Elevated Venous Pressure Research Articles

Impact of the Valsalva manoeuvre on the choroid: A systematic review with meta-analyses.

A variety of daily activities can intentionally or unintentionally cause the Valsalva manoeuvre, which induces a physiological response of elevated peripheral venous pressure. Studies have speculated that it may ultimately affect the choroidal anatomy. This is particularly important from a clinical point-of-view since patients occasionally hold their breath while undergoing macular optical coherence tomography (OCT). In this study, we systematically reviewed the literature to understand the impact of the Valsalva manoeuvre on the choroid and conducted meta-analyses on the changes induced in the subfoveal choroidal thickness (SFCT) and the choroidal vascularity index (CVI). We searched 12 literature databases for studies in healthy participants undergoing Valsalva manoeuvre with choroidal OCT scans before and during the manoeuvre. Seven studies with a total of 444 eyes of 279 individuals were eligible for the review. The Valsalva manoeuvre led to a statistically significant but numerically small increase in the SFCT of 6.5 μm (95% CI: 1.6-11.4 μm; p = 0.01) and a statistically significant increase in the CVI of 1.48 (95% CI: 1.23-1.73; p = 0.0002). Thus, the Valsalva manoeuvre has a measurable impact on the choroid, and we recommend careful observation of how the patient sits and behaves behind the OCT scanner while scanning in order to allow accurate measurements of the choroid for diagnosis and monitoring.

Elevated systemic venous pressures as a possible pathology in prepubertal pediatric idiopathic intracranial hypertension.

Pediatric idiopathic intracranial hypertension (IIH) is a rare and challenging condition. As implied by the nomenclature, the etiologies remain unknown, and multiple etiologies are being investigated. In this study, we explored the potential role of increased systemic or cerebral venous pressure in the pathogenesis. An observational cohort study following the STROBE guidelines, including prepubertal children with clinical symptoms and imaging findings consistent with IIH referred to the neurosurgical department, was conducted. The patients underwent a comprehensive diagnostic protocol, including MRI, continuous intracranial pressure (ICP) monitoring, and endovascular venography with venous pressure measurements. The study included 11 consecutive patients (six boys and five girls) with an average age of 2.3years, and an average BMI of 18.4. Among these, one patient was found to have venous stenosis with a gradient; the other 10 patients presented with normal intracranial anatomy. All patients exhibited elevated venous pressures, with an average superior sagittal sinus pressure of 18.9mmHg, average internal jugular vein pressure of 17.0mmHg, and average central venous pressure of 15.9mmHg. Daytime ICP averaged 12.9mmHg, whereas nighttime ICP averaged 17.2mmHg with either A- or B-waves in 10 of the 11 patients. Despite pathological ICP, only three patients had papilledema. All patients had an increased systemic venous pressure, indicating a possible pathological factor for prepubertal IIH. Additionally, our findings show that young children often only partly meet the Friedman criteria due to a lack of papilledema, emphasizing the need for pediatric-specific diagnostic criteria. Further large-scale studies are needed to confirm these findings and to explore the underlying reasons for this increase in venous pressure and potential new treatment avenues.

Analysis of cerebral venous sinus stenosis by flat panel angiographic CT (FP-CT) to guide treatment for idiopathic intracranial hypertension.

Cerebral venous sinus stenting (CVSS) is an effective treatment for idiopathic intracranial hypertension (IIH) secondary to dural venous sinus stenosis. Traditional selection of patients for CVSS has been made by microcatheter manometry, but pressure measurements are often equivocal. Here we present the results of a series of cases in which venous flat-panel CT (FP-CT) was used as an adjunct to microcatheter manometry to improve decision making and precise stent placement during CVSS. Ten consecutive patients with IIH underwent angiography with microcatheter manometry and venous FP-CT, with CVSS if indicated by the results. Cross-sectional measurements of the narrowed sinus were obtained on FP-CT before and after stenting. After the procedure, clinical outcomes were tracked. Follow-up with quantitative MRA with sinus flow measurements was also performed, when available. There was an exponential correlation between measured pressure gradient and degree of stenosis calculated using venous FP-CT. All patients with both a high degree of stenosis measured by FP-CT and a high pressure gradient across the stenosis showed a clinical benefit from stenting. True measurement of the cross-sectional area of the dural sinus, made by venous phase FP-CT, has a high degree of correlation with elevated venous pressure gradient across the point of stenosis. Even in a limited series of cases, we found an exponential decrease in flow with increasing severity of stenosis. Furthermore, patients with both an elevated venous pressure gradient and critical stenosis of the sinus on FP-CT showed symptomatic improvement after stenting.

