Contralateral Vein Research Articles

Unusual Venous Drainage Of The Common Facial Vein. A Morphologycal Study

Background: Anatomical knowledge of the facial vasculature is crucial not only for anatomists but also for oral and maxillofacial surgery, plastic surgeon, otorhinolaryngologists. Access pathways, pedicled and free flap transfer, and explantation and transplantation of total faces are based on the proper assessment and use of the facial veins and arteries. The anatomical variations reported in the present study confirms the need for preoperative vascular imaging for sure good venous outflow for the free flap survival.
 Aims: The aim of the present study was to describe a rare anatomical variation of the common facial vein which not been previously described.
 Methods and Findings: Head and neck region were carefully dissected as per standard dissection procedure, studied serially during the years 2013-2017 in 15 males and 2 females, i.e. 34 sides, embalmed adults cadavers with different age group, in the laboratory of Morphology of the University of Pamplona. In 33 sides (97 %) of the cases the anterior facial vein (FV) terminated into the internal jugular vein via the common facial vein (CFV) as per standard anatomic description. The right common facial vein in one side (3%) was found to drain into the contralateral internal thoracic vein and contralateral pericardiophrenic vein. Remarkable communications with the external jugular vein, the internal jugular vein, the anterior jugular vein, and left brachiocephalic vein. The length of the right common facial vein from the level of its formation till its termination in the contralateral pericardiophrenic and internal thoracic vein was about 22.75 cm. The venous drainage pattern on the left side of the face was found to be normal. 
 Conclusion: The existence of this anatomical variation among others supposes a double edge sword in the medical practice with its own opportunities and risks, especially in the surgical treatment; therefore, we need to study with more strictness these possibilities with the aim of facilitate this practices, and improve the life quality of our patients.

The recyclability and safety of Celect retrievable vena cava filter

Objective To explore the recyclability and safety of Celect retrievable filter placement in the prevention of pulmonary embolism in patients with deep venous thrombosis (DVT). Methods The data of 120 DVT patients with Celect retrievable filter were collected from the Second Hospital of Shanxi Medical University from August 2015 to March 2017 and analyzed retrospectively. The Celect filter was placed in the inferior vena cava (IVC) at the inferior margin of the renal vein for 1 to 2 cm by puncturing the contralateral femoral vein or right internal jugular vein. The filter retrieve risk was assessed within 8 weeks after being implanted. The filters would be recovered through the right jugular vein when meeting the recovery standard, and the retrieve methods included conventional method, removing the guide wire into a loop trap method and guiding wire into a loop combined with balloon assisted method. The perforation of the vena cava was observed and the tilt angle of the filter was measured. The success rate of Celect filter retrieve was evaluated by the Kaplan-Meier method. Results Celect filters were successfully implanted in 120 patients with DVT. The IVC filters were implanted through femoral vein in 111 patients and 2 cases via right internal jugular vein. No complications, asymptomatic pulmonary embolism and related death was found in all patients. Twenty four patients did not reach the standard of filter retrieve, and were follow-uped. Ninety six cases were treated with Celect retrievable filter, among which, 93 cases were successfully recovered with the filter indwelling time ranging from 7 to 144 days and the median being 50 days. The failure of the filter retrieve occurred in 3 cases because of the serious tilt of the filter or the encapsulation of filter by inferior vena cava thrombus. Perforation of vena cava with no clinical symptoms occurred in 21 cases. Filter tilt was found in 35 cases, among which, 15 cases had inclined angle>15 degrees or the recovery hook closed to the IVC wall. Thirteen cases with filter tip or recovery hook attached to the wall were successfully removed by using the guide wire into a loop or trap guide wire into a loop combined with balloon assisted method instead of routine removal method. The retrieve rate was 100% when the retention time of Celect filter in the body was within 106 days. Conclusion Celect retrievable filter can be implanted in DVT patients with long retrieve time window and high retrieve rate, but the filter inclination rate and vena cava perforation rate are high. Key words: Veinous thrombosis; Pulmonary embolism; Inferior vena cava filter

Application of bipedicled massive cross arm flap with dual blood supply for repair of forearm soft tissue defects

