Contralateral Vein Research Articles

Comparison of Contralateral vs Ipsilateral Vein Graft for Traumatic Vascular Injury Repair: A Cohort From PROOVIT.

Traumatic injury leading to arterial damage has traditionally been repaired using autologous vein graft from the contralateral limb. This often requires a secondary surgical site and the potential of prolonged operative time for patients. We sought to assess the use of ipsilateral vs contralateral vein grafts in patients who experienced traumatic extremity vascular injury. A multicenter database was queried to identify arterial injuries requiring operative intervention with vein grafting. The primary outcome of interest was need for operative reintervention. Secondary outcomes included risk of thrombosis, infection, and intensive care unit length of stay. 358 patients (320 contralateral and 38 ipsilateral) were included in the analysis. The ipsilateral vein cohort did not display a statistically significant decrease in need for reoperation when compared to the contralateral group (11% vs 23%; OR 0.41, 95% CI -0.07-1.3; P = .14). Contralateral repair was associated with longer median intensive care unit (ICU) LOS (4.3 vs 3.1days; P < .01).

Serum activities of complement 1q and antibodies to the virulence-associated protein A are lower in foals that develop rhodococcal pneumonia.

To determine the effects of transfusion of Rhodococcus equi hyperimmune plasma (REHIP) on serum concentrations of complement component 1q (C1q) and to examine the association of serum C1q and anti-rhodococcal antibodies of newborn foals with subsequent development of rhodococcal pneumonia. Foals (n = 205) from 2 Thoroughbred breeding farms in New York transfused with REHIP between January 1, 2022, and December 1, 2022. Blood was collected immediately before transfusion with REHIP and again from the contralateral vein immediately after transfusion. Foals were followed through weaning for clinical and ultrasonographic evidence of rhodococcal pneumonia. Serum samples were tested by ELISA for concentrations of C1q and for activity of IgG1 and IgG4/7 recognizing the virulence-associated protein A (VapA) of R equi. Logistic regression analysis was used to determine the association between rhodococcal pneumonia and levels of C1q and anti-VapA IgG1 and IgG4/7. REHIP significantly decreased C1q concentrations immediately after transfusion. Accounting for effects of farm and birth month, estimated odds of pneumonia were 2.1-fold (P = .0330) higher for foals with pretransfusion C1q concentrations less than or equal to the population median and 3.3-fold (P = .0051) higher for foals with posttransfusion IgG1 activity in the lower quartile. Both C1q and IgG appear to contribute to protection against R equi, and IgG1 appears to be especially important. Increasing IgG1 concentrations targeting rhodococcal proteins in REHIP or serum of foals might improve protection against R equi foal pneumonia.

Ultrasound and magnetic resonance of extrinsic stenosis and hypoplasia of internal jugular veins

Highlights. Ultrasound and MR venography of internal jugular veins in case of unilateral cerebellar hypoplasia or extrinsic stenosis enables noninvasively and without contrast agents differentiation of these conditions due to local and region-specific indicators, including the area and velocity of blood flow, arterial-venous balance, visualization of low blood flow, compression factor, and the overall clinical picture of venous network of the neck remodeling and the development of collateral circulation.Aim. To compare the visual and hemodynamic characteristics of ultrasound and magnetic resonance venography of extrinsic stenosis and hypoplasia of internal jugular veins (IJV).Methods. Ultrasound and magnetic resonance (MR) venography were performed in 47 patients with extrinsic stenosis and 23 patients with hypoplasia of one of internal jugular veins, and in the control group (30 patients).Results. In case of obvious vein compression and deformation and local stenosis (65% on average), there is a decrease in the vein cross-sectional area by 2 times compared with the contralateral vein, the blood flow velocity in the stenotic vein in acute cases increases (on average, up to 45 cm/s), and in chronic cases it significantly (p = 0.00001) decreases (to 13 cm/s on average). The criteria for hypoplasia are the small caliber of the vein (on average 0.22 cm², within the range of 0.13–0.46 cm²) throughout its entire length - with the cross-sectional area not exceeding that of the common carotid artery, and the vein being 4 times smaller than IJV on contralateral side, as well as a significant (p = 0.0006) velocity increase on the contralateral side (on average 40.9±12.52 cm/s) with normal velocity in the hypoplastic vein. Ultrasound assessment of the arterial-venous balance (AVB) makes it possible to evaluate the contribution of each IJV to the outflow of venous blood from the brain separately. From the hypoplastic side it was only 11.01±6.72%, and from the stenotic side it was 18.22±17 42% on average, which is significantly (p = 0.000001) below the norm, but does not allow us to differentiate these conditions. The total AVB for IJVs on both sides was within normal values (65–85%), and the absence of a pronounced expansion of the vertebral veins during MR venography confirms their insignificant role in the compensatory mechanisms of ensuring adequate outflow of venous blood from the brain in cases of unilateral hypoplasia and extrinsic stenosis of IJV.Conclusion. Ultrasound and MR venography of internal jugular veins in cases of unilateral hypoplasia or extrinsic stenosis enable noninvasively and without contrast agents differentiation of these conditions due to local and region-specific indicators, including the area and velocity of blood flow, arterial-venous balance, visualization of low blood flow, compression factor, and the overall clinical picture of venous network of the neck remodeling and the development of collateral circulation.

