Superficial Vein Research Articles

(157) Primary Erectile Dysfunction Caused by Cavernovenous Leakage: Clinical Presentation and New Surgical Treatment in 81 Consecutive Patients with Severe Erectile Dysfunction

Abstract Introduction Introduction. Primary erectile dysfunction (PED) due to cavernovenous leakage (CVL), a disease in which blood entering corpora cavernosa escapes too early because of abnormal venous network, may affect as many as 1 to 2% of men under 30 with failure of erections to develop or maintain. When resistant to PDE5Is, it is a devastating condition leaving men with no possibility of sexual intercourse with penetration, and usually absence of diagnosis and specific treatment. Objective Evaluate symptoms and results of a new method of treatment combining open surgery and embolization simultaneously during the same procedure, in patients with PED and CVL resistant to PDE5Is. Methods 81 consecutive patients with severe PED with CVL diagnosed by pharmacologically-challenge penile duplex sonography (PC-PDS) were operated-on. Leaks were imaged by caverno-computed tomography. Patients with other cause of ED were excluded, all had refused a penile implant, signed an informed consent, had a control PC-PDS three months after surgery, and were clinically evaluated during follow-up. A retrospective analysis was performed on prospectively collected data. Comparisons of variables before and after surgery used a paired t-test. Results Mean age at PED onset reported by patients was 19.0±4.6 years, range 13–30. Mean age at surgery was 34.5±9.2 years, range 18–70. Mean ED duration before surgery was 15.4±10.1 years (range 1–40). All patients had clinical signs of organic ED (no phase of erection improvement in the past six months, erectile dysfunction during masturbation (Erection Hardness Score (EHS)<3 and/or erection instability). CVL could be suspected in all patients based on reported erection instability during masturbation, and in 86.4%, based on variation of EHS according to body position during masturbations. At three-month evaluation, mean pharmacologic EHS had increased from 2.59±.77 before surgery, to 3.45±.63 (p<.0001). The mean pharmacologic EHS increase was 0.83±.92. All CVL hemodynamic parameters at PC-PDS had decreased compared to pre-surgery: mean End Diastolic Velocity (from 9.9±9.22 to 6.77±7.34 cm/s, p<.023), mean leakage speed on Deep Dorsal Vein (from 10.87±12.48 to .69±2.77 cm/s, p<.0001), mean speed on any superficial vein (from 10.96±10.08 to 4.77±6.90 cm/s, p<.0001). Patients unable to perform penetrations despite intracavernous injection of Prostaglandin E1 20 micg plus Papaverine 40 mg (pharmacological EHS<3) decreased from 64.2 to 13.5% (Chi-square test: p<.001). At the end of the 26.0±21.9-month follow-up, IIEF-5 score had increased from 8.9±5.3 to 16.1±5.8 (p<.013), clinical EHS during sexual intercourse from 1.97±.67 to 3.31±.71 (p<.0001), penetration success rate from 18.3±28.2 to 64.2±40.1%, morning EHSfrom 1.11±1.40 to 2.12±1.49 (p<.0002), masturbation EHS from 2.14±.84 to 3.07±.77 (p<.002) before and after surgery, respectively. 38.3% did not take any medication for erection. Conclusions Simultaneous open surgery and embolization is a conservative treatment that should be discussed for patients with PED and CVL. PED can be suspected during consultation. Detection of CVL in all patients under 30 with ED should be evaluated in sexual medicine practice. Disclosure No.

(235) False Negative Penile Duplex Sonography: Results of Cavernovenous Leakage Surgery in 41 Patients with Normal End-Diastolic Velocity. The Need for Venous Leak Hemodynamic Criteria Re-Evaluation?