Objective To introduce a procedure and application of bipedicled latissimus dorsi and thoraco umbilical flap with dual blood supply, and to discuss the operative indication and key technology of massive long narrow flap for repair of forearm soft tissue defects. Methods From January 2009 to December 2011, 3 patients with forearm and hand soft tissue defects were treated by bipedicled latissimus dorsi and thoraco umbilical flap with dual blood supply. The flap area ranged from 25 cm×12 cm to 42 cm×10 cm. Double sets of arteriovenous were applied. The dorsal thoracic artery and vein were anastomosed to the ulnar or radial proximal artery and vein of the forearm, respectively, at the proximal of flap. The inferior epigastric artery and vein were anastomosed to the contralateral radial artery and vein, respectively, at the distal of flap. Both arms were fixed crossly. The distal pedicle was separated from contralateral upper limb 3 weeks after the operation. Results Three cases of flap all survived with upper limb retention. All the patients were follow-up for 8 to 36 months. Flap color, texture and forearm shape were good. Wrist and hand function partially recovered. The protective sensation of the flaps also recovered. Conclusion According to the principle of latissimus dorsi muscle and thoracic umbilical flap combined with double segment arterial blood supply, it can be designed as a huge long and narrow flap. It is a practical surgical method for repair of upper limb large soft tissue defects due to large area cutting, surgical safety and minor damage to donor sites. Key words: Surgical flaps; Forearm injuries; Double blood supply

Erratum: Transection of the hepatic parenchyma associated or not with the contralateral portal vein branch ligature and its effect in liver regeneration.

[This corrects the article doi: 10.1590/S1679-45082017AO3831].

Role of contrast-enhanced digital mammography in evaluation of breast lesions

Objective The purpose of this study was to assess the role of dual-energy contrast mammography (MX) in evaluating breast lesions. Background Contrast-enhanced digital mammography (CEDM) can significantly improve diagnostic quality such as clarification of mammographic and sonographic equivocal lesions, detection of occult lesions on MX, determination of the extent of disease, and assessment of recurrent disease. Patients and methods A total of 50 female patients were enrolled into the present study, with their ages ranging from 22 to 77 years (mean age of about 49.5), during the period between 2012 and 2014. All of them presented with benign or malignant breast lesions detected by sonomammography, categorized as Breast Imaging Reporting and Data System from 2 to 5. All were subjected to CEDM, and the images were obtained by a modified full-field digital MX system. The nonionic iodinated contrast agent was administered into the contralateral antecubital vein manually. The results were compared with the sonomammography results, and cases were histopathologically proven. Results In our study, 37/50 cases were histopathologically proven as malignant and 16/50 were benign, whereas three patients had double pathology. Different patterns of enhancement were depicted on contrast-enhanced digital mammography (CEDM) in all histologically proven breast carcinomas. Our results show that sensitivity was higher for MX + CEDM (83.3%) compared with pathology and Breast Imaging Reporting and Data System analysis, respectively, with no loss in specificity. Compared with MX associated with breast ultrasound, CEDM had a better diagnostic accuracy mainly because of improved specificity and better positive and negative predictive values (positive predictive value and negative predictive value were 86 and 64.7%, respectively). Conclusion The addition of dual energy contrast-enhanced MX technique to conventional sonomammography can significantly improve diagnostic quality and cancer detection rate.

Trans-falcine and contralateral sub-frontal electrode placement in pediatric epilepsy surgery: technical note.

