Chronic Thrombus Research Articles

Factors predicting resolution of left ventricular thrombus in different time windows after myocardial infarction

BackgroundLeft ventricular thrombus (LVT) is a serious complication after myocardial infarction. However, due to its asymptomatic nature, early detection is challenging. We aimed to explore the differences in clinical correlates of LVT found in acute to subacute and chronic phases of myocardial infarction.MethodsWe collected data from 153 patients who were diagnosed with LVT after myocardial infarction at the Affiliated Hospital of Qingdao University from January 2013 to December 2022. Baseline information, inflammatory markers, transthoracic echocardiograph (TTE) data and other clinical correlates were collected. Patients were categorized into acute to subacute phase group (< 30 days) and chronic phase group (30 days and after) according to the time at which echocardiograph was performed. The resolution of thrombus within 90 days is regarded as the primary endpoint event. We fitted logistic regression models to relating clinical correlates with phase-specific thrombus resolution.ResultsFor acute to subacute phase thrombus patients: C-reactive protein levels (OR: 0.95, 95% CI: 0.918–0.983, p = 0.003) were significantly associated with thrombus resolution. For chronic phase thrombus patients: anticoagulant treatment was associated with 5.717-fold odds of thrombus resolution (OR: 5.717, 95% CI: 1.543–21.18, p = 0.009).ConclusionsHigher levels of CRP were associated with lower likelihood of LVT resolution in acute phase myocardial infarction; Anticoagulant therapy is still needed for thrombus in the chronic stage of myocardial infarction.

Aging of deep venous thrombosis in-vivo using polarization sensitive optical coherence tomography.

Deep venous thrombosis (DVT) is a medical condition with significant post-event morbidity and mortality coupled with limited treatment options. Treatment strategy and efficacy are highly dependent on the structural composition of the thrombus, which evolves over time from initial formation and is currently unevaluable with standard clinical testing. Here, we investigate the use of intravascular polarization-sensitive optical coherence tomography (PS-OCT) to assess thrombus morphology and composition in a rat DVT model in-vivo, including changes that occur over the thrombus aging process. PS-OCT measures tissue birefringence, which provides contrast for collagen and smooth muscle cells that are present in older, chronic clots. Thrombi in the inferior vena cava of two cohorts of rats were imaged in-vivo with intravascular PS-OCT at 24 hours (acute, nrats = 3, 73 cross-sections) or 28 days (chronic, nrats = 4, 41 cross-sections) after thrombus formation. Co-registered histology was labelled by an independent pathologist to establish ground-truth clot composition. Automated analysis of OCT cross-sectional images differentiated acute and chronic thrombi with 97.6% sensitivity and 98.6% specificity using a linear discriminant model comprised of both polarization and conventional OCT metrics. These results support PS-OCT as a highly sensitive imaging modality for the assessment of DVT composition to differentiate acute and chronic thrombi. Intravascular PS-OCT imaging could be integrated with advanced catheter-based treatment strategies and serve to guide therapeutic decision-making and deployment, by offering an accurate assessment of DVT patients in real time.

Abstract 1120: Untargeted 16s Ribosomal Rna Survey Of Microbial Communities In The Patient With Aneurysmal And Occlusive Aortic Disease

Introduction: Inflammation is a hallmark of aneurysmal disease, but the etiology for the inflammation is unknown. Previously, bacteria and bacterial nucleic acid sequences have been identified within abdominal aortic aneurysm tissue. However, only one study has taken an un-targeted approach to assess the diversity of species and no study has surveyed bacterial species across the various environments in patients with aortic disease. Research Question: Does the distribution of bacterial sequences differ between environments and by disease status in patients with abdominal aortic disease? Methods: Whole blood, acute (luminal) thrombus, chronic (medial/abluminal) thrombus, and aortic wall specimens were obtained from 14 patients undergoing open aortic surgery. Five patients had aneurysm disease and nine patients had aortic occlusive disease. Sequencing using universal primers targeting the V3 - V5 16s rRNA bacterial gene was performed. Reads were processed and aligned to reference banks using QIIME2 to the genus level. Results: The average patient age was 60.9 years with no significant difference in baseline demographics. Phyllobacterium was the most common genus identified in acute and chronic thrombus for aneurysmal and occlusive disease while pseudomonas was the most common genus identified in aortic wall. Chao1 alpha diversity was higher in aneurysmal aortic wall samples compared to occlusive disease (10.6 vs 6.6, p=0.047). On principle component analysis, samples from similar tissue environments cluster together with 16% of the sequence variation explained by the grouping (p=0.003, Figure 1). Conclusions: The diversity of bacterial sequences groups by microenvironment within patients with aortic disease, suggesting a spectrum of bacterial communities that progress from blood through the luminal thrombus to the aortic wall. Further work could distinguish genus level variations that associates with disease in the different environments.

