney in patient 4) and one limp loss (patient 5). There was one major bleeding in patient 7; he had melena, hematemesis, epistaxis that required transfusion and withdrawal of concomitant heparin. Three of the patients had minor bleedings (epistaxis, gingival bleeding, venipuncture site bleeding) that could be easily controlled.Summary/Conclusion:Thrombolysis with tPA seems safe and effective in pediatric patients. A dose between 0.06‐0.1 mg/kg/h seems safer regarding bleeding complications. Doses between‐ 0.15‐0.4 mg/kg/h may be used if necessary with close monitorization.

SS16. A Novel Technique for Iliocaval Extravascular Reconstruction and Associated Outcomes in Patients With Inferior Vena Cava Agenesis

Congenital absence of the inferior vena cava is a rare deep venous malformation associated with venous stasis ulceration. Endovascular recanalization is limited as patients lack normal anatomic pathways required for endovascular repair. The purpose of this study was to report outcomes of a novel retroperitoneal technique for iliocaval extravascular reconstruction (TIER) using re-entry techniques for the treatment of C5 to C6 disease in patients with iliocaval agenesis. A prospectively maintained single-institution database was used to observe patients who underwent TIER for management of C5 to C6 venous disease. Reconstruction was performed by sharply exiting the deep venous system and entering the retroperitoneum at or above the renal confluence and the bilateral external iliac veins. Cone beam computed tomography was used to exclude potential injury to adjacent structures during retroperitoneal transcatheter dissection. Reconstruction was performed using self-expanding Elgiloy stents. The Villalta clinical scoring system for post-thrombotic syndrome was used to assess symptomatic improvement preoperatively and postoperatively. Postoperatively, patients with C6 venous disease underwent continued compression therapy and were monitored for wound healing. Twelve patients underwent TIER for complete absence of the inferior vena cava resulting in C5 to C6 disease during the study period (Fig 1). Technical success was 100%, with primary patency achieved in all patients (Fig 2). There were no significant intraoperative complications, and the 30-day mortality was 0%. Mean contrast agent volume used was 87 mL, mean fluoroscopy time was 143 minutes, and mean reference air kerma was 6239 mGy. A minimum of six stents were used in all cases. At follow-up intervals of 1, 3, and 6 months, primary patency was 100%. Symptomatic and sustained improvement was seen in all patients with an average decrease in Villalta score of 13. Nine patients had C6 venous disease with ulcers on 15 limbs due to the presence of bilateral disease. Thirteen limbs had complete ulcer resolution during the follow-up period. The remaining limbs demonstrated >75% ulceration size reduction. Iliocaval extravascular reconstruction using novel re-entry techniques appears to be a safe and effective endovascular approach for the treatment of symptomatic congenital absence of the inferior vena cava. The TIER procedure can be performed with excellent patency, minimal morbidity, improved Villalta scores, and improved healing.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Renal transplantation in bilateral iliac vein thrombosis: A difficult case scenario

Renal transplantation in bilateral iliac vein thrombosis: A difficult case scenario

Clinical study on the different lengths of inferior vena cava stent implantation for non-thrombotic iliac vein lesions

Objective To assess the safety and influence of the stents extended into inferior vena cava in patients with non-thrombotic iliac vein lesions (NIVLs) on the bilateral iliac vein blood flow. Methods We retrospectively reviewed data from July 2008 to June 2017 in 197 patients with NIVLs who underwent iliac vein stenting and complete follow-up was obtained at our institution.Of these patients, stents extended into IVC more than 10 mm in 141 cases, less than 5 mm in 22 cases, and 34 cases were between 5 and 10 mm.Restenosis and thrombosis of bilateral iliac vein and patency of these stents were assessed in the follow-up.The count data were expressed by percentage (%), and the sample comparison rate was analyzed by Fisher exact test formula.The measurement data were first tested for normal distribution and homogeneity of variance, and then corrected t test. Results The two hundred and five iliac vein stents were placed in 197 patients. During a mean follow-up of 58.7 months (6 to 98 months), there were no thrombosis occurred in the contralateral iliac vein, 6 patients suffered restenosis or new thrombosis in the stents, the incidence between stenting positions less than 5 mm (13.6%, 3/22) and those more than 5 mm (3.43%, 6/175) was sighificantly different (P<0.001), and 5 of 6 patients had a good patency after endovascular therapy. During the fllow-up, the primary and assisted-primary patency rates were 97.0% and 99.5%. Conclusions From these data, it appears that there is a very high patency rates of the stenting treatment for the NIVLs, and it is safe for the stents extended into the IVC, stenting across the iliocaval confluence can result in a small number of new contralateral thromboses. Moreover, the risk of stents restenosis or occlusion is high when stents are not extended into IVC. Key words: Iliac vein; Stent; Vein thrombosis; Interventional therapy

