External Iliac Vein Research Articles

Reconstruction of the inferior vena cava: different strategies

Purpose: Resection and reconstruction of the inferior vena cava (IVC) is an unusual and challenging procedure. Malignant disease invading or obstructing IVC is the most frequent entity, while nonmalignant is rare and differential diagnostic is difficult. Methods: We report two cases required resection and reconstruction of IVC. Results: A 31-year-old man with left lower extremity paresthesias. His work-up revealed a large (9x3 cm) mass at the right renal hilum involving the IVC and right renal vein (RV) with complete thrombosis of bilateral external and common iliac veins (CIV), as well as the infrarenal IVC. The tumor contacted the aorta in greater than 90 degrees, as well as the third portion of the duodenum. Surgical intervention: through a midline laparotomy, we attained complete control of the IVC (above and below) as well as left RV and bilateral CIV. The IVC was transected at its origin. After thrombectomy of both iliac veins, no relevant venous flow was observed, therefore we sutured the lower IVC stump. We then divided the left RV and the IVC above the RV level, extracting the tumor en-bloc with the IVC and the right kidney. Finally, we anastomosed the left RV to a “cone” cavoplasty of the remaining IVC stump. Histologically, it was a large (11x4.5 cm) benign mesenchymal tumor involving the right renal hilum, with the diagnosis of calcifying fibrous tumor, a rare benign tumor. During follow-up after 6 years patient develops post-thrombotic syndrome of the lower limbs and subcutaneous venous collateral circulation, but without any evidence of tumor recurrence. On the other hand, we present a 39-years-old male with history of left nephrectomy after inferior vena cava and left RV thrombosis when he was one month old. He came for outpatient consultation due to recurrent deep vein thrombosis and thrombophlebitis. CT scan revealed absence of the infrarenal IVC with prominent collateral veins in multiple pathways. Due to unfavorable response to medical treatment, a surgical approach was offered. IVC reconstruction was performed with cadaveric vein graft, from the remaining iliac veins to the junction of the IVC with the right RV. At 2 years of follow up, the patient presented partial clinical improvement, nevertheless, an MRI scan showed thrombosis of the graft. Conclusion: Transplant and Hepato-Pancreato-Biliary surgeons are familiarized with IVC approach, but surgical treatment is usually difficult and may require a major vascular reconstruction.

Posterolateral uterine rupture in scarred uterus complicated by external iliac vein injury

Uterine wall rupture is a rare yet catastrophic complication of pregnancy with a high mortality rate of both the mother and the fetus. The condition could be classified according to etiology into primary unscarred uterus, and secondary scarred uterus or according to the site of rupture. Our case presented with scarred uterine rupture through a posterolateral injury. The patient had history of 3 previous CS and a D&C procedure. The rupture was complicated by EIV injury. Uterine rupture does not always present with profound manifestations of shock especially in posterior wall rupture and timely management ensures the best possible outcome. Finally, meticulous examination of the anatomically related structures and vessels, and the repair of any associated injuries, is essential.

Post-Traumatic Arteriovenous Fistulas Leading to Heart Failure

IntroductionThe detection of acquired arteriovenous fistulas (AVFs) is mostly incidental. However, the modification of haemodynamic conditions secondary to AVFs can lead to dramatic systemic complications, including cardiac complications. In this report, two unusual cases of congestive heart failure secondary to acquired AVF are presented.ReportA 40 year old man with past history of gunshot wound of the right flank complained of severe right limb swelling and shortness of breath. An AVF between the right external iliac artery and external iliac vein responsible for the cardiac failure was diagnosed. A 40 year old woman with past history of spinal surgery complained of breathlessness and lower limb oedema. She presented with recurrent episodes of ascites and dyspnoea. An AVF between the right common iliac artery and the common iliac vein responsible for high output cardiac failure was diagnosed. Open surgery was performed in both patients and treatment of the AVFs led to the resolution of all symptoms. Follow up at four and three years, respectively, was uneventful in both cases.DiscussionAlthough rare, heart failure secondary to an AVF can be encountered. These rare cases highlight the significance of careful inquiry into the patient's medical history and meticulous follow up physical examinations for patients with injuries in close proximity to vessels.