Convexity dural arteriovenous fistula with Sylvian-Labbé collateral pattern: A case report.

Convexity dural arteriovenous fistula (dAVF) is associated with high-grade dAVF and is usually presented with aggressive clinical presentation. Precise diagnosis and understanding the pathogenesis are important to achieving successful treatment without complications. We report a case of dAVF with Sylvian-Labbé collateral pattern, concerning embryological development that was thought to be involved in the vascular architecture and pathogenesis of dural AVF. Thus, a 60-year-old man was presented with sudden onset of seizure with no history of trauma. Magnetic Resonance Imaging (MRI) showed cortical hemorrhage in the left precentral gyrus. Digital subtraction angiography (DSA) showed the convexity dural arteriovenous fistula (dAVF) involving a vein that appeared to be the vein of Labbé, the drainer was anastomosed with superior middle cerebral vein (SMCV) and formed the varix. With the successful treatment with trans-arterial embolization (TAE), obliteration of dAVF was achieved with no neurological deficits. This case highlights convexity dAVF with the complex relationship between embryological development and the arcade of venous drainage route, wherein the anomaly might be acquired and caused by elevated venous pressure in a vein that appeared to be the vein of Labbé. Gaining knowledge of the embryological basis may aid in a deeper understanding of acquired pathologies.

Stasis and Inflammation in Varicose Vein Development: An Interleukin-Mediated Process from Intima to Media

Introduction: This study investigated the combination of venous stasis and inflammation in varicose vein development. Methods: The study included patients with primary varicose veins operated using high ligation and stripping of greater saphenous vein. All of them showed reflux at sapheno-femoral junction on preoperative Doppler ultrasound. Mesenteric veins from early or advanced gastric cancer specimens were used as control group. Inflammatory mediators expressed in the venous wall were measured via immunohistochemistry and compared between the two groups. Results: Thirty-five (59.3%) men and 24 women with a mean age of 52.8 years (range, 23–77 years) were included and 29 (49.2%) patients had edema or skin changes according to Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification and reporting standards for chronic venous disorders. The expression of interleukin 6 (IL-6) and transforming growth factor β1 (TGF-β1) in intima and those of IL-6 in media of greater saphenous veins increased, with statistically significant differences between the two groups (p < 0.001). IL-6 in media and TGF-β1 levels in intima were independent predictors of varicose veins (adjusted odds ratios 74.62 and 66.69, respectively). Conclusion: Elevated venous pressure represented by reflux on Doppler ultrasound and increased expression of inflammatory cytokines including IL-6 in media and TGF-β1 in intima are associated with the development of varicose veins.

#1988 VExUS score as a method to guide diuretic treatment in CKD patients with congestive nephropathy by right heart failure

Abstract Background and Aims Congestive nephropathy is a kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics and most of all it is due to right heart failure. Venous congestion can lead to a circulation vicious hormonal activation, increased intra-abdominal pressure, excessive renal tubular reabsorption of sodium and volume overload. In CKD with right heart failure, management of the patient is difficult because may be hard to identify a condition of fluid overload and when to stop intravenous diuretic treatment. Inferior caval vein (ICV) diameter and ICV index (reduction of diameter with respiration) have been used to identify fluid overload and guide diuretic treatment. However, in CKD patients with heart failure the ICV may not change rapidly and could overestimate the need of intravenous diuretics. This is why VExUS has been useful in both diagnosis and monitoring therapeutic. The VExUS method is a new approach, documented in the literature for the first time once in 2020. In this study we report the usefulness of the VExUS (Venous Excess Ultrasound Score) method for the diagnosis of overload volume and venous congestion and in setting an adequate therapy. It consists of Doppler evaluation of the abdominal veins: hepatic, portal and intrarenal. In fact, the acute renal failure, in the patients studied, is to be attributed in the first instance to venous congestion rather than underfilling, resulting from decompensation and therefore requiring diuretic therapy. Method This retrospective study was conducted in CKD patients (stages 3-4) with acute kidney injury (creatinine level: 6.3-2.6 mg/dl) due to right heart failure admitted at the U.O.C. Nephrology at the S. Maria della Pietà Hospital in Nola and UOC Nephrology of Univ. of Campania. The VExUS method defines 3 degrees (score 0-3) of congestion based on the severity of the anomalies on hepatic, portal and intrarenal venous Doppler. All patients have been treated with diuretics i.v. based on a VEXUS score&amp;gt;1, and then returned to oral treatment when VEXUS score returned to 0. VExUS assessment was performed at admission, repeated every 48 hours and the last score has been considered here (on average 1 week). The relationship between change in VExUS score and ICV index vs creatinine levels was studied by correlation analysis. Lung POCUS (point of care pulmonary ultrasonography) has also been used for all patients to identify a possible contemporary overload caused by LV failure. Results Thirty patients have been included. The use of diuretics reduced the VExUS score and the ICV diameter. However, diuretic treatment changed the ICV diameter by a smaller extent (−30%) compared to the VExUS score (−80%), and one patient showed clear reduction of VExUS score, without any modification of the ICV diameter, suggesting that the latter is a slower indicator of recovery compared to VExUS. Indeed, the change of VExUS score was highly correlated to the improvement of creatinine levels (Pearson's correlation 0.837, p &amp;lt; 0.001). The change of IVC diameter explained in comparison a smaller amount of variability of the creatinine improvement (Pearson's correlation 0.65, p = 0.008). Conclusion VExUS is a promising and reliable tool in the management of congestive nephropathy in patients with CKD and right heart failure. VExUS is superior to VCI diameter and should be used routinely, along with clinical, laboratory, and other ultrasound parameters, because of its usefulness, repeatability, low cost and ease of execution.

