Bilateral Vein Research Articles

Impact of Different Flushing Frequencies on Peripheral Intravenous Catheter Failure, Coagulation, and Tissue Injury—A Counterbalanced Preclinical Human Trial

Highlights Abstract Background: Peripheral intravenous venous catheters (PIVCs) are associated with a postinsertion failure incidence of 40%, yet the common maintenance and preventive strategy of saline flushing is poorly understood at a physiological level. Methods: We developed a human model of bilateral cephalic vein cannulation to study the impact of varied PIVC flushing frequency (high frequency, HF; low frequency, LF) over 5 hours on catheter failure (primary outcome), coagulation, platelet aggregation, and local tissue injury. Ultrasound was used in a subset to assess vascular diameter/catheter to vein, blood flow velocity, and thrombus formation. Results: Out of 34 catheters in 17 adult participants, 1/17 (6%) LF catheters failed, which was not significantly different from HF catheters (0/17). Platelet function, activated partial thromboplastin time, and tissue factor were also not different (P > 0.05). However, prothrombin time (PT) increased with HF versus LF after 5 hours (P < 0.05). Ultrasound demonstrated luminal thromboses in veins experiencing both HF (6/7) versus LF (5/7) conditions after 5 hours with nonsignificant changes in vascular diameter and blood flow velocity over time. Conclusions: Although no difference in PIVC failure was observed between HF and LF flushing conditions over 5 hours, greater flushing frequency increased PT time, suggesting delayed activation or consumption of extrinsic coagulation factors. This study also demonstrated feasibility in assessment of luminal thromboses, which were remarkably prevalent after PIVC placement, and changes in vascular diameter and blood flow. This manuscript illustrates that the development of a sensitive human model will be of great use for exploring the impact of interventions on reducing PIVC failure in the future.

415 Clinical outcomes and Patient satisfaction with Bilateral Radial Artery harvest in coronary surgery

Abstract Aim Coronary artery bypass graft surgery remains an effective treatment strategy for complex coronary disease.There paucity of data regarding the use of bilateral radial artery conduits with wound, neurological and functional complications following surgical revascularisation. Method We reviewed the outcomes with retrospective analysis of prospectively collected clinical data from our database and identified 30 patients who underwent CABG requiring the use of bilateral radial harvest.Patient satisfaction was assessed using a quality of life questionnaire with the descriptors on a Likert Scale. Results The mean duration of follow-up was 29.8 ± 8.5 months.The mean age of patients was 69.0 ± 10.8 years.The commonest indications for bilateral radial harvest were existing bilateral varicose veins or previous bilateral vein surgery (combined 74% of cases) precluding venous conduit use. Three out of 24 (12.5%) patients reported arm pain or discomfort ‘rarely’ or ‘sometimes’ whilst all the others (87.5%) were asymptomatic.Three patients (12.5%) reported long term permanent sensory deficit with a further six (25%) patients having some other less significant sensory loss. Significant motor dysfunction was reported in one patient (4.2%) whilst 5 (20.8%) reported milder forms of motor deficit. 95.8% of patients considered the aesthetic outcome of the radial harvest site appearance to be at least acceptable (54.1% rated the appearance as excellent). One patient (4.2%) reported a ‘moderate’ functional change otherwise, the remaining patients reported ‘minimal’(12.5%) or ‘no change’ (83%). Conclusions Open bilateral radial artery is acceptable to patients as a conduit choice when alternatives are not favourable for surgical revascularisation.

Lesser weever fish (Echiichthys vipera Cuvier, 1829) venom is cardiotoxic but not haemorrhagic

Despite comprising over half of the biodiversity of living venomous vertebrates, fish venoms are comparatively understudied. Venom from the lesser weever fish (Echiichthys vipera syn. Trachinus vipera) has received only cursory attention despite containing one of the most potent venom toxins (trachinine). Literature records are further complicated by early studies combining the venom with that of the related greater weever (Trachinus draco). The current study used a chicken chorioallantoic membrane assay to investigate venom bioactivity following the application of measured quantities of crude venom to a major bilateral vein at 1 cm distance from the heart. The venom had a dose-dependent effect on survival rate and exhibited dose-dependent cardiotoxic properties at day six of development. Crude E. vipera triggered tachycardia at doses of 37.58 and 44.88 μg/μL and bradycardia at 77.4 μg/μL. The three highest doses (65.73, 77.4 and 151.24 μg/μL) caused significant mortality. These data also suggested intra-specific variation in E. vipera venom potency. Unlike a number of other piscine venoms, E. vipera venom was not haemorrhagic at the concentrations assayed.

