External Iliac Vein Research Articles

Pediatric Transplant Experience from a Single Center in South India

Background and Objective: Pediatric renal transplantation is a life-saving procedure for children with end-stage renal disease. This study aims to analyze the outcomes of pediatric renal transplants at our center, focusing on patient demographics, donor sources, surgical techniques, posttransplant complications, graft survival, and rejection rates. Methodology: A retrospective analysis was conducted on 43 pediatric kidney transplant recipients. Data on recipient age, gender, donor type, pretransplant dialysis, donor characteristics, surgical techniques, native kidney disease, induction therapy, maintenance immunosuppression, posttransplant infections, graft survival, and rejection episodes were collected and analyzed. Results: We performed 43 pediatric kidney transplants in total. The average age was 13.7 years (±3.81), with 8 (18.6%) being under the age of ten, 11 (25.6%) being between the ages of eleven and fourteen, and 24 (55.8%) being between the ages of fifteen and eighteen. There were 43 recipients: 27 males and 16 females. There were four (9.3%) deceased donor renal transplants and 39 (90.7%) live-related kidney transplants. Right internal iliac artery and right external iliac vein anastomosis were found in 32 (74.4%) cases, right external iliac artery and right external iliac vein in 9 (20.9%), right common iliac artery and right common iliac vein in 1 (2.3%), and right common iliac and right internal iliac in 1 (2.3%). Induction was used in 27 recipients (62.8%). Graft survival was seen at 1 year in 42 (97.7%) patients and at 5 years in 34 (81%). Biopsy-proven rejection occurred in 22 (51.2%) of the recipients, with antibody-mediated rejection occurring in 8 (18.6%) and cellular rejection occurring in 22 (51.2%). Graft loss was caused by acute cellular rejection in three (23.1%) cases, graft pyelonephritis in 2 (15.4%), and an unknown cause in 2 (15.4%). There were no significant connections with antibody-mediated rejection. Conclusion: Our study provides valuable insights into the outcomes of pediatric renal transplantation at our center. Despite the challenges of graft rejection and posttransplant infections, favorable graft survival rates were achieved. Cellular rejection emerged as a significant risk factor for graft survival, highlighting the importance of effective immunosuppressive management. Our findings emphasize the need for close follow-up, infection control measures, and individualized immunosuppressive strategies to optimize long-term outcomes in pediatric renal transplant recipients. Further research is warranted to refine protocols and address the specific needs of this vulnerable patient population.

Pediatric scurvy case report: a novel presentation with deep vein thrombosis secondary to large bilateral spontaneous iliac subperiosteal hematomas

BackgroundScurvy is an uncommon disease in developed countries caused by deficiency of vitamin C. We present a case of scurvy in a 14-year-old male with autism with both novel presentation and imaging findings. This case had the novel presentation of lower limb deep vein thrombosis (DVT) secondary to compression of the external iliac vein from large bilateral iliac wing subperiosteal hematomas. Subperiosteal hematoma is a well-recognised feature of scurvy but large and bilateral pelvic subperiosteal hematoma causing DVT has not previously been described.Case presentationA 14 year old Caucasian male with background of autism and severe dietary restriction presented with lower limb swelling and immobility. He was diagnosed with lower limb DVT. Further investigation revealed an iron deficiency anaemia, and he was found on MRI to have large bilateral subperiosteal iliac hematomata causing compression of the iliac vessels. He improved following treatment with vitamin C replacement and follow-up imaging demonstrated resolution of the DVT and hematoma.ConclusionDVT is rare in children and when diagnosed should prompt investigation as to the underlying cause. This case demonstrates an unusual cause of DVT and as an unusual presentation of paediatric scurvy.

Adrenal Vein Sampling: Does the Location of the Non-adrenal Venous Sample Matter?

