Partial Recanalization Research Articles

Effect of endovenous ablation assessment stratified by great saphenous vein size, gender, clinical severity, and patient-reported outcomes

ObjectiveThe policies of insurance carriers have used the truncal vein size as a criterion for coverage. The objective of the present study was to compare the effect of great saphenous vein (GSV) size ≥5 mm vs <5 mm on patient presentation and clinical outcomes. MethodsPatients in a national cohort were prospectively captured in the Vascular Quality Initiative Varicose Vein Registry. From January 2015 to October 2017, the Vascular Quality Initiative Varicose Vein Registry database was queried for all patients who had undergone varicose vein procedures. The CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, Venous Clinical Severity Score, and patient-reported outcomes were compared by GSV size (<5 mm, group 1; ≥5 mm, group 2) before and after the procedures. A 2-sample Wilcoxon test was performed to assess the differences between the 2 groups stratified by GSV size. To assess for postoperative improvement, a matched-pairs Wilcoxon signed rank test was performed for each group separately. ResultsDuring the study period, 5757 vein ablation procedures had been performed for GSV: 770 for GSV size <5 mm and 4987 for GSV size ≥5 mm. Patients in group 1 were more likely to be women (81.7% vs 68.4%; P = .001) and older (56.8 vs 55.6 years; P = .012). The CEAP clinical class was more advanced in group 2 than in group 1 (P = .001). The maximal GSV diameter in group 2 was significantly greater than in group 1 (8.32 vs 3.86 mm; P = .001); 64% of group 2 and 59.2% of group 1 had undergone radiofrequency thermal ablation (P = .001). No mortalities occurred in either group. Group 2 had more complications postoperatively (0.6% vs 0%; P = .027), required postoperative anticoagulation (8.8% vs 5%, P = .001), developed partial recanalization (0.8% vs 0.3%; P = .001), and missed more work days (2.32 vs 1.6 days) compared with group 1. A similar rate of hematoma developed in both groups, but group 1 had a higher rate of paresthesia. Both groups had improvement in the Venous Clinical Severity Score and HASTI (heaviness, achiness, swelling, throbbing, itching) score. The degree of symptomatic improvement between the 2 groups was similar. ConclusionsAll patients demonstrated improvement in both clinical outcomes and patient-reported outcomes after endovenous ablation, regardless of GSV size. Patients with a preoperative GSV size ≥5 mm experienced similar improvement in symptoms but an increased complication rate. Patients with a smaller vein size should not be denied intervention or coverage by vein size.

Early Recanalization in Patients With Cerebral Venous Thrombosis Treated With Anticoagulation.

Background and Purpose- The hypothesis that venous recanalization prevents progression of venous infarction is not established in patients with cerebral venous thrombosis (CVT). Evidence is also scarce on the association between residual symptoms, particularly headache, and the recanalization grade. We aimed to assess, in patients with CVT treated with standard anticoagulation, (1) the rate of early venous recanalization, (2) whether lack of early recanalization was predictor of parenchymal brain lesion progression, and (3) the prevalence and features of persistent headache according to the recanalization grade achieved. Methods- PRIORITy-CVT (Pathophysiology of Venous Infarction - Prediction of Infarction and Recanalization in CVT) was a multicenter, prospective, cohort study including patients with newly diagnosed CVT. Standardized magnetic resonance imaging was performed at inclusion (≤24 hours of therapeutic anticoagulation), days 8 and 90. Potential imaging predictors of recanalization were predefined and analyzed at each anatomical segment. Primary outcomes were rate of early recanalization and brain lesion progression at day 8. Secondary outcomes were headache (days 8 and 90) and functional outcome (modified Rankin Scale at days 8 and 90). Results- Sixty eight patients with CVT were included, of whom 30 (44%) had parenchymal lesions. At the early follow-up (n=63; 8±2 days), 68% (n=43) of patients had partial recanalization and 6% (n=4) full recanalization. Early recanalization was associated both with early regression (P=0.03) and lower risk of enlargement of nonhemorrhagic lesions (P=0.02). Lesions showing diffusion restriction (n=12) were fully reversible in 66% of cases, particularly in patients showing early venous recanalization. Evidence of new or enlarged hemorrhagic lesions, headache at days 8 and 90, and unfavorable functional outcome at days 8 and 90 were not significantly different in patients achieving recanalization. Conclusions- Venous recanalization started within the first 8 days of therapeutic anticoagulation in most patients with CVT and was associated with early regression of nonhemorrhagic lesions, including venous infarction. There was an association between persistent venous occlusion at day 8 and enlargement of nonhemorrhagic lesions.