The effect of cilostazol on the platelet-derived growth factor-beta/beta isoform reduction on venous hyperplasia in an experimental balloon-induced injury model.

Intimal hyperplasia is the response to endothelial injury. Platelet-derived growth factor is released early and favors the formation of intimal hyperplasia. Although multiple treatments, from open surgery to endovascular techniques, have been used they remain controversial. There is currently interest in developing pharmacological strategies to address this pathology. Local vascular inflammation induced by vessel barotrauma generates intimal hyperplasia due to mechanical stress over the venous endothelium. Cilostazol is a selective phosphodiesterase type 3 (PDE3) selective inhibitor with a regulatory effect over intimal hyperplasia. The objective was to investigate cilostazol's role in inhibiting smooth muscle cell proliferation due to changes in the expression and release of PDGF-BB isoform and the effect on developing IH using an experimental model of vascular barotrauma (balloon-induced injury model). We included 12 New Zealand rabbits. The balloon-induced injury model (BIIM) and experimental group cilostazol (20mg/kg/day) included 6 rabbits each. Contralateral veins from 6 rabbits used in BIIM model has been taken as control group. We measured and compared the expression of PDGF-BB and the development of IH. A pathologist board chooses a PDGFRα antibody to localized its expression by immunohistochemistry analysis. Subsequently, using an automated immunohistochemical staining machine, the PDGFR expression was evaluated using a Zeiss Primo Star 4 light microscope. The measurement obtained in the intimal layer was: 126.12μm2 in the CG, 232μm2 in the BIIM group, and 178μm2 in the EG. A statistically significant difference was observed. Baseline serum concentrations of PDGF-BB in the BIIM group were 0.22pg/mL. At 12h 0.42pg/mL, and 0.17pg/mL at seven days. In the experimental group, the basal levels were 0.33pg/mL. With the use of cilostazol, a lower peak was obtained at 12h (0.08pg/mL). This difference was statistically significant. Cilostazol induced a significant reduction of IH caused by barotrauma in the venous endothelium, which correlates with decrease in the PDGF-BB in serum. This could be attributed to the pharmacologic effect on PDGFR expression.

Peripherally Inserted Central Catheter Malpositioned in the Ipsilateral Thoracodorsal Vein: Clinical Case

A peripherally inserted central catheter (PICC) is a catheter that is inserted into a peripheral vein of the elbow or upper arm and which access the superior vena cava or inferior vena cava. These catheters present a low risk of serious complications but malpositioning of the distal tip is very frequent, with an incidence ranging from 5 to 31%. The most frequent tip locations of malpositioned PICC lines are the internal jugular vein, subclavian vein, axillary vein, brachial vein, contralateral veins, right atrium and right ventricle.