Microbubble Biointerfacing by Regulation of the Platelet Membrane Surfactant Activity at the Gas‐Liquid Interface for Acute Thrombosis Targeting

AbstractBiointerfacing nanomaterials with cell membranes has been successful in the functionalization of nanoparticles or nanovesicles, but microbubble functionalization remains challenging due to the unique conformation of the lipid monolayer structure at the gas‐liquid interface that provides insufficient surfactant activity. Here, we describe a strategy to rationally regulate the surfactant activity of platelet membrane vesicles by adjusting the ratio of proteins to lipids through fusion with synthetic phospholipids (i.e., liposomes). A “platesome” with the optimized protein‐to‐lipid ratio can be assembled at the gas‐liquid interface in the same manner as pulmonary surfactants to stabilize a microsized gas bubble. Platesome microbubbles (PMBs) inherited 61.4 % of the platelet membrane vesicle proteins and maintained the active conformation of integrin αIIbβ3 without the talin 1 for fibrin binding. We demonstrated that the PMBs had good stability, long circulation, and superior functionality both in vitro and in vivo. Moreover, by molecular ultrasound imaging, the PMBs provide up to 11.8 dB of ultrasound signal‐to‐noise ratio enhancement for discriminating between acute and chronic thrombi. This surface tension regulating strategy may provide a paradigm for biointerfacing microbubbles with cell membranes, offering a potential new approach for the construction of molecular ultrasound contrast agents for the diagnosis of different diseases.

Microbubble Biointerfacing by Regulation of the Platelet Membrane Surfactant Activity at the Gas-Liquid Interface for Acute Thrombosis Targeting.

Biointerfacing nanomaterials with cell membranes has been successful in the functionalization of nanoparticles or nanovesicles, but microbubble functionalization remains challenging due to the unique conformation of the lipid monolayer structure at the gas-liquid interface that provides insufficient surfactant activity. Here, we describe a strategy to rationally regulate the surfactant activity of platelet membrane vesicles by adjusting the ratio of proteins to lipids through fusion with synthetic phospholipids (i.e., liposomes). A "platesome" with the optimized protein-to-lipid ratio can be assembled at the gas-liquid interface in the same manner as pulmonary surfactants to stabilize a microsized gas bubble. Platesome microbubbles (PMBs) inherited 61.4 % of the platelet membrane vesicle proteins and maintained the active conformation of integrin αIIbβ3 without the talin 1 for fibrin binding. We demonstrated that the PMBs had good stability, long circulation, and superior functionality both in vitro and in vivo. Moreover, by molecular ultrasound imaging, the PMBs provide up to 11.8 dB of ultrasound signal-to-noise ratio enhancement for discriminating between acute and chronic thrombi. This surface tension regulating strategy may provide a paradigm for biointerfacing microbubbles with cell membranes, offering a potential new approach for the construction of molecular ultrasound contrast agents for the diagnosis of different diseases.

Systematic review of risk factors and outcomes of post-implantation syndrome following endovascular aortic repair

