Common Iliac Vein Research Articles

Thrombophilia in Budd-Chiari syndrome patient

A 27-years old female patient presented with a severe general condition of generalized edema and hypotension. Two months earlier computed tomography imaged thrombosis of the inferior vena cava and the three hepatic veins, or Budd-Chiari syndrome (BCS). Additional findings were thrombosis of the right common iliac vein and thrombosis of the renal veins bilaterally. Genetic testing proved congenital thrombophilia. Anticoagulation therapy did not affect thrombotic occlusions. In another cardiovascular center, an unsuccessful attempt for interventional treatment of the inferior vena cava with a jugular approach was made. The patient was admitted to our hospital for further evaluation and decision on treatment strategy. Laboratory and non-invasive imaging at admission rejected hepatic cirrhosis. An abdominal ultrasound scan demonstrated complete occlusion of the three hepatic veins and post hepatic portal hypertension. When thrombosis of all hepatic veins was detected transjugular intrahepatic portosystemic shunt (TIPS) was an option. An endovascular strategy for inferior vena cava was undertaken and complete revascularization was achieved with the right femoral approach as a bridge to TIPS shunt procedure, since the patient didn’t meet the criteria for liver transplantation. In diagnosing disease, the main contributors were the gastroenterologist, diagnostic imaging specialist, and hematologist, while the multidisciplinary team included also cardiologist, interventional cardiologist, and angiologist. In this case the multidisciplinary decisions played a major role in diagnosing and building an appropriate therapeutic strategy for systemic illnesses and conditions for which medical guidance does not yet have clear guidelines.

Left leg swelling: A case of May-Thurner syndrome

May-Thurner Syndrome is a left common iliac vein thrombosis caused due to its compression by right common iliac artery, an anatomical variant that is underreported. We report the case of a 52 year old female who presented with left leg swelling and was diagnosed with May-Thurner Syndrome. She underwent an iliac vein thrombectomy and was discharged on life-long anticoagulants.

A practice audit of short-term outcomes of Wallstents versus Venovo stents for the treatment of nonthrombotic iliac vein outflow stenoses

ObjectiveThe Wallstent (WS; Boston Scientific, Malborough, MA) is currently the standard of care for comparisons of clinical efficacy for new stent devices in the treatment of iliac vein outflow disease. Many vein-specific Nitinol-based stents have been now approved by the Food and Drug Administration for use in the iliofemoral venous system. However, few comparisons of these devices to the current standard have been reported. The purpose of this investigation was to compare the complication and reintervention rates between the WS and Venovo stent (VS; BD, Franklin Lakes, NJ). MethodsA random sample of 100 WS and 100 VS cases performed from April 2018 through December 2020 were selected for retrospective analysis. The demographics, presenting symptoms, and CEAP (Clinical, Etiology, Anatomy, Pathophysiology) class were assessed. The complication logs and 90-day follow-up data were reviewed for every case to assess the incidence of postoperative deep vein thrombosis, stent thrombosis, in-stent restenosis, bleeding, and transient back pain. ResultsWSs had been placed more often in the left common iliac vein segment (52 vs 1), and VSs had been placed more often in the left common iliac vein and external iliac vein segments (36 vs 63; P = .0069). The average diameter and length of the WSs and VSs were 19.7 ± 2.2 mm vs 15 ± 1.4 mm (P = 2.4∗10−44) and 80.8 ± 9 mm vs 117.6 ± 20.4 mm (P = 2.4∗10−38), respectively. The average number of stents per patient was 1.05 for the WSs and 1.03 for the VSs (P = .47). The reintervention rates were similar between the two groups: WS, n = 5; and VS, n = 4 (P = .74). Four of the five WS reinterventions were stent extensions to treat in-stent restenosis and recurrence of symptoms, and one was secondary to occlusion requiring ipsilateral venoplasty and stenting. Two of the four VS reinterventions were venoplasty for in-stent restenosis and two were stent extensions for symptom recurrence. Transient back pain was the most common complication (WS, 37%; VS, 47%; P = 0.28). Insertion site deep vein thrombosis had developed in the three patients in the WS group and four patients in the VS group (P = .71). No patient had experienced bleeding requiring hospitalization, and no stent fractures, stent migration, or deaths had occurred. ConclusionsThe complication and reintervention rates between the WS and VS groups were similar. Both stents demonstrated evidence of in-stent stenosis requiring reintervention. Implanted VSs tended to be smaller in diameter and longer in length and covered the common and external iliac veins more often compared with the WSs. Therefore, one VS can be used to cover two territories compared with the WS for which two stents will be required to cover the same vein territory length.