PurposeAdrenal vein sampling (AVS) is used to lateralise and differentiate unilateral from bilateral aldosterone production in primary aldosteronism. The adrenal venous samples are standardised to a peripheral or low inferior vena cava (IVC) sample and compared. It is unknown whether the location of the non-adrenal sample affects the results. This study compares AVS results standardised to the low IVC and right external iliac vein (REIV).MethodsPatients who underwent AVS between March 2021 and May 2023 were included. All procedures were undertaken by a single operator (AA). Demographic data and AVS results were collected from patients’ electronic records. Catheterisation success and lateralisation were assessed using both low IVC and REIV samples. Equivalence test was used to compare the cortisol and aldosterone levels.ResultsEighty-one patients, (M: F = 38:43), aged between 29 and 74 were included. Bilateral successful adrenal vein cannulation was achieved in 79/81 (97.5%) cases. The mean cortisol levels from the REIV were statistically equivalent although there was a small and not biologically significant difference from the low IVC (respective geometric means 183 nmol/l vs. 185 nmol/l, p = 0.015). This small difference in cortisol may be due to accessory adrenal venous drainage into the IVC. The aldosterone and aldosterone/cortisol ratios were statistically equivalent. There was no discordance in selectivity or lateralisation when the IVC or REIV measurements were used.ConclusionThe IVC and REIV samples may be used interchangeably during AVS.Graphical

The wandering ghost: A rare case report dealing with an incarcerated hemodialysis femoral venous catheter and its successful retrieval

Abstract The increasing prevalence of chronic kidney diseases worldwide has eventually increased the demand for dialysis. It is usually achieved by creating an arteriovenous fistula or by the placement of temporary hemodialysis catheters. Without a doubt, the creation of an arteriovenous fistula is the best long-term solution for patients needing frequent dialysis because it carries the least risk of infection. We report a rare case dealing with a fractured and incarcerated single-lumen nontunnel temporary hemodialysis catheter secured in the right femoral vein, and the procedure opted for its successful retrieval from the right external iliac vein.

External iliac vein injury and acute iliofemoral deep venous thrombosis after total hip arthroplasty: a rare iatrogenic complication and its successful endovascular repair.

External iliac vein injury and acute iliofemoral deep venous thrombosis after total hip arthroplasty: a rare iatrogenic complication and its successful endovascular repair.

Considerations for Iliac Vein Repair in the Setting of Urologic Procedures

Introduction: Iliac vein injuries are associated with high morbidity and mortality, with a feared complication of hemorrhage. We discuss management and the thought process behind mitigating such emergencies. Case Presentation: An 81-year-old Caucasian male was seen intraoperatively by Vascular Surgery for hemorrhage from an injured left external iliac vein (LEIV) in the setting of left radical nephrectomy and ureterectomy. Conclusion: Despite initial temporizing efforts by Urology, Vascular Surgical intervention proved necessary in hemostasis, venous reconstruction and thus, establishing continuity of lower extremity venous drainage.

Nonhealing vulvar ulcer from complete left common iliac and external iliac vein occlusion.

Nonhealing vulvar ulcer from complete left common iliac and external iliac vein occlusion.

Clinical and Radiological Outcomes of Patients With Anterior Acetabulum Fractures Treated by the Modified Stoppa Approach.

Introduction Acetabular fractures are intra-articular fractures involving the lower extremity's weight-bearing dome. These fractures require an anatomical reduction of the fracture fragments. This aim can be accomplished by the selection of an appropriate surgical approach. This study aimed to analyze the clinical and radiological outcomes of patients with fractures in the anterior part of the acetabulum who were treated by the modified Stoppa approach. Methods This prospective observational study was conducted from April 2022 to September 2023. The inclusion criteria were: (i) age between 18 and 70 years, (ii) displaced acetabular fracture (displacement > 3 mm), (iii) within three weeks of trauma (iv) acetabular fractures with involvement of anterior column. Exclusion criteria included: (i) patients with visceral injuries requiring colostomy, (ii) pathological fracture, (iii) open fractures of the acetabulum, and (iv) neglected fracture (more than three weeks). Intraoperative data regarding surgical time, amount of blood loss, and incidence of intraoperative complications were recorded. In the postoperative period, anteroposterior X-ray and Judet views of the pelvis X-ray were obtained. Matta criteria were used to judge the quality of Fracture reduction and fixation. All the patients to be included in this study had undergone a minimum follow-up duration of six months. At the last follow-up, an assessment of the functional outcome of the affected hip by Merle d'Aubigné Hip Score and Harris Hip Score was done. Results Twenty-four patients were included in the study. The mean patient age was 36.08±11.65 years. Eighteen patients were male (75%) and six patients were female in this study. All acetabular fractures were due to high-energy trauma: road traffic accidents in 22 cases (91%) and fall from height in two cases (9%). According to Judet & Letournel's classification, there were 13 T-type fractures, five transverse fractures, and six associated both column fractures. The mean duration of surgery was 152.08 ±29.19 minutes, and the mean intraoperative blood loss was 277.08±85.95 ml. Intraoperatively one unit of blood transfusion was done in most cases. There were intraoperative complications of rent in the external iliac vein in two patients. Postoperative X-rays showed anatomical reduction in 17 cases, imperfect reduction in five cases, and poor reduction in two cases. Functional outcome of the hip by Merle d'Aubigné Hip Score was very good in 15, good in four, fair in three, and poor in two patients. Similar functional outcomes were obtained with the Harris Hip Score. Conclusion The results of the current study demonstrated that the modified Stoppa approach allows good visualization of the pelvic brim, quadrilateral surface, and posterior column. Lesser experienced orthopedic surgeons should utilize this approach to get good radiological and functional outcomes.