ObjectivePost implantation syndrome (PIS) is an early systemic inflammatory response following endovascular aortic repair (EVAR). The response is variable in patients and the clinical significance of PIS upon outcomes is unknown. This study aims to evaluate the incidence, risk factors, and prognostic implication of PIS. MethodsSystematic literature review and analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines of PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Eligible English-language studies regarding PIS after infrarenal EVAR were included, after removing duplicates. ResultsAfter screening, 31 studies were included. A total of 2847 patients were reviewed, with mean age of 70.7 years, of which 2012 (90.4%) were male, with a pooled mean follow-up of 26.1 months. PIS was reported in 25.3% of cases, with mean aneurysm diameter of 56.4 cm. Polytetrafluoroethylene (PTFE) grafts were utilized in 794 patients (27.9%) with polyester in 1839 (64.6%). White blood cell count, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 levels were all significantly elevated postoperatively. Thirty-day outcomes included type I endoleak rate of 0.8%, type II endoleak rate of 1.7%, reintervention rate of 0.35%, and mortality rate of 0.25%. Subgroup pooled analysis of patients with PIS (n = 309) vs No-PIS (n = 691) revealed that polyester (n = 642), rather than PTFE (n = 234) grafts, were associated with a higher rate of PIS (94.8% vs 3.7%; P = .0001), White blood cell count was higher in the PIS group both preoperatively (7.61 vs 6.76 × 109/L; P = .04) and postoperatively (15.0 vs 9.8 × 109/L; P = .0007) and IL-6 levels were higher in the PIS group postoperatively (98.6 vs 25.2 pg/mL; P = .02). Aneurysm diameter and amount of chronic or new thrombus within the aneurysm sac was not identified as a risk factor for PIS. Pooled outcomes of patients with PIS vs No-PIS demonstrated a significantly higher rate of 30-day mortality (0.6% vs 0%; P = .03) and major adverse cardiac events (5.8% vs 0.43%; P < .0001) without any differences seen in reintervention or 30-day type I or type II endoleaks. ConclusionsThis systematic review suggests that polyester grafts are strongly associated with PIS compared with PTFE. Interestingly, this report is suggestive of an association between 30-day mortality and major adverse cardiac events and PIS. Given these clinical sequelae, consideration for use of PTFE over polyester grafts to reduce the incidence of PIS may be a simple step to improve overall outcome. Further, exploration of the relationship between inflammatory mediators associated with PIS and mortality and cardiac complications may engender deeper understanding of risks, leading to eventual mitigation of harm for patients experiencing PIS.

Case report: hunting the hidden: surgical treatment of chronic silent thrombus in the left ventricle in a young alcoholic patient with myocardial bridging

BackgroundA silent left ventricular thrombus is dangerous. The current standard anticoagulation therapy was ineffective in our case or similar, and the outcome was poor.Case presentationA 33-year-old man with a silent left ventricular thrombus was detected incidentally by transthoracic echocardiography. After admission, anti-coagulation with low-molecular-weight heparin therapy was carried out. The CAG revealed 70% systolic stenosis in the middle of the right coronary artery along with myocardial bridging. Unfortunately, an acute left temporal embolism emerged 5 days later, then the patient was transferred to the neurology department for further treatment. One month later, the patient underwent left ventricular thrombectomy, ventricular aneurysm resection, and coronary artery bypass grafting (CABG) and was discharged uneventfully after surgery.ConclusionsSurgical treatment should be a priority for patients with giant or hypermobile left ventricular thrombus or recurrent systemic emboli.

The role of malondialdehyde in the evaluation of the treatment response in acute pulmonary thromboembolism

Aims: To facilitate the early diagnosis of the related patient group by investigating the level of Malondialdehyde (MDA) in high-risk pulmonary thromboembolism (PTE). In addition, it was aimed to see the effect of treatment after acute PTE on oxidative stress and to evaluate whether it is associated with the development of chronic thrombus. Methods: This study was conducted prospectively in 44 patients diagnosed with PTE in single-center. At the time of diagnosis, after 6 months of follow-up and treatment, the MDA levels of the patients were evaluated together with the controlled tests. Results: MDA level was found to be a determinant in the estimation of high-risk PTE. In addition, MDA level was found to be higher at the time of diagnosis and after treatment in patients with chronic thromboembolism. Conclusion: MDA level is a guiding parameter in high-risk PTE. In addition, the continuation of oxidative stress in the case of chronic thrombus may be important in the remodeling of the precapillary pulmonary artery.

An Unusual Case of Huge Cervical Fibroid with Tubercular Aortic Nodes in Case of Aortic Occlusion

We report a 29-year-old female who had coexistence of huge cervical fibroid with aortic nodes of tubercular origin with aortic occlusion due to chronic thrombus of lower abdominal aorta.

Portal Vein Thrombosis in Patients with Liver Cirrhosis: What Went Wrong?