Abstract Introduction In cavernovenous leakage (CVL), blood entering corpora cavernosa escapes too early due to abnormal venous network, for erections to develop or maintain. CVL diagnosis relies on persisting blood flow velocity in cavernosal arteries at the end of diastole (EDV), with a consensus 5 cm/s cut-off value at pharmacologically-challenged penile duplex sonography (PC-PDS). Objective We present clinical, hemodynamic characteristics, and response to surgery of 41 patients with severe ED resistant to PDE5Is, with EDV5 cm/s at PC-PDS, considered non pathologic, but with CVLs identified by gold standard pharmacologically-challenged penile CT-cavernography. Methods Prospectively collected data from 41 consecutive patients with ED resistant to PDE5Is, with cavernosal artery EDV5 cm/s (Group A), were compared to data from 130 patients with EDV>5 cm/s (Group B). CVLs in Group A were detected by PC-PDS on deep dorsal vein or penile superficial veins after intracavenosal injection of Prostaglandin E1 plus Papaverine. All patients had refused a penile implant and underwent CVL intervention consisting in open surgery and embolization during the same procedure. Inter-group comparison used a T-test of means, pre- and post-operative data comparison a paired t-test. Results Patients in Group A were younger than in Group B (mean age 38.2±14.0 and 45.9±11.6 years, respectively, p<.0022). Pharmacologic Erection Hardness Score (EHS) was higher (2.9±.7 vs. 2.4±.6, p<.0001), EDV velocity was less (1.6±2.2 vs. 15.1±2.2 cm/s, p<.0001) in Group A than B, respectively. Pre-operative IIEF5 score was higher in Group A than in B (13.3±5.3 and 9.4±4.8, respectively, p<.0181). Other pre-operative erection parameters were otherwise similar in the two groups (morning erection EHS and frequency, masturbation and sexual intercourse EHS, percentage of successful penetration (p<.498, .543, .682, .510, .289, respectively). Patients in Group A and B responded similarly to surgery, with a similar pharmacologic EHS increase at systematic three-month post-operative PC-PDS (0.77±.94 vs. .81±.67, p<.80). Mixing Group A and B 171 patients, at the end of the 29.8±20.4-month follow-up, a significant improvement on all clinical parameters was observed: IIEF-5 score had increased from 9.7±5.1 to 15.5±6.0 (p<.0001), clinical EHS during sexual intercourse from 2.0±.7 to 3.3±.7 (p<.0001), penetration success rate from 22.3±31.7 to 70.1±37.2% (p<.0001), mean EHS during masturbation from 2.11±.67 to 3.04±.75 (p<.0001), morning erection EHS from .95±1.24 to 2.12±1.37 (p<.0001), before and after surgery, respectively. There was no statistically significant difference between Group A and B regarding all these parameters, demonstrating similar clinical responses to surgery. Conclusions Patients with EDV5 cm/s may have CVL evidenced by PC-PDS flow analysis directly on veins, and gold standard PC-PCTC. Their erection disability is severe. They respond well to combined open and embolization surgery, a confirmation that they suffer CVL. EDV criterium misses CVL in as much as one patient out of four with actual CVL in our series. Since false negative diagnosis has severe, life-long, patient and partner implications, hemodynamic criteria for CVL diagnosis should be debated in the field of sexual medicine. Disclosure No.

Early experience with endovascular arteriovenous fistula creation

Background: Patients opting for haemodialysis as a form of renal replacement therapy require prompt and reliable vascular access. The gold standard for delivering high-quality and safe haemodialysis is through the creation of an arteriovenous fistula (AVF), typically formed at the wrist or elbow. This intervention promotes increased blood flow through superficial veins, fortifying them for repeated needle insertion during haemodialysis treatment. The emergence of percutaneous endovascular arteriovenous fistula (pAVF) introduces a non-surgical alternative for AVF creation. This method eliminates the need for incisions, reducing the likelihood of surgical scarring and changes in vein appearance. Advantages of pAVF encompass the potential for accelerated convalescence, enhanced comfort for the patient, and a diminished adverse effect on body image perception. These non-surgical options may motivate patients to undergo the procedure promptly, enhancing the timeliness of vascular access for haemodialysis and positively impacting overall health outcomes. These relatively new interventions are evolving, enabling the refinement of more efficient and safer techniques. Dialysis nurses play a crucial role in overall success, necessitating further training and development of their skills and knowledge for needling these new fistulas. With an increasing number of successful cases and more readily available information, these non-surgical techniques are gaining popularity among patients, particularly those conscious about their body image. Aim: The goal is to outline an early experience with a comprehensive approach to planning a percutaneous endovascular arteriovenous fistula service at King's College Hospital. Method: This article describes the referral process, screening, clinical assessments, procedural elements and cannulation. Insights are drawn from a single-centre experience in the UK with the WavelinQ System (BD). Emphasis will be placed on key staffing needs, particularly related to patient selection and dialysis nurse training. Conclusion: By addressing these essential considerations, a pAVF service can be successfully implemented.