Bladder-Induced Compression of the External Iliac Veins: Recognition and Implications for Treatment.

The effect of changes in bladder volume on the caliber of adjacent veins is underappreciated but essential to recognize to avoid complications such as unnecessary stenting or clot migration causing pulmonary embolism. Here the authors illustrate the importance of this finding in 3 cases using venographic and endovascular sonographic imaging: the first in which BPH-induced chronic bladder outlet obstruction resulted in DVT formation, the second in which the cause was unrecognized and unnecessary stenting performed, and the third in which inappropriate treatment was avoided by decompressing the bladder.

Recurrent Leg Deep Vein Thrombosis in a Female with Atypical Right-Sided Variant of May Thurner Syndrome and Factor V Leiden Mutation

I ntroduction: May-Thurner syndrome (MTS) is a condition in which the right common iliac artery presses on the left common iliac vein, causing it to narrow over time. Right-sided MTS is a rare event. We present this unique case of recurrent right leg deep vein thrombosis in a female with atypical right sided variant of MTS and Factor V Leiden mutation. Case Presentation: A 34-year-old lady with with no signficiant past medical history presented to the hospital with right lower leg edema, tingling, and discolouration. She was taking oral contraceptive pills. Vitals were unremarkable. Doppler studies revealed right lower extremity deep vein thrombosis in the right external iliac vein, common iliac vein and common femoral vein. She was started on an intravenous heparin drip and subsequently had a thrombectomy procedure. She was subsequently discharged home on apixaban anticoagulation. We opted to request a hypercoagulable and vasculitis workup in light of the extensive thrombosis, despite the OCP risk factor, and discovered a heterozygous Factor V Leiden mutation. She returned to the hospital 2 days later with worsening right leg pain. Repeat Doppler studies demonstrated acute right femoral and popliteal deep vein thrombosis. CT angiography of abdomen and pelvis revealed significant right femoral vein DVT that extends into the External iliac vein, common iliac vein, and IVC to at least slightly below renal vein level. Invasive Radiology was consulted and she had a venogram and intravascular ultrasound (IVUS) which showed high-grade right common iliac vein and IVC stenosis (>90%) at L4 superior endplate. Iliac stenting and angioplasty improved iliac and inferior IVC diameters. Patient also underwent thrombectomy & IVC filter placement. The diagnostic venography revealed a popliteal-to-proximal femoral vein rethrombosis. This was treated with tissue plasminogen activator (TPA) by 8 French power pulse AngioJet and a mechanical thrombectomy. This resulted in partial clearing of the common femoral vein with persistent narrowing and thrombosis of the popliteal vein. TPA was infused at 1 mg/hour with a 5 French McNamara lysis catheter over the popliteal region.Patient transferred to ICU for overnight intravenous thrombolysis. The patient was then re-initiated on the heparin drip and then bridged to therapeutic warfarin. Discussion: MTS is a phenomenon commonly described as an acquired stenosis of the left common iliac vein secondary to compression by the right common iliac artery 1. It has been associated with genetic clotting factor abnormalities, repeated pregnancies, postpartum, contraceptive pills, prolonged immobilization, scoliosis, anti-phospholipid syndrome, COVID-19, and recurrent DVT 2. In patients with left lower-limb DVT, the incidence of MTS is about 20-50%. Right lower limb DVT in patients with right sided variant of MTS is rare. Right lower limb DVT with right sided variant of MTS with co-existing Factor V Leiden mutation is even rarer. Ultrasound imaging typically cannot detect the high pelvic abnormalities seen in MTS. Contrast venography, MRI, or IVUS are needed to diagnose MTS 4. As was the case in our patient, venography should be done to evaluate stenosis and iliac vein compression hemodynamics after thrombus removal. Treatment of MTS depends on the presentation, severity of symptoms, and whether the patient has developed DVT. Conservative treatment such as compression stockings can be used for patients who are asymptomatic or have mild symptoms. For patients with moderate symptoms or DVT, endovascular treatment with stenting is recommended 5. Conclusion: This is a very atypical presentation of MTS variation affecting the right lower extremity with limited description in the literature. To our knowledge, this is the first case presentation of right sided MTS resulting in a DVT in a patient with factor V Leiden mutation. MTS is a potentially treatable and often-overlooked pathology. In the era of expanded endovascular management of MTS, recognition of this disease entity is essential for early diagnosis and treatment.