The Creation of a Novel Low-Cost Bench-Top Kidney Transplant Surgery Simulator and a Survey on Its Fidelity and Educational Utility

IntroductionResident inexperience during time-sensitive vascular anastomoses of a kidney transplant can negatively impact outcomes. In light of this, we created a low-cost bench-top kidney transplant surgery simulator to help residents practice vascular anastomoses.MethodsWe searched for inexpensive materials to design an iliac fossa and kidney allograft. Eighteen residents with real-life kidney transplant experience trialed the simulator and scored its fidelity and educational utility on a 0-100 visual analog scale (VAS) survey.ResultsA 35.9 x 19.4 x 12.4 cm plastic box mimicked the iliac fossa. Hooks attached to the box’s sidewall held under tension 1.27 and 0.64 cm diameter Penrose drains to replicate the external iliac vein and artery. A modified kidney-shaped stress ball with 1.27 x 4, 0.64 x 4, and 0.64 x 15 cm Penrose drains replicated a kidney allograft with its vein, artery, and ureter, respectively. Residents performed and assisted in vascular anastomoses on the simulator. The iliac fossa and allograft cost $20.20 and each practice run cost $7.20. Residents thought that the simulator was less difficult than real-life procedure, had acceptable fidelity levels, and they highly rated its educational utility.ConclusionOur novel low-cost bench-top kidney transplant surgery simulator focusing on vascular anastomoses received positive educational feedback from residents.

Iliocaval Skip Stent Reconstruction Technique for Chronic Bilateral Iliocaval Venous Occlusion

PurposeTo report safety and efficacy of a skip stent technique using nitinol stents in patients with chronic bilateral iliocaval venous occlusions. Materials and MethodsA retrospective analysis of 48 consecutive patients (32 men; mean age, 40.7 years; age range, 18–68 years) with chronic bilateral iliocaval obstructions treated using a nonoverlapping stent technique was conducted at a single center. None of the patients had May-Thurner syndrome. Iliocaval confluence was treated by deploying a nitinol stent in inferior vena cava (IVC) and a nitinol stent in each common iliac vein close to the caval stent. Patency of stents was assessed by duplex US at 2 weeks, 3 months, and 6 months and yearly thereafter. ResultsRecanalization and stent reconstruction was technically successful in 47 (98%) patients. The sinus-XL venous stent was used to treat IVC (95 [100%]). Common iliac and external iliac veins were treated with sinus-Venous and VENOVO stents (80 [83%] and 16 [17%] limbs, respectively). External iliac and common femoral veins were treated with sinus-Venous and VENOVO stents (83 [92%] and 7 [18%] limbs, respectively). Early thrombosis (< 30 days) of the iliac vein with stent occurred in 2 limbs. Cumulative primary, assisted primary, and secondary patency rates at 30 months were 74%, 83%, and 97%. ConclusionsFindings of this study suggest that leaving a skipped lesion at the level of iliocaval confluence may not adversely affect stent patency. Patency rates were comparable with other reported techniques of stent reconstruction at the level of iliocaval confluence.

Periacetabular vascular anatomy in high-riding dysplastic hips: a CT angiographic study.

Developmental hip dysplasia (DDH) is shown to have osseous and neural abnormalities but literature is sparse with investigation of vascular structures. Therefore, we aimed to evaluate periacetabular vascular structures. By computerised tomography angiography (CTA), 13 highly dislocated hips of 11 patients' iliac bone to external iliac and obturatory artery and vein proximities were measured and compared with the same measurements of 20 healthy hips of 12 patients. Numbering from superior to inferior, a total of 7 axial images were created on the 2D CTA coronal images with 1 cm apart, the 4th being at the level of acetabular dome. The mean age of the patients was 53 (18-72) years. Dysplastic hips tended to have curved (53%) and healthy hips tended to have straight iliac arteries (p = 0.037). As compared to healthy hips, external iliac veins were significantly closer to the bone at all levels, but the external iliac arteries were closest at 1st to 4th levels (p < 0.001) in dysplastic hips. The course of the obturatory arteries was similar in both groups (p = 0.147). The external iliac artery and vein is in close proximity to the iliac bone which dangers acetabular screw, acetabular reaming or retractor placement in highly dislocated hips. The surgeon should be aware of this proximity in operations of these hips to avoid vascular complications.