Incidence and clinical progression of asymptomatic peripherally inserted central catheter–related thrombosis in solid neoplasm patients: ultrasound insights from a prospective cohort study

BackgroundManaging central venous catheters in patients with neoplasms is challenging, and peripherally inserted central catheter PORT (PICC-PORT) has emerged as a promising option for safety and efficacy. However, understanding the clinical progression of catheter-related thrombosis (CRT) in cancer patients with central venous catheters remains limited, especially in certain neoplasm types associated with a higher risk of venous thrombosis. ObjectivesThis study aims to assess the effectiveness of ultrasound-guided management in detecting and treating asymptomatic CRT in cancer patients with PICC. MethodsIn this prospective cohort study of 120 patients with solid neoplasms receiving chemotherapy, we investigated the incidence of isolated upper-extremity superficial vein thrombosis, upper-extremity deep vein thrombosis, and fibrin sheath formation through ultrasound follow-up at 30 and 90 days after catheter insertion. We analyzed risk factors associated with CRT and compared incidence rates between PICC-PORT and traditional PICC. ResultsAmong the cohort, 69 patients (57.5%) had high-risk thromboembolic neoplasm, and 31 cases (25.8%) of CRT were observed, mostly within 30 days, with only 7 cases (22.6%) showing symptoms. Traditional PICC use (odds ratio, 5.86; 95% CI, 1.14-30) and high-risk thromboembolic neoplasm (odds ratio, 4.46; 95% CI, 1.26-15.81) were identified as independent risk factors for CRT. ConclusionThe majority of CRT present asymptomatically within the first 30 days of venous catheter insertion in patients with solid neoplasms. Ultrasound follow-up is valuable for detecting asymptomatic CRT. The risk of CRT was lower with PICC-PORT than with PICC. Additionally, the risk of CRT was found to be higher in patients with high-risk thromboembolic neoplasms. It is crucial for larger studies to confirm the utility of treating asymptomatic thromboses and isolated superficial thrombosis.

IMPLICATION OF LEECH THERAPY AND ASBAB-E-SITTA ZAROORIYAH IN THE PREVENTION AND TREATMENT OF VARICOSE VEINS: A COMPREHENSIVE REVIEW

Varicose veins are characterized by abnormally twisted, dilated superficial vessels that are caused by the inefficient or defective valves within the vein. It is currently a prevalent disease with the incidence varying globally between 10% and 60%. The Unani Medicine (also called Greco-Arab medicine) is the ancient system of medicine practiced all around the world. According to the Unani classical text, Leech therapy (Irsal-e-Alaq) is one of the most important regimenal therapy for the successful treatment and management of varicose vein and a unique combination of Asbab-e-Sitta Zarooriyah (Six essential factors) is involved in the prevention of this disease. The research studies have proved that medicinal leech therapy displays anticoagulant, antimicrobial, anti-inflammatory and analgesic effects. Leech saliva contains medicinally useful bioactive molecules like hirudin, histamine, etc. that shows anti-coagulant effect and hence improve microcirculation in diseases like varicose vein. Leech therapy is reliable, well tolerated, cost effective treatment that has the potential of preventing varicose vein complications. This review seeks to describe medicinal leech therapy, present therapeutic leech species, and highlight the processes by which leech saliva affects wound healing. Additionally, the review paper highlights the role of Asbab-e-Sitta Zarooriyah in prevention and control of varicose veins. Irregularity in diet and lifestyle may cause disturbance in normal body functioning, which may lead to lifestyle disorder that is a major risk factor thought to influence the susceptibility of varicose vein. The Unani System exerts a major influence on preventing the development of varicose vein by making modification in Asbab-e-Sitta Zarooriyah.

Uncommon case of rupture of the superficial dorsal vein of the penis

Penile dorsal vein rupture is a rare condition that affects the vascular network of the penis. It is often misdiagnosed as a penile fracture. Diagnosis can be facilitated by ultrasound of the penis coupled with Doppler or magnetic resonance imaging. Treatment options include conservative or surgical approaches. This case report presents an adult patient who presented to the emergency department with a suspected penile fracture six hours after vigorous sexual intercourse. Although a fracture of the corpora cavernosa was ruled out, an intraoperative discovery revealed a rupture of the dorsal vein of the penis. The purpose of this article is to report an uncommon case of rupture of the superficial dorsal vein of the penis.