Long-term follow-up of the stenting across the iliocaval confluence in patients with iliac venous lesions.

Stent implantation is the common treatment method for iliac vein (IV) occlusion. IV stents usually enter into the inferior vena cava (IVC) to partially or completely cover the contralateral IV, but it is still uncertain whether this can increase the risk of thrombosis in the contralateral IV. The purpose of this study was to investigate the effect of the stent position on the bilateral IVs patency. A total of 261 patients with symptomatic IV lesions, including 177 patients with non-thrombotic iliac vein lesions (NIVLs) and 84 patients with thrombotic iliac vein lesions (TIVLs), were implanted with IV stents between July 2007 and June 2017. The data of these patients were retrospectively studied. The follow-up time was 6-114 months, and the median time was 62 months. A total of 183 cases had stenting into the IVC for more than 5mm. The incidence of thrombosis in the contralateral IV was only 0.55% (1/183). A total of 17 short- and long-term cumulative cases had ipsilateral thrombosis on the stent side. There was no significant difference between the incidence of patients (8.79%, 7/78) with stenting into the IVC for less than 5mm and those with more than 5mm (5.46%, 10/183, P = 0.287). However, in the TIVLs group, the incidence of ipsilateral thrombosis between stenting positions less than 5mm (29.6%, 8/27) and those more than 5mm (8.77%, 5/57) was significantly different (P = 0.022). Stent implantation for NIVLs had an excellent long-term patency rate; the primary patency rate and the assisted primary patency rate were 97.7% and 100%, respectively. The entry of IV stents into the IVC was safe and had a very low incidence of thrombosis in the contralateral vein. Stenting less into the IVC increased the incidence of thrombosis in the ipsilateral vein, especially among thrombotic cases. Treatment of NIVLs using stent implantation had a better long-term patency rate. This principle plays an important guiding role in the endovascular therapy of IV lesions.

Kissing stents for radiation-induced bilateral common iliac vein stenosis

Radiation-induced venous stenosis is rare, with only a few cases reported in the literature. We report a case of radiation-induced venous stenosis of the bilateral iliac vein after radiation therapy for the treatment of recurrent bladder cancer. The patient was successfully treated using endovascular kissing stents.

New method for ultrasound-guided inferior vena cava filter placement

ObjectiveTransabdominal ultrasound (TAUS)-guided inferior vena cava filter (IVCF) placement currently uses an inferior vena cava (IVC) longitudinal plane with cross-section of the right renal artery or the transverse plane of the right renal vein (RRV)-IVC intersection. The goal of this study was to introduce a new method for TAUS-guided IVCF placement. MethodsThe study enrolled patients who were at high risk for or had pulmonary embolism from October 22, 2010, to June 30, 2016. The probe was positioned on the right flank to centralize the RRV-IVC junction during imaging and to permit a straight line through the midpoint of the probe on the surface and a parallel line 1.0 cm below the straight line as a marker. The probe was subsequently placed on the abdominal wall with the upper edge at the marker line to show the long axis of the IVC during the process of filter placement. The upper edge of the probe was considered the filter tip position. ResultsA total of 1029 patients were evaluated, and 98 patients (9.5%) were excluded because of poor IVC visualization (n = 14 [1.4%]), IVC or bilateral iliac vein thrombosis (n = 79 [7.7%]), and unsuitable anatomy (n = 5 [0.5%]). The remaining 931 patients (90.5%) were selected for TAUS-guided IVCF placement, and all filters (100%) were successfully placed. There were no procedure-related complications. Suprarenal IVCF was observed in 4 patients (0.4%) by computed tomography, and the filter tip exceeded the upper edge of L2 in 15 patients (1.6%) by plain film radiography; one of them had two RRVs. Severe filter tilting (20.8 degrees) occurred in one patient. ConclusionsThis new method of TAUS-guided IVCF placement was simple, safe, and effective. It may be widely applied for the bedside placement of vena cava filters.

