Ectatic Veins Research Articles

Manejo multimodal de aneurisma cirsoideo. Reporte de un caso y revisión de la literatura

Scalp arteriovenous malformations (AVMs), commonly known as cirsoid aneurysms, are complex collections of arteries and veins that communicate directly. It has been postulated that AVMs occur both through the activation of inactive fistulous lesions and through the formation of new fistulous vascular channels through the canalization of injured vessels. Depending on their size and complexity, a variety of strategies can be used to treat them. The case of a 53-year-old male is presented who came for evaluation due to an increase in the volume of a pulsating lesion that extended from the right parietotemporal region accompanied by holocraneal headache and tinnitus. A cerebral angiotomography was performed in which a lesion composed of ectatic serpentine images, with a right extracranial location, subsequently diagnostic cerebral angiography was performed demonstrating a right frontoparietal fistulous and plexiform arteriovenous shunt fed by afferents from the right superficial temporal, posterior auricular, occipital and middle meningeal arteries, with drainage through a varicose and ectatic vein towards the external jugular vein. An endovascular embolization of the arteriovenous shunt was performed via the femoral route in two stages, achieving a “pressure cooker” construction to perform the injection of embolizing fluid and have a subtotal embolization of 93%, with this it was possible to perform a microsurgical resection with a right fronto-parietal-temporal approach resecting the deepest part, leaving the scalp with embolized vessels without resecting. To close the surgical wound, a simple flap rotation was performed to cover the skin defect derived from its resection. The patient underwent post-resection cerebral panangiography, identifying the absence of arteriovenous shunt. Depending on the extent and anatomical complexity of the malformation, clinical manifestations may vary. More than 80% of AVMs will be present at birth and the rest may develop after head trauma or surgical interventions. Appropriate therapeutic intervention is needed through selective angiography, during which endovascular embolization of the major feeding vessels can be performed before open surgical intervention. Volume-based three-dimensional computed tomography reconstructions can be used for further planning. Surgical reduction of post-embolization arterial supply will reduce intraoperative hemorrhage, facilitating total surgical resection. Removal can result in large, full-thickness skin defects that may be difficult to reconstruct without compromising functional and cosmetic results. Keywords: Cirsoid aneurysm; multimodal management; treatment; endovascular; giant

GAVE-синдром как редкая причина трансфузионно-резистентной железодефицитной анемии у женщины пожилого возраста

Antrum vein ectasia or GAVE syndrome, although rare, can lead to bleeding from the upper gastrointestinal tract in 4% of elderly patients. Its main manifestation includes refractory anemia, requiring regular blood transfusions and constant intake of iron supplements. It is diagnosed by presence of longitudinally located ectatic veins of the antrum of the stomach and histological examination data. Standard treatment includes endoscopic argon plasma coagulation. We present a clinical case report of an elderly woman with GAVE syndrome, severe recurrent iron deficiency anemia, and implanted permanent pacemaker. The treatment complexity in this case was presented by underestimating the endoscopic findings in the gastric mucosa at the onset of the disease, which made it difficult to find the source of bleeding, and the presence of a permanent pacemaker in the patient required correction of its work before the argon plasma coagulation procedure.