This study aimed to explore inflammatory biomarkers, stool's functional bacterial groups and their possible link to portal vein thrombosis (PVT) in patients with liver cirrhosis (LC). An observational study of 300 participants: 200 inhospital cirrhotic patients, who met inclusion criteria, equally assigned into two groups, based on the presence or absence of PVT and 100 healthy controls was carried out. The PVT group displayed significant differences related to older age, cigarettes smoking history, emergency admission, higher Child-Pugh score, metabolic related disorders and nonalcoholic fatty liver disease, as well as non-obstructive aspects, with chronic thrombi. The PVT group exhibited significant differences related to biomarkers such as tumor necrosis factor (TNF)-alpha, C-reactive protein (CRP), D-dimers (D-D), as well as gut overall dysbiosis (DB) and alteration of different functional bacterial groups of the gut microbiota. Strong positive correlations were observed between PVT severity, and TNF-alpha, CRP, D-D as well as lipopolysaccharide (LPS) positive bacteria. Esophageal varices, age and abdominal pain were independent predictors for PVT severity as well as CRP, TNF-alpha and D-D. Patients with LC and PVT displayed elevation of TNF-alpha, CRP, D-D alterations of the functional gut microbiota, as well as several morphological and clinical particularities. Although the LPS positive gut microbiota was linked to inflammatory biomarkers and PVT severity, it was not proven to be an independent predictor of the PVT severity like CRP, TNF-alpha and D-D.

Results of a Flexible Patient-Centered Approach to the Timing of Thoracic Outlet Decompression in Paget Schroetter Syndrome

Treatment algorithms for subclavian vein (SCV) effort thrombosis (Paget-Schroetter syndrome- PSS) are multiple, ranging from thrombolysis (TL) with immediate or delayed thoracic outlet decompression (TOD) to conservative treatment with anticoagulation alone. We follow a regimen of TL / pharmacomechanical thrombectomy (PMT) followed by TOD with first rib resection, scalenectomy, venolysis and selective venoplasty (open or endovascular) performed electively at a time convenient for the patient. Oral anticoagulants are prescribed for 3 months or longer based upon response. The aim of this study was to evaluate outcomes of this flexible protocol. Clinical and procedural details of consecutive patients treated for PSS from Jan 2001 to August 2016 were retrospectively reviewed. Endpoints included success of TL and eventual clinical outcome. Patients were divided into two groups-Group I: TL/PMT + TOD; Group II: medical management / anticoagulation + TOD. PSS was diagnosed in 114 patients; 104 (62 female, mean age 31 years) who underwent TOD were included in the study. Group I: 53 patients underwent TOD after initial TL / PMT (23 at our institution and 30 elsewhere) with success (acute thrombus resolution) in 80% (n=20) and 72% (n=24) respectively. Adjunctive balloon-catheter venoplasty was performed in 67%. TL failed to recanalize the occluded SCV in 11% (n=6). Complete thrombus resolution was seen in 9% (n=5). Residual chronic thrombus in 79% (n=42) resulted in median SCV stenosis of 50% (range 10 to 80%). With continued anticoagulation, further thrombus retraction was noted with median 40% improvement in stenosis including in veins with unsuccessful TL. TOD was performed at a median of 1.5 months (range 2 - 8months). Re-thrombosis of the SCV occurred in 3 patients 1-3 days postoperatively and was managed with MT / SCV stenting/balloon angioplasty and anticoagulation. Symptomatic relief was achieved in 49/53 (92%) patients at a median follow up of 14 months. 51 patients underwent TOD following medical treatment elsewhere with anticoagulation alone for an average 6 months (range 2-18 months) with recurrent SCV thrombosis in 5 (11%). Thirty-nine patients (76%) had persistent symptoms; the remaining had asymptomatic compression of the SCV with maneuvers. SCV occlusion persisted in 4 patients (7%); the indication for TOD being residual symptoms from compression of collateral veins, the median residual stenosis was 70% (range 30-90%). TOD was performed at a median of 6 months after diagnosis of PSS. Open venous reconstruction with endovenectomy and patch was performed in 4 patients and stenting in 2. Symptomatic relief was achieved in 46/51 (90%) at a median follow up of 24 months. For Paget Schroetter syndrome a management protocol encompassing elective thoracic outlet decompression at a convenient time following thrombolysis is safe and effective, with low risk of re-thrombosis. Continued anticoagulation in the interim results in further recanalization of the subclavian vein and may reduce the need for open venous reconstruction.