Noninvasive measurement of ambulatory venous pressure via column interruption duration in chronic venous disease

BackgroundColumn interruption duration (CID) is a noninvasive surrogate for venous refill time (VFT), a parameter used in ambulatory venous pressure measurement. CID is more accurate than invasive VFT measurement because it avoids errors involved with indirect access of the deep system through the dorsal foot vein. The aim of this retrospective single center study is to analyze the clinical usefulness of CID in assessment of chronic venous disease (CVD). MethodsA total of 1551 limbs (777 patients) were referred with CVD symptoms over a 5-year period (2018-2023); CID, air plethysmography, and duplex reflux data were analyzed. Of these limbs, 679 had supine venous pressure data as well. The pathology was categorized as obstruction if supine peripheral venous pressure was >11 mm Hg and as reflux if duplex reflux time in superficial or deep veins was >1 second. CID was measured via Doppler monitoring of flow in the great saphenous vein (GSV) and one of the paired posterior tibial (PT) veins near the ankle in the erect posture. The calf is emptied by rapid inflation cuff. CID is the time interval in seconds when cephalad venous flow in great saphenous vein and posterior tibial veins reappear after calf ejection. A CID <20 seconds in either vein is abnormal similar to the threshold used in VFT measurement. ResultsThirty-two percent of the limbs had obstruction, 17% had reflux, and 37% had a combination; 14% had neither. Higher clinical-etiology-anatomy-pathophysiology (CEAP) clinical classes (C4-6) were prevalent in 44% of pure reflux, significantly less (P < .0001) than in pure obstruction (73%) or obstruction plus reflux subsets (72%), partly reflecting distribution of pathology. There is a progressive increase in supine venous pressure and abnormal CID (P < .0001 and P < .0001, respectively) in successive CEAP clinical class. No such correlation between CEAP and any of the reflux severity grading methods (reflux segment score, Venous Filling Index, and Kistner axial grading) was observed. Abnormal CID (55%) was more prevalent in higher CEAP classes (>4) (P < .0001) than in lesser clinical classes (0-2) or limbs with neither obstruction nor reflux (P < .01). ConclusionsObstruction seems to be a more dominant pathology in clinical progression among CEAP clinical classes than reflux. CID is abnormal in both obstructive and refluxive pathologies and may represent a common end pathway for similar clinical manifestations (eg, ulcer). These data suggest a useful role for CID measurement in clinical assessment of limbs with CVD.

A Neonatal Rodent Model of Retroorbital Vein Injection.

Intravenous (iv) injection is the most used route of drug administration in neonates in the clinical setting. Therefore, retroorbital vein injection is an important method for compound administration in research, where successful proof-of-concept studies can progress into much-needed neonatal clinical trials. Most intravenous studies in neonatal rodents use the superficial temporal/facial vein. However, retroorbital injection becomes unreliable in neonatal rodents older than 2 days after the skin darkens and the vein is no longer visible. In the present protocol, we describe the retroorbital injection of the venous sinus in both the neonatal mouse and rat at ages when the superficial temporal vein is no longer visible, but the eyes have not opened yet. Eye-opening facilitates retro-orbital injection by enabling the researcher to clearly see that they are not perforating the eye when inserting the needle. We demonstrate that this technique can be performed in a reliable and reproducible manner without adverse effects. Additionally, we show that it can be used in many studies, such as administering compounds to study neonatal brain injury.

Superficial Venous Thrombosis: A Comprehensive Review.

Superficial venous thrombosis (SVT), an inflammatory-thrombotic process of a superficial vein, is a relatively common event that may have several different underlying causes. This phenomenon has been generally considered benign, and its prevalence has been historically underestimated; the estimated incidence ranges from about 0.3 to 1.5 event per 1000 person-years, while the prevalence is approximately 3 to 11%, with different reports depending on the population studied. However, such pathology is not free of complications; indeed, it could extend to the deep circulation and embolize to pulmonary circulation. For this reason, an ultrasound examination is recommended to evaluate the extension of SVT and to exclude the involvement of deep circulation. Also, SVT may be costly, especially in the case of recurrence. Therefore, accurate management is necessary to prevent sequelae and costs related to the disease. This review aims to analyse the epidemiology of SVT, its complications, optimal medical treatment, and open questions with future perspectives.