Treatment of Bilateral Venous Thrombosis in a Patient with Aplasia of the Inferior Vena Cava

The aim. In the treatment of venous thromboembolism, a special place is occupied by patients with congenital anomalies of the development of the inferior vena cava (IVC). To date, only single cases of treatment of this pathology have been described in the literature. Studying the experience of treating patients with congenital anomalies of the IVC will allow to improve the results of treatment of this category of patients.
 Materials and methods. Patient B., a 36-year-old man, applied to the vascular surgery clinic of the Vinnytsia Regional Pyrohov Clinical Hospital in July 2010 with complaints of pain, swelling, cyanosis of both lower extremities, which bothered the patient for about 10 days. The patient had no history of venous insufficiency of both lower extremities.
 An objective examination revealed cyanosis and swelling of both lower extremities.
 A duplex scan of both lower extremities revealed hyperechoic iliofemoral thrombosis of both lower extremities. Aplasia of the IVC was diagnosed. The common iliac veins on both sides formed a collateral that flowed into the left renal vein. The infrarenal segment of the inferior vena cava was absent. Thrombosis spread from tibial to popliteal, femoral, iliac veins with venous collateral thrombosis up to the level of the left renal vein.
 The patient received enoxaparin at a dose of 1 mg per kg of body weight twice a day for 7 days with subsequent transition to warfarin under the control of international normalized ratio. Warfarin was prescribed from a starting dose of 5 mg with subsequent control of international normalized ratio in the range of 2.0-3.0. Venotonic and anti-inflammatory drugs were also prescribed. In combination with drug therapy, class 2 elastic compression stockings were recommended.
 After the treatment, the patient’s condition improved, swelling and cyanosis of both lower extremities regressed. Repeated duplex scanning at the discharge of the patient from the hospital after 7 days showed signs of initial recanalization of the affected venous segments and no progression of thrombosis.
 Conclusions. Thus, this clinical case showed that the use of anticoagulant therapy allows to obtain satisfactory results in the treatment of patients with congenital anomalies of the development of IVC, to avoid the development of pulmonary embolism and other life-threatening conditions. At the same time, such patients need regular follow-up examinations in order to adjust the treatment and prevent the development of IVC syndrome.

The combination of EGCG with warfarin reduces deep vein thrombosis in rabbits through modulating HIF-1α and VEGF via the PI3K/AKT and ERK1/2 signaling pathways.

Deep venous thrombosis (DVT) poses a major challenge to public health worldwide. Endothelial cell injury evokes inflammatory and oxidative responses that contribute to thrombus formation. Tea polyphenol (TP) in the form of epigallocatechin-3-gallate (EGCG) has anti-inflammatory and oxidative effect that may ameliorate DVT. However, the precise mechanism remains incompletely understood. The current study was designed to investigate the anti-DVT mechanism of EGCG in combination with warfarin (an oral anticoagulant). Rabbits were randomly divided into five groups. A DVT model of rats was established through ligation of the inferior vena cava (IVC) and left common iliac vein, and the animals were orally administered with EGCG, warfarin, or vehicle for seven days. In vitro studies included pretreatment of human umbilical vein endothelial cells (HUVECs) with different concentrations of EGCG for 2 h before exposure to hydrogen peroxide. Thrombus weight and length were examined. Histopathological changes were observed by hematoxylin-eosin staining. Blood samples were collected for detecting coagulation function, including thrombin and prothrombin times, activated partial thromboplastin time, and fibrinogen levels. Protein expression in thrombosed IVCs and HUVECs was evaluated by Western blot, immunohistochemical analysis, and/or immunofluorescence staining. RT-qPCR was used to determine the levels of AGTR-1 and VEGF mRNA in IVCs and HUVECs. The viability of HUVECs was examined by CCK-8 assay. Flow cytometry was performed to detect cell apoptosis and ROS generation was assessed by 2',7'-dichlorofluorescein diacetate reagent. In vitro and invivo studies showed that EGCG combined with warfarin significantly reduced thrombus weight and length, and apoptosis in HUVECs. Our findings indicated that the combination of EGCG and warfarin protects HUVECs from oxidative stress and prevents apoptosis. However, HIF-1α silencing weakened these effects, which indicated that HIF-1α may participate in DVT. Furthermore, HIF-1α silencing significantly up-regulated cell apoptosis and ROS generation, and enhanced VEGF expression and the activation of the PI3K/AKT and ERK1/2 signaling pathways. In conclusion, our results indicate that EGCG combined with warfarin modifies HIF-1α and VEGF to prevent DVT in rabbits through anti-inflammation via the PI3K/AKT and ERK1/2 signaling pathways.