Phase II monitoring with intracranial electroencephalography (ICEEG) occasionally requires bilateral placement of subdural (SD) strips, grids, and/or depth electrodes. While phase I monitoring often demonstrates a preponderance of unilateral findings, individual studies (video EEG, single photon emission computed tomography [SPECT], and positron emission tomography [PET]) can suggest or fail to exclude a contralateral epileptogenic onset zone. This study describes previously unreported techniques of trans-falcine and sub-frontal insertion of contralateral SD grids and depth electrodes for phase II monitoring in pediatric epilepsy surgery patients when concern about bilateral abnormalities has been elicited during phase I monitoring. Pediatric patients with medically refractory epilepsy undergoing stage I surgery for phase II monitoring involving sub-frontal and/or trans-falcine insertion of SD grids and/or depth electrodes at the senior author's institution were retrospectively reviewed. Intra-operative technical details of sub-frontal and trans-falcine approaches were studied, while intra-operative complications or events were noted. Operative techniques included gentle subfrontal retraction and elevation of the olfactory tracts (while preserving the relationship between the olfactory bulb and cribriform plate) to insert SD grids across the midline for coverage of the contralateral orbito-frontal regions. Trans-falcine approaches involved accessing the inter-hemispheric space, bipolar cauterization of the anterior falx cerebri below the superior sagittal sinus, and sharp dissection using a blunt elevator and small blade scalpel. The falcine window allowed contralateral SD strip, grid, and depth electrodes to be inserted for coverage of the contralateral frontal regions. The study cohort included seven patients undergoing sub-frontal and/or trans-falcine insertion of contralateral SD strip, grid, and/or depth electrodes from February 2012 through June 2015. Five patients (71%) experienced no intra-operative events related to contralateral ICEEG electrode insertion. Intra-operative events of frontal territory venous engorgement (1/7, 14%) due to sacrifice of anterior bridging veins draining into the SSS and avulsion of a contralateral bridging vein (1/7, 14%), probably due to prior anterior corpus callosotomy, each occurred in one patient. There were no intra-operative or peri-operative complications in any of the patients studied. Two patients required additional surgery for supplemental SD strip and/or depth electrodes via burr hole craniectomy to enhance phase II monitoring. All patients proceeded to stage II surgery for resection of ipsilateral epileptogenic onset zones without adverse events. Trans-falcine and sub-frontal insertion of contralateral SD strip, grid, and depth electrodes are previously unreported techniques for achieving bilateral frontal coverage in phase II monitoring in pediatric epilepsy surgery. This technique obviates the need for contralateral craniotomy and parenchymal exposure with limited, remediable risks. Larger case series using the method described herein are now necessary.

Abstract 635: Role of Micro RNA-21 in Venous Neointimal Hyperplasia (VNH): Implications in Targeting MiR-21 For VNH Treatment

The exact molecular mechanisms involved in hemodialysis arteriovenous fistula (AVF) failure caused by venous neointimal hyperplasia (VNH) are not clear. It has been observed that there is an accumulation of extracellular matrix and up regulation of pro-fibrotic genes accompanied with presence of fibroblasts, smooth muscle cells, and inflammatory cells in the stenotic veins. Previous studies have demonstrated that adventitial and medial fibroblasts have a pivotal role(s) in VNH formation. MicroRNA-21 (miR-21) contributes to fibroblast to myofibroblast differentiation and dysregulation of miR-21 plays a pathological role in failure of coronary artery bypass grafts. The aim of the present study was to determine the role of miR-21 in VNH associated with AVF. We assessed miR-21 expression using qRT-PCR in the outflow veins of AVFs compared to control (contralateral jugular veins) veins in the C57BL/6J mice with chronic kidney disease (CKD). MiR-21 expression was upregulated accompanied with down regulation of miR-21 target genes; PPAR-α, PTEN and TIMP-3. In addition, gene expression of fibroblast specific protein (FSP) -1, TGF (transforming growth factor) -β1, matrix metalloproteinases (MMP)-2, -9, collagen-I, and IV were significantly increased at day 7 after AVF creation. Immunohistochemistry revealed that there was a significant increase in proliferating cell index (Ki-67) and fibroblast index (FSP-1) in the outflow veins of AVFs. Hypoxia has been shown to increase fibroblast to myofibroblast differentiation and this is predicted to be an early step in VNH formation. Therefore we assessed miR-21 expression in hypoxic (1%O 2 ) mouse pulmonary vein fibroblasts compared to normoxic cells in vitro and it was found that miR-21and TGF-β1 significantly elevated with down regulation of miR-21 target genes PTEN and TIMP-3. Furthermore, miR-21 knockdown in hypoxic fibroblasts attenuated TGF-β1 expression with a significant upregulation of genes targeted by miR-21 compared to controls. Together these results indicate that upregulation of miR-21 expression may result in fibroblast to myofibroblast differentiation resulting in VNH formation.