Unilateral optic neuritis with contralateral central retinal artery and central retinal vein occlusion in a post-COVID-19 case of rhino-orbital-cerebral mucormycosis: An unusual presentation

Introduction: The corona virus disease (COVID)-19 is a severe acute respiratory syndrome (SARS-CoV-2) which is posing a great threat to mankind and has been associated with a high risk of opportunistic fungi infection presenting as rhino-orbital-cerebral-mucormycosis. We report a rare and never reported case of unilateral optic neuritis with contralateral central retinal artery (CRA) and central retinal vein (CRV) occlusion in a patient of post-COVID-19 rhino-orbital-cerebral-mucormycosis. Case Report: A 45-year-old diabetic, Indian gentleman reported to our clinic in Dehradun, Uttarakhand, India with complaints of bilateral diminution of vision in right eye (RE) five days and left eye (LE) five weeks duration. He provided recent history of COVID-19 infection for which he was hospitalized and treated. Fundus examination confirmed optic neuritis in right eye and a combined established central retinal artery and vein occlusion in left eye. Fundus fluorescein angiography, visual evoked potential, and magnetic resonance imaging (MRI) were crucial in clinching the diagnosis. Conclusion: Rhino-orbital-cerebral-mucormycosis invades tissue through multiple routes. However, it is extremely rare to see a combination of angioinvasion leading to visual loss in one eye and perineural spread leading to optic neuritis and visual loss in the contralateral eye. Clinicians must be aware of such rare presentations which could serve as benchmark in diagnosis and treatment.

Duplex Analysis of Cannulated Vessels in Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation.

Background and objectives: Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) cannulas have major repercussions on vascular hemodynamics that can potentially lead to limb ischemia. Duplex ultrasound enables the non-invasive analysis of vascular hemodynamics. This study aims to describe the duplex parameters of the femoral vessels during V-A ECMO support, investigate differences between cannulated and non-cannulated vessels, and analyze the variations in the case of limb ischemia and intra-aortic balloon pumps (IABPs). Methods: Nineteen adults (≥18 years), supported with femoro-femoral V-A ECMO, underwent a duplex analysis of the superficial femoral arteries (SFAs) and veins (FVs). Measured parameters included flow velocities, waveforms, and vessel diameters. Results: 89% of patients had a distal perfusion cannula during duplex analysis and 21% of patients developed limb ischemia. The mean peak systolic flow velocity (PSV) and end-diastolic flow velocity (EDV) of the SFAs on the cannulated side were, respectively, 42.4 and 21.4 cm/s. The SFAs on the non-cannulated side showed a mean PSV and EDV of 87.4 and 19.6 cm/s. All SFAs on the cannulated side had monophasic waveforms, whereas 63% of the SFAs on the non-cannulated side had a multiphasic waveform. Continuous/decreased waveforms were seen in 79% of the FVs on the cannulated side and 61% of the waveforms of the contralateral veins were respirophasic. The mean diameter of the FVs on the cannulated side, in patients who developed limb ischemia, was larger compared to the FVs on the non-cannulated side with a ratio of 1.41 ± 0.12. The group without limb ischemia had a smaller ratio of 1.03 ± 0.25. Conclusions: Femoral cannulas influence flow velocities in the cannulated vessels during V-A ECMO and major waveforms alternations can be seen in all SFAs on the cannulated side and most FVs on the cannulated side. Our data suggest possible venous stasis in the FV on the cannulated side, especially in patients suffering from limb ischemia.

Abstract 473: Cilostazol Decreases Venous Outflow Inflammation And Improves Avf Patency Inmurine Arteriovenous Fistula