Duplication of superficial femoral artery: imaging findings and literature review

BackgroundDuplication of the superficial femoral artery (SFA) is an extremely rare anatomic variation, with few case studies reported. We report one case of the duplicated SFA, discovered by both ultrasonography (US) and computed tomography angiography (CTA). We also reviewed literatures concerning 6 cases of the duplicated SFA (including our present case), and summarized the clinical and imaging features of the anatomic variation.Case presentationA 55-year-old woman presented to our hospital with an intermittent cramp in the lateral aspect of the right leg. The patient underwent Doppler US examination on bilateral lower extremity arteries and veins to examine potential vascular abnormality. Incidentally, US discovered the duplicated left SFA and CTA of bilateral lower extremities revealed the anatomic orientation, course, length, diameter and distance of the duplicated left SFA. It was revealed to be divided into two trunks with similar luminal diameter and courses parallel. They reunited at distal thigh level. The findings of US and CTA examination did not correspond with the symptom of the patient, and the patient was discharged.ConclusionWe report a rare case of the duplicated SFA diagnosed with the combinations of US and CTA examination, which served as valuable imaging methods to detect and diagnose the vascular anatomic variation in lower extremities.

Venous Stenting in Proximal Venous Outflow Obstruction – Lessons Learned from 500 Cases

Introduction - Venous stenting is emerging as an important treatment strategy in venous disease. What is the real world experience with this procedure? This study reviews our experience with venous stenting in chronic venous insufficiency, highlighting patient selection, procedural considerations, outcomes, and re-interventions. Methods - This is a retrospective study of 500 patients who underwent venous stenting for chronic proximal venous outflow obstruction (PVOO) in the iliac veins from October 2013 to August 2016 at one centre. Preoperatively, we utilized venous duplex scan and magnetic resonance venogram to assist in patient selection. Intraoperative evaluation comprised of bilateral venogram and intravascular ultrasound. Wallstents were used in all cases (Boston Scientific, MA). Patients were discharged on day of procedure with rivaroxaban 10 mg initially followed by long-term Aspirin 81 mg. Wilcoxon-Mann-Whitney, Kruskal-Wallis, and logistic regressions were used in statistical analysis of variables and outcomes. Results - Of these 500 patients, follow-up was maintained in 90% of patients with a mean follow-up 320 days. Mean age of patients was 60 years old (SD 13.4 years) and 57% were female. Preoperatively, edema was present in 90.5%, and active ulceration 10.7%. 85 patients (17%) presented with persistent symptoms after a prior endovenous thermal ablation or surgery for superficial venous disease, and 69 patients (13.8) presenting with post-thrombotic syndrome. Among patients without any known DVT history, 21.5% had findings of chronic phlebitic changes (long segment diffuse disease, occlusion of vessel, intraluminal filling defects) on venogram or IVUS. Bilateral vein stents were performed in 59%. Kruskal-Wallis tests were significant for improvement (symptoms, CEAP class, and physical exam) in patients at thirty days (p=0.027), ninety days (p=0.045), six months (p=0.037), and one year (p=0.012). Ordered logistic regressions found the presence of edema (coefficient 1.59, 95% CI [0.52, 2.65], p=0.004), active ulceration (95% CI [0.022, 3.40], p=0.047), and decreased number of stents placed (coefficient -0.56, 95% CI [-1.08, -0.036], p=0.036) to predict increased improvement at thirty days, and a history of DVT (coefficient: -0.94, 95% CI [-1.79, -0.096], p=0. 029) to predict decreased improvement at one year post-operatively. Wilcoxon-Mann-Whitney tests were significant for more improvement in patients who had unilateral versus bilateral stents placed at thirty days (p=0.013) and six months (p=0.039). Major re-interventions (61.7% for recurrent symptoms, 17.6% for persistent symptoms, 6% for DVT) were performed in 7.6% of patients. Mean time to re-intervention was 191 days, and re-interventions were more prevalent (29. 4%) among patients with a known history of DVT. Conclusion - Our experience with venous stenting in chronic PVOO on an expanded scale suggested a satisfactory outcome at one year. Those patients with a prior history of DVT have poorer outcomes after venous stenting. Unilateral stents have better outcomes than bilateral stents, but the difference may reflect complexity of disease. Approximately 8% of patients will require a secondary re-intervention. Patient selection, procedural indications, and optimal pharmacologic therapy after venous stenting need further studies and clarification.