Monitoring the venous circulation: novel techniques and applications.

Venous pressure is an often-unrecognized cause of patient morbidity. However, bedside assessment of PV is challenging. We review the clinical significance of venous pressure measurement, existing techniques, and introduce the Venous Excess Ultrasound (VExUS) Score as a novel approach using doppler ultrasound to assess venous pressure. Studies show clear associations between elevated venous pressure and adverse outcomes in critically ill patients. Current venous pressure measurement techniques include physical examination, right heart catheterization (RHC), two-dimensional ultrasound, and a variety of labor-intensive research-focused physiological maneuvers. Each of these techniques have specific shortcomings, limiting their clinical utility. To address these gaps, Beaubien-Souligny et al. introduced the VExUS Score, a novel doppler ultrasound-based method that integrates IVC diameter with doppler measurements of the hepatic, portal, and renal veins to generate a venous congestion assesment. Studies show strong correlations between VExUS score and RHC measurements, and well as an association between VExUS score and improvement in cardiorenal acute kidney injury, diuretic response, and fluid status shifts. However, studies in noncardiac populations have been small, heterogenous, and inconclusive. Early studies evaluating the use of doppler ultrasound to assess venous congestion show promise, but further research is needed in diverse patient populations and clinical settings.

In vitro hemodynamic performance of a blood pump for self-powered venous assist in univentricular hearts

Univentricular heart anomalies represent a group of severe congenital heart defects necessitating early surgical intervention in infancy. The Fontan procedure, the final stage of single-ventricle palliation, establishes a serial connection between systemic and pulmonary circulation by channeling venous return to the lungs. The absence of the subpulmonary ventricle in this peculiar circulation progressively eventuates in failure, primarily due to chronic elevation in inferior vena cava (IVC) pressure. This study experimentally validates the effectiveness of an intracorporeally-powered venous ejector pump (VEP) in reducing IVC pressure in Fontan patients. The VEP exploits a fraction of aortic flow to create a jet-venturi effect for the IVC, negating the external power requirement and driveline infections. An invitro Fontan mock-up circulation loop is developed and the impact of VEP design parameters and physiological conditions is assessed using both idealized and patient-specific total cavopulmonary connection (TCPC) phantoms. The VEP performance in reducing IVC pressure exhibited an inverse relationship with the cardiac output and extra-cardiac conduit (ECC) size and a proportional relationship with the transpulmonary pressure gradient (TPG) and mean arterial pressure (MAP). The ideal VEP with fail-safe features provided an IVC pressure drop of 1.82 ± 0.49, 2.45 ± 0.54, and 3.12 ± 0.43 mm Hg for TPG values of 6, 8, and 10 mm Hg, respectively, averaged over all ECC sizes and cardiac outputs. Furthermore, the arterial oxygen saturation was consistently maintained above 85% during full-assist mode. These results emphasize the potential utility of the VEP to mitigate elevated venous pressure in Fontan patients.