Budd-Chiari syndrome at the young woman with thrombophilia and myeloproliferative disease

In the clinic of various diseases (especially hematological) Budd-Chiari syndrome occupies a signifi cant place. The occurrence of blood fl ow disorders in the portal vein system can be a manifestation and the only symptom that manifests itself in a number of diseases. Given the rapid development of portal hypertension, this syndrome requires rapid diagnosis and timely initiated therapeutic measures, as well as comprehensive research to identify the etiological cause of Budd-Chiari syndrome.Objectives: In this paper we demonstrated a clinical case of a young patient with Budd-Chiari syndrome, an unusual course and a combination of etiological factors.Materials and methods. Data from the medical history of the patient who was on treatment at the surgical department of the City Multi-profile Hospital № 2, Military-medical Academy St. Petersburg were used as materials.Result. The patient developed severe ascites 3 months after delivery, for which she was unsuccessfully examined by gynecologists to exclude ovarian tumors. Then, in the course of laboratory and instrumental studies, a final diagnosis was made of Budd-Chiari syndrom (thrombosis of the intrahepatic part of the inferior vena cava in the phase of partial recanalization against the background of chronic myeloproliferative disease and genetically determined thrombophilia.Conclusion: As this case shows, in the development of non-cirrhotic portal hypertension, it is necessary to exclude hepatic thrombosis, in the detection of which it is recommended to conduct a comprehensive examination to exclude all causes of this thrombosis (genetic analysis for thrombophylia, antiphospholipid syndrome, Jak-2 v617f for exclude polycythemia and myelofi brosis, examination for cancer pathology). Manifestation and the only symptom of thrombophilia and idiopathic myelofi brosis may be acute Budd-Chiari syndrome, which requires complex medical and surgical treatment, further observation and especially treatment of causal diseases.

Graft and patient survival in portal vein thrombosis in living donor liver transplantation

Abstract Background and Rational To date, only few studies have evaluated the benefits of anticoagulation in individuals with cirrhosis. An obvious goal of anticoagulation is PV recanalization: when cirrhotic individuals with PVT are treated with anticoagulation, complete recanalization has been described in 33–45% while partial PV recanalization is observed in 15–35% of cases. LDLT has emerged as the alternative life-saving treatment to DDLT. Over the past 2 decades, the number of LDLTs has steadily increased in many transplant centers, especially in Asia. The separation between occlusive and non-occlusive thrombosis is very important; in patients with partial PVT, post-transplant mortality outcomes are no different from non-PVT patients but it is significantly increased in patients with complete PVT. Patients and Methods This randomized prospective study will include 79 patients who will undergo LDLT in Ain Shams Specialized and Egypt Air hospitals, there are two groups of patients according to presence of portal vein thrombosis or not group A 39 patients of non PVT and group B 40 patient of PVT including different grades of PVT according Yerdel classification. Results In this study, there is no significant difference between groups regard age but Males were significantly associated with group B. In this study, there is no significant difference between groups regard CHILD and MELD scores and this findings. In our study there is no significantly difference between groups A and B regarding ICU stay, hospital stay and cell saver. In this study, comparisons of the PVT patients and controls showed no statistical significant differences regard HA thrombosis, post operative pulmonary embolism and biliary leak but PV rethrombosis is significantly associated with PVT patients, mortality sig associated with PVT patients. Conclusion The outcomes of patients with PVT who underwent LDLT are inferior to those without PVT. Patients with PVT has lower survival rate, higher postoperative PV rethrombosis.

Abstract No. 376 A chronic comparison of clinically used embolic agents with GPX in domestic swine

Embolics vary in their handling, occlusion properties, and histological response. The purpose of this study was to examine these characteristics in a chronic animal study (30, 90 days) using the preclinical GPX embolic agent and several comparison devices. GPX is a liquid embolic agent that does not rely on precipitation from DMSO or in situ polymerization. Instead, it is comprised of oppositely charged polymers that remain dissolved in water at high salt concentrations and form a solid in physiological conditions. Previous short-term studies have shown reliable occlusions with minimal non-target embolization. In 10 swine, standard endovascular technique was used to introduce a microcatheter into the target site. Embolization was performed in a single pole of each kidney and in two distinct arterial sites in the liver. In addition to GPX (n = 15), NBCA (n = 7), Onyx-34 (n = 5), PVA-200 (n = 6), and coils (n = 6) were used as comparisons. Flow was monitored before and after embolization using the AFA flow scale. Handling and performance attributes were assessed on a semi-quantitative (1-5) scale. Post procedure blood chemistry and clinical signs were monitored. Angiograms were performed prior to termination at 30 or 90 days (5 pigs each). All embolizations achieved stasis initially (AFA = 0). In the physician survey, liquids rated similar in radiographic visualization and ability to occlude, but GPX achieved higher scores in ease of prep and ease of delivery, which were statistically significant. No abnormalities in blood chemistry were found following the procedure. In the 30-day group, all sites embolized with GPX (8) and NBCA (4) remained occluded (AFA = 0) with no device migration. Some partial angiographic recanalization (AFA = 1 or 2) was observed with coils (3/3), Onyx (1/3) and PVA (2/3). Necropsy revealed hard infarcts in the areas embolized with GPX, consistent with the angiography. No adverse effects from the devices were seen. Histopathology and 90-day data will be presented. GPX and NBCA produced stable, long-term occlusions at 30 days while partial recanalization was seen with Onyx, PVA, and coils. All animals remained healthy, and the devices were well tolerated.