Abstract 530: In vivo DVT Inflammation Presages Vein Wall Injury, and is Ameliorated by Statin Therapy

Objective: Inflammation mediates early venous thrombosis (VT) resolution and can induce vein wall scarring (VWS), a key driver of the morbid post-thrombotic syndrome (PTS). Statins exhibit anti-inflammatory properties, and may positively impact VWS after VT. However, whether early inflammation contributes to this process and can be detected is not known. In this study, we hypothesized that early VT inflammation detected by 18F-fludeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) could predict subsequent VWS and that both VT inflammation and VWS would be attenuated by statin therapy. Methods: Stasis VT was induced by complete ligation in male C57BL/6J mice (n=55) in either the infrarenal inferior vena cava (IVC, n=42) or right jugular vein (n=13). IVC VT mice were randomized to statin or control groups. Statin (rosuvastatin 5mg/kg) was given by oral gavage starting one day prior to VT induction; control mice received PBS. All mice underwent survival FDG-PET/CT venography imaging on day 2. FDG-PET inflammation signals (standard uptake value (SUV), SUVmax, target-to-background ratios (TBR)) were measured. Picrosirius red staining of day 14 VT sections measured vein wall collagen/thickness. Ex vivo VT tissue gamma counting of a subgroup was performed at day 2. Whole-thrombus protein/mRNA and VT tissue sections assessed neutrophil content. Results: FDG-PET/CT at day 2 revealed increased FDG uptake in jugular VT over the contralateral sham surgery vein (p<0.001). Statin-treated mice showed a decrease in FDG-PET SUV, SUVmax and TBR (p<0.05 for all). Whole-thrombus analyses and tissue section immunostaining showed reduced thrombus neutrophil content at day 2, without reducing GLUT1 or MPO expression (p>0.05). At day 14, statin therapy significantly reduced VWS (p=0.02). In mice undergoing survival imaging, the day 2 FDG-PET VT inflammation signal correlated significantly with the magnitude of day 14 VWS (IVC VT r=0.74, p<0.001) and jugular models of VT (r=0.62, p=0.02). Conclusions: Quantitative FDG inflammation imaging demonstrates that early VT inflammation presages subsequent VWS, and is ameliorated by prophylactic statin therapy. The overall findings support the concept that statins and could reduce VWS and PTS.

Dorsal metacarpal veins: anatomic variation and potential clinical implications.

The dorsal metacarpal veins are frequently cannulated. Cannulation success is determined by several variable anatomic features. The objective of this study is to classify, for the first time, the anatomic variants of the dorsal metacarpal veins. In this cross-sectional study, 520 university students and staff were conveniently recruited. The dorsal metacarpal veins in 1040 hands were studied. Venous visibility was enhanced by either tourniquet application or near-infrared illumination. Variant patterns of the dorsal metacarpal veins were classified. The final analysis included 726 hands, for an exclusion rate of 30%. Eight pattern types were identified. Three anatomic features informed the variation. Bilateral symmetry of the dorsal metacarpal veins was present in 352 participants (83% of the total). The overall frequency distribution of variants in both hands was similar (P=0.8). The frequency distribution of variants was subject to sexual dimorphism (P=0.001), ethnic variation (P<0.001), and technical variation (P<0.001). The anatomic variants of the dorsal metacarpal veins were sorted into decreasingly frequent primary, secondary, and tertiary groups. The groups may signify a progressive increase in difficulty of peripheral cannulation, in the mentioned order. As such, primary patterns are the most common and likely the easiest to cannulate, while tertiary patterns are the least common and likely the most difficult to cannulate. The preceding premise, in tandem with the bilateral asymmetry of the veins, is clinically significant. With cannulation difficulty likely signifying an underlying tertiary pattern, the contralateral dorsal metacarpal veins are probabilistically characterized by a primary pattern and are, as such, the easier option for peripheral venous cannulation.

Ipsilateral Prominent Thalamostriate Vein on Susceptibility-Weighted Imaging Predicts Poor Outcome after Intravenous Thrombolysis in Acute Ischemic Stroke.