A rare case of Radius Maumenee syndrome with unilateral open angle glaucoma

Elevated episcleral venous pressure (EEVP) is a rare but important cause of raised intraocular pressure. The resultant glaucoma is often severe and refractory to routine anti glaucoma treatment. Usually it occurs due to arteriovenous fistulas or venous congestion. This entity is important to detect as it may be associated with serious pathologies like retrobulbar tumor, cavernous sinus thrombosis, mediastinal tumor to name a few. EEVP is considered idiopathic after ruling out such disorders. Here, we have described idiopathic EEVP also known as Radius-Maumenee syndrome along with a detailed diagnostic and therapeutic approach of management.

De novo formation of remote dural arteriovenous fistula following treated cavernous sinus dural arteriovenous fistula

BackgroundThe development of new dural arteriovenous fistulas (DAVFs) at another location following endovascular treatment of cavernous sinus DAVFs (CSDAVFs) are extremely rare. Our aim is to review cases of de Novo DAVFs that occurred after treatment of CSDAVFs at our institution and those reported in the literature. MethodsWe reviewed all cases of CSDAVFs evaluated by 2 experienced neuroradiologists. A literature search was performed using the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines focusing on De Novo DAVFs following the endovascular treatment of cerebrovascular malformations. Addition articles were searched through the reference lists of the included articles. ResultsFrom June 2004 and September 2019., we identified 3 (2.5%) cases of De Novo DAVFs occurred after endovascular treatment or spontaneous obliteration of CSDAVFs from 119 treated CSDAVFs at our institute. Our review yielded 9 articles involving 12 patients with 15 de novo DAVFs, including our 3 patients. The mean age was 55.08 ± 12.9 years (range 43–69), 83.3% were females (n = 10). The new remote DAVFs occurred after endovascular treatment of CSDAVFs in 10 (83.3%) patients. The de novo DAVFs occurred following spontaneous complete regression in 2 (16.7%) patients. All de novo DAVFs developed after complete obliteration of treated CSDAVFs. ConclusionSinus thrombosis and elevated venous pressure may play an important role in the pathogenesis of a de novo DAVF formation. In addition, thrombophilic abnormalities and the use of contraceptives may contribute to sinus thrombosis, leading to the development of the second remote DAVF after treatment of CSDAVFs.

Low Mean Perfusion Pressure Indexed to Body Surface Area is a Powerful Predictor of Poor Outcomes After Heart Transplantation in Patients With High Pre-Transplant Venous Pressure: A Clinical Study With Physiological Insights From Mathematical Modelling of Biventricular Heart Failure

The deleterious consequences of chronically elevated venous pressure in patients with profound right ventricular or biventricular dysfunction are well known, including renal and hepatic dysfunction, and volume overload. The only option for these patients, if they fail optimal medical treatment, is a heart transplant, as they are not candidates for left ventricular assist device therapy. Mean perfusion pressure (MPP) is important in the outcomes of critically ill patients with high venous pressure. The question arises whether MPP is important for the outcomes of heart transplants in patients with elevated pre-transplant venous pressure. Medical management of heart failure patients with reduced ejection fraction involves lowering the systemic afterload with vasodilators while awaiting a transplant. We hypothesised that when venous pressure is elevated prior to transplant, a substantial reduction in systemic arterial elastance (Ea) through vasodilation may significantly decrease MPP, resulting in compromised end-organ function and consequent unfavourable outcomes after heart transplantation. This study aims to investigate whether a low MPP serves as a risk factor for adverse outcomes in heart transplant recipients with high venous pressure. A retrospective analysis was conducted on 250 heart transplant recipients undergoing isolated heart transplantation at a single institution from October 2012 to March 2020. Right atrial pressure (RAP) of more than 15 mmHg was considered high. Additionally, Ea calculated as the ratio of end-systolic pressure to stroke volume, and MPP calculated as the difference between mean arterial pressure and RAP were considered in our analysis. The outcomes of transplantation were measured in terms of 90-day mortality and survival up to 7 years. High RAP was a significant risk factor for short-term and medium-term survival if Ea was low (<2.7 mmHg/mL, the median value). This group had 39.39% in-hospital mortality compared to 14.49% for RAP<15 mmHg (p∼0.005). When Ea was high, this difference in survival was not evident: 8% for RAP<15 mmHg vs 4.8% for RAP>15 mmHg (p∼0.550). This effect was mediated through a lower MPP, and the mortality due to lower MPP increased strikingly with higher body surface area (BSA). A negative correlation was observed between MPP indexed to BSA (MPPI) and the Model for End-Stage Liver Disease score (r∼-0.3580, p<0.0001) as well as creatinine (r∼-0.3551, p<0.0001). MPPI less than 40 mmHg/m2 was associated with poorer short-term (23.2% for MPPI<40 mmHg/m2 vs 7.1% for MPPI>40 mmHg/m2, p∼0.001) and medium-term survival. The impact of high RAP and low Ea on survival was evident even on medium-term follow-up; only 30% survival at 7 years follow-up for high RAP and low Ea vs 75% for RAP<15 mmHg (p∼0.0033). The acceptable blood pressure during vasodilator therapy in patients with high RAP needs to be higher, especially in those with higher BSA. MPPI less than 40 mmHg/m2 is a risk factor for survival, in the short and medium-term, after heart transplantation.