Background: Arteriovenous fistula (AVF) have high failure rates, and no pharmacotherapeutics can improve AVF patency. The most common cause of AVF failure is inflammation-driven neointimal hyperplasia and thrombosis. Limited observational data suggests that cilostazol (CIL), an FDA-approved phosphodiesterase-3 inhibitor that inhibits platelet activation and smooth muscle cell proliferation, could help improve AVF maturation. Here, we investigated the effects of cilostazol on murine AVF patency, and further assessed the fibrinogenesis and anti-inflammatory effects using intravital fluorescence molecular imaging. Methods: One week prior to fistula creation, mice were randomized to CIL (40mg/kg/day) or PBS group (n=20 each). AVF was created using an end-to-side external jugular vein and carotid artery anastomosis. AVF blood flow was measured post-operatively (Transonic) and then every 7 days until AVF was occluded (&lt;0.1 ml/min). Macrophages and fibrin were imaged after 10mg/kg FMX-AF555 and/or 4.5nmol FTP11CyAm7 i.v. injection prior to imaging on day 7 or day 14, respectively. The target-to-background ratio (TBR) was calculated as mean signal intensity (MSI) of the fistula divided by the MSI of the contralateral vein. Results: Post-operative AVF blood flow was similar between CIL and PBS treated groups (p=0.3). Average AVF patency was significantly longer in CIL group compared to PBS group (42 vs 21 days, p&lt;0.01, figure 1A). Both day 7 and day 14 venous outflow fibrinogenesis signal assessed by IVM was significantly lower in CIL group compared to PBS group (ps&lt;0.05, Figure 1B). On day 14, CIL significantly lower venous outflow FMX signals compared to PBS group (p&lt;0.05). Conclusion: Oral cilostazol therapy prolongs AVF patency, and decreases venous outflow inflammation and fibrinogenesis in experimental AVF in vivo. The current data supports investigating cilostazol as a clinical pro-AVF patency pharmacotherapeutic strategy in dialysis patients.

Parallel Cross-Leg Free Flap with Posterior Tibial Artery Perforator Pedicle Propeller Cable Bridge Flap for the Treatment of Lower Extremity Wounds: A Case Series Report

Background A cross-leg flap can be used to treat severely injured lower limbs but associated with complications. Herein, we describe a technique of a parallel cross-leg free flap combined with posterior tibial artery perforator pedicle propeller cable bridge flap for the treatment of lower extremity wounds. Methods The artery and veins of the free flap are anastomosed to the contralateral posterior tibial artery and vein, respectively. The vascular pedicle is wrapped with a posterior tibial artery perforator pedicle propeller flap. The legs are allowed to remain in a straight, relaxed position which is maintained with a bandage or Kirschner wire placed at the distal limbs. Pedicle division is performed around 21 days after flap creation, and the posterior artery is re-anastomosed and pedicled flap returned to its original position. Results From June 2017 to March 2020, 7 patients with lower extremity wounds and tissue loss received reconstruction with this method. The recipient vessels for all flaps were the posterior tibial artery and vein. The average operation time was 5 hours. The average time to ambulation was 4 weeks, and the average follow-up time was 13.7 months. All flaps survived, and limb salvage was successful in all patients. Patients were not uncomfortable with the limbs held in position until pedicle division, and there were no complications. At the final follow-up, the function of all limbs was normal, and the esthetic appearance was acceptable to all patients. Conclusions The method described overcomes the disadvantages of traditional cross-leg flaps for the treatment.

Do Waveforms Matter? Yes They Do! A Case in Point

A 38-year-old G1P0 presented to the Vascular Lab at 32 weeks gestation for evaluation of persistent left lower extremity edema. The patient reported a 1-month history of left leg pain and swelling after a long car trip. Of note, she had 3 negative lower extremity ultrasounds at outside imaging facilities over the previous 6 weeks. Left lower extremity venous duplex was performed with B-mode, color, power, and spectral Doppler using a linear 12-3 MHz transducer and curvilinear 5-1 MHz transducer. Images were documented using Intersocietal Accreditation Commission Vascular Testing (IAC VT) protocol. Left lower extremity duplex revealed continuous flow in the bilateral common femoral veins. Right common iliac and external iliac vein Doppler waveforms demonstrated spontaneous and phasic flow. Left proximal common iliac and external iliac veins revealed continuous flow. Acute, occlusive deep venous thrombosis (DVT) was identified in the left distal common iliac vein. The left common iliac vein was enlarged, measuring 2.2 cm compared with the contralateral common iliac vein measuring 1.4 cm. Ultrasonographic infrainguinal demonstration of acute DVT is straightforward and usually achievable with standard ICA VT protocol. However, imaging of the proximal pelvic venous circulation can be more elusive, particularly in the pregnant patient. Therefore, it is imperative to assess the spectral Doppler waveforms and to investigate pelvic venous flow. Because of the sonographer’s attention to the common femoral waveforms, additional focused pelvic imaging was performed and located acute, occlusive iliac DVT as the cause of significant edema.