Endovascular Treatment of Duplicated Inferior Vena Cava Compression From Retroperitoneal Fibrosis

Retroperitoneal fibrosis (RPF) is a rare condition that can affect the iliocaval veins, leading to treatment of this condition. We report a unique case of RPF causing symptomatic compression of a duplicated inferior vena cava treated successfully with stenting. A 68-year-old African American man presented for evaluation of severe debilitating venous claudication and bilateral lower extremity swelling. He reported chronic and progressive symptoms of venous insufficiency that became lifestyle limiting a few months before presentation. His past medical history was significant for hypertension, anemia, and idiopathic RPF with mild renal insufficiency. His surgical history was significant for retroperitoneal exploration and ureterolysis for left-sided hydronephrosis as well as bilateral hydrocele resection. On physical examination, he had normal pulses and severe edema, right worse than left, but no varicosities. Duplex ultrasound was negative for deep venous thrombosis or reflux but demonstrated blunting of respiratory variations in the bilateral external iliac veins. Computed tomography scan showed near obliteration of the venous structures in the pelvis (Fig 1, A). The patient was fitted for compression stockings but could not get relief. Venography was performed and demonstrated a duplicated inferior vena cava with severe bilateral stenosis of the iliocaval vasculature (Fig 2). Intravascular ultrasound was performed to confirm the sites of stenosis and for sizing. Bilateral balloon angioplasty and iliocaval stenting were performed using two 16-mm Wallstents (Boston Scientific, Marlborough, Mass) on the right and two 14-mm Wallstents on the left. The completion venogram showed excellent flow bilaterally (Fig 3). Intravascular ultrasound confirmed complete resolution of all areas of stenosis. The patient was started on clopidogrel and was discharged the next day. The edema cleared within a week, and he experienced excellent relief of symptoms. After 1 year, he was switched to aspirin, and he continues to have minimal symptoms with no recurrence. On his latest follow up, 33 months after intervention, computed tomography scan demonstrated patent stents in the duplicated cava and no venous stenosis (Fig 1, B). Iliocaval compression from RPF is rare but can be debilitating. Endovascular stenting seems to be an effective and durable treatment.Fig 2Pelvic venogram demonstrating severe stenosis in the right (A; arrow) and left (B; arrow) iliocaval systems.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3Completion venogram after iliocaval stenting showing brisk flow and resolution of areas of stenosis on the right (A) and left (B).View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Contrast-enhanced CT findings of intravenous leiomyomatosis

To characterise the contrast-enhanced computed tomography (CT) imaging findings of nine patients with intravenous leiomyomatosis (IVL). The contrast-enhanced CT imaging findings of nine patients with histopathologically proven IVL were examined. The location, morphology, extension pathway, adhesion, and degree and pattern of enhancement of the tumour were assessed. Four patients had tumours located within the inferior vena cava, and five had tumours that involved the right heart. Seven patients with residual uterus myoma showed enhanced heterogeneous contrast of the uterus. Eight tumours extended into the inferior vena cava through the iliac veins and one through the bilateral iliac veins. All the IVLs demonstrated heterogeneous enhancement on contrast-enhanced CT and appeared to have lower density than the contrast-enhanced venous blood. On the coronal and sagittal images, tumours were continuous and, when the right heart was involved, the lesions displayed a characteristic "walking stick head" or "snake head" appearance. The lesion looked similar to a "sieve" on axial contrast-enhanced CT images, and a "luffa sponge" on post-processing coronal or sagittal images. Contrast-enhanced CT imaging has unique advantages in the diagnosis of IVL, namely, luffa sponge and sieve appearance, which can be helpful for differential diagnosis. Contrast-enhanced CT can demonstrate tumour location and full-scale extension pathway, which are important for diagnosis, surgical planning, and follow-up of the tumour.