Venous Recanalization and Stenting After Iliac Vein Injury

The objective of this study was to report an endovascular treatment for patients experiencing complications after iliac vein ligation. Management of venous injury consists largely of venous ligation or primary repair. Complications consist of lower extremity swelling, venous hypertension, venous thromboembolism, and compartment syndrome. Whereas conservative management is often successful for symptomatic swelling, there is little current literature regarding treatment of failed conservative therapy. A retrospective chart review performed from 2017 to 2020 identified three patients who underwent recanalization and venous stenting after previously ligated iliac vein. Case 1: A 23-year-old man suffered a gunshot wound to the left external iliac requiring ligation. He developed venous hypertension requiring fasciotomy of the left lower leg and thigh. Recanalization with stenting of the left external iliac vein with mechanical thrombectomy of the common femoral and external iliac vein was performed. Completion venography showed no residual stenosis. The patient was discharged on anticoagulation with normal flow on noninvasive studies 2 months later. Case 2: A 21-year-old man suffered a gunshot wound to the abdomen with injury to the inferior vena cava (IVC) and right iliac vein requiring ligation. Postoperatively, he developed iliac vein stenosis with symptomatic lower extremity swelling. Iliac vein recanalization with bilateral iliac vein stenting and IVC confluence reconstruction was performed. He was discharged on anticoagulation with patent venous stents and normal flow on noninvasive studies 2 months later. Case 3: A 44-year-old man presented with chronic swelling and left leg pain following ligation of the left iliac vein after iatrogenic injury during spinal surgery. Conservative compression therapy was unsuccessful. Preoperative computed tomography venography revealed chronic occlusion of the left iliac vein. Recanalization was performed, with improvement of flow through the left iliac system with filling into the IVC. The patient was discharged on anticoagulation, with patent stents on noninvasive studies at 6-month follow up. Venous recanalization with stenting is a successful treatment for complications after iliac vein ligation.

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

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

Robotic Resection of Deep Infiltrating Pelvic Sidewall Endometriosis and Concomitant Nephrectomy

Study Objective To demonstrate a surgical video wherein deep infiltrating endometriosis (DIE) was resected off the left pelvic sidewall. Design Step-by-step video demonstration of DIE resection from the external iliac vessels and the ureter. Setting Academic tertiary referral center. Patients or Participants 41-year-old female with history of endometriosis, presented with pelvic pain and left lower extremity swelling. Abdominal and pelvic imaging revealed extensive left pelvic sidewall fibrosis, resulting in compression of the external iliac vein, hydroureter and renal atrophy. Further urologic workup showed minimal to no residual function of the left kidney. Interventions Patient was taken to the operating room for resection of sidewall endometriosis and concomitant nephrectomy. Exploration of the peritoneal cavity showed that endometriosis was confined to the pelvis, heavily involving the left pelvic sidewall. The left retroperitoneum was entered and avascular spaces were elaborated. The left hydroureter and IP ligament were identified above the pelvic brim, as well as the common iliac vessels. Once proximal and distal access to the external iliac vessels were obtained, the majority of DIE was resected off the vessels. Complete resection of sidewall DIE would have led to vascular injury; therefore, the decision was made to proceed with debulking of fibrosis off the vessel surface and the remainder of the lesions inferior to the external iliac vessels. Given inability to salvage distal left ureter and non-functional kidney, concomitant left nephrectomy was performed. Measurements and Main Results The procedure and post-operative course were uncomplicated. There was significant improvement in patient's pelvic pain and lower extremity swelling. One month after surgery, she underwent balloon angioplasty and stenting of left external iliac vein to attain complete patency of the vein. Conclusion Long-standing DIE can lead to vascular compression and unsalvageable renal obstruction, which requires a multidisciplinary team approach in order to address this multisystem disease.