Vasculo-Behcet's Disease: Profile and Management - Single Center Experience

Background Behçet's disease (BD) is a multisystem vasculitis characterized by exacerbations and remissions with unknown etiology. Males are more affected than females with the usual onset in the third decade. Vascular involvement can occur in up to 40% of cases of BD. BD is unique among the vasculitides that it may involve all sizes and types of vessels. Objectives 1. To study the pattern of vascular involvement of Behçet's disease (BD) in the Saudi population; use of anticoagulation and its duration, thromboembolic, and major bleeding complications during anticoagulant therapy. 2. The effect of combined immunosuppression and anticoagulation treatment approach in reducing the risk of venous and arterial thromboembolism. 3. The role of vascular surgery for peripheral arterial and abdominal aortic aneurysms (AAA), and the role of immunosuppression in the treatment of pulmonary artery aneurysm (PAA) without the need for surgical intervention. Methods Twenty-three patients with confirmed vasculo-BD attending the thrombosis clinics at our tertiary care center between 2010 and 2015 were studied retrospectively and analyzed through descriptive statistics SPSS version 22. Results Demographics and pattern of vascular involvement are shown in tables 1 and 2. HLA-typing was performed for 13 patients, and HLA- B51 was positive in 7 (54%) patients tested. The acute phase reactants (ESR and CRP) were high in all 23 (100%). Hereditary and acquired thrombophilia workup was performed for all patients and only 1 (4.3%) was positive for antiphospholipid antibodies. Oral ulcers were present in all the patients, genital ulcers in 12 (52%), ocular involvement in 8 (35%), skin manifestations in 3 (13%), and arthritis in 1 (4.3%). Lower extremity vein thrombosis is the most frequent manifestation of Vasculo-BD in Saudi Arabia, followed by CVT, PAI, SVT/Budd-Chiari syndrome, IVC thrombosis, peripheral artery aneurysms, and AAA. Peripheral arterial and abdominal aortic aneurysms in 3 (13.6%), all of whom had successful vascular surgery for aneurysm repair. Inferior vena cava filter was inserted in 3 (13.6%). One patient was admitted to the intensive care unit with fulminant hepatic failure due to bilateral hepatic vein thrombosis and subsequently died. The vascular thrombosis recurrence was in 11 patients (48%, all venous) despite adherence to the prescribed anticoagulant therapy and lack of any provocation. These patients were initially treated with anticoagulant monotherapy. After combining immunosuppressive therapy to the pre-existing anticoagulant therapy, none had thrombosis recurrence. There was a complete resolution of the two patients with PAA with mono-immunosuppressant therapy and no surgical intervention. The most commonly prescribed initiation anticoagulant therapy was low molecular weight heparin (87%). Conclusion BD with vascular involvement continues to pose a major diagnostic and therapeutic challenge to physicians due to the heterogeneity of the clinical presentation and lack of the diagnostic laboratory test. Therefore, we must have a low threshold for BD in any patient with vascular thrombosis or aneurysm. Combined immunosuppressive therapy is essential in suppressing and preventing the venous and arterial recurrence attacks. Disclosures No relevant conflicts of interest to declare.

CYTOMEGALOVIRUS RETINITIS WITH BELATACEPT IMMUNOSUPPRESSION

To report two cases of cytomegalovirus (CMV) retinitis in renal transplant patients after conversion to belatacept immunosuppression. Case report. Case A was a 41-year-old African American man with no ocular history, chronic hepatitis B infection on entecavir, status-post living relative renal transplant for end-stage renal disease secondary to IgA nephropathy presented with a chief complaint of "blurry vision" in his right eye. Fundoscopic examination of the right eye revealed perivascular retinitis of the superior arcade extending temporally and a lesion nasal to the optic disk. The patient was diagnosed with CMV retinitis with macular involvement. Case B was a 52-year-old woman with an ocular history significant for bilateral vein occlusions treated with laser, and a medical history of hypertension, hyperlipidemia, and end-stage renal disease secondary to hypoplastic kidney status-post deceased donor renal transplant presented with one week of blurred vision in the right eye. Fundoscopic examination of the right eye revealed macular star configuration of exudates, as well as subretinal fibrosis temporal to the macula. Fundoscopic examination of the left eye showed Grade 4 vitreous haze and multiple areas of retinal whitening and hemorrhage, consistent with CMV retinitis infection. The patient was diagnosed with bilateral CMV retinitis, with macular involvement in the right eye. Renal transplant patients converted to belatacept immunosuppression may be at an increased risk for herpes virus infection, and thus herpes virus retinitis. Although the degree of risk remains uncharacterized, patients on belatacept therapy who are at the high risk of CMV infection (i.e., donor-positive/recipient-negative patients) should be counseled on the presenting signs and symptoms of CMV retinitis. In these cases, clinicians should also consider regular monitoring of serum CMV titers or continuation of antiviral prophylaxis.

Antagonistic Effects of Suramin Against the Venom of Snake, Echis Carinatus, on the Circulatory System of Developing Chicken Embryos