Surgical Outcome of Renal Cell Carcinoma with Tumor Thrombus Extension into Inferior Vena Cava and Right Atrium (Beating Heart Removal of Level 4 Thrombus): A Challenging Scenario.

Aim“To evaluate oncological and surgical outcomes of different levels of tumor thrombus and tumor characteristics secondary to renal cell carcinoma (RCC)”.Materials and MethodsRetrospective review from 2013 to 2020 of 34 patients who underwent radical nephrectomy with thrombectomy for RCC with tumor thrombus extending into the inferior vena cava (IVC) and right atrium (RA) at our center. Level I and most level II tumors were removed using straight forward occluding maneuvers with control of the contralateral renal vein. None of the patients had level III tumor extensions in our study group. For level IV thrombus, a beating heart surgery using a simplified cardiopulmonary bypass (CPB) technique was used for retrieval of thrombus from the right atrium.Results“ Of the 34 patients with thrombus”, 19 patients had level I, 12 patients had level II, none had level III, and three patients had level IV thrombus. Two patients required simplified CPB. Another patient with level IV thrombus CPB, was not attempted in view of refractory hypotension intraoperatively. Pathological evaluation showed clear-cell carcinoma in 67.64%, papillary carcinoma in 17.64%, chromophobe in 5.8%, and squamous cell carcinoma in 8.8% of cases. Left side thrombectomy was difficult surgically, whereas right side thrombectomy did not have any survival advantage. Mean blood loss during the procedure was 325 mL, ranging from 200 to 1000 mL, and mean operative time was 185 min, ranging from 215 to 345 min. The immediate postoperative mortality was 2.9%. Level I thrombus had better survival compared to level II thrombus.ConclusionRadical nephrectomy with tumor thrombectomy remains the mainstay of treatment in RCC with inferior venacaval extension. The surgical approach and outcome depends on primary tumor size, location, level of thrombus, local invasion of IVC, any hepato-renal dysfunction or any associated comorbidities. The higher the level of thrombus, the greater is the need for prior optimization and the adoption of a multidisciplinary approach for a successful surgical outcome.

Early clinical outcomes for treatment of post-thrombotic syndrome and common iliac vein compression with a hybrid Oblique self-expanding nitinol stent - the TOPOS study.

Background: Physical attributes of conventional stents used in the ilio-caval territory are often unfavorable in the presence of external compression close to the bifurcation. A hybrid oblique stent was developed for the treatment of common iliac vein compression without compromising the contralateral iliac vein inflow. Patients and methods: The ongoing international monitored TOPOS study enrolled 60 patients with post-thrombotic syndrome (PTS) treated with the sinus-Obliquus stent (optimed) and provisional distal stent extension. At 3-month follow-up, patency rates were obtained from duplex ultrasound, and clinical outcomes were assessed by the Villalta score, revised venous severity score (rVCSS), pain intensity score and chronic venous disease quality of life questionnaire (CIVIQ-20). Results: Mean age was 46.6 ± 14.9years (68.3 % women). Mean number of implanted stents was 1.9 ± 0.6; 12 (20 %) patients received the hybrid oblique stent only. Forty-eight (80 %) patients had distal stent extension, and 42 (70 %) had stents below the inguinal ligament. Four (7 %) patients (all with stent extension) developed stent thrombosis. Primary and secondary patency rates at 3 months were 93.1 % (95%CI 83.3-98.1 %), and 100 % (95%CI 93.8-100 %), respectively. Improvement in Villalta, rVCSS, CIVIQ-20, and pain intensity score from baseline to 3-month follow-up was 6.9±1.4 points (95%CI 4.1-9.8; p<0.0001), 3.4 ± 1.0 points (95%CI 1.3-5.4 points; p<0.01), 13.6 ± 2.7 points (95%CI 8.2-19.0 points; p<0.0001), and 2.4±0.5 (95%CI 1.4-3.3; p<0.0001), respectively. At follow-up, 38 (63 %) patients were free from the PTS and none developed contralateral deep vein thrombosis. Conclusions: In patients with PTS and common iliac vein compression, treatment with the hybrid oblique stent with provisional stent extension resulted in high patency rates and improvement in PTS severity and quality of life at 3-month. Two-year results of TOPOS will assess the durability of this treatment.