First live birth after uterus transplantation in the Middle East

BackgroundThe first live birth after uterus transplantation took place in Sweden in 2014. It was the first ever cure for absolute uterine factor infertility. We report the surgery, assisted reproduction, and pregnancy behind the first live birth after uterus transplantation in the Middle East, North Africa, and Turkey (MENAT) region.A 24-year old woman with congenital absence of the uterus underwent transplantation of the uterus donated by her 50-year-old multiparous mother. In vitro fertilization was performed to cryopreserve embryos. Both graft retrieval and transplantation were performed by laparotomy. Donor surgery included isolation of the uterus, together with major uterine arteries and veins on segments of the internal iliac vessels bilaterally, the round ligaments, and the sacrouterine ligaments, as well as with bladder peritoneum. Recipient surgery included preparation of the vaginal vault, end-to-side anastomosis to the external iliac arteries and veins on each side, and then fixation of the uterus.ResultsOne in vitro fertilization cycle prior to transplantation resulted in 11 cryopreserved embryos. Surgical time of the donor was 608 min, and blood loss was 900 mL. Cold ischemia time was 85 min. Recipient surgical time was 363 min, and blood loss was 700 mL. Anastomosis time was 105 min. Hospital stay was 7 days for both patients. Ten months after the transplantation, one previously cryopreserved blastocyst was transferred which resulted in viable pregnancy, which proceeded normally (except for one episode of minor vaginal bleeding in the 1st trimester) until cesarean section at 35 + 1 weeks due to premature contractions and shortened cervix. A healthy girl (Apgar 9-10-10) weighing 2620 g was born in January 2020, and her development has been normal during the first 6 months.ConclusionsThis is the first report of a healthy live birth after uterus transplantation in the MENAT region. We hope that this will motivate further progress and additional clinical trials in this area in the Middle East Region, where the first uterus transplantation attempt ever, however unsuccessful, was performed already three decades ago.

INFERIOR VENA CAVA AGENESIS: ANATOMICAL VARIANT AS CAUSE OF RECURRENT DVT

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Abnormalities of the inferior vena cava (IVC) are rare causes of deep venous thrombosis (DVT). The clinical presentation is often similar to that of an inherited hypercoagulabe condition. CASE PRESENTATION: A 27-year-old man with a past medical history of premature birth presented to the emergency department (ED) with left lower extremity (LLE) tightness and pain for one day. He had no history of recent travel and family history was negative for clotting disorders. Ultrasound (US) of the left leg showed an occlusive thrombus from the left common femoral to the left popliteal vein. The patient was discharged from the ED on rivaroxaban. Two weeks later, he presented to the ED again with progressive LLE swelling despite medication compliance. Physical exam was negative for testicular masses. Interventional Radiology (IR) performed a LLE venogram, which showed thrombus extention to the common iliac vein. US-assisted catheter thrombolysis (EKOS) was initiated. Heparin infusion was started and the patient was transferred to the intensive care unit. Repeat visualization the following day revealed improved clot in the left femoral and external iliac veins and a chronically thrombosed left common iliac vein. LLE pain and swelling improved and EKOS was discontinued twenty-four hours later. Hypercoagulability work-up was negative except for lupus anti-coagulant, the significance of which was difficult to determine, given prior anticoagulant exposure. On discharge, the patient was transitioned back to rivaroxaban. Five days later, the patient presented to the ED again with worsening LLE pain and swelling after initial improvement. Repeat venous US showed occlusive thrombus throughout much of the left femoral vein with only some flow at the distal aspect. An inferior vena cavogram revealed agenesis of the IVC with azygous continuation. CT angiogram of the abdomen and pelvis confirmed an occluded infra-renal IVC secondary to atresia. Patient was discharged on indefinite rivaroxaban therapy. DISCUSSION: This patient presented with an unprovoked DVT involving the common iliac vein that extended despite appropriate anticoagulation. Eventually, a venogram revealed agenesis of the IVC as the predisposing risk factor. In this condition, venous stasis presumably leads to increased risk of clotting. While bilateral DVTs are rare in the general population (approximately 10% of cases), they have been described in up to three quarters of patients with IVC abnormalities. This patient however, had extensive unilateral clot burden, usually seen in more distal anatomical abnormalities, such as May-Thurner syndrome. His premature birth likely predisposed him for an anatomical malformation. CONCLUSIONS: Unprovoked DVT in a young patient, recurrent DVTs despite medication compliance, and occlusion of the iliac veins, should raise suspicion for anatomical abnormalities, such as IVC atresia. Reference #1: 1. Chee YL, Culligan DJ, Watson HG. Inferior vena cava malformation as a risk factor for deep venous thrombosis in the young. Br J Haematol. 2001;114(4):878. Reference #2: 2. Ruggeri M, Tosetto A, Castaman G, Rodeghiero F. Congenital absence of the inferior vena cava: a rare risk factor for idiopathic deep-vein thrombosis. Lancet. 2001;357(9254):441. Reference #3: 3. Hamoud S, Nitecky S, Engel A, Goldsher D, Hayek T. Hypoplasia of the inferior vena cava with azygous continuation presenting as recurrent leg deep vein thrombosis. Am J Med Sci. 2000;319(6):414. DISCLOSURES: No relevant relationships by Amy Cohen, source=Web Response No relevant relationships by David Cohen, source=Web Response No relevant relationships by Aaron Dickinson, source=Web Response No relevant relationships by Mouhanned Eliliwi, source=Web Response No relevant relationships by Jennifer Meyfeldt, source=Web Response