Infrainguinal bypass using varicose veins with external scaffolding

Background: Chronic limb-threatening ischemia (CLTI) is associated with high rates of mortality, amputation, and impaired quality of life. The great saphenous vein (GSV) is the first-choice material for surgical revascularization of the infrapopliteal arteries. It may occur that the autologous material is not of good quality, presenting varicosities and ectasias which can affect bypass patency. The long-term patency rate of these operations is still not clear and few evidences are still present in literature. The aim of our study is to report the technical feasibility and efficacy of infrainguinal bypasses performed with autologous ectatic or varicose vein and with the use of external vascular supports. Materials and Methods: From September 2005 to January 2023, infrainguinal venous bypasses with autologous varicose or ectatic vein using an external vascular support were collected in the present study. The indication for surgery was the presence of CLTI with rest pain and/or gangrene. In case of localized dilatations of a segment of the GSV a partial bypass scaffolding (i.e. 10 to 15 cm) was used. Patients with a long segment of varicose vein underwent a completely covered ex situ vein bypass after a bench devalvulation. Follow-up was performed at 1, 3, 6 and 12 months and every 6 months thereafter, by clinical examination and color Doppler ultrasound. The outcome measures were technical success, 30-day and long-term primary and primary assisted bypass patency, as well as the limb salvage rate. External support infection rates upon reoperation for surgical wound infection as well as graft aneurysmal dilatation over time were also analyzed. Results: 63 patients underwent infrainguinal bypass with autologous varicose or ectatic venous material. In 51 patients (80.9%) the GSV was used, in 3 cases (4.8%) the short saphenous vein (SSV) and in 9 cases (14.3%) a composition of both saphenous veins or with one arm vein. Technical success was achieved in all cases and the mean surgical time was 320±80 minutes. No intraoperative mortality was recorded. At 30 days the primary patency and limb salvage rate were 97.8%, due to two early bypass occlusions. No infections of the external vascular support were recorded. During a mean follow-up of 54.6±27.2 months 8 (13.1%) hemodynamic stenoses requiring reoperation and 3 (4.9%) thromboses of the bypass were found. The primary patency rate was 62.8%, assisted primary 76.3%, with a limb salvage rate of 78%. Conclusion: In our experience, the great saphenous vein, even if ectatic or varicose, has proved to be a valuable conduit for the preparation of a infrainguinal bypasses in CLTI patients, with a satisfactory patency and limb salvage rates. In addition, composite vein graft also using arm vein, could be used in infrainguinal bypass with acceptable results. Also in the light of these results, a “saphenous sparing" surgical approach during corrective surgery for venous insufficiency of the lower limbs should be recommended, so as not to preclude future surgical treatments for limb salvage.

Extreme lateral supracerebellar infratentorial approach for tentorial arteriovenous fistula associated with a giant venous ectasia: how I do it

BackgroundSurgery of tentorial dural arteriovenous fistulas (DAVF) associated with large ectatic vein remains challenging due to the intimate neurovascular relationships in the incisural space. Interruption of the arterialized vein requires a good knowledge of the regional anatomy and a precise preoperative evaluation.MethodsWe describe the key steps extreme lateral supracerebellar infratentorial (ELSI) approach for tentorial DAVF with a video illustration. The surgical anatomy is described along with the advantages and limitations of this approach.ConclusionsIn cases of tentorial DAVF where the foot of the arterialized vein is located in the infratentorial compartment, ELSI offers good surgical exposure and outcomes.

Use of a 4 mm Amplatzer Vascular Plug II in the treatment of a renal arteriovenous fistula: a case report

BackgroundWe report the use of a 4 mm vascular Amplatzer for the occlusion of a renal arterovenous fistula between the renal artery, at the hylum trifurcation point, and an aneurismatic vein draining into the main renal vein, where there was no possibility to use any other device from the venous side, because of the diameter and the high flow, neither from the arterious side without sacrificing lobar branches. The device was implanted at the exact point of communication, like a patent foramen ovale occluder, with the distal disc into the artery lumen and the other two proximal discs into the venous side.Case presentationA 34-years-old Caucasian woman suffered several episodes of paroxysmal supraventricular tachycardia associated with dyspnoea, after the onset of post-pregnancy hypertension. She underwent CTA, spectral Doppler sonography and angiography which showed a renal arteriovenous fistula (RAVF) between the renal artery, at the hylum trifurcation point, and an extremely ectatic vein draining into the main renal vein of the right kidney.With both arterial and venous access, the RAVF was selectively embolized using a 4 × 6 mm Amplatzer Vascular Plug II, released into the communication between artery and vein ensuring the patency of vessels involved.The RAVF was almost completely excluded and the hemodynamic effects associated were also corrected.ConclusionsThe use of this device, though in an alternative way, allowed the exclusion of the high flow A-V fistula without sacrificing any parent renal vessel and preserving the renal function.