3:27 PM Abstract No. 320 Management of portal vein thrombosis in cirrhotic patients

To compare the efficacy of transjugular intrahepatic portosystemic shunt (TIPS) to anticoagulation and no treatment in cirrhotic patients with portal vein thrombosis (PVT). This single-center retrospective study evaluated 64 consecutive cirrhotic patients with imaging diagnosis of PVT between November 2005 and July 2019. 15 patients were excluded due to lack of adequate follow-up imaging. Of the remaining 49 patients, 11 (22%) were female. The median age was 61.5 (range, 24-80) years. 9 (18%) patients were treated with TIPS, 12 (24%) with anticoagulation, and 28 (57%) received no treatment. Demographic and clinical data were collected by reviewing the electronic medical record. PVT was evaluated using contrast-enhanced CT or MRI. Thrombus burden in the main portal (MPV), superior mesenteric (SMV), and splenic (SV) vein was graded as follows: grade 1, < 25%; grade 2, 26-50%; grade 3, 51-75%; and grade 4, > 75% of the luminal diameter. Yerdel scoring system was also used to evaluate the extent of portomesenteric thrombus. Thrombus burden at 6 and 12 months was compared to baseline imaging. Patient survival was estimated using Kaplan-Meier analysis. The extent of baseline thrombus was compared using Kruskal-Wallis test. Treatment response was analyzed by chi square test. There was no statistically significant difference in baseline thrombus burden between the 3 groups (MPV, P = 0.345; SMV, P = 0.244; SV, P = 0.541; Yerdel grade, P = 0.230). At 6 months, 87.5%, 58.3%, and 4.8% patients demonstrated complete or partial recanalization in the TIPS, anticoagulation, and no treatment groups respectively (TIPS/no treatment, P <0.0001; TIPS/anticoagulation, P = 0.163). At 12 months, 100%, 57.1%, 11.1% patients demonstrated complete or partial recanalization in the TIPS, anticoagulation, and no treatment groups respectively (TIPS/no treatment, P <0.0001; TIPS/ anticoagulation, P = 0.051). The overall survival between the 3 groups was not significantly different (P = 0.788) TIPS has significantly higher recanalization rate compared to no treatment and has a trend towards higher recanalization rate than that of anticoagulation at 6 and 12 months in cirrhotic patients with PVT.

Abstract 106: Safety and Efficacy of Sonothrombolysis in Acute Ischemic Stroke Patients With Large Vessel Occlusion: International Collaborative Individual Patient Data Meta-Analysis

Introduction: Conflicting evidence has been published regarding the safety and efficacy of ultrasound-enhanced thrombolysis (sonothrombolysis) in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). Methods: We conducted an individual participant data meta-analysis of available randomized controlled trials (RCTs) comparing sonothrombolysis with or without addition of microspheres (treatment group) to intravenous thrombolysis alone (control group) in AIS patients with LVO. Results: We included 6 in total RCTs that enrolled 1077 AIS patients. A total of 138 and 134 confirmed LVO patients were randomized to treatment and control groups respectively (median age 68 years, 58% men, median baseline NIHSS score 16). Patients randomized to sonothrombolysis had increased odds of complete recanalization compared to patients receiving intravenous thrombolysis alone (40.3% vs. 22.4%; OR=2.30, 95%CI: 1.05-5.02; adjusted OR=2.33, 95%CI: 1.02-5.34). They also tended to have increased odds of any (complete or partial recanalization (66.4% vs. 53.0%; OR=1.78, 95%CI: 0.95-3.33; adjusted OR=1.85, 95%CI: 0.97-3.53). The likelihood of symptomatic intracranial hemorrhage did not differ between the two groups (7.3% vs. 3.7%, OR=2.52, 95%CI: 0.77-8.29; adjusted OR=2.55, 95%CI: 0.76-8.52). No differences in the likelihood of asymptomatic intracranial hemorrhage (adjusted OR: 1.30, 95%CI: 0.38-4.39), three-month mortality (adjusted OR: 1.23, 95%CI: 0.25-6.05), three-month favorable functional outcome (mRS-scores of 0-1; adjusted OR: 1.43, 95%CI: 0.64-3.19) and three-month functional independence (mRS-scores of 0-2; adjusted OR: 1.43, 95%CI: 0.77-2.64) were documented. Conclusion: Sonothrombolysis was associated with a two-fold increase in the odds of complete recanalization compared to intravenous thrombolysis alone in AIS patients with LVOs. Further study of the safety and efficacy of sonothrombolysis is warranted.

Transjugular intrahepatic portosystemic shunt is an effective and safe treatment of cirrhotic patients with portal vein thrombosis or cavernoma