S2290 Venous and Arterial Thromboembolism: Unusual Harbinger of Ulcerative Colitis in a 64-Year-Old

INTRODUCTION: Arterial and venous thromboembolic events are known extraintestinal manifestations of inflammatory bowel disease (IBD). Since elderly patients with IBD require tailored treatment strategies, establishing the initial diagnosis and assessing the etiology of future symptoms are critical. We present a 64-year-old male who underwent left iliofemoral vein and artery thrombectomy for phlegmasia with subsequent diagnosis of severe active ulcerative colitis. CASE DESCRIPTION/METHODS: A 64-year-old otherwise healthy white male presented with a 3-month history of abdominal pain, hematochezia, 20 lb unintentional weight loss, and left lower extremity pain. He quit smoking one year prior to presentation and denied family history of IBD or colon cancer. Vital signs were stable and physical exam revealed left leg swelling and tenderness, cyanosis of the left great toe, and positive fecal occult blood test. Labs showed mild normocytic anemia and elevated fecal calprotectin. The abdominal CT showed thrombosis of the left femoral vein, right sided subsegmental pulmonary embolus, distal abdominal aorta mural thrombus, and left iliac artery occlusion (Figure 1). Anticoagulation was not initiated given concerns for lower gastrointestinal bleed. An Inferior Vena Cava filter was placed the following day with stenting of the left common and external iliac arteries, and thrombectomy of the left common femoral, superficial femoral, and external iliac veins. A colonoscopy showed severe inflammation from the rectum to the descending colon (Figure 2). Colonic biopsies showed active chronic colitis with cryptitis and crypt abscesses consistent with ulcerative colitis (UC). Patient was started on steroids, discharged on hospital day 5, and readmitted 5 days later for right leg pain. The Doppler ultrasound showed an occlusive acute Deep Vein Thrombosis (DVT) of the right posterior-tibial vein, nonocclusive DVT of the right common femoral, superficial femoral, and popliteal veins, and occlusion of right proximal superficial femoral artery. He was started on heparin drip, switched to apixaban on hospital day 5, and discharged on hospital day 8. DISCUSSION: The risk of venous thromboembolism is quite high in elderly adults with UC. The literature suggests that thrombosis and hypercoagulability are features of IBD involved in the occurrence of thromboembolic events. Therefore, it is imperative to consider IBD as a differential diagnosis in elderly patients presenting with unprovoked thromboembolism and gastrointestinal bleeding.Figure 1.: Mural thrombus of the distal abdominal aorta and high-grade left iliac artery occlusion.Figure 2.: Colitis up to the descending colon.