Constitutive Active Mutant TIE2 Induces Enlarged Vascular Lumen Formation with Loss of Apico-basal Polarity and Pericyte Recruitment

Abnormalities in controlling key aspects of angiogenesis including vascular cell migration, lumen formation and vessel maturation are hallmarks of vascular anomalies including venous malformation (VM). Gain-of-function mutations in the tyrosine kinase receptor TIE2 can cause VM and induce a ligand-independent hyperactivation of TIE2. Despite these important findings, the TIE2-dependent mechanisms triggering enlarged vascular lesions are not well understood. Herein we studied TIE2 p.L914F, the most frequent mutation identified in VM patients. We report that endothelial cells harboring a TIE2-L914F mutation display abnormal cell migration due to a loss of front-rear polarity as demonstrated by a non-polarized Golgi apparatus. Utilizing a three-dimensional fibrin-matrix based model we show that TIE2-L914F mutant cells form enlarged lumens mimicking vascular lesions present in VM patients, independently of exogenous growth factors. Moreover, these abnormal vascular channels demonstrate a dysregulated expression pattern of apico-basal polarity markers Podocalyxin and Collagen IV. Furthermore, in this system we recapitulated another pathological feature of VM, the paucity of pericytes around ectatic veins. The presented data emphasize the value of this in vitro model as a powerful tool for the discovery of cellular and molecular signals contributing to abnormal vascular development and subsequent identification of novel therapeutic approaches.

Hand rejuvenation: Combining dorsal veins foam sclerotherapy and calcium hydroxylapatite filler injections.

Background The hands are an important aesthetic feature that can reveal aging through surface pigmentary changes, loss of skin thickness and ectatic dorsal hand veins. Techniques addressing these changes already exists but are not routinely combined for optimum results. Objective The combination techniques of dorsal hand veins sclerotherapy and sub-dermal filler injections are described. Methods The dorsal hand veins are treated with sclerotherapy (0.5% Sodium tetradecyl sulphate). This is then followed by subdermal injection of 0.75 mL-1.5 mL calcium hydroxylapatite (Radiesse, Merz) per hand, in conjunction with tumescent anaesthetic. The dorsal hands should be gently massaged for 2 min (per hand), twice a day for two days. If necessary, the procedure can be repeated after one month for further improvement. Results The techniques of sclerotherapy and filler injections complement each other well in hand rejuvenation. Calcium hydroxylapatite is safe and effective for hands and associated with high patient satisfaction. In suitable patients, the reduction in ectatic veins from sclerotherapy results in a longstanding improvement that complements volume restoration with fillers. Conclusion Aging hands with ectatic dorsal hand veins and skin atrophy/wrinkling not fully responsive to filler correction alone can further improve with the combination of sclerotherapy and filler injections.

The Potential of Color Doppler Ultrasound Efficiency in Monitoring Diabetic Nonulcerated Neuroarthropathic (Charcot) Foot

A 30 year-old female having type 1 diabetes for 23 years, noticed progressively, for four months, inflammatory mild painful signs on her right foot. During the interview she recalled a post-traumatic fracture of her ipsilateral 5th toe. We documented an acute nonulcerated neuroarthropathic foot (Eichenholtz I, Brodski 1) but no occlusive arterial disease. The patient agreed offloading the foot only for three months (removable total contact cast). Before offloading, physical signs revealed midfoot are inflammatory swelling, ectatic veins and no plantar arches, still keeping after, a higher temperature without visible edema (Figure 1).

Synchronous Endobypass of Bilateral Superficial Femoral Artery Aneurysms (After Bilateral Popliteal Aneurysm Bypass Surgery) Using Heparin-Bonded Stent-Grafts

Introduction: Bilateral superficial femoral artery aneurysms are a rare entity, managed here via a synchronous endovascular approach. Report: An 84-year-old male presented with bilateral peri-anastomotic superficial femoral artery aneurysms 3 years after femoropopliteal bypass for bilateral popliteal aneurysms. He underwent successful synchronous bilateral endobypass using overlapped 13 × 100 mm (proximal) and 11 × 100 mm (distal) heparin-bonded endoprostheses. Discussion: Calibre mismatch between ectatic vessel and narrower vein graft may be related to peri-anastomotic aneurysm formation in a patient who has a predilection for aneurysm formation. Bilateral superficial femoral artery aneurysms can be managed by synchronous endobypass with the attendant benefits of avoiding repeat admission/anaesthetic episodes.

