Tibial Vein Research Articles

Percutaneous Deep Venous Arterialization by Balloon Angioplasty without Stent Implantation for Patients with Chronic Limb-Threatening Ischemia Undergoing Hemodialysis: A Retrospective Cohort, Single-Center, Single-Arm Study.

This retrospective, single-center study aimed to determine the efficacy of percutaneous deep venous arterialization in patients on hemodialysis with chronic limb-threatening ischemia. Twenty-one consecutive limbs on hemodialysis with chronic limb-threatening ischemia were treated with percutaneous deep venous arterialization using balloon angioplasty following a failed pedal arterial reconstruction between May 2021 and June 2022. An arteriovenous fistula near the ankle joint was created to ensure sufficient venous flow reversal to the pedal veins. In case of occlusion of the tibial artery, a guidewire was advanced (subintimal) to the ankle joint vicinity was technically important. The primary outcome measures were the 6-month complete wound healing and freedom from major amputation rates; the secondary outcome measure was the 6-month amputation-free survival. Occlusion of all pedal arteries was observed in 17 limbs (81.0%). Arteriovenous fistulas were predominantly created at the distal portions of the posterior tibial artery and vein in 18 limbs (85.7%). No extravasation at the fistulas was observed. Re-intervention was required in 16 limbs (76.2%) due to tibial artery or deep vein occlusion. The 6-month complete wound healing rate was 42.9% (nine limbs), with a median healing time of 85 days (interquartile range: 58-151 days). The 6-month freedom from major amputation and amputation-free survival rates were 90.5% (19 limbs) and 61.9% (13 limbs), respectively. Balloon angioplasty without stent implantation for percutaneous deep venous arterialization is promising for improving the complete wound healing and amputation-free survival rates after pedal artery reconstruction failure. Level 3b, retrospective cohort study.

Advances in Reconstructive Robotic Microsurgery in the Extremity.

Robotic surgery has emerged as a promising technique for reconstructive procedures, offering potential advantages across various surgical fields. Following initial case reports on the use of the Symani Surgical System (Medical Microinstruments, S.p.A) for microsurgical anastomosis, the authors evaluated its full potential in extremity reconstruction. They conducted a retrospective analysis of patients with soft tissue defects of the upper and lower extremities treated between February 2022 and May 2024. Each patient underwent soft tissue reconstruction with free tissue transfer with microsurgical anastomosis performed using the Symani Surgical System. The study included 7 male patients and 1 female patient, aged between 19 and 71 years (mean age: 50.6y). The most used recipient vessels were the anterior tibial artery and vein (37.5%). The preferred anastomotic technique was end-to-side in arterial anastomoses (6/8). All arterial anastomoses were performed using the Symani Surgical System. The mean anastomosis time was 33.2±5.8 minutes. One out of 8 patients required surgical revision outside of the anastomosis. The authors' findings suggest that using the Symani Surgical System for microanastomosis in extremity reconstruction is a safe and effective approach, leading to satisfactory outcomes in different anatomic regions. The system allows for the successful execution of various anastomosis techniques, including end-to-end and end-to-side connections, using single interrupted or running sutures, which enhances its versatility in complex reconstructive procedures. The benefits of robotic assistance in terms of precision and ergonomics are promising for the future of reconstructive microsurgery.

Percutaneous transluminal angioplasty of femoropopliteal veins for treatment of post-thrombotic syndrome.

Background: Controversy persists concerning the endovascular treatment of the post-thrombotic syndrome (PTS), particularly if femoropopliteal veins are involved. Methods: We screened consecutive patients with PTS who underwent percutaneous transluminal angioplasty (PTA) of femoropopliteal veins using posterior tibial or popliteal vein access who had at least 3-month follow-up. Our assessment included the evaluation of primary and secondary patency of the treated segments by Doppler ultrasound (DUS) and clinical outcomes measured by the change in Villalta score as well as ulcer healing. Results: Among 29 patients, 8 (27.7%) were women and the mean (SD) age was 53.3 (13.6) years. Posterior tibial vein and popliteal access were used in 26 (89.7%) and 3 patients (10.3%), respectively. 13 (44.8%) patients had prior (n = 11, 37.9%) or concomitant (n = 9, 31.0%) endovascular treatment of the iliac or common femoral veins. At a median follow-up of 395 days (Q1: 205-Q3: 756 days), primary patency of femoropopliteal veins was 79.3% (95% CI 64.6-94.1%) and secondary patency was 82.8% (95% CI, 69.0-96.5%). The percentage of patients with moderate or severe PTS according to the Villalta score decreased from baseline to last follow-up from 34.5% to 18.5% and from 31% to 14.8%, respectively (p<0.003). Overall, the mean (SD) Villalta score decreased from 11.5 (1.7) to 8.0 (1.7) (p<0.0001). Postprocedural complete ulcer healing occurred in 4 out of 5 (80%) patients. Two (6.9%) patients developed new ulcers. No major bleeding, pulmonary embolism, stroke, or death occurred. Conclusion: PTA of femoropopliteal veins via posterior tibial or popliteal vein access appears to improve the severity of PTS with acceptable patency rates.