Single-center experience with the ClotTriever BOLD catheter for deep vein thrombosis percutaneous mechanical thrombectomy of the lower extremity.

The ClotTriever System is a percutaneous mechanical thrombectomy system used to treat deep vein thrombosis (DVT). The BOLD catheter is a newer compatible component with a modified coring element for which reported outcomes are limited. This retrospective study aims to assess the preliminary procedural safety and success data for patients treated with the BOLD catheter. All consecutive patients with symptomatic lower extremity DVT who underwent thrombectomy with the BOLD catheter between 23 November 2021 and 26 June 2022 at a single center were included. Baseline and procedural characteristics were reported. The primary outcome, intraprocedural safety, was assessed by a chart review of recorded intraprocedural adverse events (AEs) or device malfunction. The secondary outcome, procedural success, was defined as ≥75% reduction in the total occlusion across treated venous segments. This was assessed by an interventionalist review of pre- and postprocedural venograms. Additional outcomes included length of postprocedural hospital stay and assessment of AEs at discharge and a 30-day follow-up visit. Eleven patient cases were reviewed. The median patient age was 65 years, the majority were women, and all were treated unilaterally. All procedures were completed in a single session without intraprocedural AEs or device malfunction. The median procedural blood loss was 50 ml. A review of pre- and postprocedural venograms showed that 35 venous segments were treated, including the femoral (n = 9), common femoral (n = 9), external iliac (n = 10), and common iliac (n = 7) veins. Procedural success was achieved in 10 patients (90.9%), and the median reduction rate in venous occlusion was 100%. The median length of postprocedural hospital stay was 1 day, and no AEs were noted at discharge (N = 11). One adverse event occurred among the eight patients who completed their follow-up visit. A patient with advanced-stage cancer and medication failure had a recurrent DVT 13 days postprocedure, which was not related to the device or procedure. No safety concerns concerning the BOLD catheter were raised during the review of the cases included in this analysis, and the device was successful in reducing venous occlusion in patients with symptomatic proximal lower extremity DVT.

Feasibility of a three-sided encapsulation procedure based on fascia anatomy in laparoscopic lateral lymph node dissection for middle and low rectal cancer