TIPS is a well established treatment in selected patients with refractory ascites and/or gastrointestinal bleeding (GIB). Whether TIPS may also be a safe and effective therapeutic option for cirrhotic patients with chronic portal vein thrombosis (PVT) or cavernoma is still not clear. We Investigated the feasibility, safety and efficacy of TIPS in cirrhotic patients with PVT. All consecutive patients with PVT or cavernoma undergoing TIPS placement from April 2014 to April 2019 in GOM Niguarda are here considered. All patients completed at least 6 months of follow-up after TIPS. Of 153 patients undergoing TIPS insertion, 50(32%) had cirrhosis complicated by PVT or cavernoma. In 11 cases(22%) PVT was associated with GIB, in 16 (32%) with ascites. 32(64%) patients had failed recanalization while on anticoagulation, 18 could not be anticoagulated for contraindications. Majority of patients was male (72%), leading etiologies were post-viral and post-alcohol cirrhosis. Median age was 57 years. Median MELD was 14 (range 8–18). TIPS placement was technically feasible in 96%(48/50)of patients. PVT extension is described in table 1. Trans-splenic approach was necessary in 8/50(16%). Early post-TIPS complications were: hemoperitoneum (3 cases,6%), sovra-hepatic vein occlusion (1 case,2%) and systemic infection (6 cases, 12%). During follow-up 94%(15/16) recovered ascites and 15 patients(30%) had at least 1 portosystemic-encephalopathy episode; 33/48 (68%) patients had a complete recanalization and 11/48 (22%) had a partial recanalization. Liver related mortality was 6%. 18 patients were listed to transplantation after achieving portal patency, 6 have been already transplanted, 8 are on waiting list and 4 could be delisted for clinical improvement. TIPS in cirrhotic patients with PVT with or w/o cavernoma is effective and well tolerated. Complete recanalization was achieved in 2 patients out of three, obtaining a clinical beneficial effect on symptomatic PH. Recanalization allowed patients to be listed for LT when needed

Upper extremity deep vein thrombosis treated with direct oral anticoagulants: a multi-center real world experience.

Upper-extremity deep vein thrombosis (UEDVT) accounts for about 5-10% of all cases of deep vein thrombosis (DVT). It is often associated with cancer and/or presence of a central venous catheter (CVC), but it may also occur in the absence of these favoring conditions. The safety and efficacy of using direct oral anticoagulants (DOACs) in subjects with UEDVT has not been systematically evaluated and the only data available in the literature derive from anecdotal evidence, analysis of registries, and small single-centre studies. In addition, a specific analysis of UEDVT not associated with cancer and/or CVC has never been made. In this study, we specifically focused on patients with no cancer and without a CVC who were diagnosed with a first episode of UEDVT and were treated with a DOAC. We studied 61 patients, treated in six Italian centres between January 2014 and December 2018. Treatment lasted at least 3months in all patients. In terms of efficacy, no recurrence of thrombosis or pulmonary embolism were recorded, while Doppler ultrasonography, performed after at least three months of treatment, documented in all cases either partial or complete recanalization of obstructed veins. In terms of safety, no cases of major bleedings were recorded. This is the only series available in the literature of patients treated with DOACs for UEDVT not associated with cancer and/or CVC. This small multicenter real world experience supports the concept that DOACs might be safe and effective for treating UEDTV. Further studies are required to better understand the role of DOACs in these patients.

Timing of Recanalization and Functional Recovery in Acute Ischemic Stroke

Background and PurposeAlthough onset-to-treatment time is associated with early clinical recovery in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (tPA), the effect of the timing of tPA-induced recanalization on functional outcomes remains debatable. MethodsWe conducted a multicenter, prospective observational cohort study to determine whether early (within 1-hour from tPA-bolus) complete or partial recanalization assessed during 2-hour real-time transcranial Doppler monitoring is associated with improved outcomes in patients with proximal occlusions. Outcome events included dramatic clinical recovery (DCR) within 2 and 24-hours from tPA-bolus, 3-month mortality, favorable functional outcome (FFO) and functional independence (FI) defined as modified Rankin Scale (mRS) scores of 0–1 and 0–2 respectively. ResultsWe enrolled 480 AIS patients (mean age 66±15 years, 60% men, baseline National Institutes of Health Stroke Scale score 15). Patients with early recanalization (53%) had significantly (jos-2019-01648P<0.001) higher rates of DCR at 2-hour (54% vs. 10%) and 24-hour (63% vs. 22%), 3-month FFO (67% vs. 28%) and FI (81% vs. 39%). Three-month mortality rates (6% vs. 17%) and distribution of 3-month mRS scores were significantly lower in the early recanalization group. After adjusting for potential confounders, early recanalization was independently associated with higher odds of 3-month FFO (odds ratio [OR], 6.19; 95% confidence interval [CI], 3.88 to 9.88) and lower likelihood of 3-month mortality (OR, 0.34; 95% CI, 0.17 to 0.67). Onset to treatment time correlated to the elapsed time between tPA-bolus and recanalization (unstandardized linear regression coefficient, 0.13; 95% CI, 0.06 to 0.19). ConclusionsEarlier tPA treatment after stroke onset is associated with faster tPA-induced recanalization. Earlier onset-to-recanalization time results in improved functional recovery and survival in AIS patients with proximal intracranial occlusions.