Isolated Calf Muscle Venous Thrombosis: A Review of Anticoagulation Strategies.

Deep vein thrombosis (DVT) of the lower extremities is divided into 2 categories according to the extent of thrombosis involvement. Thrombosis involving the popliteal vein, femoral vein, and iliac vein is classified as proximal DVT, while thrombosis involving the anterior tibial vein, posterior tibial vein, peroneal vein, and calf muscles vein is regarded as distal DVT. There are updated guidelines for the anticoagulant treatment for proximal DVT, but the best anticoagulant treatment for distal DVT is still controversial, especially for isolated calf muscular vein thrombosis (CMVT). The risk of isolated CMVT extending to the proximal deep veins and developing into pulmonary embolism is lower than with distal DVT. Some scholars believe that isolated CMVT has the risk of evolving into proximal deep vein thrombosis and pulmonary embolism, and active early anticoagulation therapy can reduce the risk and benefit patients. In addition, based on the characteristics of CMVT and the bleeding risk of anticoagulation therapy, some studies have recommended use of non-anticoagulation methods such as compression therapy. There is still a lack of multicenter, big-data, randomized, controlled trials on the benefits or risks of anticoagulation therapy. Among scholars who support anticoagulation therapy, there is still a lack of consensus on the optimal duration. This article reviews the current evidence on anticoagulant therapy for patients with isolated CMVT and how long the anticoagulation course should be if anticoagulation is required. Our research will provide a theoretical basis for subsequent research. More prospective studies with larger sample sizes are needed to provide more clinical evidence.

Comparative Study of Two Different Access Points, One Tibial Vein and the Popliteal Vein, for Catheter-Directed Thrombolysis in the Treatment of Acute Mixed Lower Extremity Deep Vein Thrombosis

Although the popliteal vein approach is commonly used for catheter-directed thrombolysis (CDT) treatment in patients with acute lower extremity deep vein thrombosis (DVT), CDT via a new access route, the posterior tibial vein, is also used and has demonstrated good results. However, this tibial approach has not been tested in large samples. In this article, we compare the early efficacy of CDT using the tibial and popliteal vein approaches for the treatment of acute mixed lower extremity DVT. In this retrospective cohort study, 87 patients with acute mixed lower extremity DVT treated at the Department of Interventional Medicine of Zhuhai People's Hospital were enrolled; those with tibial vein access and popliteal vein access were included in the observation (n=55) and control (n=32) groups, respectively. The safety and efficacy of CDT via tibial vein access were investigated by collecting and comparing indicators such as venous patency, thrombus removal effect, thigh and calf circumference difference, swelling reduction rate of the affected limb, surgical complications, and postdischarge complication rate of the patients in the 2 groups. The postoperative thrombus clearance effect of the observation group was significantly better than that of the control group (P<0.05), and the postoperative venous patency rate of the observation group was 83.2±15.7%, which was higher than that of the control group (62.2±38.2%) (P=0.005). The swelling reduction rate of the lower extremity was 74.0±33.8% in the observation group and 51.4±30.0% in the control group, with a statistically significant difference (P=0.002). However, there was no statistically significant difference (P>0.05) in the rates of thigh swelling reduction, bleeding-related complications, or postoperative complications between the 2 groups of patients. CDT via the tibial vein approach is safe, effective, and may be a better approach for CDT access, offering superior thrombus clearance, venous patency, and lower extremity swelling reduction postoperatively.

Beyond The Ordinary: A Case of a Unilateral Persistent Sciatic Vein

Uncommon anatomical variations in venous structures continue to intrigue anatomists and clinicians alike. Here, we present a rare case of a unilateral persistent sciatic vein observed in the right thigh of an adult male cadaver. Unlike the commonly associated Klippel-Trenaunay-Weber syndrome, this finding emerged as an isolated phenomenon. During routine dissection, a conspicuous enlarged sciatic vein of lower type morphology was discovered in the right lower limb. This prominent vein, comparable in size to the sciatic nerve, originated from the confluence of posterior tibial, central soleal and peroneal veins at the distal end of the popliteal fossa. It ran a short course along the posterior thigh medial to the sciatic nerve, before terminating into the profunda femoris vein. This case underscores the importance of recognizing rare venous anatomical occurrences such as a persistent sciatic vein which predisposes one to deep vein thrombosis.