Objective: To explore the feasibility and value of performing a three-sided encapsulation procedure based on fascia anatomy in laparoscopic lateral lymph node dissection (LLND) for middle and low rectal cancer. Methods: This was a retrospective review. The study cohort comprised patients who met the diagnostic criteria for rectal cancer according to the Chinese Guidelines for the Diagnosis and Treatment of Colorectal Cancer, had a short lymph node diameter of >5 mm on the lateral side within the 15 days before surgery, were evaluated as feasible candidates for laparoscopic total mesorectal excision+LLND surgery, had been diagnosed with low or intermediate level rectal cancer, and whose tumor was less than 8 cm away from the anal verge according to pathological examination of the operative specimen. Patients with a history of other malignant tumors of the abdomen or with incomplete follow-up data were excluded. Forty-two patients with middle and low rectal cancer who had undergone lateral lymph node dissection in diagnosis and treatment center of Gastrointestinal Cancer of Guangdong Hospital of Chinese Medicine from Jan.2018 to Dec.2022 were enrolled. There were 24 men (57.1%) and 18 women (42.9%) aged 58.4±11.8 years and the median BMI was 22.5 (19.3-24.1) kg/m2. The main point of the three-sided encapsulation procedure is to expand the external side medial to the external iliac artery and vein, narrowing the range of exterior side dissection. The anterior-medial side is designed to expand the vesical fascia to define the range of anterior-medial side extension. The internal side is fully extended to the ureterohypogastric nerve fascia; the distal point of the caudal extension reaches the level of the Alcock canal and the bottom reaches the piriformis, enabling dissection of the obturator nerve and No.283 lymph nodes. No.263D lymph nodes are dissected by exposing the internal iliac artery and its branches, dissecting the group No.263P lymph nodes, and severing the inferior vesical artery. Finally, the lateral lymphatic tissue is completely resected. Relevant variables were recorded, including the number of lateral lymph nodes detected, the rate of lymph node metastasis, operation duration, intraoperative blood loss, postoperative complications, postoperative hospital stay, and 3-year overall survival rate. Results: Laparoscopic surgery was successfully completed in all patients with no conversions to open surgery and no intraoperative complications. Twenty-seven (64.3%) of the study patients underwent left-sided LLND, 10 (23.8%) right-sided LLND, and five (11.9%) bilateral LLND, with lymph nodes cleared on both sides. All patients' lymph nodes were examined pathologically. A median of 17.0 (11.7, 26.0) lymph nodes was detected, the median of lateral lymph nodes being 5.0 (2.0, 10.2). The median operation time was 254.5 (199.0, 325.2) minutes. The median intra-operative blood loss was 50.0 (30.0, 100.0) mL. All patients were diagnosed with adenocarcinoma by pathological examination of the operative specimen. Two patients developed postoperative intestinal obstruction, one lymphatic leakage, and one a perineal incision infection. There were no cases of anastomotic leakage. The median postoperative hospital stay was 6.0 (5.0, 7.0) days and the median follow-up time 23.5 (9.0, 36.7) months. During follow-up, three patients (7.1%) died of tumor recurrence and metastasis. Two (4.8%) experienced mild urinary dysfunction, and one (2.4%) had moderate postoperative erectile dysfunction. One patient (2.4%) was found to have prostate and lung metastases 3 month after surgery. The 3-year overall survival rate was 74.4%. Conclusions: Three sided encapsulation is a safe and feasible procedure for LLND, achieving accurate and complete clearance of lateral lymphatic tissue.

Lymphadenectomy before and after radical cystectomy: does this affect the radicality? A prospective randomized comparative study

PurposeTo compare the oncological outcome of performing ePLND before or after RC in 200 patients in a prospective randomized manner.Materials and methodsFrom January 2014 to December 2019, 200 patients with T2-T3b N0M0 BCa were included in the current study after signing an informed consent. Patients were divided into two groups, 100 in each one. Group I underwent ePLND before RC, whereas group II underwent ePLND after RC. Postoperative evaluation included clinical, laboratory, and radiographic studies.ResultsPatients’ characteristics were comparable between both groups. The mean operative time excluding that of urinary diversion was significantly shorter in group II than in group I (p = 0.01). The mean number of LNs removed was 25 ± 6 in group I and 32 ± 8 in group II (p = 0.141). Intraoperative complications occurred in four patients in the form of external iliac artery and vein injury [two in each group (p = 0. 245)]. Postoperative complications were comparable between both groups with no statistically significant difference (p = 0.375). Oncological failure occurred in 28 patients [16 (17.6%) in group I and 12 (22%) in group II (p = 0.389)].ConclusionsEPLND before and after RC has comparable oncological outcomes. The stage of the disease, the time since the first diagnosis till RC and the surgeon experience in performing meticulous ePLND are more important. In absence of oncological superiority, the timing of ePLND should be judged according to the patient-related factors to facilitate safe RC with minimal morbidity.

Morphometric measurements for potential dangers of anterior intra-pelvic approach in women: A cadaveric study.