Ultrasound Aspects and Recanalization Rates in Patients with Lower-Limb Deep Venous Thrombosis Treated with Rivaroxaban

In this article, we report the ultrasound aspects and recanalization rates of patients with deep venous thrombosis (DVT) in the lower limbs treated with the rivaroxaban, focusing on the recanalization rate and the ultrasonographic aspects. This was a prospective and consecutive cohort study of patients admitted with DVT who were submitted to treatment with rivaroxaban for 6months at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil, between March 2016 and July2018. Fifty-one patients with DVT were admitted to the Vascular Surgery Department and received rivaroxaban for 6months. The follow-up time was 360days. Analyses were performed at 180 and 360days. The rate of total venous recanalization at 360days was 76.4% (39 patients). The incidence of partial venous recanalization was 23.5% (12 patients). At the first month, 11 patients (21.7%) continued with total occlusion of the vein, with 4 patients (6.5%) with no residual thrombi. However, at 6months, only 2 patients (2.2%) continued with total occlusion of the vein, with 26 patients (47.8%) with no residual thrombi. At 12months, there were 39 patients (76.4%) with no residual thrombi. Univariate and multivariate logistic regression identified the following factors related to total venous recanalization: the absence of popliteal vein reflux (odds ratio [OR], 0.386; P=0.007), no residual thrombi (OR, 3.213; P=0.008), femoropopliteal clot length at 1month (OR, 3.021; P=0.016), femoropopliteal clot length at 6months (OR, 2.234; P=0.008). The incidence of post-thrombotic syndrome (PTS) at 12months was 8.3%. In this study, patients who received oral rivaroxaban displayed satisfactory total vein recanalization rate after 6months and 12months. The factors associated with better total recanalization rates were the absence of popliteal vein reflux, the absence of residual thrombi in the veins, femoropopliteal clot length at 1month (OR, 3.021; P=0.016), and femoropopliteal clot length at 6months (OR, 2.234; P=0.008). Moreover, the incidence of PTS at 12months was 8.3%.

Effective use of various minimally invasive technologies eliminating vertical reflux in the treatment of chronic diseases of the lower limb veins

The aim: To analyze and evaluate the efficacy of CDLLV treatment, using high-frequency endovascular welding (EVW), endovenous laser coagulation (EVLC) and catheter microfoam echosclerotherapy. Materials and methods: We have treated 329 patients with CDLLV C2-C6 functional classes according to the Clinical Etiological Anatomical Pathophysiology. Of these, 102 patients had vertical reflux eliminated by EVW, in 112 - by EVLC, and in 115 - by catheter microfoam echosclerotherapy. Results: In the EVW group 3 patients (2.94%) had a partial recanalization of coagulated veins 3 months after the procedure. In EVLC group 2 patients (1.79%) also had partial recanalization group after 6 months. In the group of catheter microfoam echosclerotherapy partial recanalization occurred in 3 patients during 3 months of observation, in the period of 6 months - in 2, in the period of 12 months - in 9, in total - in 14 patients (12.17%). The EVW and EVLC methods showed high efficacy of vertical reflux elimination on the great and small subcutaneous veins (GSV/SSV) in CDLLV and have no fundamental differences in the immediate and long-term results of treatment. Microfoam catheter echosclerotherapy leads to a greater number of recanalisations, compared with EVW and EVLC. Conclusions: High-frequency endovenous welding results in complete fibrotic GSV/SSV transformation in 97.06% of patients. Endovascular laser coagulation results in complete fibrotic GSV/SSV transformation in 98.21% of patients. Elimination of vertical reflux by microfoam echosclerotherapy results in complete fibrotic GSV/SSV transformation in 87.83% of patients.

Direct Thrombin Inhibitors as the Primary Treatment Modality for Cerebral Venous Sinus Thrombosis (CVST)

Background: Cerebral venous sinus thrombosis (CVST) is an uncommon entity with improved clinical outcome over time due to utilization of advanced diagnostic tools and effective treatment modalities. Previous treatment regimen pertained to primarily medical therapies, with use of anticoagulants like Coumadin and Heparin. However the advent of Direct Thrombin Inhibitors (DTI) which do not need regular monitoring of blood coagulation panel and has better safety profile than Coumadin, has been suggested as a treatment modality for CVST in recent literature. Case Description: It is a case series of 3 adult patients presenting with intracerebral hemorrhage secondary to CVST from occlusion of dural venous sinuses. Dabigatran, a DTI was used as the primary treatment modality for a period of 6 months for 2 patients who had identifiable underlying cause and lifelong for 1 patient who had no identifiable underlying cause for dural sinus thrombosis. Patients has been followed for a total period of six months while on DTI treatment, with Magnetic Resonance Venography (MRV) of the brain performed at 6 months follow up visit to assess recanalization of the obstructed dural sinuses. All the 3 patients had improved clinical outcome at 6 months follow up visit with no added morbidity upon using DTI. Two patients had complete recanalization of obstructed venous sinuses, while 1 patient had partial recanalization at 6 months follow-up visit. No patient had increased hematoma volume while on treatment with DTI. Conclusion: This case series suggests DTI are probably effective primary treatment modality for patients with CVST with good safety profile.