A Study of Blood Viscosity and Inflammatory Biomarkers’ Levels in Bilateral Primary Varicose Veins/Reticular Veins as Predictive Markers

Objectives Cross-sectional data was collected for a period of 1 year to assess the biomarkers of inflammation, and blood viscosity as predictive markers in patients with primary bilateral varicose veins or reticular veins that might progress to varicose veins. Material and Methods A sample of 40 participants, 20 controls and 20 patients aged 18–65 years falling under the reticular veins and symptomatic varicose veins (C1, 2s), primary etiology (Ep), superficial veins (As), reflux pathology (Pr) categories of Clinical, etiologic, anatomic, Pathophysiologic (CEAP) classification with the exception of telangiectatic veins, were included in the study. Blood viscosity was measured using a Capillary Viscometer. Evaluated inflammatory markers were tissue Plasminogen Activator (tPA), Plasminogen Activator Inhibitor-1 (PAI-1), and fibrinogen. Analysis was done using Statistical Package for the Social Sciences (SPSS) software and Chi-square, Fisher’s, Bonferroni, and Analysis of Variance (ANOVA) tests were applied. Results There was a statistically insignificant relationship between occupation and different study groups. Standing hours and serum fibrinogen levels had a significant difference in different study groups. Serum tPA, Serum PAI-1, and blood viscosity had an insignificant difference between different study groups. It was revealed that the pairwise group comparisons of study group C2 vs. control group C0, study group C1 vs. control group C0 and study group C2 vs. study group C1, and study group C2 vs. control group C0 each were significantly different pairwise. Conclusion Blood viscosity, tPA and PAI-1 cannot be used as predictive markers in patients with bilateral (B/L) primary varicose veins/reticular veins. Serum fibrinogen levels can be used as predictive markers for the development of B/L primary varicose veins and in our particular study with a predictive range of 189.4–327.9 mg/dL but not for B/L reticular veins. Prolonged standing, irrespective of the occupation of the patient, is associated with the development of B/L reticular veins and B/L varicose veins.

Correlation between choroidal vascularity and retrobulbar ocular blood flow changes and thyroid-associated ophthalmopathy activity: a cross-sectional study

ObjectiveTo evaluate the alterations in retrobulbar color Doppler imaging (CDI) parameters and retinal/choroidal optical coherence tomography angiography (OCTA) parameters and their association with the clinical activity and severity in thyroid-associated orbitopathy (TAO) patients.MethodsIn this study, the retrobulbar flow parameters including resistance index (RI), Pulsatile Index(PI), peak systolic velocity (PSV) and end diastolic velocity (EDV) in posterior ciliary artery (PCA), central retinal artery (CRA) and ophthalmic artery (OA) were determined by CDI. Moreover, the retina and choroidal vascularity including the superficial vessel density (SVD), deep vessel density (DVD), choroidal thickness (ChT) and choroidal vascularity, including total choroidal area (TCA), luminal area (LA), stromal area (SA) and Choroidal Vascularity Index (CVI), were determined by OCTA. All patients grouped as active TAO and inactive TAO based on Clinical activity score (CAS). We picked the severe eye among the subjects and compared all parameters between two groups. We analyzed the correlations among those parameters.ResultsThere was a significant difference in CAS score, proptosis value, ChT, LA, CVI between patients with active TAO and inactive TAO. In the active group, PSV and EDV of PCA were significantly higher than the inactive group. On logistic regression analysis, CAS was closely associated with PSV-PCA. On multiple linear regression, proptosis value was closely associated with ChT, LA, SA and CVI.ConclusionChoroidal vascularization and retrobulbar blood flow were concurrently higher in active TAO patients and several variables in choroid circulation was closely related to TAO clinical features.

Clinical Outcomes of Arteriovenous Grafts Using the Superficial Vein versus Venae Comitantes as Venous Outflow.