Tumor thrombus formation in the right common iliac vein after radical proctectomy in a patient with rectal cancer: a case report

BackgroundIntravascular tumor thrombi are mainly found in patients with liver cancer or renal carcinoma but rarely occur in those with rectal cancer.Case presentationThis is a case report of a 58-year-old woman with a swollen right lower extremity 14 months after radical resection for rectal cancer. Although ultrasonography indicated the presence of deep venous thrombosis (DVT) located in the right common iliac vein, interventional angiography showed that a circular mass, considered a tumor thrombus, was located in the right common iliac vein. The tumor thrombus was cured by interventional therapy, and the pathological report confirmed that the metastatic tumor thrombus originated from the rectal cancer. The patient underwent concurrent chemoradiotherapy and systemic therapy. However, right lung, retroperitoneum, and 2nd sacral vertebral metastases were discovered during follow-up.ConclusionThe correct diagnosis of a tumor thrombus and its differentiation from DVT can prevent incorrect treatment and prolong the survival of patients with rectal cancer.

Thrombectomy in deep vein thrombosis: a definitive treatment

Background: The development of blood clots (thrombi) in the deep veins is known as deep vein thrombosis (DVT). It frequently affects the deep pelvic veins or the deep leg veins (such as the calf veins, femoral vein, or popliteal vein). It is a potentially fatal condition that may result in morbidity and mortality that can be prevented. Aim was to assess the effectiveness of thrombectomy in treating patients with DVT.Methods: The 196 patients with DVT reporting to VKP’s VJ hospital, Tirunelveli, Tamil Nadu, were selected for this retrospective study. Thrombectomy was chosen as the treatment modality in this study.Results: Most patients were in the age group between 41 to 60 years (59.5%), with male predominance noted (77.4%). Pain and swelling are the most typical clinical features, 64.6% of patients presented with this sign. In patients with chronic and sub-acute DVT, 25% and 10.2% had residual thrombus visualized in doppler. Late complication, varicose veins were seen higher in patients with common iliac vein thrombosis (2/3) 66.7%, 52.6% (10/19) in external iliac vein thrombosis and 34.8% (8/23) in popliteal vein thrombosis. Late complication recurrence was seen higher in patients with partial occlusion (5/14) 35.7%, 21.4% (3/14) had varicose veins.Conclusions: The best course of treatment for DVT patients is thrombectomy, which can restore venous patency, stop DVT from returning, alleviate PTS, and prevent pulmonary embolism.

Safety and Efficacy of the Treatment of Iliofemoral Deep Vein Thromboses With the Inari ClotTriever

Safety and Efficacy of the Treatment of Iliofemoral Deep Vein Thromboses With the Inari ClotTriever

P118. Anterior versus lateral lumbar fusion: a comparison of 2-year outcomes in the treatment of degenerative spinal disorders

<h3>BACKGROUND CONTEXT</h3> Extreme lateral interbody fusion (XLIF) and anterior lumbar interbody fusion (ALIF) have both been progressively utilized by spinal surgeons, offering advantages of reduced tissue trauma, blood loss and improvements in postoperative patient reported outcomes. Although the literature has reported a higher proportion of neurological complications in XLIF, the anterior approach has been associated with a larger overall complication proportion, including a greater number of vascular and visceral complications. However, there is a paucity of reports comparing the two approaches over the long-term. Therefore, the purpose of this study was to assess and compare the overall revision rates, perioperative complications and functional clinical outcomes with minimum 2-year followup in both ALIF and XLIF. <h3>PURPOSE</h3> To compare ALIF versus XLIF in the treatment of degenerative spinal disorders with minimum 2-year followup. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort comparative study. <h3>PATIENT SAMPLE</h3> A total of 293 patients from 2013-2018 with a minimum follow-up of 2 years. One hundred and seventy-eight patients underwent ALIF and 115 patients underwent XLIF. <h3>OUTCOME MEASURES</h3> (1) Revision rate and average time to revision; (2) Perioperative complications; (3) Functional outcome scores including Oswestry Disability Index (ODI) and Visual Analog Scale for back (VAS-b). <h3>METHODS</h3> A retrospective review was performed to identify all patients between 2013-2018 who underwent ALIF or XLIF for degenerative lumbar spinal disorders with a minimum followup of 2 years. Demographic data was recorded and compared between both cohorts. Revision rates and time to revision in each group were compared. Perioperative complications were recorded. Functional outcomes were assessed with ODI and VAS back measurements at followup visits. Standard binomial and categorical comparative analyses were performed. <h3>RESULTS</h3> A total of 293 patients were included, 178 in the ALIF cohort and 115 in the XLIF cohort. Mean followup for the XLIF and ALIF groups were 46.3 and 42.2 months, respectively. The overall revision rate was 7.8% for the XLIF group and 7.9% for the ALIF group (p= 0.990). The average time to revision was 270.1 ± 133.0 days and 301.1 ± 140.7 days for the ALIF and XLIF groups, respectively (p= 0.058). The most common reason for revision in each cohort was persistent radiculopathy in the ALIF group (57.1%) and symptomatic adjacent segment disease in the XLIF group (44.4%). Three patients (1.7%) in the ALIF group required intraoperative repair of the common iliac vein due to incidental transection perioperatively whereas one patient (0.9%) underwent repair of the dura due to incidental durotomy in the XLIF cohort (p= 0.557). There were 46 males and 69 females in the XLIF cohort compared to 89 males and 89 females in the ALIF cohort (p= 0.094). Both cohorts experienced significant improvements in their functional outcomes scores compared to their preoperative values. VAS scores decreased by a mean of 5.6 in the XLIF group and a mean of 2.5 in the ALIF group, a significant difference (p= <0.001). <h3>CONCLUSIONS</h3> Our 2-year results show revision and overall complication rates did not differ significantly between XLIF and ALIF after 2-year followup. However, the ALIF group had a larger number of complications which were all related to vascular injury. Regarding patient reported outcomes, the XLIF cohort had significantly greater VAS-b score improvement compared to the ALIF cohort. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Double-barrel iliocaval reconstruction using closed-cell dedicated venous stents