The impact of deep cerebral veins on neurologic outcome after intravenous thrombolysis in patients with acute ischemic stroke is unclear. We investigated the relationship between the appearance of deep cerebral veins on susceptibility-weighted imaging and neurologic outcome in patients who underwent thrombolysis. We retrospectively analyzed 109 consecutive patients with acute ischemic stroke who had pretreatment SWI and received intravenous thrombolysis within 6 hours. We calculated the signal difference ratio (defined as the relative difference in signal intensity between the ipsilateral and contralateral veins) of the thalamostriate vein, septal vein, and internal cerebral vein on pretreatment SWI. Only the signal difference ratio of the thalamostriate vein was significantly associated with poor outcome (3-month modified Rankin Scale score > 2, P = .008). The optimal threshold was relative hypointensity of the ipsilateral vein of >4.8% (sensitivity of 53.7% and specificity of 80.9%). We defined a signal difference ratio of the thalamostriate vein of ≥5% as an ipsilateral prominent thalamostriate vein. Patients with an ipsilateral prominent thalamostriate vein were more likely to have poor outcome (OR = 3.66; 95% CI, 1.25-10.68; P = .02) and a lower rate of successful reperfusion (reperfusion rate of ≥70%; OR = 0.35; 95% CI, 0.13-0.92; P = .03), compared with those without an ipsilateral prominent thalamostriate vein. However, patients with an ipsilateral prominent thalamostriate vein were still less likely to experience poor outcome when reperfusion was achieved compared with when reperfusion did not occur (80.0% versus 44.4%, P = .04). A pretreatment ipsilateral prominent thalamostriate vein was associated with reduced reperfusion after thrombolysis and poor outcome. More intensive reperfusion approaches may be required for patients with an ipsilateral prominent thalamostriate vein.

Perivascular Perfusion on Contrast-Enhanced Ultrasound (CEUS) Is Associated with Inflammation in Patients with Acute Deep Vein Thrombosis.

Background Inflammatory processes of the venous wall in acute deep vein thrombosis (DVT) play a role in thrombus formation and resolution. However, direct evaluation of the perivascular inflammation is currently not feasible. Objective To assess perivascular perfusion in acute proximal DVT using contrast-enhanced ultrasound (CEUS) reflecting perivenous inflammation and its association with systemic inflammatory markers in a single-centre, prospective observational study. Patients/Methods Twenty patients with proximal DVT underwent CEUS imaging in the thrombosed and contralateral popliteal vein at baseline and after 2 weeks and 3 months. Perfusion was quantified by measuring peak enhancement (PE) and wash-in rate (WiR) in a perivenous region after bolus injection of the contrast agent. High-sensitive C-reactive protein (hsCRP) and interleukin-6 (IL-6) were determined at the time of each CEUS imaging. Results PE and WiR were significantly higher in the thrombosed compared with the unaffected leg at baseline (1,007 vs. 34 au and 103 vs. 4 au/s) and 2-week follow-up (903 vs. 35 au and 70 vs. 4 au/s). Compared with baseline, PE and WiR in the thrombosed leg significantly decreased to 217 au and 18 au/s at 3-month follow-up.At baseline, hsCRP and IL-6 were elevated at 20.1 mg/mL and 8.2 pg/mL and decreased significantly to 2.8 mg/mL and 2.6 pg/mL at 2-week follow-up, remaining low after 3 months. There was a weak association between the level of inflammatory markers and the CEUS parameters at baseline on the thrombosed leg. Conclusion Elevated perivascular perfusion assessed by CEUS imaging is associated with the inflammatory response in acute DVT.