Management of Venous Malformations

Venous malformations (VMs) frequently occur in the head and neck with a predilection for the parotid gland, submandibular triangle, buccal space, muscles of mastication, lips, and upper aerodigestive tract. They are composed of congenitally disrupted ectatic veins with inappropriate connections and tubular channels. Because VMs have poorly defined boundaries and a tendency to infiltrate normal tissue, they require calculated treatment decisions in the effort to preserve surrounding architecture. Sclerotherapy, surgical excision, neodymium:yttrium aluminum garnet laser therapy, or a combination of these modalities is employed in the management of VMs. Although many small VMs can be cured, the objective is often to control the disease with periodic therapy. Location, size, and proximity to vital structures dictate the type of therapy chosen. Vigilance with long-term follow up is important. This review outlines current diagnostic and therapeutic approaches to simple and extensive cervicofacial VMs.

Catheter-Induced Venous Spasm

Digital subtraction venography provides invaluable anatomic and hemodynamic information about the venous system, particularly in patients with congenital venous anomalies. An 18-year–old male patient with congenital phlebectasia of the superficial and deep veins of the left calf associated with anomalous veins presented with pain and heaviness. Prior to percutaneous occlusion of the ectatic veins, sonographic image demonstrated a patent popliteal vein (Figure 1). Multiple venous accesses were obtained to study the lower extremity venous drainage. Antegrade venography via an anterior tibial vein and retrograde venography via left …

7 Tesla MRI demonstrates vascular pathology in Baló’s concentric sclerosis

Baló’s concentric sclerosis (BCS) is an inflammatory demyelinating disease related to multiple sclerosis; its underlying pathology remains unclear. At 7 T MRI in a 19-year-old female BCS patient, microhaemorrhages and ectatic veins were found in T2 hyperintense regions, features which have not been previously reported in conjunction with BCS, and these findings may support the view that vascular pathology plays a role in BCS. MRS data suggest that neuron loss and lipid turnover still took place months after a remission. Plasma exchange was effective in treating a relapse with severe motor deficits, and the off-label use of natalizumab was successful in maintaining remission in this patient.

Portomesenteric venous thrombosis associated with rectal venous malformations

Purpose We report thrombosis of portal and mesenteric veins in patients with a pattern of rectal venous malformations (VMs) and ectatic major mesenteric veins. Methods Eight patients having rectal VMs with either ectatic mesenteric veins and/or evidence of portomesenteric venous thrombosis (PVT), evaluated from 1995-2009, were reviewed. Results Portomesenteric venous thrombosis was evident in 5 patients at presentation. Three had patent ectatic mesenteric veins, 2 with demonstrated reversal of flow, and 2 of whom went on to thrombosis during observation. Six patients developed portal hypertension. Five remain on long-term anticoagulation. After recognizing this pattern, one patient underwent preemptive proximal ligation of the inferior mesenteric vein (IMV) to enhance antegrade portal vein flow and prevent propagation or embolization of venous thrombus from the IMV to the portal vein. Conclusion Rectal VMs should be evaluated for associated ectatic mesenteric veins. The ectatic vein siphons flow from the portal vein down to the rectal VM, leading to stagnation of blood in the portal vein and resultant thrombosis. Primary thrombosis in the stagnant rectal VM and/or mesenteric vein can also predispose to embolization up into the portal vein. This pattern of rectal VM and ectatic mesenteric vein should be considered a risk factor for devastating PVT.