ObjectiveDouble-barrel iliocaval reconstruction is performed by deploying two stents simultaneously in a side-by-side, or “double-barrel,” configuration in the inferior vena cava (IVC) with extension into the bilateral common iliac veins. The aim of this study was to examine the outcomes of double-barrel reconstruction using closed-cell dedicated venous stents for the treatment of iliocaval deep venous thrombosis and iliac vein compression syndrome. MethodsAll endovascular procedural reports comprising vascular surgery and interventional radiology operators from a single urban academic hospital between May 1, 2019, and April 30, 2021, were retrospectively searched. A cohort of 22 consecutive patients who underwent double-barrel iliocaval stenting with closed-cell dedicated venous stents for chronic or acute-on-chronic iliocaval venous disease without prior endovascular iliocaval repair was identified. Baseline characteristics, procedural data, and patient outcomes were determined via a manual review of preprocedure clinical notes, diagnostic imaging studies, procedure notes and images, and follow-up clinical notes. ResultsThe median (range) age was 59 (27-81) years, and the cohort consisted of 59.1% female. The most common presenting symptoms of venous disease were lower extremity swelling (90.9%) and pain (50.0%). CEAP clinical classification was C3 in 86.4% of patients, whereas the remainder had C4 disease. Most patients (72.7%) had post-thrombotic syndrome, 22.7% had a nonthrombotic iliac vein lesion, and one patient (4.5%) had the congenital absence of the infrarenal IVC. A total of 40.9% of patients had a pre-existing IVC filter at the time of treatment. Six of the 22 patients underwent concurrent pharmacomechanical thrombectomy during the index iliocaval reconstruction and stenting procedure. The number of stents placed ranged from 2 to 5. With a mean follow-up period of 7.1 months, ranging from 12 days to 16.7 months, the freedom from reintervention rate was 90.9%. Twenty of 22 patients achieved subjective improvement or resolution of symptoms. The major adverse event rate was 9.1%, as two patients had access site complications requiring intervention. ConclusionsDouble-barrel iliocaval reconstruction with closed-cell dedicated venous stents for the treatment of post-thrombotic syndrome or iliac vein compression syndrome is technically feasible and clinically effective with a low reintervention rate.

Improvement following restoration of inline flow argues against comprehensive thrombus removal strategies and for selective stenting in acute symptomatic iliofemoral venous thrombosis