Lower extremity deep vein thrombosis: an ultrasound revisit regarding its diagnostic value

Aim: To determine the diagnostic value of ultrasound in lower extremity deep vein thrombosis (LEDVT). Methods: Data of 20 patients diagnosed with LEDVT and underwent endovascular treatment at Hue University of Medicine and Pharmacy hospital from 01/2021 - 08/2022 were analyzed. Ultrasound findings were documented and correlated with venography. All patients were initialized with anticoagulation upon the diagnosis of LEDVT. Endovascular treatment included diagnostic venography, inferior vena cava filter insertion, intraclot thrombolysis, manual thromboaspiration with or without venoplasty and stenting. Results: The mean age was 58.63 ± 16.9 (range, 17 - 85 age). The major risk factors were trauma, surgery, and a history of DVT. LEDVT was found prominently in the left leg and at the femoropopliteal level. Ultrasound had a sensitivity of 93.6%, a specificity of 97.6%, a positive predictive value of 98.6%, a negative predictive value of 89.1% and accuracy of 95% in the diagnosis of LEDVT. The sensitivity and specificity of ultrasound in differentiating between chronic and acute thrombus were 96.5% and 92%. Ultrasound had low sensitivity in evaluating collaterals and venous outflow obstruction (May-Thurner syndrome). Conclusion: Ultrasound has a high diagnostic value and remains the first line imaging modality in the investigation of LEDVT. Key words: deep vein thrombosis; ultrasound; venography; thromboaspiration; May-Thurner syndrome

Percutaneous mechanical thrombectomy to remove post-thrombotic obstructions and manage post-thrombotic syndrome-associated venous leg ulceration

BackgroundUp to one half of patients with a diagnosis of deep vein thrombosis will develop post-thrombotic syndrome (PTS). Patients with PTS can develop venous leg ulcers (VLUs) due to post-thrombotic obstructions (PTOs) that contribute to prolonged ambulatory venous hypertension. The current treatments for PTS, which include chronic thrombus, synechiae, trabeculations, and inflow lesions, do not target PTOs, and such obstructions can affect stenting success. The aim of the present study was to determine whether removal of chronic PTOs using percutaneous mechanical thrombectomy would promote VLU resolution and positive outcomes. MethodsIn this retrospective analysis, the characteristics and outcomes for patients with VLUs secondary to chronic PTO who were treated using the ClotTriever System (Inari Medical) between August 2021 and May 2022 were assessed. Technical success was considered the ability to cross a lesion and introduce the thrombectomy device. Clinical success was defined as a decrease of ≥1 in the severity category for the ulcer diameter using the revised venous clinical severity score (score 0, no VLU; score 1, mild VLU [size <2 cm]; score 2, moderate VLU [size 2-6 cm]; score 3, severe VLU [size >6 cm]) at the latest follow-up visit. ResultsA total of 11 patients with 15 VLUs on 14 limbs were identified. Their mean age was 59.7 ± 11.8 years, and four patients (36.4%) were women. The median VLU duration was 11.0 months (interquartile range [IQR], 6.0-17.0 months), and 2 patients had VLUs secondary to a deep vein thrombosis event >40 years previously. All treatments were performed in a single session, with technical success achieved in 100% of the 14 limbs. A median of five passes (IQR, four to six passes) with the ClotTriever catheter were performed per limb. Chronic PTOs were successfully extirpated, and intraprocedural intravascular ultrasound showed effective disruption of venous synechiae and trabeculations. Stents were placed in 10 limbs (71.4%). The time to VLU resolution or the latest follow-up was 12.8 ± 10.5 weeks, and clinical success was achieved for all 15 VLUs (100%), with the revised venous clinical severity score for the ulcer diameter improving from a median of 2 (IQR, 2-2) at baseline to a median score of 0 (IQR, 0-0) at last follow-up. The VLU area had decreased by 96.6% ± 8.7%. Of the 15 VLUs, 12 (80.0%) had resolved completely, and 3 had demonstrated near-complete healing. ConclusionsAll patients showed complete or near-complete VLU healing within a few months after mechanical thrombectomy. Mechanical extirpation and interruption of chronic PTOs allowed for luminal gain and restoration of cephalad inflow. With additional investigation, mechanical thrombectomy with the study device could prove a vital component to the treatment of VLUs secondary to PTOs.