A CASE OF PHLEGMASIA CERULEA DOLENS AND MAY-THURNER SYNDROME IN A YOUNG MALE WITH TRIPLE-POSITIVE ANTIPHOSPHOLIPID ANTIBODY SYNDROME

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Phlegmasia cerulea dolens (PCD) is an uncommon form of deep vein thrombosis (DVT) typically presenting with acute limb swelling, pain, and cyanosis. Diagnosis of PCD should be made promptly as these patients may develop limb-threatening complications such as gangrene and compartment syndrome. We describe a young male presenting with his first episode of provoked venous thromboembolism (VTE) as PCD complicated with May-Thurner syndrome (MTS) and Antiphospholipid antibody syndrome (APS). CASE PRESENTATION: A 37-year-old obese male with type 2 diabetes, hypertension, and hyperlipidemia was directly admitted to the medicine floor with extensive left lower extremity DVT (including ileofemoral vein thrombosis) found on outpatient duplex ultrasonography. At initial hospitalization, he was tachycardic but without respiratory distress or hemodynamic instability. His left lower extremity was tender and edematous with cyanosis. Diagnosis of PCD was made and patient was treated with subcutaneous enoxaparin. He received catheter-directed thrombolysis for PCD with alteplase and heparin infusion. During left leg venogram, he was discovered to have MTS, and subsequently underwent stent placement of left common iliac vein, external iliac vein, and common femoral vein. After stent placement, patient received bridging to warfarin with enoxaparin and was discharged home two days later. Patient’s family history was significant for Systemic Lupus Erythematosus. During hospitalization, his antibody testing revealed positivity for anti-cardiolipin, anti-beta-2 glycoprotein antibodies in addition to positive functional lupus anticoagulant assay. Positivity confirmed with repeat testing of anti-cardiolipin antibodies and lupus anticoagulant assay at 15 weeks after hospitalization - confirming the diagnosis of triple-positive APS. DISCUSSION: Treatment of PCD is anticoagulation therapy with adjunctive catheter-directed thrombolysis. Outcomes comparing additional catheter-directed thrombolysis versus anticoagulation alone have shown that combination treatment reduces the incidence of post-thrombotic syndrome in patients with acute iliofemoral DVT. Recognition of DVT associated with MTS is important as treatment includes stent placement to maintain venous outflow. Recognition of triple-positive APS is an indication for extended anticoagulation as this portends a high risk of recurrent VTE. Patient was discharged with warfarin therapy because the use of direct oral anticoagulation in patients with APS remains controversial. Recent studies showed increased risk of recurrent thrombosis, particularly in patients with APS who are triple-positive. CONCLUSIONS: We reported a case, 37 year old male with phlegmasia cerulea dolens and May-Thurner syndrome resulting from triple-positive antiphospholipid antibody syndrome. Reference #1: Casey ET, Murad MH, Zumaeta-garcia M, et al. Treatment of acute iliofemoral deep vein thrombosis. J Vasc Surg. 2012;55(5):1463-73 Reference #2: Haig Y, Enden T, Grøtta O, et al. Post-thrombotic syndrome after catheter-directed thrombolysis for deep vein thrombosis (CaVenT): 5-year follow-up results of an open-label, randomised controlled trial. Lancet Haematol. 2016;3(2):e64-71 Reference #3: Dufrost V, Risse J, Reshetnyak T, et al. Increased risk of thrombosis in antiphospholipid syndrome patients treated with direct oral anticoagulants. Results from an international patient-level data meta-analysis. Autoimmun Rev. 2018;17(10):1011-1021 DISCLOSURES: No relevant relationships by Waqas Adeel, source=Web Response No relevant relationships by Robert Decker, source=Admin input No relevant relationships by Shuisen Li, source=Web Response No relevant relationships by Preysi Patel, source=Web Response No relevant relationships by Chun Siu, source=Web Response

Endovascular Stenting for a Crush Injury of the Common Femoral Artery Followed by Open Repair of Unveiled External Iliac Vein Injury after a Horse Fall

Accurate diagnosis and management of a femoral vascular injury is important as it is a life-threatening injury with high morbidity and mortality. This is the case of a 75-year-old man admitted to the emergency room with trauma to the right groin due to a horse fall. Computed tomography showed active bleeding of the femoral artery without pelvic or femoral fracture. We inserted a stent-graft, but hypotension persisted. Exploration of the groin was completed, and the bleeding from the external iliac vein was identified and repaired. In conclusion, vascular injury is rare in groin trauma without associated fracture, however, arterial and venous injury should not be completely ruled out. Endovascular therapy is worth recommending as a quicker and safer management than surgery in patients with active bleeding in the femoral artery. However, the possibility of combined injury of the femoral vein should be suspected in case of ongoing hemodynamic instability.