Calf deep veins are safe and feasible accesses for the endovascular treatment of acute lower extremity deep vein thrombosis

This study was designed to assess the optimal access route for the endovascular treatment of acute lower extremity deep vein thrombosis. This was a retrospective analysis of patients with acute lower extremity deep venous thrombosis who underwent endovascular treatment from February 2009 to December 2020. Patients underwent non-direct calf deep vein puncture (NDCDVP) from February 2009 to December 2011 and direct calf deep vein puncture (DCDVP) from January 2012 to December 2020. Catheter directed thrombolysis (CDT) was used to treat all patients in the NDCDVP group, whereas patients in the DCDVP group were treated with CDT or the AngioJet rhyolitic thrombectomy system. In patients exhibiting iliac vein compression syndrome, the iliac vein was dilated and implanted with a stent. Technical success rates and perioperative complication rates were compared between these two treatment groups. The NDCDVP group included 83 patients (40 males, 43 females) with a mean age of 55 ± 16 years, while the DCDVP group included 487 patients (231 males. 256 females) with a mean age of 56 ± 15 years. No significant differences were observed between these groups with respect to any analyzed clinical characteristics. The technical success rates in the NDCDVP and DCDVP groups were 96.4 and 98.2%, respectively (P > 0.05). In the NDCDVP group, the small saphenous vein (SSV)or great saphenous vein (GSV)were the most common access routes (77.1%, 64/83), whereas the anterior tibial vein (ATV) was the most common access route in the DCDVP group (78.0%, 380/487), followed by the posterior tibial vein (PTV) and peroneal vein (PV)(15.6% and 6.4%, respectively). Relative to the NDCDVP group, more patients in the DCDVP group underwent the removal of deep vein clots below the knee (7.2% [6/83] vs. 24.2% [118/487], P < 0.001). Moreover, relative to the NDCDVP group, significantly lower complication rates were evident in the DCDVP group (local infection: 10.8% vs. 0.4%, P < 0.001; local hematoma: 15.7% vs. 1.0%, P < 0.001). The position change rate was also significantly lower in the DCDVP group relative to the NDCDVP group (0% [0/487] vs. 60.2% [50/83], P < 0.001). The calf deep veins (CDVs) represent a feasible and safe access route for the endovascular treatment of lower extremity deep vein thrombosis.

Abstract 1143: Unraveling Histological Dynamics In Deep Venous Arterialization For Chronic Limb-threatening Ischemia

Introduction: Deep venous arterialization (DVA) is emerging as a promising alternative for no-option CLTI) but its pathophysiology remains incompletely understood. Research question: What histologic changes occur in the limb after DVA to allow tissue oxygenation? Study aim: To uncover histological alterations induced by DVA and provide a framework for future experimental models to explore early radiologic and histologic markers of successful DVA. Methods: We report the case of a 53-year-old female who underwent a percutaneous DVA for CLTI using a covered stent (Fig.1). The intervention was successful with evidence of improved blood flow to the foot, but the patient presented worsening infection leading to a below-knee amputation 4 weeks later. A high-resolution 7T MRI was used to scan the amputated limb, and the blood vessels were harvested for histology analysis. Results: The MRI confirmed the patency of the DVA stent graft (Fig. 2A) and plantar loop while histology demonstrated evidence of valvular disruption and eccentric neointimal hyperplasia (NIH) in the vein that underwent intervention (Fig 2B). There was also evidence of NIH and increased smooth muscle cells in the media of the paired vein that did not undergo intervention, resulting in greater thickness compared to the media of the anterior tibial vein at the same level (Fig 2C). Conclusion: Our case reveals some of the changes induced by DVA and demonstrates a possible role of the untouched paired vein in facilitating arterialized flow to the foot. This offers a framework for experimental studies to further investigate these histological alterations and their role in prognosticating DVA outcomes.

Training in Vascular Microsurgery: The Ex Vivo Biological Model on Domestic Turkey Leg (Meleagris gallopavo).

There are various models for practicing microsurgical anastomoses, from synthetic to ex vivo and in vivo biological ones. In this study, we present the domestic turkey (Meleagris gallopavo) as an ex vivo biological model in the practice of surgical anastomoses. In our opinion, it represents a model that is very similar to a human one, low cost, and easy to find. In fact, our study shows that the diameters of the arteries and veins used for anastomoses (tibial artery diameter: 2.5 ± 0.6 mm; tibial vein diameter: 3.5 ± 1.2 mm) are similar to those of human arteries and veins most frequently used in microsurgical free flaps. So, we believe that this animal model is a great model for microsurgical training for doctors who approach this difficult and long to learn discipline.