COMPARATIVE EVALUATION OF THE RESULTS OF SURGICAL TREATMENT OF ACUTE ASCENDING THROMBOPHLEBITIS OF THE GREAT SAPHENOUS VEIN USING THE ENDOVASCULAR HIGH-FREQUENCY WELDING TECHNIQUE AND TRADITIONAL TECHNIQUE

The aim of the study was to conduct a comparative evaluation of the effectiveness of surgical treatment of acute ascending thrombophlebitis of the great saphenous vein using the endovascular high-frequency welding technique and traditional phlebectomy. Materials and methods: Two groups were formed in the conducted study. Group I included patients (n=42) with the acute ascending thrombophlebitis of the great saphenous vein, in whom their thrombosed great saphenous vein was removed using the endovascular high-frequency welding technique. As a source of current, an EK300M1 Svarmed electric welding machine (Ukraine) was used. Electric welding of a thrombosed vein segment was carried out using the endovenous electric welding catheter. Group II included patients (n=31) with the acute ascending thrombophlebitis of the great saphenous vein, who underwent the traditional phlebectomy of the thrombosed great saphenous vein according to Babcock's technique. Results: In group I no patient revealed presence of pain syndrome with significant intensity during the postoperative period. An infiltrate along the coagulated segments ofnthe great saphenous vein, postoperative oedema and paresthesiae were observed in considerably fewer cases from group I versus group II (р=0.0005, р=0.0001, р=0.0018). During their follow-up for more than 12 months, 2 (4.76 %) of 42 patients from group I revealed partial recanalization of the great saphenous vein (р=0.632). In group I the postoperative inpatient period was 1.3±0.1 days. In group II the above period averaged 4.8±0.8 days (p<0.001). Absence of an intense pain syndrome in group I was caused by a gentle effect of high-frequency electric current itself on the venous wall and paravasal structures. A significant reduction of side effects and complications with a shorter stay of patients in hospital versus the traditional phlebectomy was achieved owing to reduction in the extent of injury of the surgical operation itself with the use of endovascular high-frequency welding. Conclusions: The technique of endovascular high-frequency welding in treatment of acute ascending thrombophlebitis of the great saphenous vein makes it possible to reduce the extent of injury of the surgical operation versus the traditional phlebectomy, results in a significant decrease in the number of side effects and complications and shortens the period of the patient's stay in hospital.

LEV 2. Comparison of the Recanalization Rate and Post-thrombotic Syndrome in Patients With Deep Venous Thrombosis Treated With Rivaroxaban or Warfarin

In this paper, we report the outcomes of patients with deep venous thrombosis (DVT) in the lower limbs treated with the oral anticoagulant rivaroxaban or warfarin, focusing on the recanalization rate (measured with duplex ultrasound) and the incidence of post-thrombotic syndrome (PTS). This was a prospective, consecutive, randomized, blind cohort study of patients admitted with DVT to the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil, between March 2016 and July 2018. The patients were randomized into two groups and treated with oral anticoagulation for 6 months: either rivaroxaban (group 1) or warfarin (group 2). The study was registered at ClinicalTrials.gov under NCT02704598. Eighty-eight patients with DVT were admitted to the vascular surgery department and randomized into the two groups. The follow-up time was 360 days. Analyses were performed at 180 and 360 days. Four patients were excluded from the study during follow-up because of a diagnosis of ovarian cancer (one patient), head and neck cancer (one patient), lung cancer (one patient), and stomach cancer (one patient). Therefore, 84 patients were evaluated: 46 patients in group 1 and 38 in group 2. The incidence of PTS (Table I) was 17.9% (15 cases) in the total cohort but was significantly higher in group 2 (11 cases [28.9%]) than in group 1 (4 cases [8.7%]; P < .001; odds ratio, 4.278). The rate of total venous recanalization at 360 days was 40.5% (34 patients) in the total cohort but was significantly higher in group 1 (35 patients [76.1%]) than in group 2 (5 patients [13.2%]; P < .001). The incidence of partial venous recanalization was 46.4% and was significantly higher in group 2 (28 patients [73.7%]) than in group 1 (11 patients [23.9%]; P = .016). Five patients in the total cohort (6%) showed no venous recanalization, all of them in group 2 (P = .016; Table II). In this study, patients who received oral rivaroxaban displayed a lower incidence of PTS and a better total vein recanalization rate after 6 and 12 months than patients who received warfarin.Table IVillalta score and post-thrombotic syndrome (PTS) at 6 months and 12 monthsVariableTotal (N = 84)Group 1 (n = 46 [54.7%])Group 2 (n = 38 [45.3%])P valueVillalta score <566 (78.5)42 (91.3)24 (63.1).025 5-914 (16.6)4 (8.7)10 (26.3).012 10-144 (4.9)04 (10.5).007PTS at 6 months <518 (21.4)4 (8.7)14 (37.8)<.001 5-969 (82.1)42 (91.3)27 (71.1).025 10-1411 (13.1)4 (8.7)7 (18.4).012PTS at 12 months4 (4.8)04 (10.5).007Segment affected and PTS at 12 monthsa15 (17.9)4 (8.7)11 (28.9)<.001 Femoropopliteal10 (14)3 (8.6)8 (22.2)<.001 Iliofemoral4 (28.6)1 (9.1)3 (100)<.001Values are reported as number (%).aPercentage refers to the incidence of deep venous thrombosis in the segment. Open table in a new tab Table IIUltrasound data on venous flow at admission and at 3 months, 6 months, and 360 daysVariableTotal (N = 84)Group 1 (n = 46 [54.7%])Group 2 (n = 38 [45.3%])P valueAt admission Occlusion78 (92.9)43 (93.5)35 (92.1).56 Partial flow6 (7.1)3 (6.5)3 (7.9).56At 3 months Occlusion8 (9.5)1 (2.2)7 (18.4).006 Partial flow60 (71.4)33 (71.7)27 (71.1).006 Total flow16 (19)12 (26.1)4 (10.5).006At 6 months Occlusion5 (6)05 (13.5).001 Partial flow50 (59.5)21 (45)29 (76.3).001 Total flow25 (29.8)22 (47.8)3 (7.9).001At 360 days Occlusion5 (6)05 (13.2)<.001 Partial flow38 (45.2)10 (21.7)28 (73.7)<.001 Total patency41 (48.8)36 (78.3)5 (13.2)<.001Values are reported as number (%). Open table in a new tab