Graft outflow vein venoplasty for a laparoscopically harvested left lateral section graft in pediatric living donor liver transplantation

Laparoscopically harvested left lateral section (LLS) grafts have drawbacks regarding the size of the graft left hepatic vein (LHV) orifice although they have the merit of cosmetics concerning the donor’s wound. We present a case of pediatric living donor liver transplantation (LDLT) using a laparoscopically harvested LLS graft and describe the refined surgical techniques for graft LHV venoplasty with a circumferential vein patch. The patient was a 46-month-old boy with marked growth retardation who was diagnosed with progressive familial intrahepatic cholestasis type 2. The donor was his 25-year-old mother. The LLS graft weighed 285 g. A circumferential patch of external iliac vein homograft was attached to the graft LHV orifice after incisions were made at the medial wall of the LHV trunk and superficial LHV branch, which made the graft LHV orifice much larger. The recipient’s hepatic vein orifice was also enlarged by unifying the three hepatic vein orifices. Other surgical procedures followed the standard LDLT operation. This patient recovered uneventfully and has been doing well for 1 year. In conclusion, our incision-and-patch venoplasty to enlarge the graft outflow vein orifice was beneficial for reducing the risk of hepatic vein outflow obstruction in LDLT using a laparoscopically harvested LLS graft.

Torode &amp; Zeig type IV fracture with a blunt injury of external iliac vessels with innovative arterial reconstruction by internal iliac translocation. A 12-year follow-up

This report describes the case of a 4-years-old female, who was admitted due to motor vehicle accident, with pelvic Torode & Zeig type IV fracture, blunt trauma to the right external iliac artery and vein, and femoral nerve. Associated injuries included open fracture of the left femur, contaminated abdomen due to jejunal tear, and hemorrhagic shock. We performed Orthopedic Damage Control by fluid resuscitation, and ligation of the right iliac artery and vein. Orthopedic Damage Control was performed by external fixation of the pelvis, and titanium elastic nailing of the left femur. The patient was left without arterial blood supply to the right leg. We faced the dilemma of selecting the optimal method of arterial reconstruction, considering the pelvic contamination. PTFE graft was not considered due to caliber discrepancy of 6mm compared to 3mm of the child's external iliac artery, and a 30% probability of synthetic graft infection in a contaminated abdomen. To avoid the complications mentioned above, we used an autologous graft of the right internal iliac artery, which was translocated distally and anastomosed to the distal external iliac artery. A 12 years follow-up, with left femoral plating, hamstring to patellar transfer, and right talar arthrodesis was conducted. The artery grew with the patient with no need for replacement. Twelve years post-injury, the patient walks with circumduction of the right leg with left leg shortening treated with a lift heel of 4 cm. The patient has consented to this publication.

The association between vascular risk factors and the occurrence of non-thrombotic iliac vein lesions in patients with chronic venous disorders

Introduction: Recently non-thrombotic iliac vein lesions (NIVL) due to their possible role in chronic venous insufficiency on one side and to the development of endovascular venous techniques on the other side have gained much interest. The purpose of this study was to establish if vascular risk and anthropometric factors are associated with the occurrence of NIVL in patients with chronic venous disorders. Material and methods: Thirty-three patients (8 men and 25 women) of the median age of 48 years with primary varicose veins that were qualified for great saphenous veins high ligation and stripping were included. The data concerning age, sex, body mass, height, body mass index, body surface area, hypertension, hypercholesterolemia, smoking and diabetes have been collected. During the varicose vein surgery, both iliac venous axis were interrogated with intravascular ultrasound. Percentage of stenosis of interrogated veins was calculated. The association between analyzed factors and morphology of iliac veins was statistically determined. Results: In a univariate analysis age negatively correlated with left common iliac vein (LCIV) stenosis and male sex, greater weight and body surface area and hypertension were associated with lesser stenosis of left external iliac vein. In a multivariate analysis, only age significantly negatively correlated with LCIV stenosis (p = 0.027). There was a correlation of borderline statistical significance between female sex and LCIV stenosis (p = 0.073). No other correlations were observed. Conclusions: Except for age and possibly sex, there is no association between NIVL and other anthropometric and vascular risk factors.

