Percutaneous Venous Angioplasty Research Articles

Percutaneous Venous Angioplasty in Patients with Multiple Sclerosis and Chronic Cerebrospinal Venous Insufficiency: A Randomized Wait List Control Study

Venous percutaneous transluminal angioplasty (vPTA) in patients with multiple sclerosis (MS) and chronic cerebrospinal venous insufficiency (CCSVI) have shown contradictory results. The aim of the study is to evaluate the efficacy of the procedure in a randomized wait list control study. 66 adults with neurologist-confirmed diagnosis of MS and sonographic diagnosis of CCSVI were allocated into vPTA-yes group (n=31) or vPTA-not group (n=35, control group). vPTA was performed immediately 15days after randomization in the PTA-yes group and 6months later in the control group. Evoked potentials (EPs), clinical-functional measures (CFMs), and upper limb kinematic measures (ULKMs) were measured at baseline (T0) and six months after in both groups, just before the venous angioplasty in the vPTA-not group (T1). Comparing the vPTA-yes and vPTA-not group, the CFM-derived composite functional outcome showed 11 (37%) versus 7 (20%) improved, 1 (3%) versus 3 (8%) stable, 0 versus 7 (20%) worsened, and 19 (61%) versus 18 (51%) mixed patients (χ2=8.71, df=3, P=0.03). Unadjusted and adjusted (for baseline confounding variables) odds ratio at 95% confidence interval were, respectively, 1.93 (1.3-2.8), P value 0.0007, and 1.85 (1.2-1.7), P value 0.002. EP- and ULKM-derived composite functional outcome showed no significant difference between the two groups. Venous angioplasty can positively impact a few CFMs especially for the quality of life but achieving disability improvement is unlikely.

Posterior tibial vein approach to catheter-directed thrombolysis for iliofemoral deep venous thrombosis

ObjectiveDeep venous thrombosis (DVT) remains a significant cause of morbidity in the American population. Catheter-directed thrombolysis for acute iliofemoral DVT is an effective therapy not only to restore venous patency but also to reduce the development of post-thrombotic syndrome (PTS), especially in patients with extensive thrombosis involving the iliac and femoral venous segments. We hypothesized that delivery of thrombolytics through an access site in a vein distal to the segments containing thrombus would provide the greatest short- and long-term therapeutic clinical benefit with similar safety and efficacy. MethodsAll patients treated at a single institution between 2009 and 2016 undergoing mechanical and chemical thrombolysis for iliofemoral DVT were retrospectively reviewed. Patients were divided into groups by access site, including contralateral and ipsilateral femoral vein, popliteal vein, and posterior tibial vein (PTV). Preoperative demographics, intraoperative data, and postoperative outpatient charts were analyzed. Primary end points included evidence of incompetence after the procedure by duplex ultrasound assessment and development of complications of PTS as defined by the Villalta scale. ResultsFifty-eight patients underwent mechanical and chemical thrombolysis, and 51 patients met the inclusion criteria. Thrombolysis access was through PTV (n = 27), popliteal vein (n = 20), or femoral vein (n = 4). More patients were female (55%), and the mean age was 57 years. Forty patients had unilateral DVT, whereas 11 patients had bilateral involvement. After lysis, 44 patients underwent percutaneous venous angioplasty and 11 patients underwent venous stenting in the acute setting. Although not statistically significant, mean operative times were slightly longer in the posterior tibial approach (156.7 minutes vs 130.6 minutes; P = .08), and mean fluoroscopy time was higher in the posterior tibial group (18.1 minutes vs 14.3 minutes; P = .17). Overall 90-day morbidity was 9.8%, and no deaths were recorded. Patency of the deep venous system was similar between the posterior tibial and the popliteal or femoral approach (95% vs 88%; P = .29); 21.6% developed symptoms of PTS. There was no difference for development of PTS between posterior tibial and popliteal or femoral approaches (22% vs 20.8%; P = .52). There was no difference in development of chronic nonocclusive DVT (37% vs 35%; P = .61). Median follow-up was 8.7 months (range, 0.4-58.9 months). ConclusionsThe PTV approach to catheter-directed thrombolysis is a safe and sensible option for the treatment of iliofemoral and femoropopliteal DVT. A larger cohort will be necessary to demonstrate superiority of tibial vein access in the treatment of iliofemoral DVT with popliteal involvement.

Venous Hemodynamic Insufficiency Severity Score variation after endovascular treatment of chronic cerebrospinal venous insufficiency