対側上肺静脈へ流入する右後上葉区肺静脈（V2）を認めた右下葉肺癌の1例

対側上肺静脈へ流入する右後上葉区肺静脈（V2）を認めた右下葉肺癌の1例

Comparative Study of Histological Alterations in Intravascular Catheter Region with and without the Use of Local Corticosteroid

Introduction: Central venous access is one of the most common procedures in pediatric surgery worldwide for infusion of antibiotics, electrolytes, chemotherapy, total parenteral nutrition, etc. Local regional complications due the permanence of venous catheters are described most frequently as: thrombosis, infection, edema and local cellulites, mobilization and catheter loss. As a result, the catheter must be prematurely removed. The use of local corticosteroid (Betamethasone) can be an alternative to lengthen the catheter maintenance. Aim: This study objective is to analyze perivascular inflammatory alterations in phlebotomies with polytetrafluoroethylene (20 GA) catheter in two periods of permanence 15 and 30 days with or without local Corticosteroid. Material & Method: 32 New Zealand adult rabbits were submitted to catheterization of the External Right Jugular Vein(RJV) and were divided in 4 groups: G1: with 8 rabbits’ catheters collected in the 15th day, without corticosteroid use; G2: with 8 rabbits’ catheters collected in the 15th day, with corticosteroid use; G3: with 8 rabbits’ catheters collected in the 30th day, without corticosteroid use; G4: with 8 rabbits’ catheters collected in the 30th day, with corticosteroid use; G5: Control was the contralateral vein of the rabbit itself. Results: G2 presented lower inflammatory incidence when compared to G1, despite this difference was not statistically significant (p = 0.7333). G4 also displayed lower inflammatory incidence than G3, however it was not statistically significant (p = 0.3571). When G1 and G3 were compared with G2 and G4, there was also lower incidence of the inflammatory process in those subjects using Betamethasone, although this difference was not statistically significant (p = 0.3202). Conclusion: Betamethasone used in the vascular catheters insertion areas through phlebotomy can lessen local inflammatory manifestations of venous catheterizations.

Association of Cortical Vein Filling with Clot Location and Clinical Outcomes in Acute Ischaemic Stroke Patients.

Delay in cortical vein filling during the late-venous phase (delayed-LCVF) is characterized by opacification of cerebral veins despite contrast clearance from contralateral veins on dynamic computed tomography angiography (dCTA) in acute ischemic stroke (AIS) patients. The aim of the study was to investigate the associations of delayed-LCVF with clot location, reperfusion status at 24 hours, and 90-days functional outcome in AIS patients who received reperfusion therapy. A prospective cohort of AIS patients treated with intravenous thrombolysis was studied. Groupwise comparison, univariate, and multivariate regression analyses were used to study the association of delayed-LCVF with clot location and clinical outcomes. Of 93 patients (mean age = 72 ± 12 years) with hemispheric AIS included in the study, 46 (49%) demonstrated delayed-LCVF. Patients with delayed-LCVF demonstrated a significantly higher proportion of proximal occlusion (72% vs 13%, P =< 0.0001), and poor reperfusion at 24 hours (41% vs 11%, P = 0.001). The proportion of poor functional outcome at 90 days was not significantly different (22/56 (48%) vs 17/61 (36%), P = 0.297). The appearance of delayed-LCVF on baseline dCTA may be a surrogate for large vessel occlusion, and an early marker for poor 24-hour angiographic reperfusion.

Abstract 35: DVT Inflammation Assessed by 18F-FDG-PET/CT Predicts Subsequent Vein Wall Scarring