Background: The snake, Echis carinatus, one of the most venomous snakes in Asia, possesses a deadly hemotoxic venom. It has been reported that suramin, an anti-trypansomiasis drug, can inhibit the toxic effects of some snake venoms. This study was conducted to evaluate the possible antagonistic effects of suramin against the hemorrhagic activity of the venom from an Iranian snake, Echis carinatus, in developing chicken embryos. Methods: One day old fertile eggs (n=250) were incubated for six days at 37ºC and 60% humidity. Paper discs (5 mm diameter) containing different concentrations of E. carinatus venom (5, 10, 20 & 30 μg) were placed on the chorioallantoic membrane over the major bilateral vein and were left in place until hemorrage occurred and the embryos died. Results: We found the standard hemorrhagic dose (SHD) of E. carinatus venom to be (5 μg/disc). Various concentrations (5, 10 & 20 μg) of suramin were tested against SHD of E. carinatus venom in different protocols. Control experiments were performed with the buffered saline solution, venom and suramin individually. The results demonstrated that suramin at 5, 10 and 20 μg significantly (P<0.05) delayed time to death (717, 521 & 208 min) of embryos poisoned with E. carinatus venom in a dose-dependent manner. Conclusion: Suramin exerted protective and inhibitory effects against the deadly E. carinatus venom, and therefore, may potentially offer future therapeutic applications against poisoning with E. carinatus venom.

A practical approach to tumescent local anaesthesia in ambulatory endovenous thermal ablation.

Thermal ablation, usually performed with tumescent local anaesthesia (TLA), is the preferred method for varicose veins treatment. Tumescent local anaesthesia is always cited; however, little detail of the procedure is presented in publications. This retrospective audit of clinical tumescent local anaesthesia practice aims to provide detailed information on an important aspect of endovenous practice. Patients who underwent three types of endothermal treatment (Venefit, Radiofrequency Induce Thermal Therapy and Endovenous Laser Ablation) to a single saphenous trunk using tumescent local anaesthesia were assessed. Differences in tumescent local anaesthesia volume per unit length of treated vein were assessed for the followings: type of saphenous trunk, length of vein treated, effect of additional phlebectomy and bilateral versus interval unilateral treatment for bilateral veins. Descriptive data are reported as mean and standard deviation, and groups were compared using the one-way ANOVA test. Between 2008 and 2014, single-saphenous-trunk ambulatory TLA thermal ablation was performed in 979 patients, mean age was 54 years. A total of 1229 limbs had truncal ablations and synchronous phlebectomy was performed in 470 limbs. No tumescent local anaesthesia-related complications occurred. There was no significant difference in standardised tumescent local anaesthesia volume per centimetre (ml) used for the three devices. Tumescent local anaesthesia volume per centimetre (ml) differed significantly between saphenous trunks. On average, a standard 10-12 ml/cm of tumescent local anaesthesia was used for saphenous trunks. Mean total tumescent local anaesthesia volume per patient, when treating the great saphenous vein alone, was 931 ml for bilateral and 425 ml for unilateral treatment. This report of over 1000 endovenous procedures demonstrates safe performance of laser and radiofrequency treatments using tumescent local anaesthesia. Although no attempt was made to determine minimum volume requirements, a mean tumescent local anaesthesia volume of 10-12 ml/cm administered to the perivenous space provides adequate anaesthesia for truncal saphenous ablation.

Autopsy case of acute pulmonary thromboembolism with neurosyphilis

BackgroundSyphilis is caused by the bacterium Treponema pallidum. Syphilis is a multistage disease, and the clinical stages of syphilis are divided to primary, secondary, and tertiary syphilis, where the tertiary stage is classified as neurosyphilis, cardiovascular syphilis, or gummatous syphilis. Here, we describe an autopsy case of acute pulmonary thromboembolism with neurosyphilis.Case presentationA male in his early 40s began to complain of hallucinations. He was admitted to a psychiatric hospital as an emergency case 4 days before death. He was physically restrained to control agitation and aggressiveness. The patient was severely obese (BMI 36.45). At autopsy, large thromboembolic masses filled the pulmonary trunk and both pulmonary arteries. Thrombi were also noted in the right popliteal vein and bilateral gastrocnemius and soleus veins, suggesting bilateral lower extremity deep vein thrombosis. Dissection of the brain, which weighed 1457 g, revealed no noteworthy macroscopic findings. Histological examination showed lymphocyte infiltration into the perivascular space of the brain tissue with no vasculitis. Immunohistochemical staining of T. pallidum was negative, the fluorescent treponemal antibody-absorption test was positive, the rapid plasma reagin titer was 1:4, and the T. pallidum hemagglutination assay titer was 1:10,240. Real-time PCR assay of the brain tissue detected low copy numbers of T. pallidum genes. Altogether, the cause of death was acute pulmonary thromboembolism resulting from bilateral lower extremity deep vein thrombosis. The patient also had early-stage meningovascular neurosyphilis.ConclusionAn autopsy case of acute pulmonary thromboembolism with meningovascular neurosyphilis is presented, including histopathological examination, serological assessment, and genetic testing. Forensic pathologists should pay attention to a myriad of syphilitic manifestations. The contributing factors for thrombosis in the present case included severe obesity, probable dehydration, and physical restraints implemented to control meningovascular neurosyphilis-induced neuropsychiatric symptoms.

Assessment of Hemodynamic Alterations in Cerebral Veins in Patients With Intracerebral Hemorrhage Using Duplex Color-Coded Sonography.