Silent Progressive Glaucoma in Encephalofacial angiomatosis (Sturge-Weber Syndrome): A Vision-Preserving Trabeculectomy

Introduction : Encephalofacial angiomatosis, also known as Sturge-Weber Syndrome (SWS), is a rare, non- hereditary condition affecting multiple organs. Glaucoma occurs in almost 70% SWS children, more commonly when the port-wine stain involves the upper eyelid skin. Secondary glaucoma was present due to elevated venous pressure.&#x0D; Case Illustration : An 8-year-old boy with typical port-wine stain involving eyelid, came with recurrent painful right eye (RE) and headache in the past 3 months. He was diagnosed with SWS at 1 year and was on daily doses of carbamazepine and valproic acid for seizure control. His best visual acuity and intraocular pressure were 0.5/60 RE, 6/38 LE, 38 mmHg RE, 28 mmHg LE, respectively. Examination revealed Cup-disc-ratio (CDR) 0.9-1.0 RE and 0.5-0.6 LE. During the first three months, he showed favourable outcome with timolol and latanoprost (controlled IOP with target of &lt;12 mmHg and markedly similar Cup-Disc Ratio). However, at 4th and 5th month visit, his IOP significantly increased despite of additional regiments, thus underwent trabeculectomy on both eyes for preserving his sight. After procedure, his IOP remained stable &lt;12mmHg with maintained bleb, deep anterior chamber, also attached posterior segment.&#x0D; Discussion : Treatments of secondary glaucoma of SWS typically involved surgery with significantly lower success rate compared to Primary Congenital Glaucoma. Trabeculectomy or tube shunt surgery should be performed with caution due to risks of choroidal effusion and hemorrhages.&#x0D; Conclusion : Secondary glaucoma in children with SWS is common and challenging. Trabeculectomy should be pursued when the benefit outweighs the risks, even with a slim chance, to preserve the vision.

Dissociation in hepatic vein pressure gradient, liver stiffness measurement and complications in histological subtypes of porto-sinusoidal vascular disease

Background and aimsPortosinusoidal vascular disease (PSVD) is a broad term encompassing varied histological patterns with changes in portal tracts and sinusoids without cirrhosis. We aimed to assess whether there is...

Management of Sinistral Portal Hypertension after Pancreaticoduodenectomy.

Sinistral, or left-sided, portal hypertension (SPH) is a rare cause of upper gastrointestinal (GI) hemorrhage resulting from obstruction of the splenic vein. Venous drainage from the spleen via collaterals can result in venous hemorrhage into both the retroperitoneal and intra-abdominal spaces due to increased venous blood pressure in peripancreatic and gastroduodenal vasculature. SPH can occur secondary to pancreatitis with thrombosis of the splenic vein. Another possible cause is the surgical ligation of the splenic vein as part of pancreaticoduodenectomy (PD). Although splenectomy has been traditionally considered as the treatment of choice to relieve venous hypertension, individual concepts for each patient have to be developed. Considering the venous collateral drainage pathways, a comprehensive approach involving surgical, endoscopic, and interventional radiology interventions may be necessary to address the underlying cause of variceal bleeding. Among these approaches, splenic artery embolization (SAE) has demonstrated efficacy in mitigating the adverse effects associated with elevated venous outflow pressure. This review summarizes key imaging findings in SPH patients after PD and highlights the potential of minimally invasive embolization for curative treatment of variceal hemorrhage. (i) SPH is a potential consequence after major pancreas surgery. (ii) Collateral flow can lead to life-threatening abdominal bleeding. (iii) Depending on the origin and localization of the bleeding, a dedicated management is required, frequently involving interventional radiology techniques.