ObjectiveRandomized trials have demonstrated the benefit of thrombus removal strategies in iliofemoral deep venous thrombosis (IFDVT) in providing early symptom relief and decreasing the incidence of post-thrombotic syndrome (PTS), especially severe PTS. However, the impact of quantum of residual thrombus burden (RTB) on PTS as determined by intravascular ultrasound examination and the role of venous stenting in the acute setting have not been evaluated and represent the focus of this study. MethodsSixty-nine limbs (65 patients) undergoing thrombus removal for acute symptomatic IFDVT between 2015 and 2021 formed the study cohort. The Venous Clinical Severity Score (VCSS) (range, 0-27) grade of swelling (GOS) (range, 0-4), and visual analog scale (VAS) pain scores (range, 0-10) were evaluated initially and at 6, 12, and 24 months after thrombus removal. Quality of life was appraised using the CIVIQ-20 instrument. The extent of initial and RTB after the intervention was estimated using intravascular ultrasound examination. Grading was done as less than 50% (1), 50% to 99% (2), or 100% (3) of luminal thrombus fill within each segment (common femoral vein, external iliac vein, and common iliac vein) by a blinded rater and then combined to generate a total score. The use of stenting, both concurrent (severe residual stenosis/persistent occlusion) and delayed (quality of life impairing residual or recurrent symptoms), was evaluated. ResultsOf the 69 limbs, 53 underwent pharmacomechanical/mechanical thrombectomy (PMT), whereas 16 patients underwent PMT and catheter-directed thrombolysis with restoration of inline flow in all limbs. Post-intervention VCSS improved from 6 to 2 at 24 months (P < .0001). GOS improved from 4 to 0 at 24 months (P < .0001). The VAS pain score went from 5 to 0 at 6 months (P < .0001) and remained at 0 at 12 months (P < .0001), but increased to 3 at 24 months (P = .02). The CIVIQ-20 score improved from 38 to 22 (P = .001) over a median follow-up of 19 months. The median RTB total score improved from 9 to 4 (P < .0001). There was no impact of RTB total score (<3 vs >3) on VCSS (P = NS), GOS (P = NS), VAS pain score (P = NS) or CIVIQ-20 score (P = NS) at the various time points. Concurrent stenting was used in 23 limbs (33%) and delayed stenting was carried out in 10 limbs (14%). The median time to delayed stenting was 4 months after the initial thrombus removal intervention. ConclusionsIn patients undergoing PMT or PMT with catheter-directed thrombolysis for acute symptomatic IFDVT, the restoration of inline flow seems to be adequate to provide symptom relief and decrease the incidence of PTS. The extent of RTB does not seem to impact the VCSS, GOS, VAS pain score, or quality of life after such restoration. Stenting can be pursued selectively in the acute setting to help restore inline flow.

Three Lumens Full of Blood—An Unusual Case of Gastrointestinal Bleeding

Question: A 58-year-old man was initially referred to our gastroenterology outpatient clinic for investigation of iron-deficiency anemia and positive fecal occult blood test (FOBT). His medical history was significant for simultaneous pancreas-kidney transplants 9 years earlier in the context of type 1 diabetes, for which he remained on triple immunosuppressive therapy with prednisolone, mycophenolate, and tacrolimus. His transplants were complicated by biopsy-proven chronic antibody-mediated rejection 4 years earlier, for which he received 6 months of intravenous immunoglobulin. There was no history of chronic liver disease or nonsteroidal medication use. Investigations demonstrated iron-deficiency anemia with a hemoglobin of 88 g/L, ferritin 14 μg/L, transferring saturation 5%, and a positive FOBT (1 of 3 samples). The patient underwent further evaluation with gastroscopy and colonoscopy, which were both unremarkable and did not identify a cause for iron-deficiency anemia. One month later, the patient re-presented to the emergency department with several days of melena and symptomatic anemia with a hemoglobin of 78 g/L. The patient underwent repeated gastroscopy, which did not reveal a cause for his symptoms. He received a blood transfusion and was referred for outpatient capsule endoscopy. Several weeks later, the patient represented with 3 days of melena and symptomatic anemia with a hemoglobin level of 45 g/L. The patient underwent an urgent push enteroscopy. What are the differential diagnoses of gastrointestinal bleeding in this patient? Look on page 335 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. A pediatric colonoscope was inserted 60 cm beyond the pylorus. There was no evidence of esophageal varices, esophagitis, or gastric varices. There was no ulceration or stigmata of recent hemorrhage found in the stomach or duodenum. At 55 cm distal to the pylorus, the anastomosis of the pancreatic transplant was encountered. It demonstrated a side-to-side duodenojejunostomy with 2 short blind duodenal limbs and the native efferent jejunal limb (Figure A). At the anastomosis, multiple varices were noted, of which one vessel was actively bleeding (Figure B). Hemostasis was achieved with the injection of adrenaline (2 mL, 1:10,000) and 2 through-the-scope hemostatic clips (Figure C). The patient then underwent a computed tomographic scan with pancreas protocol to characterize the anatomy and vasculature at the duodenojejunal anastomosis. Multiple venous varices were identified that communicated with a distended transplant pancreatic vein (Figure D). The transplant pancreatic vein anastomoses with the proximal right common iliac vein, and therefore the varices were not due to portal venous hypertension. There was no anastomotic stenosis, no venous thrombosis, and no arteriovenous fistulae. The hemoglobin remained stable after endoscopy and the patient was discharged home 3 days later. At outpatient follow-up 2 months after discharge, there was no evidence of further gastrointestinal bleeding and the hemoglobin level was stable. The patient will continue to be closely observed in the outpatient setting, with a view to endovascular intervention if further gastrointestinal bleeding occurs. Ectopic variceal bleeding from anastomotic varices between the donor duodenum and recipient small bowel are rare, with only 3 cases reported in the literature.1Gopal J.P. Jackson J.E. Palmer A. Taube D. Rathnasamy Muthusamy A.S. Gastrointestinal bleeding in a pancreas transplant recipient: a case to remember.Am J Case Rep. 2020; 21e923197Crossref PubMed Scopus (3) Google Scholar, 2Rostambeigi N. Shrestha P. Dunn T.B. et al.Recurrent ectopic variceal bleed after pancreas transplantation with no portal hypertension: case report and outcomes of endovascular onyx embolization.Vasc Endovasc Surg. 2019; 53: 415-419Crossref PubMed Scopus (5) Google Scholar, 3Fontana I. Bertocchi M. Di Domenico S. et al.Percutaneous embolization of periduodenal varix due to portal hypertension in a patient with kidney-pancreas transplantation: a case report.Transplant Proc. 2010; 42: 2162-2163Crossref PubMed Scopus (5) Google Scholar The mechanism by which ectopic varices develop after pancreas transplantation are not clear. Potential explanations include portal hypertension secondary to cirrhosis, increased vascular resistance, rejection of pancreatic transplant, and chronic venous obstruction. In our case, the mechanism was not elucidated.