To investigate the contributions of hemodynamic alterations in cerebral veins to the prognosis of patients with primary intracerebral hemorrhage (ICH). Duplex color-coded sonography was performed on 87 ICH patients between July 2016 and October 2017. The time-averaged peak velocity, the time-averaged mean velocity (TAMV), the blood flow volume (BFV) of bilateral internal jugular veins (IJVs) and vertebral veins (VVs), and the mean velocities of bilateral basal veins of Rosenthal, straight sinus, and bilateral transverse sinuses were calculated to understand the relationship of hemodynamic data with prognosis in patients with ICH. The study revealed that the time-averaged peak velocities, TAMVs and BFVs of both right IJV and VV in ICH patients with good clinical outcomes were higher than those of the left IJV and VV, whereas statistically significant differences were not found in the mean velocity of bilateral veins of Rosenthal. The perihematomal edema volume, time-averaged peak velocities, TAMVs, and BFVs of the bilateral IJVs and right VV and the TAMV of the left VV were associated with the prognosis of ICH patients in the univariate analysis. However, the TAMV of the right IJV and BFV of the left IJV were the independent factors that predicted prognosis in multivariate analysis. Partial correlation showed that there was a linear dependence between the differences in TAMV and BFV between bilateral IJVs. The presence of hemodynamic changes in cerebral veins in patients with ICH has an impact on prognosis.

Recanalization After Endovenous Thermal Ablation

Endovenous thermal ablation in the form of radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) has quickly ascended to a prime position in the treatment of venous insufficiency. Although there are good data examining the rates of thrombotic complications, there is a relative paucity of data examining the recanalization rates after endovenous thermal ablation (ETA). Data analysis was performed for 1475 thermal ablations in 485 patients from 2012 to 2015 as a retrospective chart review. RFA was performed in 1027 patients and EVLA in 448 patients. The target veins included the great saphenous vein (GSV) (778), short saphenous vein (SSV) (401), accessory saphenous vein (ASV) (140), and perforator veins (PV) (156). Data were collected from follow-up visit within 1 week of procedure, every 3months for the first year, and every 6months thereafter. Recurrence was defined as >500ms for the GSV, SSV, and ASV and as >350ms for the PV. Data for recanalization were also correlated with age, gender, laterality, presenting symptoms, and treated targeted vein. The average age of the study population was 64.7years (SD±15.6) with 66% women and 326 bilateral veins. At 1-week follow-up, women (2.6%) had higher recanalization rate (P=0.018). Failure rate of obliteration for GSV and SSV were 0.8% and 0.8%, respectively (P=0.98). PV had the highest failure rate (16.6%), followed by ASV (2.9%) (P<0.001). At mean follow-up after 13.5±12 months, PV (41.2%) and ASV (14.85) had higher recanalization rate than GSV (7.7%) and SSV (8.5%) (P<0.001). Excluding PVs, no difference with recurrence rates between RFA (10%) and EVLA (8.8%) was observed at 1-week and 1-year follow-ups (P=0.54). Also, 56% of patients with recanalization were symptomatic. Among these 1475 procedures, redo for recurrent symptoms were performed in 76. At 1 week, there was no difference between nonrepeated (92.7%) and repeated procedures (89.5%) (P=0.41). However, 1 year later, there was significant difference between obliteration rate in nonrepeated (86.9%) and repeated (76.3%) procedures (P=0.014). These data do suggest low overall rates of recanalization after thermal ablation of the GSV and SSV. However, at 1-year follow-up, accessory veins had almost twice the recurrence rate as compared with GSV and SSV, and PV had almost 5 times the recurrence rate. There was no significant difference between RFA and EVLA in recanalization rates. Redo procedures in recanalized veins after venous ablation are effective with a success rate at 76.5%.

Chronic iliofemoral vein obstruction – an under-recognized cause of exercise limitation

Local symptoms of chronic venous insufficiency after deep vein thrombosis (DVT) are well described, but little is known about the effect of residual venous obstruction on exercise capacity. We tested our hypothesis that chronic residual iliofemoral vein occlusion (IFVO) after DVT may impair exercise capacity. Nine post-DVT patients with residual IFVO and effort intolerance were studied; a comparison cohort consisted of 11 healthy volunteers. Exercise tolerance was assessed by bimodality incremental symptom-limited cardiopulmonary testing, using leg and arm ergometers. In healthy subjects, leg vein obstruction was modelled by application to the thighs of cuff tourniquets inflated to 30–40 mmHg. Leg exercise tolerance as measured by oxygen uptake at peak exercise (peak ⩒’O2) was reduced in patients (median 50% predicted (range 36–83%) vs. 88% predicted (67–129%) in normal subjects, p < 0.001). Arm exercise tolerance was also reduced in patients, but less severely than in the legs – the median arm: leg ratio of peak ⩒’O2 was 0.95 (0.77–1.43) in patients vs. a normal ratio of 0.73 (0.6–1.0) in healthy subjects (p < 0.003). In healthy subjects, bilateral leg vein obstruction by tourniquets reduced peak ⩒’O2 in leg exercise to 76% predicted (range 55–108%; p < 0.001 vs. standard test). In conclusion, the comparison of arm vs. leg exercise capacity in post-DVT patients with residual IFVO and the effect of experimental venous obstruction (thigh tourniquets) in healthy subjects suggest that reduced exercise capacity in patients was at least partially caused by reduced venous return. Chronic venous obstruction should be recognized as a cause of exercise limitation.