The superficial veins are commonly used in conventional autogenous arteriovenous fistulas and the placement of prosthetic grafts. When they are unsuitable, however, the use of the deep veins (venae comitantes) is generally considered to be a reasonable alternative. This study conducted a comparative analysis of clinical outcomes for arteriovenous grafts between 2 groups based on the type of venous outflow: superficial veins or venae comitantes. In total, 151 patients who underwent arteriovenous grafts from November 2005 to March 2022 were retrospectively analyzed. The patients were divided into 2 groups: group A (superficial veins, n=89) and group B (venae comitantes, n=62). The primary, secondary patency, and complication rates were analyzed in each group. A propensity score-matched analysis was performed. In total, 55 well-balanced pairs were matched. Kaplan-Meier analysis revealed no significant differences in the primary patency rate between the 2 groups at 1-year, 3-year and 5-year intervals (group A, 54.7%, 35.9%, 25.4% vs. group B, 47.9%, 16.8%, 12.6%; p=0.14), but there was a difference in the secondary patency rate (group A, 98.2%, 95.3%, 86.5% vs. group B, 87.3%, 76.8%, 67.6%; p=0.0095). The rates of complications, simple percutaneous transluminal angioplasty, and stent insertion were comparable between the groups. Although this study demonstrated not particularly favorable secondary patency rates in the venae comitantes group, the venae comitantes may still be a viable option for patients with unsuitable superficial veins because there were no significant differences in the primary patency and complication rates between the 2 groups.

(184) Gender-Affirming Abdominal Phalloplasty

Abstract Introduction Phalloplasty can alleviate gender dysphoria in transgender individuals. Various techniques exist and selection of phalloplasty technique depends on patient preference, body habitus, and surgeon experience. Objective We demonstrate the creation of a neophallus using a pedicled abdominal flap using live surgical footage. Methods The patient was a 19 year old transmasculine individual who had been on gender-affirming hormone therapy for 3 years and desired a neophallus to align external appearance with his gender identity. The flap is designed using a fasciocutaneous flap based off the inferior epigastric and superficial circumflex iliac vessels, with innervation from the ilioinguinal nerve. Perfusion is assessed using fluorescence imaging prior to tubularization. Rotational flaps are used to cover the abdominal wound. Results The patient had an uneventful recovery after 48 hours of bedrest and was discharged on post-operative day 4 without complications. He has recovered well without any complications at 6 months postoperatively. Patients may elect to undergo next staged phalloplasty procedures with or without urethroplasty at least 6 months afterwards. Conclusions A pedicled abdominal flap phalloplasty is a safe and effective option for patients desiring a more easily concealed scar and fewer complications compared to alternative techniques. Disclosure No.

Unrecognized Superficial Venous Thrombosis in a Female Division-1 Athlete: A Case Report

BACKGROUND: Superficial venous thrombosis (SVT) is a blood clot that forms in superficial veins and may occur after surgery. Treatment typically consists of anticoagulation medication and palliative care. CASE PRESENTATION: A 20-year-old female basketball athlete presented to physical therapy (PT) after posterior labral repair. Examination revealed tenderness along the medial forearm, venous distension of the hand, and discomfort with wrist extension overpressure and resisted wrist flexion. The patient was referred by the physical therapist to the team physician, who ordered ultrasonography, which demonstrated SVT of the right basilic vein. The patient was placed on anticoagulation medication for 4 months. OUTCOME AND FOLLOW-UP: At 4 months after initial diagnosis, a computed tomography venogram revealed resolution of SVT. The patient continued with physical therapy throughout this period, with no adverse effects reported. DISCUSSION: Physical therapists play an important role in medical screening and referral of patients who present with potential vascular complications postsurgery. Physical therapists may also safely implement a plan of care in patients who develop medical complications after surgery. JOSPT Cases 2024;4(1):34-38. Epub 26 January 2024. doi:10.2519/josptcases.2024.12174

A Study of Valvular Incompetencies in the Lower Limb Veins Using Doppler Ultrasound Findings.

Varicose veins (VV) are one of the most common pathologies associated with the venous system of the lower limb. In the Indian population, its incidence is higher, and it is one of the most commonly encountered cases in the hospital. The study aimed to note the widely affected anatomical structure in male and female varicose patients using Doppler ultrasound (DU) examination findings. A total of 200 Doppler ultrasound reports of varicose patients were retrospectively analyzed and categorized based on the affected structure. The demographic data of all cases, such as age, sex, brief history, signs, symptoms, and affected side of the lower limb, was noted. Anatomical structures causing venous refluxes in the saphenous systems, junctions, and perforating venous systems were noted. Pearson's correlation coefficient was applied to find out its association. Out of 200 Doppler reports studied, 133 (67%) were male and 67 (33%) were female patients. The majority, 180 (90%) cases, belonged to C1-C3 stages according to the Clinical, Etiology, Anatomy, and Pathological (CEAP) classification, while 20 (10%) were in C4-C5 stages. Male patients aged between 31 and 40 years were predominantly affected, with their left side being affected most commonly. In female patients, the older age group of 50-60 years was predominantly affected.Great saphenous reflux in the groin due to incompetent terminal valve was noted in 126 (63%) cases. In the perforator venous (PV)system,defects in the medial leg perforator (189 (95%)), posterior leg (92(46%)), and thigh perforator (20 (10%)) were noted. In the present study, the occurrence of varicose veins is due to the involvement of superficial, deep, and perforator veins with varying percentages. Among the structures, the medial leg perforator was predominantly involved, followed by other perforators. Since most patients were in C1-C3 stages, the involvement of deep veins was noted minimally.