Imaging Signs of May-Thurner Syndrome in Asymptomatic Patients: Computed Tomography Angiography Analysis of Kidney Donors

The current study aimed to evaluate the distance between the right common iliac artery (RCIA) and lumbar vertebra in asymptomatic patients in order to determine whether such distance was statistically correlated with the left common iliac vein (LCIV) diameter (LCIVD) and to investigate if both measures were related to demographic characteristics and anthropometric data, such as sex, age, height, and body mass index (BMI). In this descriptive and uncontrolled anatomic study, data from high-definition computed tomography (CT) angiography images of living kidney donors without a medical history of chronic venous insufficiency or past deep vein thrombosis (DVT) were analyzed. The RCIA crossed over the LCIV in 311 individuals, who were then included in this study. CT scans were reviewed to measure (1) the narrowest space between the RCIA and fifth lumbar vertebral body and (2) the LCIVD. Measures were subjected to normality tests and were divided according to the sex of the study population. Correlations of measures with age, BMI, and height were calculated. Of the 311 patients analyzed, 66.6% (n=207) were female. The mean lumbar vertebral body-iliac artery distance (LVBIAD) was 7.2mm, whereas the mean LCIVD was 8.5mm; both were higher in men (P<0.001). The statistical analysis of LVBIAD and LCIVD distributions revealed no normality pattern (P<0.05). The analysis of the correlation between them showed a weak statistically significant relationship with age. A linear regression model considering the normality percentile interval indicated a strong positive correlation between LVBIAD and LCIVD (R2=0.884). The LVBIAD was <5mm and <3mm in 25% and 5% of asymptomatic individuals, respectively. The LCIVD correlated with the space between the RCIA and lumbar vertebra. The distance between the RCIA and lumbar vertebra and the LCIVD were higher in male subjects and older patients, but did not correlate with BMI and height.

Synergistic Effect of May–Thurner Syndrome and COVID-19

May–Thurner syndrome (MTS) is also called Cockett syndrome or iliocaval syndrome is described as compression of the left iliofemoral vein by the right common iliac artery against the vertebral body. We present a rare case of MTS in a 31-year-old female in the left lower extremity complicated after COVID-19. Screening magnetic resonance imaging pelvis showed compression of left common iliac vein by right common iliac artery over L5 lumbar vertebra suggestive of MTS. Findings were confirmed by a lower limb computed tomography venogram. A high degree of clinical suspicion of COVID-19 post sequela is needed for early diagnosis in this era.