Deep vein thrombosis and pulmonary embolism secondary to urinary retention: a case report

BackgroundPulmonary embolism occurs when a blood thrombus forms and travels from a vein in the body to an artery in the lung. Thrombi often develop in one of the deep veins of the legs, thighs, or pelvis, a condition known as deep vein thrombosis. In this report, we describe a rare instance of a patient who developed deep vein thrombosis and pulmonary embolism secondary to urinary retention, and we also review some of the literature.Case presentationA 75-year-old Japanese man visited our hospital with the complaint of lower extremity weakness. A physical examination revealed bilateral leg edema. Contrast-enhanced computed tomography showed thrombi in both the bilateral intrapelvic veins and the right pulmonary artery, with an extremely distended bladder. We diagnosed deep vein thrombosis and pulmonary embolism due to urinary retention, which was attributed to detrusor insufficiency owing to both taking an anticholinergic drug and neurogenic bladder. The patient was immediately started on both management of voiding dysfunction and anticoagulant therapy.ConclusionsWe encountered a patient with deep vein thrombosis and pulmonary embolism secondary to urinary retention that could have been fatal. In such cases, clinicians should always take into account appropriate management of voiding dysfunction.

Factors influencing the choice of treatment modality for individual patients with varicose veins.

INTRODUCTION There is evidence of effectiveness for a range of different treatment modalities for varicose veins but limited information about factors that influence treatment choice for individual patients. METHODS A postal survey was sent to 438 UK members of the Vascular Society of Great Britain and Ireland. RESULTS Overall, 251 responses were received (response rate 57%). A total of 222 respondents treated varicose veins using conventional surgery (84%), endothermal ablation (82%) and foam sclerotherapy (68%). The clinical pattern of veins appeared to have the greatest influence on treatment choice. This was followed by guidance from the National Institute for Health and Care Excellence, patient expectations, facilities, cost and whether treatment was carried out in the public or private sector. Respondents were asked to indicate whether each of 13 clinical 'scenarios' (eg very extensive varicose veins in both legs) would influence them towards or against using specified treatment modalities. 'Consensus' was defined as ≥80% of responses either towards or against any treatment modality; and disagreement as 41-59% both towards and against any modality (i.e. ∼50:50 split). There was consensus towards using endothermal ablation for truncal reflux, towards UGFS for localised varicose veins and towards conventional surgery for large, extensive, bilateral veins. There was consensus against UGFS for large truncal veins, and against surgery for obese patients and those with a history of venous thromboembolism. There were important disagreements about the influence of large or extensive veins, about whether patients were obese or slim and about a prior history of venous thromboembolism. CONCLUSIONS Conventional surgery is still widely available in the UK. Disagreements about treatment choice in different clinical scenarios suggest substantial variation in the treatments patients are offered. Attention to identifying subgroups in trials would help to guide treatment choice for individual patients.

Promoting Vasa Vasorum Neovascularization of Vein Grafts Extenuates Hypoxia of the Wall and Its Subsequent Influence on Intimal Hyperplasia.