Modified human uterus transplantation using ovarian veins for venous drainage: the first report of surgically successful robotic-assisted uterus procurement and follow-up for 12 months

To report the 12-month results of the first human uterus transplantation case using robot-assisted uterine retrieval. This type of transplantation may become a treatment for permanent uterine factor infertility. Case study. University hospital. A 22-year-old woman with complete müllerian agenesis who underwent a previous surgery for vaginal reconstruction. The live uterine donor was her mother. The uterus transplantation procedure consisted of robot-assisted uterine procurement, orthotopic replacement and fixation of the retrieved uterus, revascularization, and end-to-side anastomoses of bilateral hypogastric arteries and ovarian-uterine vein to the bilateral external iliac arteries and veins. Data from preoperative investigations, surgery, and follow-up (12months). The duration of the donor and recipient surgeries were 6 and 8hours, 50minutes, respectively. No immediate perioperative complications occurred in the recipient or donor. The recipient experienced menarche 40days after transplant surgery, and she has had 12 menstrual cycles since the surgery. No rejection episodes occurred in the recipient. These results demonstrate the feasibility of live-donor uterine transplantation with a low-dose immunosuppressive protocol and the role of DaVinci robotic assistance during human uterine procurement. XJZT12Z06.

Bilateral pulmonary embolism and ilio-femoral DVT associated with recent amputation of lower limb, long distance air travel and suspected thrombophilia.

We present a 36 years old Bangladeshi male, known smoker, while working in Bahrain, suffered from arterial thromboembolism on left lower extremity resulting in gangrene of left leg. He underwent above knee amputation of the affected limb. After 16 days stay in the hospital with an open amputated stump wound, he was sent back to Bangladesh by air. While in the airplane, he complained of chest discomfort about two hours before landing at Dhaka airport of Bangladesh. Following disembarkation he was admitted into local cardiac hospital where a diagnosis of left ventricular failure with unstable angina was made. Five days later he was transferred to ICU of Ibn Sina Hospital for better management. Patient had high serum D-dimer level and fibrin degradation products (FDP) level. negative antinuclear antibody (ANA) test, negative anti-cardiolipin antibody test, normal troponin I, Homocysteine, antithrombin III, protein S, &amp; protein C levels. Initial X-ray chest showed left lower zone wedge shaped density. ECG showed sinus tachycardia. CT angiogram of chest showed bilateral pulmonary embolism (PE) and large left pleural effusion. Contrast CT abdomen showed bilateral iliac vein thrombus extending to lower inferior vena cava. Left pleural effusion was found to be grossly hemorrhagic. Patient was treated with low molecular weight heparin and warfarin. As thrombolysis was not feasible, he was advised to have thrombo-embolectomy. He refused surgical option and left hospital against medical advice. This case illustrates that multiple risk factors can be responsible for PE, and appropriate &amp; timely interventions are always needed to prevent morbidity and or mortalityBangladesh Crit Care J March 2016; 4 (1): 46-50

Surgical Management of Ectopic Kidney with Bilateral Iliac Vein Invasion.

Renal cell carcinoma (RCC) is a very rare phenomenon in an ectopic kidney. We come across a 61-year-old gentleman with a history of 2 months of gross, painless haematuria and palpable pelvic mass on examination. CT scan showed 6.5cm X 5.1cm X 5.8cm mass in pelvic kidney with bilateral iliac vein invasion. With the help of intra-operative ultra-sound, tumour thrombus was extracted from both iliac veins with en mass removal of tumour. Patient was well intraoperatively as well as in postoperatively. We also presented an elegant imaging for the case.

Invivo evaluation of safety and performance of a nitinol venous stent in an ovine iliac venous model.