This study aimed to improve the surgical anatomical knowledge of pelvic/acetabular trauma surgeons by providing detailed morphometric data on some of the most vulnerable arteries and nerves due to constant bony landmarks during anterior intra-pelvic approach fixation of acetabular fractures in women. Ten hemipelvis were dissected from 5 female cadavers. The following measurements relative to the symphysis were performed: (1) the distance of the corona mortis anastomosis and (2) the bisection of the external iliac vein with the pubic ramus. In addition, dis- tance to the pelvic brim at the level of pectineal convexity of the following structures was measured: (3) depth of obturatory neurovascu- lar bundle, (4) superior vesical artery, and (5) vaginal artery. Also, the clock position of the (6) gluteal superior and inferior vessels due to sciatic notch in the supine position. Due to antero-superior corner of sacroiliac joint (7) location of the common iliac artery bifurcation, (8) location of the bifurcation of internal iliac vessels to truncuses, (9) bifurcation of superior gluteal artery and lateral sacral artery, and (10) L5 nerve were measured. The descriptive statistics were given as medians and ranges as this is a descriptive anatomical study without comparisons. The median distance of corona mortis to symphysis pubis was 59.5 mm (range = 58-61). The external iliac vein bisected the pubic arm 68.5 mm (range=65-70) lateral to the symphysis pubis. At the level of pectineal convexity (about the middle of the pelvic brim), obturatory neurovascular bundle, superior vesical artery, and vaginal artery were 15 mm (range=13-16), 24 mm (range=23-25), and 36 mm (range=34-38) inferior to the pelvic brim, respectively. The superior gluteal vessels leave the sciatic notch at 12 o'clock position in supine position. Inferior gluteal vessels leave the sciatic notch at 31⁄2 o'clock position (given for left side). Common iliac artery bifurcation bisects the SI joint 5 mm (4-7) superior to antero-superior corner of the Sacro-iliac (SI) joint. The internal iliac artery gives its posterior trunk 18 mm (range=15-20) straightly anterior to antero-superior corner of the SI joint. Bifurcation of superior gluteal artery and lateral sacral artery was 11 mm (range = 10-12) away from the beginning of the posterior truncus. L5 root's medial margin was 9 mm (range = 7-10) medial to this landmark, where its lateral margin was on the SI joint (2 mm medial to 2 mm lateral). The majority of the bleeding complications of the major branches of the internal and external iliac arteries and neurologic palsies due to obturatory nerve and L5 nerve root damage within the operative field of the anterior intra-pelvic approach can be avoided or managed by utilizing morphometric data provided from this study. N/A.

Ultrasound-guided stenting in the common femoral vein for accurate stent distal landing.

Venous stenting has been reported with excellent clinical results; however, inadequate inflow can increase the risk of stent occlusion. When extending the stent into the common femoral vein (CFV), it is essential to ensure adequate inflow from the femoral vein, deep femoral vein (DFV), and great saphenous vein. Accurate identification of the distal landing zone (DLZ) of the stent is crucial to ensure adequate inflow. The DLZ is usually determined by venography or intravascular ultrasound (IVUS) with reference to bony landmarks. However, the uncertainty can lead to misidentification of the DLZ and inadequate stent placement, resulting in stent occlusion. From December 2016 to December 2022, 42 venous stent placements were performed in 40 patients with post-thrombotic iliofemoral vein obstruction and/or stenosis. Three patients had developed early stent occlusion owing to a misidentified DLZ. To improve accuracy in identifying the DLZ during venous stenting, ultrasound-guided placement was performed in the CFV of five patients (four on the left and one on the right) with post-thrombotic changes in the CFV and occlusion of the common iliac vein and external iliac vein. The distal end of the stent was adjusted just above the saphenofemoral junction in two cases and just proximal to the DFV confluence in three cases. Stent placement was verified using both long-axis ultrasound and fluoroscopy. Ultrasound images of the CFV region provided clear visualization of the stent deployment site and accurate landmark locations, such as the saphenofemoral junction and DFV confluence, allowing for precise adjustments during stent deployment. This technique enabled easier and more definitive identification of other branches of the CFV than previously provided by IVUS and venography. No complications were observed in any of the 42 cases, and long-term patency was achieved at the final follow-up after stenting (average, 10months; range, 3-14months). Ultrasound-guided stenting in the CFV allows for real-time and accurate stent deployment with precise adjustment to the optimal DLZ. Using this technique, combined with venography and IVUS, missed distal lesions and subsequent stent occlusion can be prevented, potentially contributing to better treatment outcomes.

Bilateral Common Origin of Obturator and Inferior epigastric Arteries from the External Iliac Arteries, Accompanied by Venous Corona Mortis Duplicated on the Left Hemi-Pelvis

During the dissection of the pelvis of a 93-year-old female donor, aberrant obturator artery and inferior epigastric artery were found to arise by a common trunk from the external iliac arteries bilaterally. Both right and left AOAs descended into the lesser pelvis with a venous corona mortis and entered the obturator canal on its anterolateral wall where each artery is joined by two (superior and inferior) obturator veins (OVs) and the obturator nerve on the respective side. The bilateral venous corona mortis connected the superior obturator veins with inferior epigastric veins, while on left hemi-pelvis, a second venous corona mortis additionally connected the inferior obturator vein with external iliac vein. These variant pelvic vessels are prone to injuries by trauma during accidents, iatrogenic injuries during inguinal and femoral hernia operations, and other orthopedic, gynecologic and urologic procedures. Such injuries have high morbidity and mortality rate due to hemorrhagic shock, therefore, caution must be exercised to avoid excessive hemorrhage and other complications.