Acute portal vein thrombosis in noncirrhotic patients – different prognoses based on presence of inflammatory markers: a long-term multicenter retrospective analysis

Background: Portal vein thrombosis (PVT) is a partial or complete thrombotic occlusion of the portal vein and is rare in noncirrhotic patients.Patients and methods: 78 adult patients with noncirrhotic acute PVT without known malignity were evaluated. Patients with initial CRP level 61–149 mg/l were excluded.Results: Patients were divided into two groups – the first one (33 patients) was characterized with signs of inflammation and CRP over 149 mg/l. The second group (45 patients) was without signs of inflammation and CRP level less than 61 mg/l. The frequency of prothrombotic hematologic factors was statistically significantly different in levels of factor VIII and MTHFR 677 C mutation. All patients from both groups underwent the same oncologic and hemato-oncologic screening which was positive in 23 patients (51.1%) in the group without signs of inflammation. In the group of patients with clinical and laboratory signs of inflammation oncologic and hemato-oncologic screening was positive only in 1 patient (3.0%). Complete portal vein recanalization was achieved in 19.2%, partial recanalization in 26.9%.Conclusions: Patients with clinical signs of inflammation and acute PVT have a low risk of malignancy in contrast to patients without signs of inflammation and acute PVT, which have a high risk of oncologic or hemato-oncologic disease. Patients with negative hemato-oncologic screening should be carefully observed over time because we expect they are at higher risk for the development of hemato-oncologic disease, independent from the presence and number of procoagulation risk factors.

Long-term results after the application of the high-frequency endovenous electric welding on the trombosed great saphenous veins of lower extremities according to morphological and ultrasonography data

The aim — to study morphological and ultra‑sonic changes in the thrombosed magistral vein after the high‑frequency endovascular electric welding and to determine the effectiveness of the method for the acute ascending thrombophlebitis treatment.Materials and methods. Surgical treatment of 52 male and female patients with acute ascending thrombophlebitis of the great subcutaneous vein was performed in the surgical departments during the period from 2016 to 2018, in which the endovenous high‑frequency electro welding with the EK300M Svarmed (Ukraine) apparatus was done. Their age ranged from 19 to 78 years old (average age — 51.28 ± 2.63 years). С2 stage was registered for 4 patients, С3 — for 19, С4 — for 13, С5 — for 9, С6 — for 7 according to the international CEAR (Clinical Etiological Anatomical Pathophysiological) classification. The morphological study of sections was carried out. Photos were archived with the light optical microscope Zeiss (Germany) and the Axio Imager. A2 data processing system. Ultrasonic duplex angioscanning was carried out by the Toshiba Nemio XG (Japan) device with a curvilinear transducer with at working frequency of 3.5 — 5 MHz and a linear transducer in the range of 7.5 — 12 MHz. The ultrasound examination was performed in 2 — 7 days after the surgery, the remote results were evaluated in 3.6.12 months.Results and discussion. A morphological study of vein preparations revealed homogenization of thrombotic masses in the vein’s lumen, a close connection of the latter with the treated vessel wall. In most cases, the thrombotic masses totally obstructed the lumen of the vein. All layers of the vein wall merged into a single homogeneous complex. With specific coloring on elastic fibers, their total destruction in the inner and middle layers, thinning and fragmentation of adventitia elastic fibers were revealed. Ultrasound examination showed complete occlusion of the great saphenous vein on the 2nd — 7th day in 49 (94.24 %) cases. Partial recanalization was detected after 3 — 6 months in 3 (5.76 %) cases, after 9 — 12 months in 2 (3.84 %) cases the partial hemodynamically insignificant recanalization was preserved according to color mapping. In 1 case (1.92 %) there was a complete, hemodynamically significant recanalization of the whole welded segment of the great subcutaneous vein. The analysis of ultrasonic testing showed that, despite the complete destruction of the entire vein wall, during the first days after the endovascular electric welding in 5.76 % of the welded great subcutaneous vein, areas of the wall blood flow were detected.Conclusions. Endovascular high‑frequency electrical welding of the thrombosed great subcutaneous vein for acute ascending thrombophlebitis causes complete destruction of the thrombotic masses and all layers of the vein wall; and in 94.24 % of cases it allows achieving a complete obliteration of the welded vein.