Chronic cerebrospinal venous insufficiency (CCSVI) is a vascular condition characterized by anomalies of the internal jugular veins (IJVs) and/or azygos veins with disturbed flow and formation of collateral venous channels. The presence of CCSVI has been associated with multiple sclerosis (MS). Percutaneous venous angioplasty (PVA) has been proposed to improve extracranial outflow; however, a non-invasive, post-procedural follow-up outcome measure has not been established. To evaluate the short-term hemodynamic follow-up of CCSVI after PVA using color Doppler ultrasound (CDU) and to investigate whether hemodynamic variation correlated with clinical variation. Forty-five patients affected by MS with confirmed CCSVI underwent IJVs PVA. Venous hemodynamic (VH) parameters indicative of CCSVI and the Venous Hemodynamic Insufficiency Severity Score (VHISS) were evaluated by CDU at baseline and 3 months post-PVA. Concurrently, the MS-related disability status (EDSS) was evaluated. The VH parameters and VHISS 3 months after IJVs PVA significantly decreased: the VH parameters -32.1% and the VHISS -33.8% (p < 0.001). The EDSS score 3 months after IJVs PVA was significantly lower than the baseline (-5.5%, p < 0.001). Using the median value of the VHISS variation as the cut-off, we were able to identify two groups of patients: responders, group A; and non-responders, group B. The EDSS score variation at 3 months was 0.310 in group A and 0.275 in group B (p = 0.746). CCSVI endovascular treatment can induce an improvement in VH parameters and the VHISS. The neurological disability score (EDSS) also improved after PVA; however, there was no correlation to the VHISS variation after PVA, MS type and duration.

Surgery Remains the Most Effective Treatment for Paget-Schroetter Syndrome: 50 Years' Experience

Significant improvements were made in the diagnosis and management of Paget-Schroetter syndrome (thrombosis of the axillary-subclavian vein) secondary to thoracic outlet syndrome during the past 50 years. The diagnosis has often been extremely difficult. Multiple approaches both in diagnosis and therapy have been tried during the years. After recognizing that the underlying pathologic process resulted from an abnormal insertion of the costoclavicular ligament laterally on the first rib, along with hypertrophy of the scalenus anticus muscle, 506 of 626 extremities have been managed by thrombolytic therapy followed by prompt transaxillary resection of the first rib. These patients have been followed up from 1 to 32 years (average of 7.2 years +/- 1.0 standard deviation). Four hundred eighty-six patients (96%) improved. Because the pathophysiology is not well understood, many venograms suggest intraluminal disease rather than external compression. Therefore, attempts at opening the narrowed vein with intraarterial techniques do not work. Use of percutaneous venous angioplasty with stents have all occluded in our experience, making further management difficult. Venous bypass grafts fail because of low venous pressure. Recognition that an abnormal congenital lateral insertion of the costoclavicular ligament on the first rib causes venous occlusion in Paget-Schroetter syndrome has led to acute thrombolysis, followed by prompt first rib resection, as the ideal management.

Unilateral pleural effusions associated with stenoses of left brachiocephalic veins in haemodialysis patients

Pleural effusion is a frequent complication in patients undergoing haemodialysis. Its more common causes are congestive heart failure, infection, neoplasm and so-called uraemic pleurisy [1,2]. When the work-up of a pleural effusion in a haemodialysis patient does not identify a specific cause, it is usually attributed to uraemic pleurisy [3]. Uraemic pleural effusions have been estimated to develop in 3–10% of patients with advanced renal failure [4]; however, the diagnosis of uraemic pleurisy remains elusive, as no pathognomonic test is available. We report here on two haemodialysis patients with a novel cause of pleural effusion. In each case, the sum of a severe stenosis in the left brachiocephalic vein and the increased venous flow of an ipsilateral arteriovenous (AV) fistula coincided with the appearance of a massive left sided pleural effusion. Percutaneous venous angioplasty in one patient and ligation of the AV fistula in the other led to dramatic resolutions of the pleural effusions.

Percutaneous treatment of symptomatic central venous stenosis angioplasty

Objectives The increased use of central venous access primarily for hemodialysis has led to a significant increase in clinically relevant central venous occlusive disease (CVOD). The magnitude of and the optimal therapy for CVOD are not clearly established. The purpose of this study is to define the problem of CVOD and determine the success of percutaneous therapy for relieving symptoms and maintaining central venous patency. Methods Patients presenting with disabling upper-extremity edema suggestive of central venous stenosis or occlusion during a 3-year period were evaluated by venography of the upper extremity and central veins. Percutaneous venous angioplasty (PTA) and/or stent placement was performed as clinically indicated. The success of therapy was assessed, and the patients were observed to determine the incidence of recurrence and additional procedures. Recurrent lesions underwent similar evaluation and treatment. Results A total of 32 sides were treated in 29 patients with a mean of 1.9 interventions per side treated. Hemodialysis-related lesions were the underlying cause in 87% with the remaining 13% related to previous central venous catheterization. The lesions involved the axillary, subclavian, and innominate veins with complete venous occlusion in six (19%) cases. Percutaneous angioplasty was followed by stent placement in six (19%) cases. The procedure was a technical success and was performed without complications in all cases (100%). Mean follow-up was 16.5 months (range, 4-36 months). On average, patient symptoms were controlled for 6.5 months after the initial intervention. Recurrent edema led to additional PTA in 20 (63%) cases. Fifty percent (n = 14) of patients with an arteriovenous fistula (AVF) experienced recurrent symptoms after initial and/or repeat PTA and required AVF ligation. Complete resolution after the initial PTA was predictive of long-term success. Conclusions Central venous occlusive disease has emerged as a significant clinical problem. Percutaneous venous angioplasty can provide temporary symptomatic relief; however, multiple procedures are often required and long-term relief is rarely achieved.