Strategic Approaches to Intraflap Anastomosis: Navigating Conjoined DIEP Flap Reconstruction-A Comprehensive Roadmap.

For patients desiring autologous breast reconstruction without adequate abdominal tissue volume, the deep inferior epigastric perforator (DIEP) flap may be stacked or combined with other flaps for bilateral reconstruction. Various combinations of anastomoses have been described in the literature. We sought to describe a framework for intraflap anastomoses. A retrospective review of 17 patients who underwent conjoined DIEP flaps with intraflap anastomoses with a single surgeon was performed. Patient demographics, comorbidities, operative details, and complications were reviewed. A framework scheme was developed for the type of intraflap anastomosis performed. Between 2016 and 2020, 17 patients underwent conjoined DIEP flaps for unilateral breast reconstruction. Fourteen patients had delayed reconstruction. Eleven patients underwent an intraflap anastomosis in which a medial perforator on the left hemiabdomen flap was anastomosed with a distal lateral row perforator in the right hemiabdomen flap (type A). Four patients underwent an intraflap anastomosis in which a left lateral perforator was anastomosed to a right distal lateral row perforator (type B). Two patients underwent an intraflap anastomosis in which the left superficial inferior epigastric vessel was anastomosed to a right lateral row perforator (type C). Complications included reoperation (11.8%), partial flap loss (5.9%), seroma (23.5%), and hematoma (11.8%). We report a detailed framework for intraflap anastomoses of conjoined DIEP flap reconstruction including superficial inferior epigastric artery/superficial inferior epigastric vessel options. Knowledge of this comprehensive framework will allow surgeons to identify the type of intraflap anastomoses required for the anatomy they encounter and will standardize reporting of surgical technique in the literature.

Neuroimaging of Neonatal Stroke: Venous Focus.

Perinatal venous infarcts are underrecognized clinically and at imaging. Neonates may be susceptible to venous infarcts because of hypercoagulable state, compressibility of the dural sinuses and superficial veins due to patent sutures, immature cerebral venous drainage pathways, and drastic physiologic changes of the brain circulation in the perinatal period. About 43% of cases of pediatric cerebral sinovenous thrombosis occur in the neonatal period. Venous infarcts can be recognized by ischemia or hemorrhage that does not respect an arterial territory. Knowledge of venous drainage pathways and territories can help radiologists recognize characteristic venous infarct patterns. Intraventricular hemorrhage in a term neonate with thalamocaudate hemorrhage should raise concern for internal cerebral vein thrombosis. A striato-hippocampal pattern of hemorrhage indicates basal vein of Rosenthal thrombosis. Choroid plexus hemorrhage may be due to obstruction of choroidal veins that drain the internal cerebral vein or basal vein of Rosenthal. Fan-shaped deep medullary venous congestion or thrombosis is due to impaired venous drainage into the subependymal veins, most commonly caused by germinal matrix hemorrhage in the premature infant and impeded flow in the deep venous system in the term infant. Subpial hemorrhage, an underrecognized hemorrhage stroke type, is often observed in the superficial temporal region, and its cause is probably multifactorial. The treatment of cerebral sinovenous thrombosis is anticoagulation, which should be considered even in the presence of intracranial hemorrhage. ©RSNA, 2024 Test Your Knowledge questions in the supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.

The benefit of favorable venous outflow profile is mediated through reduced microvascular dysfunction in acute ischemic stroke.