Successful Wallstent exclusion of iliofemoral venous aneurysms—a new treatment paradigm

Treatment of venous aneurysms involving the iliac and femoral veins has generally been an open surgical approach, with a few case reports noting use of an endovascular approach. We report three cases: (1) a patient with an iliocaval occlusion involving an occluded TrapEase filter who presented with a large left external iliac vein aneurysm; (2) a patient with a left common femoral vein aneurysm; and (3) a patient with left profunda femoris vein aneurysms with associated pulmonary embolism. All three patients were successfully managed with the use of appropriately sized bare metal woven stents (Wallstents; Boston Scientific). Their clinical presentation, technical considerations, and outcomes are reviewed.

Diffuse generalized venulitis as the primary pathology of Behçet's disease: A comprehensive magnetic resonance venography study

ObjectiveBehçet's Disease (BD) is a chronic multisystem vasculitis that manifests with destructive inflammation affecting the eyes, central nervous system, and blood vessels. The pathology of vein involvement in BD is poorly characterized. Magnetic resonance (MR) venography gives more comprehensive information about deep veins and adjacent tissues. In this study, we aimed to characterize vein involvement and evaluate the diagnostic utility of MR venography in BD. MethodsSixty-five BD patients who fulfilled the International Study Group (ISG) criteria and 20 healthy control subjects were enrolled. Inferior vena cava (IVC), common iliac veins (CIV), external (EIV) and internal iliac veins (IVV), common femoral veins (CFV), femoral veins (FV), and greater saphenous veins (GSV) of BD patients and healthy controls were evaluated with MR venography and ultrasonography for the presence pathologic features, luminal thrombi, vessel wall changes, and perivascular abnormalities. Results33 vascular and 32 non-vascular BD patients (mean age 39.3 ± 11.3 years and 48 [73.8%] male) were enrolled. MR venography revealed diffuse concentric thickening of the walls of IVC, CIV, EIV, IIV, CFV, FV, and GSV in BD (healthy controls vs. BD p<0.05 for all vein segments). MR venography provided additional information about veins and perivascular tissues like contrast enhancement, enlarged lymph nodes, and seminal vesicle vascularization, which were remarkably more frequent in vascular BD than non-vascular BD and healthy controls. ConclusionThe results of our study suggest that the involvement of the venous system is diffuse and generalized in BD, and demonstration of venulitis might help diagnose the disease.

Quantitative two-dimensional phase-contrast magnetic resonance imaging characterization of lower extremity venous disease: venous reflux versus venous obstruction.

Lower extremity venous disease (LEVD) is a complex disorder, and determining the etiology of LEVD is paramount for treatment selection. Two-dimensional phase-contrast magnetic resonance imaging (2D PC-MRI) can provide an objective measure of hemodynamic status and may help differentiate between different etiologies of LEVD. A total of 271 participants, including 256 symptomatic patients with venous lower extremity disease and 15 healthy volunteers, were collected in this cohort study. It is a single-center prospective observational study using 2D PC-MRI analysis to assess the hemodynamic characteristics of patients with LEVD among participants recruited between April 2017 and October 2021 at a tertiary hospital. The approval institutional review board number for this study were 201802137B0, 201901058B0, 202100938B0, and 202102344B0. Participants were classified as venous reflux (VR) and venous obstruction (VO) by standard ultrasonography. 2D PC-MRI by 1.5 T scanner revealed stroke volume (SV), forward flow volume (FFV), absolute stroke volume (ASV), mean flux (MF), velocity time integral (VTI), and mean velocity (MV) for each selected venous segments. 2D PC-MRI assessed 167 diseased legs from the 116 VR patients [mean age ± standard deviation (SD): 57.9±12.8 years; 39 males] and 113 diseased legs from the 95 VO patients (mean age ± SD: 66.4±12.8 years; 42 males). 2D PC-MRI analysis demonstrated discrimination ability to differentiate from VR to VO [SV, FFV, ASV, MF, VTI, and MV in the various venous segments, respectively, P≤0.001; area under the curve (AUC) =62-68.8%, P≤0.001 by Mann-Whitney U test]. The ratio data (morbid limb to normal limb) in the same individual with single-leg disease revealed differences between VR and VO (SV, FFV, ASV, and MF in the various venous segments, respectively; P<0.05; AUC =60.2-68.7%, P≤0.05 by Mann-Whitney U test). The most favorable differentiating variables of ratios were FFV in the great saphenous veins [AUC =68.7%, 95% confidence interval (CI): 59.8-77.6%] and ASV in the external iliac veins (AUC =67.4%, 95% CI: 58.7-76.2%). Quantitative 2D PC-MRI analysis is capable of differentiating VR from VO. It also provides an important diagnostic capability for preoperative evaluation.