Objective: While venous thrombosis (VT)-induced inflammation facilitates thrombus resolution, inflammation causes vein wall scarring (VWS). Recently, statins have shown to improve VT resolution and reduce VT inflammatory components. In this study, we hypothesized that early VT inflammation detected by 18F-FDG positron emission tomography/computed tomography (PET/CT) could predict subsequent late stage VWS, and would be attenuated by statin therapy. Methods: Stasis VT was induced in 8-12 week old male C57BL/6 mice (n=31) in either the right jugular vein (n=13) or inferior vena cava (IVC,n=18). Animals in the IVC VT cohort were randomized to statin (n=8) or control (n=10) treatment. Statin, rosuvastatin (5mg/kg), was administered by oral gavage, daily starting 24 hours prior to VT induction; control mice received saline. All mice underwent survival FDG-PET/CT venography imaging on day 2. FDG inflammation signals (standard uptake value=SUV) were measured in the thrombosed vein and compared to the sham-operated venous segments or treatment control. On day 14, mice were sacrificed and VT tissue was resected. Picrosirius red staining allowed measurement of collagen and vein wall thickness in VT sections. Results: FDG-PET/CT at day 2 revealed increased inflammation signal activity in jugular VT (SUV 1.43 ± 0.3 VT vs. 0.81 ± 0.3 contralateral vein, p&lt;0.0001). Statin-treated mice showed a trend of decreased inflammation signal at day 2 in the IVC VT models (SUV 1.02 ± 0.1 statin VT vs. 1.42 ± 0.2 control VT, p=0.07). Day 14 histological analysis revealed significantly reduced vein wall injury in statin-treated animals (thickness, 32±9.4 μm statin; vs. 56.2±14.7 μm control, p=0.02). Day 2 FDG-PET inflammation in VT correlated positively with the magnitude of day 14 VWS (jugular VT, Spearman r=0.62, p=0.02; IVC VT r=0.74, p&lt;0.001, respectively). Conclusions: Quantitative FDG-PET/CT imaging demonstrates that early in vivo VT inflammation predicts subsequent VWS, a driver of post-thrombotic syndrome (PTS). The overall findings strengthen: (i) the link between inflammation and PTS; (ii) the translational potential of FDG-PET inflammation to predict VWS and PTS; and (iii) the concept that statins and other anti-inflammatory therapies could reduce VWS and PTS.

Assessment of micro-mechanical variations in experimental arteriovenous fistulae using atomic force microscopy.

This study presents a method to quantify micro-stiffness variations in experimental arteriovenous fistulae (AVF). AVF created by anastomosing the superficial epigastric vein to the femoral artery in Sprague-Dawley rats were allowed to remodel for 21 days before being harvested and preserved in culture medium. A custom atomic force microscope was used to measure microvascular stiffness (Young's modulus) in three areas of the AVF: the inflow artery, the juxta-anastomotic area, and the outflow vein. Morphometric measurements and collagen and elastin contents were also determined. Atomic force microscopy indentation revealed an increased stiffness in the juxta-anastomotic area of the AVF compared to the outflow vein and inflow artery. The juxta-anastomotic area was also significantly stiffer than the contralateral vein. The lack of elasticity (higher Young's modulus) of the juxta-anastomotic region was associated with a thicker vascular wall that was rich in collagen but poor in elastin. This study demonstrates for the first time the feasibility of using atomic force microscopy to measure local stiffness variations in experimental AVF. This technique could be instrumental in advancing our understanding of how micro-spatial organization of the AVF wall determines the overall biomechanical performance of this type of vascular access.

Clinical effects and safety of catheter- directed thrombolysis for acute lower extremity deep vein thrombosis in patients aged 70 years and over

Objective To analyze the efficacy and safety of catheter-directed thrombolysis (CDT) for acute lower extremity deep venous thrombosis (DVT) in patients aged 70 years and over . Methods Clinical data of 109 cases who had acute lower extremity DVT and had been treated with CDT from March 2011 to September 2014 were retrospectively analyzed. Results Inferior vena cava filters (IVCF) were implanted in 109 patients. A thrombolytic catheter was inserted from the contralateral femoral vein (21 cases), ipsilateral popliteal vein (44 cases), posterior tibial vein (28 cases) or small saphenous vein (16 cases). The duration of thrombolysis was (5.47±2.13) d. The dosage of urokinase was (3.80±0.56)million units. Forty-two cases underwent balloon dilatation alone, and 67 cases combined balloon dilatation with stent implantation. Gingival bleeding occurred in 7 patients and gross hematuria occurred in 4 patients during thrombolysis, which disappeared after medication adjustment. No symptomatic pulmonary embolism (PE) or other serious complications were found in any patients. There were significant differences in the venous patency score and lower limb circumferences at 10 cm above and below the knee one week after treatment (t=3.874, P=0.031). Ninety-seven cases were followed up for a mean period of (20.7±6.5) months, and the vein patency rate was (77.9±10.5) % and (73.1±9.4) % at 6 and 18 months after treatment, respectively. Recurrence of deep vein thrombosis was found in 6 cases, of which 2 cases had recurrent stent thrombosis, and treatment with CDT again was successful. No severe deep venous thrombosis syndrome (PTS) was found during the follow-up. Conclusions CDT is a minimally invasive procedure and can rapidly resolve limb venous drainage disorders. CDT is safe, has few complications and usually generates satisfactory outcomes. For very-old elderly patients who have no anticoagulation and thrombolytic contraindications, CDT is a useful option for the treatment of acute lower limb DVT. Key words: Venous thrombosis; Catheterization, peripheral; Thrombolytic therapy