Comparison of Blood Biomarkers in Systemic Blood and Varicose Veins: A Cross-sectional Study

Introduction: Varicose Veins (VV) are enlarged, convoluted, and elongated veins that primarily affect the superficial veins in the lower limbs and are one of the most prevalent indications of vascular diseases. The reasons for elevated venous pressure are understood, but the inflammatory cytokines that initiate the ultimate pathways of tissue destruction and are in charge of the clinical characteristics of Chronic Venous Insufficiency (CVI) are yet unknown. Although inflammation plays a crucial role in the process of tissue apoptosis, it also plays a crucial role in tissue repair and regeneration. Aim: To investigate changes in blood markers of varicose vein inflammation and endothelial damage and compare them with systemic markers in VV patients and conclude that they are increased in VV blood. Materials and Methods: The comparative cross-sectional study was conducted in the Department of Biochemistry on 70 patients with primary VV who were scheduled for Outpatient Sclerotherapy at Nootan Medical College and Research Centre, Sankalcahnd Patel Vidyadham in Visnagar, Gujarat, India from April 2021 to June 2023. Chronic lower extremity Venous Disease (CVD) was categorised using the Clinical Aetiology Anatomy Pathophysiology (CEAP) classification method. Blood samples were obtained above the knee from the tortuous and dilated varicose tributaries of the great saphenous vein (local) and from the antecubital (systemic) vein by standard venipuncture. Erythrocytes, leukocytes, platelets, haemoglobin, and haematocrit were determined using an automatic haematology analyser. D-dimer and High sensitivity C-reactive Protein (hsCRP) were determined by an immune turbidimetric assay. IL-6 and von Willebrand factor (vWF) were measured by Enzyme Linked Immunosorbent Assay (ELISA) using commercially available kits according to the manufacturers’ instructions. An Independent samples t-test was used to compare group difference, and p-value ≤0.05 were considered significant in all two-sided statistical tests. Results: Basic haematologic test results {systemic versus (vs) varicose blood samples} were comparable. In VV, the following parameters were significantly increased compared to systemic blood: Haemoglobin (12.85±1.81 g/dL vs. 15.82±1.57 g/ dL, p&lt;0.001), hsCRP (1.34±1.01 mg/L vs. 3.78±1.67 mg/L, p&lt;0.001), IL-6 (2.65±1.07 pg/mL vs. 4.17±1.51 pg/mL, p&lt;0.001), vWF (90.73±16.72% vs. 127.30±19.92, p&lt;0.001). D-dimer was also substantially higher in samples extracted from leg VV than in systemic blood (105.87±17.72 ng/mL vs. 85.61±18.18 ng/mL, p&lt;0.001). Conclusion: Blood from VV has shown a higher level of several inflammatory markers and signs of endothelial dysfunction. This is most likely the result of worsening venous pressure and dilated, convoluted superficial veins that restrict blood flow. The procoagulant qualities of the local blood and damage to the venous wall, leading to a chronic inflammatory response, may accelerate the disease’s progression and thrombotic consequences.

Supracerebellar infratentorial resection of a torcular lesion causing fulminant intracranial hypertension: illustrative case.

Venous sinus stenosis has been implicated in intracranial hypertension and can lead to papilledema and blindness. The authors report the unique case of a cerebellar transtentorial lesion resulting in venous sinus stenosis in the torcula and bilateral transverse sinuses that underwent resection. A 5-year-old male presented with subacute vision loss and bilateral papilledema. Imaging demonstrated a lesion causing mass effect on the torcula/transverse sinuses and findings of increased intracranial pressure (ICP). A lumbar puncture confirmed elevated pressure, and the patient underwent bilateral optic nerve sheath fenestration. Cerebral angiography and venous manometry showed elevated venous sinus pressures suggestive of venous hypertension. The patient underwent a craniotomy and supracerebellar/infratentorial approach. A stalk emanating from the cerebellum through the tentorium was identified and divided. Postoperative magnetic resonance imaging showed decreased lesion size and improved sinus patency. Papilledema resolved and other findings of elevated ICP improved. Pathology was consistent with atrophic cerebellar cortex. Serial imaging over 6 months demonstrated progressive decrease in the lesion with concurrent improvements in sinus patency. Although uncommon, symptoms of intracranial hypertension in patients with venous sinus lesions should prompt additional workup ranging from dedicated venous imaging to assessments of ICP and venous manometry.