Improved success rate of cardiac resynchronization therapy implant by employing an active fixation coronary sinus lead

Cardiac resynchronization therapy (CRT) is the standard treatment for heart failure with severe reduced left ventricular (LV) function and wide QRS complex. Coronary sinus (CS) lead implantation is challenging and accompanied by substantial dislocation rates. We evaluated the usage of an active fixation LV lead (Attain Starfix, Medtronic, MN, USA) with deployable lobes in challenging lead positions. Between September 2006 and August 2009, 678 CRT devices were implanted. In 82 patients (12%) (59 male, 70 +/- 10 years, 39 ICM, 41 DCM, 2 valvular CM, LVEF 28 +/- 9%, NYHA 3.0 +/- 0.4, QRS 169 +/- 29 ms), the Attain Starfix active fixation lead was used. The main reason was intra-operative dislodgement of one (n = 47) or two (n = 5) passive fixation leads during implantation or revision procedure (n = 30). Active fixation lead implantation was overall successful with 90% (n = 74). Anatomical peculiarity was mostly an optimal lead position in otherwise unstable proximal parts of the target vein or a circumscripted areal of optimal threshold without phrenic nerve stimulation. At median follow-up of 99 days the threshold remained stable (1.2 +/- 0.8 vs. 1.0 +/- 0.5 V at 0.5 ms). Revisions due to instability in ectatic vein (n = 1) after 12 months and extractions (n = 2) because of device perforation/infection after 6/15 months were performed without complication. The Attain Starfix active fixation lead proved to be an important option in anatomically challenging, otherwise unstable positions often located in the proximal part of the target vein. Lead revisions or extractions as late as 15 months after implantation were feasible.

MR and Diffusion Tensor Imaging of Vein of Galen Aneurysmal Malformation in an Infant Presenting with Spastic Diplegia and Seizures

A three-year-old girl developed spastic diplegia to the right and irregular tonc-clonic movements. Phenobarbital was started because of suspected seizure activity. The Pediatric unit asked for brain MR imaging to investigate neurological symptoms. MR and diffusion tensor imaging showed a haemorrhagic vein of Galen aneurysmal malformation (choroidal type) that shifted the corticospinal tract fibres to one side and the corpus callosum was moved forward. Vein of Galen aneurysmal malformations (VGAM) are characterized by multiple arteriovenous connections draining into a markedly enlarged median draining vein. This ectatic vein is not the vein of Galen, but its embryonic precursor, the median prosencephalic vein of Markowski. During normal development, the posterior portion of the median prosencephalic vein persists as the vein of Galen, while its anterior portion regresses in parallel with the formation of the internal cerebral veins (ICV). With the advent of endovascular neurointerventional techniques, the prospects for successful treatment of these lesions, once dismal, are now much improved. MR and diffusion tensor imaging can help in diagnosis and to guide endovascular interventional procedures.

Polypoid arteriovenous malformation in the jejunum of a child that mimics intussusception

Polypoid arteriovenous malformations, which are localized in the colon, are extremely rare in adults, with only 7 cases published to date. Here we present the case of a 6-year-old girl with a jejunal polypoid tumor that a sonogram and a computed tomographic scan have shown to resemble intussusception. Histologically, numerous large ectatic veins intermixed with small-caliber arteries, venules, arterioles, and capillaries were observed in the intestinal wall. A retrospective computed tomographic scan 3-dimensional angiographic reconstruction demonstrated that this may be a diagnostic characteristic. Clinical and morphologic comparisons with previously reported cases were discussed.