The aldosterone index could be used to diagnose the dominant gland in primary aldosteronism — a retrospective study

Failed cannulation in the right adrenal vein, which makes the sampling results in the contralateral vein and inferior vena cava (IVC) nonsense, is the main obstacle of using adrenal vein sampling (AVS) in the lateralisation diagnosis in primary aldosteronism (PA). We performed a retrospective study to evaluate the specificity and sensitivity of using the aldosterone index (AI) in PA lateralisation diagnosis. We enrolled 116 patients who were diagnosed with PA and then underwent AVS in the West China Hospital of Sichuan University from April 2015 to April 2017. The AI, calculated by dividing the aldosterone concentration of the failed side by the aldosterone concentration of IVC, was used for lateralisation diagnosis if the cannulation was judged to be failed by traditional method. Patients with dominant adrenal gland based on successful AVS were included in subgroup 2 (n = 75), while the patients diagnosed with a dominant gland using AI method were enrolled in subgroup 1 (n = 41). No significant difference of clinical and biochemical findings between the two groups was detected (p value after operation > 0.05). ROC analysis was performed to test the specificity and sensitivity based on the AI in subgroup 2. The AUC for dominant gland detection was 0.76, which resulted in 91.3% sensitivity and 67.53% specificity. The positive and negative likelihood ratios were 2.81. Our data suggested that the modified strategy using AI to diagnose the dominant gland in PA is an efficient method when cannulation has failed in the right side.

Study on the Patency of the Contralateral Iliac Vein After Stenting Across the Iliocaval Confluence With an Experimental In Vivo Model.

Stenting is the preferred treatment for iliac vein lesions. For the treatment of occlusions in the junction of the iliac vein and the inferior vena cava (IVC), the stent needs to be positioned in the IVC to cover the lesion. However, the pathological changes in the contralateral iliac vein due to stent coverage on its ostium remain unclear. We observed the patency of the contralateral iliac vein via animal experiments. The stents were placed in the left iliac vein and extended into the IVC in 8 beagle dogs. Doppler ultrasonography, angiography, and histopathological examination were used to assess the patency and histopathological changes in the contralateral iliac vein. Angiography showed patency of the contralateral iliac vein and no sign of thrombosis or stenosis. Twelve months after stenting, Doppler ultrasonography showed a stenotic change in the ostium of the contralateral iliac vein. The histopathological examination showed that the stent strut at the ostium of the contralateral iliac vein was mostly covered by the intima, and the cross-sectional stenosis rate was greater than 60%. The coverage of the iliac vein stent on the ostium of the contralateral iliac vein does not cause complete occlusion of the contralateral vein but can cause significant stenosis at the ostium of the contralateral iliac vein, which is considered to be a potential risk factor for thrombosis.

The Role of MicroRNA-21 in Venous Neointimal Hyperplasia: Implications for Targeting miR-21 for VNH Treatment.

The molecular mechanism of hemodialysis access arteriovenous fistula (AVF) failure due to venous neointimal hyperplasia (VNH) is not known. The role of microRNA-21 (miR-21) in VNH associated with AVF failure was investigated by performing in vivo and in vitro experiments. In situ hybridization results revealed that miR-21 expression increased and was associated with fibroblasts in failed AVFs from patients. In a murine AVF model, qRT-PCR gene expression results showed a significant increase in miR-21 and a decrease in miR-21 target genes in graft veins (GVs) compared to contralateral veins in mouse AVF. miR-21 knockdown in GVs was performed using a lentivirus-mediated small hairpin RNA (shRNA), and this improved AVF patency with a decrease in neointima compared to control GVs. Moreover, loss of miR-21 in GVs significantly decreased the Tgfβ1, Col-Ia, and Col-Iva genes. Immunohistochemistry demonstrated a significant decrease in myofibroblasts and proliferation with an increase in terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) staining in miR-21-knockdown vessels, along with a decrease in hypoxia-inducible factor-1 alpha (HIF-1α) and phospho-SMAD2 (pSMAD-2) and phospho-SMAD3 (pSMAD-3) and an increase in phosphatase and tensin homolog (PTEN) staining. Hypoxic fibroblast knockdown for miR-21 showed a significant decrease in Tgfβ-1 expression and pSMAD-2 and -3 levels and a decrease in myofibroblasts. These results indicate that miR-21 upregulation causes VNH formation by fibroblast-to-myofibroblast differentiation.