Venous outflow (VO) is emerging as a marker of microvascular integrity in acute ischemic stroke. Using hemorrhagic transformation (HT) and infarct growth as mediators, we tested whether a favorable VO profile benefited functional outcome by reducing consequences of microvascular dysfunction. Patients receiving thrombectomy in three comprehensive stroke centers due to acute anterior circulation occlusion were included. VO was assessed semi-quantitatively by the opacification of ipsilateral vein of Labbé, Trolard and superficial middle cerebral vein. HT was graded on follow-up CT. Infarct growth volume (IGV) was the difference of final infarct volume and baseline core volume. The association of VO and functional independence (90-day modified Rankin Scale ⩽ 2) was examined by logistic regression. Mediation analysis was performed among VO, HT or IGV, and functional outcome in patients with or without recanalization, respectively. In 242 patients analyzed, VO was strongly correlated with functional independence and VO ⩾ 4 was defined favorable. In 175 patients recanalized, favorable VO was associated with a reduced risk of HT (OR = 0.82, 95% CI 0.71-0.95, p = 0.008), which accounted for 13.1% of the association between VO and favorable outcome. In 67 patients without recanalization, favorable VO was associated with decreased IGV (β = -0.07, 95% CI -0.11 to -0.02, p = 0.007). The association of favorable VO and functional independence was no longer significant (aOR = 4.84, 95% CI 0.87-38.87, p = 0.089) after including IGV in the model, suggesting a complete mediation. In patients with acute anterior large vessel occlusion, the clinical benefit of VO may be mediated through reduced microvascular dysfunction.

Isolated cerebral varices: clinical observations and literature review

The aim of the study is to present rare clinical cases of isolated cerebral varices, summarize scientific literature data on their diagnosis and treatment.The article describes 2 clinical observations of isolated cerebral varix, presents a literature review of this topic, as well as treatment tactics for patients with this pathology.In the first clinical observation, in a male 72‑year-old patient isolated cerebral varix was interpreted as distal saccular aneurysm of the right middle cerebral artery per computed angiography data. Surgical treatment was performed: from subtemporal approach in the area of the floor of the middle cranial fossa, cerebral varix, inflow and outflow veins were visualized. The inflow and outflow veins were clipped, aneurysm was resected and sent to histological examination. The patient was discharged on day 8 after surgery. Histological examination of the cerebral varix wall showed typical components for a venous wall, in particular, individual smooth muscle fibers, absence of elastic membrane.In the second clinical observation, in a female 59‑year-old patient magnetic resonance (MR) imaging, MR angiography and MR venography in the projection of anterior basal parts of the left temporal area showed an aneurysmal malformation transitioning into the superficial middle cerebral vein. Taking into consideration venous pathogenesis of the vascular lesion, dynamic observation of the patient was chosen.Isolated cerebral varix is a rare vascular pathology without a specific clinical and instrumental picture. To avoid erroneous diagnosis and determine further treatment tactics, additional examinations are recommended: MR imaging, MR angiography and MR venography.

The Basal or Sphenopetrosal Superficial Middle Cerebral Vein Type.

Background and Objectives: The adult superficial middle cerebral vein (SMCV) commonly drains into the middle cranial fossa. However, different embryonic types persist, in which the SMCV drains into the lateral sinus. The basal type of SMCV coursing on the middle fossa floor is a scarce variant. Materials and Methods: During a retrospective study of archived computed tomography angiography (CTA) and magnetic resonance angiography (MRA) files, three rare adult cases of the basal or sphenopetrosal type of SMCV were found and further documented. Results: In the first case, which was evaluated via CTA, the basal type of SMCV formed a sagittal loop. It continued on the middle fossa floor, over a dehiscent tegmen tympani, to drain into the lateral sinus. In the second case, documented via MRA, the basal type of SMCV's anterior loop was in the coronal plane and closely related to the internal carotid artery and the cavernous sinus. It continued with the basal segment over a dehiscent glenoid fossa of the temporomandibular joint (TMJ). In the third case, documented via CTA, the initial cerebral part of the SMCV had a large fenestration. The middle fossa floor coursed within a well-configured sulcus of the SMCV and received a tributary through the tympanic roof. Its terminal had a tentorial course. Conclusions: Beyond the fact that such rare variants of the SMCV can unexpectedly interfere with specific approaches via the middle fossa, dehiscences of the middle fossa floor beneath such variants can determine otic or TMJ symptoms. Possible loops and fenestrations of the SMCV should be considered and documented preoperatively.