Initial Experience with a New Method of External Polyester Scaffolding for Infrainguinal Vein Grafts

This study aims to evaluate the feasibility of external polyester scaffolding in infrainguinal bypass grafting when available vein material is suboptimal due to varicosity or dilatation. Primary objectives were short-term primary patency, assisted primary patency and secondary patency. Secondary objectives were to assess the rate of graft stenoses, infections and other adverse effects related to the use of external scaffolding. A total of 50 consecutive patients were included in this prospective, multicentre, feasibility study from six centres. The indication for infrainguinal bypass was critical limb ischaemia (64%), severe claudication (34%) or popliteal aneurysm (2%). Indications for the use of the external scaffolding were varicosity of the vein graft, ectatic vein graft or the use of spliced vein grafts with segments of widely differing diameters. Duplex scanning of the graft was done perioperatively and at follow-up visits at 1, 3, 6 and 12 months after operation. Primary patency, assisted primary patency and secondary patency at 6 months were 82.3% (+/-SE 6.2%), 88.6% (+/-SE 4.8%) and 92.1% (+/-SE 4.4%), respectively. Six graft stenoses were detected in duplex surveillance. There were no infections related to polyester mesh. External scaffolding of infrainguinal vein grafts may be a promising innovation. Early results from this multicentre study show that polyester mesh is safe and feasible adjunct to peripheral revascularization enabling the use of otherwise non-optimal vein grafts with acceptable short-term patency.

VENOUS LESIONS AS A CAUSE OF SYLVIAN AQUEDUCTAL OBSTRUCTION

The cases of two patients who presented with sylvian aqueductal obstruction caused by venous lesions (an ectatic vein and a developmental venous anomaly, which are uncommon causes of obstructive hydrocephalus) are reported. A 42-year-old man presented with chronic headache and behavior abnormalities. Magnetic resonance imaging revealed supratentorial ventricular dilation caused by an obstruction of the sylvian aqueduct by a developmental venous anomaly. An 18-year-old man complained of intermittent headaches. The magnetic resonance imaging scan disclosed aqueductal stenosis-type hydrocephalus secondary to an ectatic vein. Both patients underwent endoscopic third ventriculostomy and recovered well. During the procedures, the aqueductal obstruction by venous elements could be seen clearly. Venous anomalies may cause obstructive hydrocephalus and can be suspected in cases of chronic and intermittent headaches. Endoscopic third ventriculostomy is an effective treatment.

Ectatic and Occlusive Diseases of the Venous Drainage System of Cerebral Arteriovenous Malformations (AVMs) -with Emphasis on Spectacular Shrinking Neurological Deficits after Embolization

During reviewing cases with AVM, the author noticed that stenotic and occlusive changes of the draining veins are commonly seen in high flow cerebral AVMs. However, little attention has been paid to these venous diseases until ectatic veins, generated in the upstream of the venous system, cause mass effect to the surrounding structures, or redistribution and shunting toward regional veins became insufficient after they are markedly overloaded or occluded. Cases with such venous abnormality are clinically important because of the possibility of dramatic improvement of neurological deficits after embolization of AVMs. Following presenting treatment results of 177 AVM case, the author is going to present five cases with abnormality in the Galenic venous system and two cases with abnormality in cortical veins associating with high flow cerebral AVMs. Consideration will be made on symptomatology and pathophysiologic mechanism of venous abnormalities associating with high flow cerebral AVMs.

Dysplasie alvéolo-capillaire avec défaut d’alignement des vaisseaux pulmonaires: Revue de la littérature à propos d’un nouveau cas

Alveolar capillary dysplasia (ACD), with or without pulmonary vein misalignment is a uniformly fatal cause of persistent pulmonary hypertension and respiratory failure, first described in 1981. We report the case of ACD in a full term newborn with post mortem pathologic confirmation. Sixty five cases have been reported in the literature, most are sporadic, but a few cases of familial ACD suggest an autosomal recessive inheritance. In 55% of the reported cases of ACD other cardiovascular, digestive or urogenital anomalies were associated. ACD is presumed to be a primary capillary disorder. It affects full-term neonates who exhibit respiratory distress during the early post natal period due to pulmonary hypertension and die within 3 weeks of birth. Histologic findings include a decrease in the number of alveolar capillaries, which are placed centrally within the intralobular septa, ectatic veins accompany the bronchovascular bundles instead of being in their normal position in the interlobular septum, and muscularized pulmonary arteries extend to the distal level. Prognosis is very poor, intravenous prostacyclin with inhaled nitric oxide have been reported in the cases with the best survival.