Six-Month Deep Vein Thrombosis Outcomes by Chronicity: Analysis of the Real-World ClotTriever Outcomes Registry

PurposeTo analyze the first 250 patients from the prospective, multicenter, industry-sponsored ClotTriever Outcomes (CLOUT) registry, assessing the safety and effectiveness of mechanical thrombectomy for acute, subacute, and chronic deep vein thrombosis (DVT). Materials and MethodsReal-world patients with lower extremity DVT were treated with the ClotTriever System (Inari Medical, Irvine, California). Adjuvant venoplasty, stent placement, or both were performed at the physician’s discretion. Thrombus chronicity was determined by visual inspection of removed thrombus, categorizing patients into acute, subacute, and chronic subgroups. Serious adverse events (SAEs) were assessed through 30 days. Clinical and quality-of-life (QoL) outcomes are reported through 6 months. ResultsThrombus chronicity was designated for 244 of the 250 patients (acute, 32.8%; subacute, 34.8%; chronic, 32.4%) encompassing 254 treated limbs. Complete or near-complete (≥75%) thrombus removal was achieved in 90.8%, 81.9%, and 83.8% of the limbs with acute, subacute, and chronic thrombus, respectively. No fibrinolytics were administered, and 243 (99.6%) procedures were single sessions. One (0.4%) patient in the subacute group experienced a device-related SAE, a fatal pulmonary embolism. On comparing baseline and 6-month data, improvements were demonstrated in median Villalta scores (acute, from 10 to 1; subacute, from 9 to 1; chronic, from 10 to 3; for all, P < .0001) and mean EuroQol group 5-dimension (EQ-5D) self-report questionnaire scores (acute, 0.58 to 0.89; subacute, 0.65 to 0.87; chronic, 0.58 to 0.88; for all, P < .0001). There were no significant differences in outcomes across the subgroups. ConclusionsMechanical thrombectomy using the ClotTriever System with adjunctive venoplasty and stent placement is safe and similarly effective for acute, subacute, and chronic DVT.

Teaching NeuroImages: High-resolution MRI before and during a sentinel headache demonstrates aneurysm wall hemorrhage

A 3T brain MRI, performed in a 48-year-old woman presenting with progressive headaches, demonstrated a 20-mm unruptured saccular basilar artery aneurysm. High-resolution vessel-wall MRI showed a chronic mural thrombus and a circumferential aneurysm wall enhancement (figure), an imaging marker of aneurysm instability.1 Two days later, she had a transient thunderclap headache, considered the worst headache she had ever reported. Repeated 3T MRI demonstrated acute mural hemorrhage without subarachnoid hemorrhage. Sentinel headaches, reported in every fourth patient preceding aneurysm rupture,2 have been interpreted as reflecting a warning for subarachnoid leak or, alternatively, structural wall changes, such as stretching or acute mural hemorrhage.

Hybrid Paraclavicular Decompression for Venous Thoracic Outlet Syndrome with Primary Endovascular Reconstruction

Venous thoracic outlet syndrome (vTOS) is characterized by severe stenosis and potential thrombosis of the axillary-subclavian vein (effort thrombosis) with significant effects on patient mobility, quality of life, and risks associated with possible anticoagulation. Treatment goals are aimed at symptomatic improvement and freedom from recurrent thrombosis. To date, there exists no clear protocols or recommendations on surgical approach that results in optimal outcomes. We highlight our institution's experience with a systematized, paraclavicular approach with intraoperative balloon angioplasty only, if needed. This was a retrospective case series identifying 33 patients that underwent thoracic outlet decompression for vTOS from 2014-2021 via paraclavicular approach at Trinity Health Ann Arbor. Demographics, presenting symptoms, perioperative details, and follow-up details describing symptomatic improvement and imaging surveillance were obtained. The average age of our patients was 37 with the most common presenting symptoms of pain and swelling (91%). The average time from diagnosis to thrombolysis for effort thrombosis was 4 days, with an average time to operative intervention of 46 days. All patients underwent a paraclavicular approach with full first rib resection, anterior and middle scalenectomy, subclavian vein venolysis, and intra-operative venogram. Of these, 20 (61%) underwent endovascular balloon angioplasty, one required balloon with stent placement, 13 (39%) required no additional intervention, and no patients required surgical reconstruction of the subclavian-axillary vein. Duplex imaging was used to evaluate recurrence in 26 patients at an average of 6 months post-op. Of these, 23 demonstrated complete patency (89%), one demonstrated chronic non-occlusive thrombus, and two demonstrated chronic occlusive thrombus. Almost all our patients (97%) had moderate or significant improvement of their symptoms. None of our patients required a subsequent operation for recurrence of symptomatic thrombosis. The mode length of anticoagulation use post-operatively was 3 months, with an average use of 4.5 months. A systematized surgical approach of paraclavicular decompression for venous thoracic outlet syndrome with primary endovascular balloon angioplasty carries minimal morbidity with excellent functional results and symptomatic relief.