A rare case of anatomical variation of the femoral artery and vein

During a dissection of the two femoral trigons in a female corpse, about 14 years old, we discovered on the right side, the deep artery of the thigh arising from the medial side of the femoral artery and passed in front of the femoral vein above the mouth of the great saphenous vein; on both sides, there was the presence of a collateral canal which communicated the external iliac vein with the femoral vein on the right, on the left, it communicated the external iliac vein with the quadricipital vein. The lower part of the femoral vein was duplicated on both sides, but on the right, there was an interconnecting channel between the two trunks of the duplication. Variations of the femoral vessels are very frequent and can be responsible for an incident during the practice of certain gestures at the level of the femoral trigon such as: catheterization of the femoral artery or vein, the treatment of femoral hernias.&#x0D; Key words: Deep thigh artery, collateral venous canal, external iliac vein, anatomic variations.

Standardized Step-by-step Technique Using Surgical Landmarks in Robotic Lateral Pelvic Lymph Node Dissection

We aimed to show that a standardized step-by-step robotic approach using surgical landmarks could make lateral pelvic lymph node dissection (LPND) less complicated. We performed robot-assisted LPND consisting of 4 steps using surgical landmarks. The first step is a dissection of uretero-hypogastric fascia, which envelopes the ureter and the hypogastric nerve. The second step is a dissection of the medial side of the external iliac vein located at the lateral border of the obturator lymph nodes (LNs) group. The third step is a dissection of the vesico-hypogastric fascia, which is at the medial border of the obturator LNs group. The final step is a dissection of the internal iliac artery until the Alcock’s canal. Indocyanine green was injected just before surgery around the dentate line to identify the lateral pelvic LNs. Standardization using a robotic approach for LPND guided by surgical landmarks allows a safer and more effective surgery.

Success Rate of Grafts With Multiple Renal Vessels in 3136 Kidney Transplants

Multiple renal vessels are often detected in living and deceased organ donors. In the past, transplant with multiple renal vessel grafts has been a contraindication because of high vascular and urological complication rates. However, improvements in vascular reconstruction and anastomosis techniques have allowed graft function to be maintained for many years. Here, we retrospectively evaluated transplant of multiple renal vessel grafts and graft survival and postoperative vascular and urological complications. From November 1975 to July 2020, there were 3136 renal transplants (716 deceased donors, 2420 living donors) performed in our center. There were 2167 living donors and 643 deceased donors with single renal vessel grafts and 253 living donors and 73 deceased donors with multiple renal vessel grafts. For anastomoses, external iliac, internal iliac, common iliac, and inferior epigastric arteries and external iliac veins were used. Cold ischemia time, anastomosis time, postoperative vascular and urological complications, acute tubular necrosis, creatinine clearance, serum creatinine levels, graft rejection episodes, and graft and patient survival rates were evaluated. With regard to creatinine clearance, cold ischemia and anastomosis time, acute tubular necrosis, rejection episodes, and 1-, 2-, and 5-year posttransplant serum creatinine levels, there were no significant differences between the groups. Graft survival rates in the single renal vessel group were 92.9% at 1 year posttransplant and 78.3% at 5 years posttransplant; rates in the multiple renal vessel group were 93.1% at 1 year and 79.7% at 5 years. The corresponding patient survival rates were 95.5% (1 year) and 92.9% (5 years) for the single renal vessel group and 96.9% (1 year) and 87.2% (5 years) for the multiple renal vessel group. Improved anastomosis and recon struction techniques have allowed the safe transplant of multiple renal vessel grafts that may remain functional for many years.