Outcomes of the treatment of contralateral iliac venous thrombosis after stenting across the iliocaval confluence

Among the complications related to the endovascular treatment of the left common iliac vein obstruction, the contralateral deep venous thrombosis consists in a late complication of the procedure. This case series describes the endovascular treatment of four patients with right iliofemoral deep venous thrombosis caused by jailing of the inferior vena cava confluence, due to previous stents implanted in the left common iliac vein. All the four patients were admitted with pain and swelling of the right lower limb, and one patient presented with phlegmasia cerúlea dolens. The patients were evaluated with duplex-scan and angioCT-Scan that confirmed extensive right iliofemoral and femoropopliteal deep venous thrombosis, except for one patient, whose DVT propagated to superficial femoral vein, without popliteal involvement. All patients were submitted to endovascular treatment with pharmacomechanical thrombectomy, previous stent recanalization and stent deployment in the iliocaval confluency. Regarding the post-operative complications, one patient presented with hemoglobinury, which evolved with anuria, and in the first day post-operative with acute kidney failure and necessity of hemodialysis for 8 days, after that evolved with total renal function recovery. During the hemodialysis period, this patient received non-fractioned heparin, instead of enoxaparin. All patients presented with satisfactory improvement on limb edema, in the first day and thereafter in the first week post-operative. The pharmacomechanical thrombectomy technique followed by angioplasty and kissing stenting was a safe and efficient procedure in this case series report.

Intraoperative Complications of Anterior Lumbar Interbody Fusion: A 5-Year Experience of a Group of Spine Surgeons Performing Their Own Approaches.

Spine surgery has evolved at an accelerated pace, allowing the development of more efficient surgical techniques while providing a decreasing rate of morbimortality. One example of these approaches is the anterior lumbar interbody fusion (ALIF). The aim of this study was to evaluate the surgical complication rate when performing ALIF without the help of a vascular "access" surgeon. A retrospective descriptive study was conducted at the Hospital Universitario San Ignacio between 2014 and 2018 and included all patients who underwent ALIF during this time. A nonsystematic review was performed assessing approach-related complications in ALIF and the impact of "access" surgeons in surgical outcomes. A total of 337 patients were included and 508 levels were fused. ALIF was performed as ALIF-360° (27%), ALIF-lateral lumbar interbody fusion (LLIF) (8.9%), and stand-alone ALIF (62%). Most procedures were single-level fusions (51.9%), 45.4% involved 2 levels, and 2.6% were 3-level fusions. The mortality rate was 0%, and only 9 cases of vascular injury were observed and described. Left and common iliac veins were the predominant affected structures. Only a single case required blood transfusion without any other treatment or intensive care unit surveillance. Our study is consistent with literature reports about ALIF complications, finding an incidence of 1.7%. Therefore, ALIF is an excellent alternative for spine procedures, especially for the levels L5-S1 that require sagittal balance restoration. The approaches were performed without a vascular "access" surgeon and presented complication rates similar to those described in the literature.

Iliofemoral venous configurations from three-dimensional computed tomography venogram and their relevance to stent design

ObjectiveIliofemoral venous stenting has become the standard of care for patients presenting with quality-of-life impairing symptoms of chronic iliofemoral venous obstruction not responding to conservative measures. This has led to an increased use of venous stenting over the last several years. However, iliofemoral venous anatomy in patients requiring such intervention remains poorly elucidated. This study attempts to fill that gap. MethodsTwenty-two consecutive patients with intravascular ultrasound examination-confirmed chronic iliofemoral venous obstruction underwent three-dimensional reconstruction of their computed tomography venogram images. Relevant angles, tortuosity (tort index-ratio between centerline length, and straight line length), lengths, and diameters were computed and analyzed. We used t tests for comparisons between the right and left sides. A P value of .05 or less was considered significant. ResultsOf the angles calculated, the median of the angles between the horizontal and common iliac vein (CIV) was 66° on the right and 60° on the left (P < .01). The median inferior vena cava-CIV angle was 172° on the right and 165° on the left (P < .0001). The CIV-EIV angle was 159° on the right and 151° on the L (P = .01). Overall, the median tortuosity was 1.07 on the right and 1.12 on the left (P = .007). The median centerline length of the CIV was 42mm on the right and 60mm on the left (P < .0001). The median external iliac vein length was 73 mm on the right and 88 mm on the left (P < .0001). The overall median iliac vein length was 220 mm on the right and 237 mm on the left (P < .01). The median diameters of the inferior vena cava at the iliocaval confluence, 20, 40, and 60 mm cranial to the confluence, were 23, 20, 22, and 23 mm, respectively. ConclusionsOverall, the left side has steeper angles, greater tortuosity, and longer lengths than the right side. These disparities should be considered during femoroiliocaval stent construction.