Pericyte detachment and renal congestion involve interstitial injury and fibrosis in Dahl salt-sensitive rats and humans with heart failure

Congestive heart failure produces fluid volume overload, central and renal venous pressure elevation, and consequently renal congestion, which results in worsening renal function. Pericyte detachment and pericyte-myofibroblast transition (PMT) were linked to renal interstitial fibrosis. Dahl salt-sensitive hypertensive (DahlS) rats are a non-surgical renal congestion model. The relation, however, between renal interstitial damage, pericyte morphology, and PMT in the renal congestion of DahlS rats has not been reported. DahlS rats (8-week-old) were fed normal salt (NS, 0.4% NaCl) or high salt (HS, 4% NaCl), and the left kidney was decapsulated to reduce renal interstitial hydrostatic pressure (RIHP) at 9 weeks old. One week after capsulotomy, both kidneys were analyzed by molecular and histological techniques. Renal pericyte structure was assessed in the body donors with/without venous stasis. Markers of tubulointerstitial damage, interstitial fibrosis, and PMT were upregulated in the right non-decapsulated kidney of DahlS rats fed HS. Renal tubular injury and fibrosis were detected in the HS diet groups in histological analysis. Pericyte detachment was observed in the right non-decapsulated kidney of DahlS rats fed HS by low vacuum-scanning electron microscopy. Decapsulation in DahlS rats fed HS attenuated these findings. Also, renal pericytes detached from the vascular wall in patients with heart failure. These results suggest that pericyte detachment and PMT induced by increased RIHP are responsible for tubulointerstitial injury and fibrosis in DahlS rats and humans with renal congestion. Renal venous congestion and subsequent physiological changes could be therapeutic targets for renal damage in cardiorenal syndrome.

The Efficacy of Carvedilol in Comparison to Propranolol in Reducing the Hepatic Venous Pressure Gradient and Decreasing the Risk of Variceal Bleeding in Adult Cirrhotic Patients: A Systematic Review.

The most common cause of portal hypertension is liver cirrhosis. Portal hypertension causes many complications in cirrhotic patients; a significant complication is the formation of varices and the subsequent life-threatening variceal bleeding due to elevated portal venous pressures. Hepatic venous pressure gradient (HVPG) is the gold standard for measuring portal hypertension and guides management. Pharmacological treatments lower the HVPG, preventing the progression of varices and subsequent variceal bleeding. The pharmacological treatments frequently used in primary and secondary prophylaxis of a variceal bleed are nonselective beta (β)-adrenergic blockers. Propranolol was the first nonselective β-adrenergic blocker used for lowering HVPG and has been well studied. However, in the past decade, clinical trials have shown that carvedilol has been more effective. This study aims to establish whether carvedilol is more effective than propranolol in reducing the hepatic venous pressure gradient and decreasing the risk of variceal bleeding in adult cirrhotic patients. A systematic review has been conducted to gather relevant clinical trials comparing drugs and their effects on HVPG. Four databases: PubMed (Medical Literature Analysis and Retrieval System Online (MEDLINE)), Google Scholar, the Cochrane Library, and ScienceDirect, were analyzed, and records from January 1, 1999, to January 1, 2023, were chosen. There were a total of 1,235 potentially eligible records across the four databases. Using the eligibility criteria for this systematic review, seven studies of 533 patients were included. Across all seven clinical trials, it was found that carvedilol reduced HVPG more than propranolol and decreased the risk of variceal bleeding in adult cirrhotic patients.

Noninvasive, patient-specific computational fluid dynamics simulations of dural venous sinus pressures in idiopathic intracranial hypertension