A DIFFERENTIATED APPROACH IN THE TREATMENT OF ACUTE FLOATING VENOUS THROMBOSIS OF THE INFERIOR VENA CAVA SYSTEM

We analyzed the results of surgical treatment floating DVT. Unfortunately, there are no randomized studies in the world regarding the determination of clear tactical approaches to the treatment of floating venous thrombosis, in many cases doctors make decisions about the choice of surgical tactics based on their own experience. In our research, we tried to systematize our own experience and form the basic principles of determining surgical tactics in the treatment of floating venous thrombosis. To date, anticoagulants, surgical interventions in the form of thrombectomy, and thrombolytic therapy are used in the treatment of DVT. Unfortunately, at the moment, no consensuses clearly define the issues of surgical treatment of floating venous thrombosis, venous thrombosis in pregnant women, venous thrombosis complicated by pulmonary embolism, venous thromboembolism.&#x0D; The goal. The aim of the research was to develop a surgical tactics in the treatment of floating DVT of the inferior vena cava.&#x0D; Materials and methods. The treatment of 76 patients with floating DVT from 2008 to 2020 were analyzed.&#x0D; In a research among patients with floating DVT in 15(20%) patients experienced thrombosis of the inferior vena cava, 19(25%) patients had ilio-femoral thrombosis in 17(22%) patients with femoral - popliteal thrombosis in 9(12%) patients with popliteal - tibial.&#x0D; Deep vein thrombosis complicated by pulmonary embolism with medium and high risk of death was observed in 10 (13%) patients. Among them, floating thrombosis of the iliac-femoral segment was observed in 4 patients.&#x0D; Floating thrombosis of deep veins in pregnant women was observed in 6 (8%) patients.&#x0D; Among patients, 20 (296%) patients were admitted within 1 day of the onset of the disease, 30 (39%) patients on 2-3 days, 11 (14%) patients on 4-7 days, 8 on 8-14 days (11%) patients, from the 15th day - 7 (10%) patients).&#x0D; The results. Patients with long of floating part of the more than 4 cm, we used an active surgical tactics. In the presence of the floating thrombus a total iliac vein thrombectomy we performed in 12 patients with the removal of the floating thrombus with femoral access. For the prevention of pulmonary embolism in these cases we implanted a temporary cava-filter. When flotation thrombus in the external iliac vein, we used the technique of thrombectomy using Fogarty two catheters in 12 patients. When flotation clots in common femoral vein and distally using a vein thrombectomy with clamping head above floating thrombus. When treating patients with floating DVT, pulmonary embolism complicated with medium and high risk of death, we used systemic thrombolysis with pre- implantation temporary coffee filter in patients with floating DVT, pulmonary embolism complicated with medium and high risk of death, we used systemic thrombolysis with pre- implantation temporary coffee filter. In the presence of pregnancy and floating thrombosis thrombectomy was performed with the removal of the thrombus floating. In our research, when performing the surgical treatment of DVT no cases of pulmonary embolism during or after treatment were observed. In 100 % of patients after treatment has been a clinical improvement in all cases floating DVT was eliminated floating nature of the danger of thrombosis and pulmonary embolism.&#x0D; Conclusions. In the presence of a floating DVT of the inferior vena cava system with a length of the floating part of the thrombus greater than 4 cm, it is necessary to use an active strategy of thrombus removal. When performing thrombectomy, it is necessary to use methods of surgical prevention of PE, taking into account the localization of the floating part.