Background:The autologous saphenous vein is the most common conduit for coronary artery bypass grafting, but the vein graft disease will occur. This study used Matrigel basement membrane matrix with many different growth factors to promote vasa vasorum neovascularization and extenuate the hypoxia to improve remodeling.Methods:This study observed the hypoxia and thickness of the vein grafts at different times. Normal veins and vein grafts with 15 min of ischemia one day postoperatively were harvested in the neck of rabbits. Paired vein grafts with 15 min ischemia bilaterally (control vs. Matrigel basement membrane matrix) were performed and harvested at 2, 6, and 12 weeks postoperatively. The rabbits were randomly divided into four postoperative groups (six rabbits in each group): Group 1, one day postoperatively; Group 2, 2 weeks postoperatively; Group 3, 6 weeks postoperatively; and Group 4, 12 weeks postoperatively. The dimensions of vessel wall were captured, and the mean thicknesses of intima, media, and adventitia were measured. The hypoxia-inducible factor (HIF)-1α and HIF-2α labeling indices of intima, media, and adventitia were also measured.Results:In Group 1, the labeling index of HIF-1α was high in the normal vein and decreased significantly in the vein graft one day postoperatively (intima: 80 ± 3% vs. 12 ± 1%, P = 0.01; media: 67 ± 5% vs. 11 ± 1%, P = 0.01; adventitia: 40 ± 10% vs. 7 ± 2%, P = 0.03). The labeling index of HIF-2α had similar trend as HIF-1α (intima: 80 ± 10% vs. 10 ± 5%, P = 0.02; media: 60 ± 14% vs. 12 ± 2%, P = 0.01; adventitia: 45 ± 20% vs. 10 ± 4%, P = 0.03). Compared with the control vein grafts, vein grafts with Matrigel basement membrane matrix had lower labeling indices of HIF-1α and HIF-2α in media and adventitia at Group 2 (HIF-1α: 34 ± 5% vs. 20 ± 4%, P = 0.04 for media; 23 ± 3% vs. 11 ± 2%, P = 0.03 for adventitia; HIF-2α: 37 ± 6% vs. 21 ± 4%, P = 0.03 for media; 24 ± 4% vs. 13 ± 2%, P = 0.04 for adventitia) and Group 3 (HIF-1α: 33 ± 4% vs. 7 ± 2%, P = 0.04 for media; 13 ± 3% vs. 3 ± 1%, P = 0.02 for adventitia; HIF-2α: 27 ± 4% vs. 12 ± 3%, P = 0.02 for media; 19 ± 2% vs. 6 ± 1%, P = 0.02 for adventitia). There were no differences in mean thickness of intima, media, and adventitia between bilateral vein grafts at 2, 6, and 12 weeks postoperatively.Conclusions:This study indicated that promoting vasa vasorum neovascularization of vein grafts extenuated hypoxia, but did not influence the intimal hyperplasia of the wall.

Preliminary study of cerebral venous oxygen saturation in healthy people using MR quantitative susceptibility mapping

Objevtive To measure the magnetic sensitive figure of cerebral vein and to evaluate the gender and bilateral difference in normal human cerebral venous oxygen saturation and the correlation with age by MR quantitative susceptibility mapping (QSM). Methods Sixty right-handed healthy volunteers were enrolled in our study and underwent MRI and susceptibility weighted imaging (SWI) scan to acquire the phase and magnitude image of healthy people from November 2012 to September 2014. The susceptibility mapping(SM) was constructed from phase diagram and amplitude image by the susceptibility mapping imaging and phase artifacts removal toolbox (SMART) software. The region of interest (ROI) of bilateral cerebral veins (cerebral cortical veins, thalamostriate veins, septal veins, internal cerebral veins and basal veins of rosenthal) in SM was outlined manually by signal processing in nuclear magnetic resonance (SPIN). The Wilcoxon test was used to compare the gender-and side-difference of susceptibility measured by cerebral venous oxygen saturation. The Spearman correlation was used to calculate the correlation between the susceptibility of cerebral veins and age. Results The median susceptibility (extent) of left and right side cerebral cortical veins was 159.16(154.88-164.13)ppb(×10-9), 164.61(156.23-168.04) ppb, respectively. The median susceptibility (extent) of left and right side thalamostriate veins was 160.51 (152.14- 170.06) ppb, 162.48(153.47- 173.66)ppb, respectively. Left were less than the right, and the difference was statistically significant (Z=- 3.14, - 2.02, P<0.05). And the difference of two side of other cerebral venous susceptibility had no statistical significance. The median susceptibility (extent) of right cerebral cortical veins, left thalamostriate veins and right septal veins of 22 male was 166.22(159.21-169.99) ppb, 168.65(159.19- 174.45)ppb and 153.42(148.10- 161.78)ppb, respectively. The coresponding positions of median susceptibility (extent) of 38 female was 161.10(155.06- 167.15)ppb, 157.70(151.53- 164.41)ppb and 147.52(142.94- 154.16)ppb, respectively. The susceptibility of right cerebral cortical vein, left thalamostriate vein, right septal vein of male was significantly different from the females (Z=-2.03, -2.20, -2.33, P<0.05). Futhermore, we also found that there had positive correlation between age and right thalamostriate vein(r=0.28,P<0.05). Conclusion The magnetic sensitive of the right thalamostriate vein tends to increase along with the age, and some of peoples had difference with bilateral and age. Key words: Cerebral veins; Magnetic resonance imaging; Age factors