BackgroundThe pathophysiology of Idiopathic Intracranial Hypertension (IIH) is poorly understood, making the disease difficult to properly diagnose and treat. Endovascular venous stenting has emerged as an effective non-invasive treatment option for a select cohort of IIH patients with venous sinus stenosis and elevated venous sinus pressure gradient. Unfortunately, current methods of determining patient eligibility for stenting treatment depend on highly invasive and insufficient measurement methods such as venous manometry, which can only measure pressure gradients and not other components of the complex 3D hemodynamic environment. Thus, there is a need for a non-invasive methodology for determining the 3D flow environment of the dural venous sinuses. ObjectiveTo develop a novel method of non-invasive, patient-specific computational fluid dynamic (CFD) simulation of venous sinus hemodynamics for evaluating stenting eligibility. MethodA patient with IIH and elevated sinus pressure gradient underwent MR venography, phase-contrast MR venography, and venous manometry. Patient-specific dural venous anatomy was segmented from the MR venography to construct 3D models of the venous sinuses. 3D transient patient-specific computational fluid dynamic simulations were conducted using flow velocities measured with phase-contrast MR venography as boundary conditions. ResultsSuccessful computational simulations were completed, allowing for the calculation of the spatio-temporal evolution of blood flow through the dural venous sinuses, and the quantitative examination of pressure gradients. Calculated pressure gradients from CFD were validated against venous manometry with an error of only ∼5%. ConclusionsWe have successfully developed time-resolved, patient-specific 3D computational simulations of the dural venous sinuses without assumptions at the boundary conditions for the first time. The methodology can accurately and non-invasively measure venous pressure gradients. This preliminary study serves as a proof of concept for our method to be used as a diagnostic tool for determining venous stenting eligibility, as well as a tool for advancing the general understanding of IIH pathophysiology. Statement of SignificanceThe pathophysiology of Idiopathic Intracranial Hypertension (IIH) is poorly understood making the disease difficult to properly diagnose and treat. Endovascular venous stenting has emerged as an effective non-invasive treatment option for a select cohort of IIH patients with venous sinus stenosis and elevated venous sinus pressure gradient. Our work provides a method for noninvasively determining eligibility for venous sinus stenting, avoiding costly and invasive venous manometry.

Acute fetal cardiovascular adaptation to artificial placenta in sheep model.

To describe the acute cardiovascular adaptation of the fetus after connection to an artificial placenta (AP) in a sheep model, using ultrasound and invasive and non-invasive hemodynamic assessment. This was an experimental study of 12 fetal sheep that were transferred to an AP system, consisting of a pumpless circuit with umbilical cord connection, at 109-117 days' gestation. The study was designed to collect in-utero and postcannulation measurements in all the animals. The first six consecutive fetuses were fitted with intravascular catheters and perivascular probes to obtain invasive physiological data, including arterial and venous intravascular pressures and perivascular blood flows, with measurements taken in utero and at 5 and 30 min after cannulation. These experiments were designed with a survival goal of 1-3 h. The second set of six fetuses were not fitted with catheters, and experiments were aimed at 3-24 h of survival. Echocardiographic assessment of cardiac anatomy and function, as well as measurements of blood flow and pre- and postmembrane pressures recorded by circuit sensors in the AP system, were available for most of the fetuses. These data were acquired in utero and at 30 and 180 min after cannulation. Compared with in-utero conditions, the pulsatility index at 30 and 180 min after connection to the AP system was reduced in the umbilical artery (median, 1.36 (interquartile range (IQR), 1.06-1.50) vs 0.38 (IQR, 0.31-0.50) vs 0.36 (IQR, 0.29-0.41); P < 0.001 for extreme timepoints) and the ductus venosus (median, 0.50 (IQR, 0.41-0.67) vs 0.29 (IQR, 0.22-0.33) vs 0.36 (IQR, 0.22-0.41); P = 0.011 for extreme timepoints), whereas umbilical venous peak velocity increased (median, 20 cm/s (IQR, 18-22 cm/s) vs 39 cm/s (IQR, 31-43 cm/s) vs 43 cm/s (IQR, 34-54 cm/s); P < 0.001 for extreme timepoints) and flow became more pulsatile. Intravascular monitoring showed that arterial and venous pressures increased transiently after connection, with median values for mean arterial pressure at baseline, 5 min and 30 min of 43 mmHg (IQR, 35-54 mmHg), 72 mmHg (IQR, 61-77 mmHg) and 58 mmHg (IQR, 50-64 mmHg), respectively (P = 0.02 for baseline vs 5 min). Echocardiography showed a similar transient elevation of fetal heart rate at 30 and 180 min after connection compared with in utero (median, 145 bpm (IQR, 142-156 bpm) vs 188 bpm (IQR, 171-209 bpm) vs 175 bpm (IQR, 165-190 bpm); P = 0.001 for extreme timepoints). Fetal cardiac structure and function were mainly preserved; median values for right fractional area change were 36% (IQR, 34-41%) in utero, 38% (IQR, 30-40%) at 30 min and 37% (IQR, 33-40%) at 180 min (P = 0.807 for extreme timepoints). Connection to an AP system resulted in a transient fetal hemodynamic response that tended to normalize over hours. In this short-term evaluation, cardiac structure and function were preserved. However, the system resulted in non-physiologically elevated venous pressure and pulsatile flow, which should be corrected to avoid later impairment of cardiac function. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.