Obstruction of the iliocaval venous outflow tract is a common cause of acute and chronic venous symptoms. Percutaneous stenting is now frequently performed to alleviate obstruction in the central venous system. However, currently used stents were primarily designed for biliary or arterial indications and may not be optimal for use in the venous system. This study evaluated the safety and performance of a novel venous stent (NVS) designed specifically for venous applications in an invivo venous animal model. The study evaluated vascular response and safety of the NVS compared with the Wallstent Stent (WS; Boston Scientific, Marlborough, Mass) at baseline, 56, and 180days in adult sheep. Four sheep received a single NVS in the iliac vein for acute evaluation, and eight underwent bilateral iliac vein stenting using a single NVS on one side and a single WS on the other for longer-term follow-up. Fluoroscopy and intravascular ultrasound imaging were performed at implantation to identify iliac vein diameters at baseline and again at 56 and 180days. Both iliac veins from all 56-day and 180-day animals (n= 16) underwent histologic examination. Three sections from each vessel were reviewed for intimal strut coverage, luminal thickening, thrombus, and evidence of venous injury. Student t-tests were used to compare mean iliac vein diameters for the WS and the NVS. Stent placement of the NVS and WS was successful to within 5mm of the preselected location in all animals. During follow-up, no clinical evidence of stent thrombosis or obstruction >50% occurred in any limb. Sections of the stented vein at 56 and 180days exhibited complete or nearly complete endothelial cell coverage, no or minimal luminal thrombus, and virtually complete neointimal coverage of every strut. The WS and NVS both caused an increase in iliac vein diameters immediately after stenting. At 180days, there was no difference in iliac vein diameter or the percentage change in diameter compared with diameters immediately after stenting as measured by venography and intravascular ultrasound. In an ovine iliac vein model, a new NVS studied to 180days was free of thrombotic complications and significant luminal stenosis. These data support clinical evaluation of this NVS in appropriately designed human clinical trials.

Iliac Vein Compression Syndrome due to Bladder Distention Caused by Urethral Calculi.

We report a rare case of iliac vein compression syndrome caused by urethral calculus. A 71-year-old man had a history of urethral stenosis. He complained of bilateral leg edema and dysuria for 1 week. Physical examination revealed bilateral distention of the superficial epigastric veins, so obstruction of both common iliac veins or the inferior vena cava was suspected. Plain abdominal computed tomography showed a calculus in the pendulous urethra, distention of the bladder (as well as the right renal pelvis and ureter), and compression of the bilateral common iliac veins by the distended bladder. Iliac vein compression syndrome was diagnosed. Bilateral iliac vein compression due to bladder distention (secondary to neurogenic bladder, benign prostatic hyperplasia, or urethral calculus as in this case) is an infrequent cause of acute bilateral leg edema. Detecting distention of the superficial epigastric veins provides a clue for diagnosis of this syndrome.

Hybrid repair of an aortocaval fistula and inferior vena cava external compression caused by an inflammatory aortoiliac aneurysm: a case study.

IntroductionWe report a case of aortocaval fistula successfully treated by hybrid operation.Case descriptionA 73-year-old female suffering from malignant lymphoma and painful leg edema was transferred to our institution. Computed tomography revealed an aortoiliac aneurysm. The inferior vena cava was compressed by displacement of the abdominal aortic aneurysm. The bilateral internal iliac and ovarian veins were markedly dilated. Diagnosis was an aortoiliac aneurysm with aortocaval fistula. The treatment options were open surgery or an intervention with bypass surgery. Because of narrow iliac access for a bifurcated stent graft, aorto-uni stentgraft treatment followed by bypass surgery was finally decided. Following stent graft insertion and iliofemoral artery bypass, the aneurysms and fistula were successfully excluded without endoleaks. To treat the inferior vena cava compression, the kissing technique was used to place bare metallic stents across the bilateral common iliac veins and inferior vena cava, which improved the clinical symptoms.Discussion and EvaluationIn this aortocaval fistula caused by AAA, a minimally invasive treatment of stentgraft and bypass surgery with venous flow recovery was chosen as a hybrid treatment. Intravascular intervention was the most suitable in this situation. Bare stent placement for venous occlusion was also effective for revascularization of vena cava flow.ConclusionRecent advances in endovascular devices, including stent grafts and bare metallic stents, will be helpful for effective noninvasive treatment for aortocaval fistula circulation.Electronic supplementary materialThe online version of this article (doi:10.1186/2193-1801-3-476) contains supplementary material, which is available to authorized users.