Case of Chronic Otitis Media with Intracranial Complication and Contralateral Extracranial Presentation

Intracranial complications of chronic otitis media have been on the decline with advent of antibiotics. Septic thrombosis of the sigmoid sinus is rarer compared to commoner complications such as otogenic brain abscesses and meningitis. This patient presented with recurrent infection after left mastoidectomy secondary to cholesteatoma and a contralateral internal jugular vein thrombosis with parapharyngeal abscess, which was drained. He recovered well postoperatively with antibiotics.

Differentiation of deep venous thrombosis from femoral vein mixing artifact on routine abdominopelvic CT.

The objective of this study is to assess the performance of qualitative and quantitative imaging features for the differentiation of deep venous thrombosis (DVT) from mixing artifact on routine portal venous phase abdominopelvic CT. This retrospective study included 40 adult patients with a femoral vein filling defect on portal venous phase CT and a Duplex ultrasound (n = 36) or catheter venogram (n = 4) to confirm presence or absence of DVT. Two radiologists (R1, R2) assessed the femoral veins for various qualitative and quantitative features. 60% of patients were confirmed to have DVT and 40% had mixing artifact. Features with significantly greater frequency in DVT than mixing artifact (all p ≤ 0.006) were central location (R1 90% vs. 28%; R2 96% vs. 31%), sharp margin (R1 83% vs. 28%; R2 96% vs. 31%), venous expansion (R1 48% vs. 6%, R2 56% vs. 6%), and venous wall enhancement (R1 62% vs. 0%; R2 48% vs. 0%). DVT exhibited significantly lower mean attenuation than mixing artifact (R1 42.1 ± 20.2 vs. 57.1 ± 23.6 HU; R2 43.6 ± 19.4 vs. 58.8 ± 23.4 HU, p ≤ 0.031) and a significantly larger difference in vein diameter compared to the contralateral vein (R1 0.4 ± 0.4 vs. 0.1 ± 0.2 cm; R2 0.3 ± 0.4 vs. 0.0 ± 0.1 cm, p ≤ 0.026). At multivariable analysis, central location and sharp margin were significant independent predictors of DVT for both readers (p ≤ 0.013). Awareness of these qualitative and quantitative imaging features may improve radiologists' confidence for differentiating femoral vein DVT and mixing artifact on routine portal venous phase CT. However, given overlap with mixing artifact, larger studies remain warranted.

Adrenal Vein Sampling for Conn’s Syndrome: Diagnosis and Clinical Outcomes

Adrenal vein sampling (AVS) is the gold standard test to determine unilateral causes of primary aldosteronism (PA). We have retrospectively characterized our experience with AVS including concordance of AVS results and imaging, and describe the approach for the PA patient in whom bilateral AVS is unsuccessful. We reviewed the medical records of 85 patients with PA and compared patients who were treated medically and surgically on pre-procedure presentation and post-treatment outcomes, and evaluated how technically unsuccessful AVS results were used in further patient management. Out of the 92 AVS performed in 85 patients, AVS was technically successful bilaterally in 58 (63%) of cases. Either unsuccessful AVS prompted a repeat AVS, or results from the contralateral side and from CT imaging were used to guide further therapy. Patients who were managed surgically with adrenalectomy had higher initial blood pressure and lower potassium levels compared with patients who were managed medically. Adrenalectomy results in significantly decreased blood pressure and normalization of potassium levels. AVS can identify surgically curable causes of PA, but can be technically challenging. When one adrenal vein fails to be cannulated, results from the contralateral vein can be useful in conjunction with imaging and clinical findings to suggest further management.