Recanalization After Endovenous Thermal Ablation

Background Endovenous thermal ablation in the form of radiofrequency ablation (RFA) or endovenous laser ablation (EVLA) has quickly ascended to a prime position in the treatment of venous insufficiency. Although there are good data examining the rates of thrombotic complications, there is a relative paucity of data examining the recanalization rates after endovenous thermal ablation (ETA). Methods Data analysis was performed for 1475 thermal ablations in 485 patients from 2012 to 2015 as a retrospective chart review. RFA was performed in 1027 patients and EVLA in 448 patients. The target veins included the great saphenous vein (GSV) (778), short saphenous vein (SSV) (401), accessory saphenous vein (ASV) (140), and perforator veins (PV) (156). Data were collected from follow-up visit within 1 week of procedure, every 3 months for the first year, and every 6 months thereafter. Recurrence was defined as >500 ms for the GSV, SSV, and ASV and as >350 ms for the PV. Data for recanalization were also correlated with age, gender, laterality, presenting symptoms, and treated targeted vein. Results The average age of the study population was 64.7 years (SD ± 15.6) with 66% women and 326 bilateral veins. At 1-week follow-up, women (2.6%) had higher recanalization rate (P = 0.018). Failure rate of obliteration for GSV and SSV were 0.8% and 0.8%, respectively (P = 0.98). PV had the highest failure rate (16.6%), followed by ASV (2.9%) (P Conclusions These data do suggest low overall rates of recanalization after thermal ablation of the GSV and SSV. However, at 1-year follow-up, accessory veins had almost twice the recurrence rate as compared with GSV and SSV, and PV had almost 5 times the recurrence rate. There was no significant difference between RFA and EVLA in recanalization rates. Redo procedures in recanalized veins after venous ablation are effective with a success rate at 76.5%.

Supratentorial subdural hematoma following microvascular decompression: a report of four cases.

IntroductionMicrovascular decompression has become an accepted surgical technique for the treatment of trigeminal neuralgia, hemifacial spasm, and other cranial nerve rhizopathies. However, critical complications still exist, and postoperative hemorrhage is one of the most life threatening complications following microvascular decompression. Most of the hemorrhages occur in the infratentorial region, and we found only four reports of supratentorial acute hemorrhages following microvascular decompression. Here, we report four cases of such hematomas and discuss the potential underlying mechanisms. Moreover, we discuss methods for handling such complications.Case descriptionBetween 2004 and 2015, four patients developed postoperative hemorrhages, all of which were supratentorial subdural hematomas. The hematomas occurred ipsilaterally in two cases and contralaterally in two cases. All of the patients were treated conservatively and discharged without clinical symptoms.Discussion and evaluationAlthough several intracranial hematomas have been reported distant from the craniotomy site, few reports of remote subdural hematomas after microvascular decompression exist. Draining large amounts of intraoperative cerebrospinal fluid may induce brain shifts and tearing of the small bridging veins. Of our four cases, two were ipsilateral and two were contralateral, and the side of the hemorrhage may suggest possible mechanisms of remote subdural hematomas in microvascular decompression. Although a lateral position for microvascular decompression mainly extends ipsilateral bridging veins, a postoperative supine position can extend bilateral veins equally. Therefore, we assumed that, supratentorial subdural hematomas occurred when the patients were returned to the supine position at the end of the microvascular decompression surgery. We may be able to prevent supratentorial subdural hematomas with the application of sufficient amounts of artificial cerebrospinal fluid immediately after a microvascular decompression.ConclusionWe suggest that it is important to avoid excessive CSF aspiration and to compensate for the cerebrospinal fluid loss with artificial cerebrospinal fluid adequately in order to avoid subdural hematomas after microvascular decompression. In addition, immediate postoperative CT scan is recommended even if the MVD has performed uneventfully.

Risk factors associated with the severity of pulmonary embolism in patients with acute deep venous thrombosis of lower extremities

To identify the risk factors associated with the severity of pulmonary embolism among patients with deep venous thrombosis of lower extremities. This prospective study enrolled 208 patients with acute deep venous thrombosis to screen for pulmonary embolism between July 2010 and July 2012 in Beijing Shijitan Hospital. There were 101 male and 107 female patients, with a mean age of (59 ± 16) years. Gender, age, extension, side of lower extremities of deep venous thrombosis was analyzed by χ² test. Ordinal Logistic regression was used to determine risk factors associated with severity of pulmonary embolism. There were 83 patients with iliofemoral deep venous thrombosis, 102 patients with femoropopliteal and 23 patients with calf deep venous thrombosis. Pulmonary embolism was detected in 70 patients with the incidence of 33.7%. Pulmonary embolism was significantly correlated with extension (χ² = 17.286, P = 0.004) and sides (χ² = 15.602, P = 0.008) of deep venous thrombosis, not with age (χ² = 7.099, P = 0.260), gender (χ² = 7.014, P = 0.067), thrombotic risk factors (χ² = 3.335, P = 0.345) in univariate analysis. Results of multivariate ordinal logistic regression showed that iliofemoral vein thrombosis (OR = 6.172, 95% CI: 1.590 to 23.975, P = 0.009) and bilateral venous thrombosis (OR = 7.140, 95% CI: 2.406 to 24.730, P = 0.001) are associated with more serious pulmonary embolism. Incidence of pulmonary embolism is still high in patients with deep venous thrombosis. Extensive iliofemoral and bilateral vein thrombosis may increase risk of severity of pulmonary embolism. Clinicians should pay more attention to these high-risk patients.