Six different surgical method options according to etiology in repair of arteriovenous fistula aneurysms

Aim: This study aims to evaluate the considerations that should be taken into account when choosing a surgical method and the early results of six methods used for repair in patients who underwent surgical repair due to arteriovenous fistula (AVF) aneurysms. Material and Methods: One hundred and five patients who underwent AVF aneurysm repair between 2012 and 2020 were reviewed retrospectively. Methods for surgical repair were used according to the etiology: Plication, Arteriotomy constrictions and plication, Aneurysm excision and creation of a new fistula, Saphenous vein or synthetic graft interposition, End-to-end anastomosis and plication after aneurysm excision, Banding method. Results: Sixty-one of the cases were male and 44 were female. The mean age was 56.6 (27-75) years. The total number of surgeries was 119, including the surgeries and reoperations performed in 2 planned sessions. As surgical method, 44 Plication, 13 Arteriotomy constrictions and plication, 10 Aneurysm excision and creation of a new fistula, 25 Saphenous vein or synthetic graft interposition, 13 End-to-end anastomosis and plication after aneurysm excision and 14 Banding methods were used. AVF flow of 38 patients was measured to be over 1700 ml/min, and 34 of these patients had an arteriotomy length of more than 7 mm. In patients who underwent repair due to high flow rate, an average of 30-65% flow reduction was achieved compared to the preoperative period. In the first postoperative 3 months, 7 (6%) patients required reoperation. Fistula loss did not occur in any of the patients who underwent repair. Conclusion: The etiology of aneurysm, flow rate, aneurysm localization, and the presence of intimal hyperplasia or chronic thrombus are important in choosing an aneurysm repair method. We think that the results will be positively affected if the surgical method is determined according to the association of one or few of these factors.

Distal vessel pulmonary thromboendarterectomy: Results from a single institution

Chronic thromboembolic pulmonary hypertension (CTEPH) is primarily managed by pulmonary thromboendarterectomy (PTE). As advanced surgical techniques permit resection at the segmental and subsegmental level, PTE can now be curative for CTEPH mostly involving the distal pulmonary arteries. Between January 2017 and June 2021, consecutive patients undergoing PTE were categorized according to the most proximal level of chronic thrombus resection: Level I (main pulmonary artery), Level II (lobar), Level III (segmental) and Level IV (subsegmental). Proximal disease patients (any Level I or II) were compared to distal disease (Level III or IV bilaterally) patients. Demographics, medical history, preoperative pulmonary hemodynamics, and immediate postoperative outcomes were obtained for each group. During the study period, 794 patients underwent PTE, 563 with proximal disease and 231 with distal disease. Patients with distal disease more frequently had a history of an indwelling intravenous device, splenectomy, upper extremity thrombosis or use thyroid replacement and less often had prior lower extremity thrombosis or hypercoagulable state. Despite more use of PAH-targeted medications in the distal disease group (63.2% vs 50.1%, p < 0.001), preoperative hemodynamics were similar. Both patient groups exhibited significant improvements in pulmonary hemodynamics postoperatively with comparable in-hospital mortality rates. Compared to proximal disease, a lower percentage of patients with distal disease showed residual pulmonary hypertension (3.1% vs 6.9%, p=0.039) and airway hemorrhage (3.0% vs 6.6%, p=0.047) postoperatively. Thromboendarterectomy for distal (segmental and subsegmental) CTEPH is technically feasible and may result in favorable pulmonary hemodynamic outcomes, without increased mortality or morbidity.