Mechano-Chemical Endo-Venous Ablation of Varicose Veins with Flebogrif Occlusion Catheter

AbstractBackground: Varicose veins may present a major health problem nowadays, as it has been detected in about 70% of population worldwide. This created a sense of urgency to develop less invasive techniques to manage such a condition.Aim of Study: The aim of this study was to evaluate the effectiveness and safety of mechano-chemical ablation tech-nique in management of varicose veins using the flebogrif endo-venous occlusion catheter.Patients and Methods: A total of 30 patients (35 lower limbs) had mechan-ochemical ablation for their varicose veins using the flebogrif endo-venous catheter; 22 for great saphe-nous vein (GSV) incompetence, 9 bilateral GSV, 3 shorts saphenous vein (SSV), one bilateral SSV and 2 combined unilateral great saphenous vein and SSV. Patients came back for follow-up one week, one month and 3 months post proce-dure having ultrasound duplex done. Recanalization, pigmen-tation, intra and post procedural pain were recorded, as post-operative complications.Results: All 35 procedures were under local anaesthesia. Complete occlusion of the treated vein was initially achieved in all the patients, but at 3 months' follow-up, there was only partial recanalization in 2 from 35 (6%) of the veins. Those two were successfully treated with additional complementary ultrasound guided foam sclerotherapy. No significant compli-cations were reported.Conclusions: Flebogrif is an effective treatment for chronic venous insufficiency of the long and short saphenous veins. Bilateral procedures can be successfully performed and toler-ated as can multiple veins in the same setting and same leg.

Variköz Venlerde Endovenöz N-Bütil Siyanoakrilat Tedavisi Sonuçlarımız

Aim: In this study, we aimed to evaluate the results of endovenous N-Butyl Cyanoacrylate (NBCA) technique which is a non-tumescence endovenous ablation technique in patients with varicose veins.Material and Methods: A total of symptomatic 542 patients with single or bilateral saphenofemoral failure who presented to our center between April 2014 and August 2016 were included in the study. NBCA was applied to 657 lower extremities of 542 patients, 115 of whom were bilateral. The patients had C2, C3, C4, C5, C6 venous insufficiency according to CEAP classification. Vena saphena magna (VSM) diameter was at least 5.5 mm at the knee level, at least 6 mm at the saphenofemoral junction (SFJ) level, and reflux time was 2 seconds or longer.Results: The mean CEAP classification of 657 lower extremities was 3.1±0.6, the VSM diameter was 6.7±1.1 mm at the knee level, 8.3±2.1 mm at the SFJ, the procedure time was 15.2±2.9 minutes, and the hospital stay was 1.7±0.6 hours. At 6 months follow-up, only 7 (1.1%) partial recanalization of VSM, 1 (0.2%) deep vein thrombosis in the popliteal vein in the lower limb, and 9 (1.4%) thrombophlebitis in the distal 1/3 segment at over the knee of VSM healing with medical treatment. All of the procedures were completed without any complications.Conclusion: Newly developing techniques rapidly replace traditional methods and increase patient comfort. NBCA; It has become an effective method among endovenous ablation therapies with its technical advantages, high success rates in early and midterm.

Comparison of the recanalization rate and postthrombotic syndrome in patients with deep venous thrombosis treated with rivaroxaban or warfarin

BackgroundIn this article, we report the outcomes of patients with deep venous thrombosis in the lower limbs treated with the oral anticoagulant rivaroxaban or warfarin, focusing on the recanalization rate (measured with duplex ultrasound) and the incidence of postthrombotic syndrome. MethodsThis was a prospective, consecutive, randomized, blind cohort study of patients admitted with deep venous thrombosis to the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil, between March 2016 and July 2018. The patients were randomized into 2 groups and treated with oral anticoagulation for 6 months: either rivaroxaban (group 1) or warfarin (group 2). The study was registered at clinicaltrials.gov under NCT 02704598. ResultsEighty-eight patients with deep venous thrombosis were admitted to the Vascular Surgery Department and randomized into the 2 groups. The follow-up time was 360 days. Analyses were performed at 180 and 360 days. Four patients were excluded from the study during follow-up because of a diagnosis of ovarian cancer (1 patient), head and neck cancer (1 patient), lung cancer (1 patient), and stomach cancer (1 patient). Therefore, 84 patients were evaluated: 46 patients in group 1 and 38 in group 2. The incidence of postthrombotic syndrome was 17.9% (15 cases) in the total cohort, but was significantly higher in group 2 (11 cases, 28.9%) than in group 1 (4 cases, 8.7%; P < .001; odds ratio, 4.278). The rate of total venous recanalization at 360 days was 40.5% (34 patients) in the total cohort, but was significantly higher in group 1 (35 patients, 76.1%) than in group 2 (5 patients, 13.2%; P < .001). The incidence of partial venous recanalization was 46.4% and was significantly higher in group 2 (28 patients, 73.7%) than in group 1 (11 patients, 23.9%; P = .016). Five patients in the total cohort (6%) showed no venous recanalization, all of them in group 2 (P = .016). ConclusionIn this study, patients who received oral rivaroxaban displayed a lower incidence of postthrombotic syndrome and a better total vein recanalization rate after 6 and 12 months than patients who received warfarin.