An atypical case of pulmonary embolism from a jugular vein

SummaryNeck venous malformations and their potentially life-threatening complications are rarely reported in the available literature. Cases of aneurysmal or hypo-plastic jugular vein thrombosis associated with systemic embolization have not been frequently reported. We present the case of a 60-year-old male, without any known risk factors for thromboembolic disease, admitted for sudden onset dyspnea. The physical examination was remarkable for a right lateral cervical mass, expanding with Valsalva maneuver. Thoracic CT with contrast established the diagnosis of bilateral pulmonary embolism and raised the suspicion of superior vena cava and right atrial thrombosis. Bedside transthoracic echocardiography confirmed the presence of a large right atrial thrombus, with intermittent protrusion through the tricuspid valve. Systemic thrombolysis with Alteplase was initiated shortly after diagnosis, in parallel with unfractionated heparin, with complete resolution of the intracavitary thrombus documented by echocardiography. The patient showed significant improvement in symptoms and was later started on oral anticoagulation. Computed vascular tomography of the neck was performed before discharge, showing hypoplasia of the left internal jugular vein and aneurismal dilation of the contralateral internal jugular vein, without thrombosis. There were no identifiable systemic causes for thrombosis. Surgical resection of the aneurismal jugular vein was excluded, because of its potential to cause intracranial hypertension. The preferred therapeutic option in this case was long-term oral anticoagulation.

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

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

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

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

Is It Really Mandatory to Harvest the Contralateral Saphenous Vein for Use in Repair of Traumatic Injuries?

Since the transition time in surgical technique of vascular repair to current civilian practice, the great saphenous vein (GSV) remains unarguably the preferred conduit for surgical reconstruction in the lower extremity. With qualities such as accessibility, expendability, and long-term durability, it is easy to understand the enthusiasm with using the GSV in arterial or venous vascular injuries. However, the question does arise whether these detailed benefits of the GSV warrant harvest from an uninjured limb for vascular reconstruction on an injured limb. For those ardent followers of surgical dogma, harvest of contralateral vein from the uninjured lower extremity traumatic vascular repair is mandated. Unfortunately, this principle is not supported by high-quality data and remains folklore at best.

Endovascular Treatment for Iliofemoral Vein Thrombosis with Composite Stents

To evaluate the applicability of endovascular treatment for iliofemoral vein thrombosis with composite stents. Between September 2013 and August 2016, 29 consecutive patients underwent endovascular therapy with composite stents for iliofemoral vein thrombosis and were followed up at our institution. All the patients with acute or chronic iliofemoral vein thrombosis enrolled in this study were evaluated by color Doppler ultrasonography and diagnosed by venography. Treatment measures and related complications were recorded, and cumulative stent patency was assessed with Kaplan-Meier curves. Patients with acute iliofemoral vein thrombosis (n=7) were successfully treated with catheter-directed thrombolysis treatment, balloon angioplasty, and stents, whereas patients (n==22) with chronic deep vein thrombosis were treated successfully by balloon angioplasty and stent only. Among all patients, 2 stents were inserted in 25 patients, whereas 3 stents were deployed in 4 patients. Endovascular treatment for iliofemoral vein thrombosis with laser-cut stents combined with Wallstents showed primary patency of treated limbs at 6, 12, and 24months was 96.6%, 93.1% and 93.1%, respectively. Mean duration of follow-up was 23months, and there was no occurrence of contralateral vein thrombosis during follow-up by ultrasound. Iliofemoral vein thrombosis was successfully recanalized by endovascular therapy with composite stents, and there was no occurrence of contralateral vein thrombosis by ultrasound during follow-up.