Abstract 13016: Tumor or Thrombus?: Intracardiac Thrombus Masquerading as a Tumor

Introduction: Intracardiac masses comprise thrombi, vegetations, and tumors. Multimodality imaging modalities are often relied upon for a definitive diagnosis. We present a case of a left ventricular (LV) thrombus with characteristic of on contrast echocardiography that thrombus based on cardiac MRI. The mass resolved with anticoagulation. Case: A 56-year-old male with non-ischemic cardiomyopathy was admitted for management of decompensated heart failure. Transthoracic echocardiography (TTE) showed reduced left ventricular ejection fraction of 20 to 25% with diffuse hypokinesis. There was a newly detected large intracardiac mass seen in the left ventricle (figures 1-3) that enhanced with echocardiographic contrast (figure 2). Delay enhancement imaging on cardiac MRI, however, revealed a hypodense mass suggestive of a thrombus (figure 3). The patient started anticoagulation. An echocardiogram performed a month later revealed complete resolution of mass, confirming the thrombotic nature of mass (figure). Discussion: Contrast enhancement echocardiography is very helpful for characterization of intra-cardiac masses. Tumors usually enhance with contrast while thrombi are generally dark. Our case is unusual, the cardiac mass hyper-enhanced with echocardiographic contrast but had thrombus-like characteristics on cardiac MRI. The mass was proven to be a thrombus over time since it resolved with anticoagulation. Echocardiographic contrast usually fails to penetrate hard, chronic thrombi. However loosely structured, fresh thrombi may allow some passage of contrast. This has been demonstrated in carefully conducted in-vitro studies showing that imaging characteristics of newly formed thrombus is often bright with echocardiographic contrast. This underscores the importance of multi-modality imaging to diagnose the nature of a cardiac mass.

S2597 Gastrointestinal Hemorrhage From Hepaticojejunal Varices: A Rare Complication of Pancreaticoduodenectomy

Introduction: Ectopic varices are portosystemic collaterals that form outside the esophageal-gastric region and frequently pose a diagnostic and therapeutic challenge. Rarely, bleeding from ectopic varices can occur as a complication of pancreatic surgery. We describe a case of gastrointestinal bleeding from ectopic hepaticojejunal varices after pancreaticoduodenectomy. Case Description/Methods: A 66-year-old man with a history of intraductal papillary mucinous neoplasm (PMN) with high-grade dysplasia status post Whipple procedure two years previously, presented to the hospital with melena. His Whipple procedure had been complicated by splenic vein thrombosis and disease recurrence, necessitating further debridement three months prior to presentation. On examination, his vital signs were stable and there were no stigmata of liver disease. His laboratory tests were notable for a hemoglobin 8.0 g/dL (from baseline of 11 g/dL), platelets 174 × 109/L, BUN 29 mg/dL, INR 1.0. He initially underwent EGD and colonoscopy, which were unremarkable. A second look endoscopy was performed and deep intubation of the afferent limb revealed ectopic varices with stigmata of recent bleeding at the hepaticojejunostomy (Panel A). Cross-sectional imaging demonstrated a patent splenic vein but chronic occlusion of the portal and proximal superior mesenteric veins with cavernous transformation, extensive upper abdominal varices and splenomegaly (Panel B). There was no clinical or radiologic evidence of cirrhosis. After multidisciplinary discussion, an endovascular approach was deemed technically infeasible given extensive chronic mesenteric thrombus and a surgical approach was deemed prohibitively high-risk. The patient ultimately underwent endoscopic injection of 2-octyl cyanoacrylate into the ectopic varices and has remained without recurrent bleeding in over 5 months of follow-up. Discussion: Hemorrhage from ectopic jejunal varices following pancreatic surgery has previously been described in only a few case reports. Given the potential for vascular injury and local inflammation, these procedures can result in mesenteric venous thrombosis with subsequent ectopic variceal formation. If present, defining the vascular supply of varices with early multi-disciplinary involvement is paramount to their management. Multiple treatments have been reported, including portal venous stenting, embolization, and local sclerotherapy or cyanoacrylate injection as in this case.Figure 1.: (A) Ectopic varices (yellow arrows) are noted in the afferent limb at the hepaticojejunostomy. (B) Coronal view of computed tomography scan of abdomen demonstrating large upper abdominal collaterals (red arrow) that drain close to the afferent limb (white arrow).