Three-Dimensional in Vivo Anatomical Study of Female Iliac Vein Variations

Objective To investigate female iliac vein variations by using the computed tomography angiography (CTA) three-dimensional (3 D) reconstruction technique. Methods We retrospectively studied 1623 patients undergoing abdominal and pelvic CTA scanning for gynecological diseases from December 2009 to December 2018. Accurate digital 3 D models of the iliac vein were constructed using Mimics 19.0 software and used to study the morphology and variations. Variations in the common iliac vein (CIV), external iliac vein (EIV) and internal iliac vein (IIV) were classified as type I, abnormal number of veins; type II, abnormal communicating branches; or type III, other variations. Results The overall variation rates of the iliac vein and CIV were 51.57% (837/1623) and 20.33% (330/1623), respectively. The main type of CIV variation was type II. The main type I CIV variation was the absence of the CIV (98.15%), which mostly occurred on the right side (64.81%, 35/54). Type II CIV variation was the most common, with abnormal communicating branches between the left CIV and right IIV (81.78%, 211/258). The overall variation rates of the EIV and IIV were 36.66% (595/1623) and 49.60% (805/1623), respectively, mainly on the right side. The main type of variation was type I. Among them, the division of the IIV into two branches plus convergence with the ipsilateral EIV was the most common (22.98%, 373/1623). Conclusion In this study, approximately half of the patients had iliac vein variations. The preoperative identification of iliac vein variation may reduce vascular injury in pelvic surgery.

Prevalence of left iliac vein compression in an asymptomatic population and patients with left iliofemoral deep vein thrombosis: A multicenter cross-sectional study in southern China.

Population-based epidemiological data on left common iliac vein (LCIV) compression is scarce. This study aimed to investigate the prevalence of LCIV compression in an asymptomatic population and patients with left iliofemoral deep vein thrombosis (IF-DVT). Nonprobability sampling method was used in this multicenter cross-sectional study. The minimum diameter of LCIV and right common iliac vein minimum were measured. The percentage of LCIV compression (LCIV-CP) was calculated. Compression severity (CS) was classified as mild (CP ≤ 50%), moderate (50% < CP ≤ 70%), and severe (CP > 70%). In all, 896 subjects constituted the asymptomatic population and 93 patients constituted the IF-DVT population. In the asymptomatic population, LCIV-CP ranged from 1.1% to 89.9% (mean 44.0%), and people with mild, moderate, and severe CS accounted for 62.3%, 28.2%, and 9.5%, respectively. In the IF-DVT population, the mean LCIV-CP was 71.1% (range 42.2%-95.2%), and patients with severe CS accounted for 75.3%. Gender and age differences in LCIV-CP and CS distribution were observed in the asymptomatic population. Females, the young- and middle-aged group had higher LCIV-CPs. In the population with moderate-severe CS, the middle-aged group accounted for a larger proportion. Middle-aged females comprised the highest percentage of patients with moderate or severe CS. Sex and age affected the LCIV-CP and CS distribution. No gender and age differences were observed in the IF-DVT population. LCIV compression is common in population. Middle-aged females are the predominant population with moderate-severe compression. Overlapping of LCIV-CP in the asymptomatic and IF-DVT population is significant and other risk factors should be integrated into the consideration when assessing the risk of IF-DVT secondary to LCIV compression.

Successful endovascular treatment with a stent graft for chronic deep vein thrombosis with multiple arteriovenous fistulas: a case report

BackgroundDeep vein thrombosis with arteriovenous fistulas is rare, with few therapeutic options available for chronic-phase deep vein thrombosis. Moreover, the effectiveness of endovascular treatment for chronic-phase deep vein thrombosis with arteriovenous fistulas has not been established. We describe herein a case of successful endovascular treatment for chronic deep vein thrombosis with multiple arteriovenous fistulas.Case presentationWe describe the case of a 72-year-old Asian woman who had begun experiencing left leg swelling and intermittent claudication 2 years prior. Enhanced computed tomography revealed left common iliac vein occlusion with vein-to-vein collateral formation and several arteriovenous fistulas. Angiography and ultrasound showed the arteriovenous fistulas to run from the common and internal iliac arteries to the external iliac and superficial femoral veins. We opted against surgical repair for the arteriovenous fistulas due to their complex nature and complicated morphology. Since her condition was progressive, endovascular treatment with a stent graft was performed for the deep vein thrombosis, after which her symptoms gradually improved. Four months following the procedure, enhanced computed tomography confirmed remarkable reduction of the vein-to-vein collaterals and arteriovenous fistulas.ConclusionsIn the present case, enhanced computed tomography with a stent graft was effective in improving symptoms. This strategy may therefore be a treatment option for intractable chronic deep vein thrombosis with arteriovenous fistulas.