VENOUS THROMBUS STIFFNESS IN COMBINATION OF PULMONARY EMBOLISM AND DEEP VEIN THROMBOSIS OF THE LOWER EXTREMITIES (CLINICAL CASE)

Many aspects of pulmonary embolism pathogenesis are still unclear: for example, what is the probability of pulmonary embolization in venous thrombosis and thrombi formation in the pulmonary artery in situ. The origin and timing of thromboemboli formation in the pulmonary artery are of great clinical importance for effective treatment and prognosis of pulmonary embolism outcome. The aim of the study was as part of clinical observation to compare the results of shear wave ultrasound elastography of a venous thrombus and the histological structure of blood clots in the lower extremity and the pulmonary artery obtained during a pathoanatomical examination. Research results. Patient Sh., 67 years old, was hospitalized with a diagnosis of pulmonary embolism. Ultrasound imaging visualized heterogeneous, predominantly hypoechoic non-occlusive thrombotic masses in the lumen of the posterior tibial vein of the left lower limb, extending into the lumen of the popliteal vein for 2 cm with an uneven "ragged" contour of the proximal part of the thrombus, without clear signs of flotation. Shear wave ultrasound elastography determined stiffness of the proximal part of the venous thrombus with an average Young's modulus of 8.5 kPa, which corresponds to the acute stage of thrombosis. Negative dynamics was observed after thrombolytic therapy. Computed tomography angiography of the cerebral vessels revealed signs of intracerebral hemorrhage. On the third day, the patient was pronounced dead. The pathological examination was supplemented with histological data from a fragment of a venous thrombus of the pulmonary artery and lower leg veins. The morphological characteristics of blood clots from the veins of the lower extremities and the pulmonary artery coincided, indicating their common origin and the time of formation (acute stage). Conclusion. A comparative analysis of ultrasound and pathoanatomical data of the clinical case give us the opportunity to recommend shear wave ultrasound elastography of venous thrombi of the lower extremities to assess the state of thromboembolism in the pulmonary artery.

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.

Prone Position Increases the Risk of Postoperative Deep Vein Thrombosis in Cervical Spine Surgery by Limiting Venous Return in the Lower Limbs.

A retrospective clinical study with confirmatory evaluation in healthy volunteers. To investigate the association between deep vein thrombosis (DVT) and surgical position after cervical spine surgery. It is unclear whether posterior cervical surgery using the prone position increases the risk of postoperative DVT relative to anterior cervical surgery. A total of 340 patients undergoing surgery for degenerative cervical myelopathy were included. Multivariate analysis was used to identify the predictors of postoperative DVT, adjusting for potential confounders. In addition, 45 healthy volunteers were used to study the blood flow velocity and intravascular diameter of the posterior tibial vein (PTV) and popliteal vein (PV) of the subjects, which were monitored by ultrasound and compared among three positions (supine, prone, and prone with iliac cushions). Multivariate analysis showed that advanced age (above 63.5yr old), preoperative varicose veins, D-dimer >0.255mg/L, bleeding volume >303mL, and prone positioning were significantly associated with DVT after cervical spine surgery. The results of vascular ultrasound showed that the blood flow velocities of the PV and PTV in the prone position with cushions were significantly lower than those in the supine position. The diameter of PV in the prone position with cushions was also significantly larger. The blood flow velocity and diameter of PV in the prone position with cushions were significantly lower and larger, respectively, than those in the prone position without cushions. Posterior cervical surgery in the prone position was significantly associated with postoperative DVT. The prone position with iliac cushions may decrease venous flow within the lower extremities due to compression of the iliac veins, obstructing venous return and thus increasing the incidence of postoperative DVT. The prone position without iliac cushions may reduce the potential for DVT. 3.

The Below-the-Knee Approach to Percutaneous Mechanical Thrombectomy for Lower Extremity Deep Venous Thrombosis: A Retrospective Single-Centre, Single-Arm Study.

The objective of this study was to evaluate the safety, efficacy, and feasibility of percutaneous mechanical thrombectomy (PMT) through a below-the-knee (BTK) approach for acute lower extremity deep venous thrombosis (DVT). A retrospective review of DVT patients treated with PMT by the BTK approach at our center from April 2022 to August 2023 was performed. Their preoperative demographics, intraoperative data, and postoperative outpatient outcomes were analyzed. A total of 12 patients (67% men; mean age, 63 years) met the inclusion criteria. The BTK approach was successfully achieved in all patients through the posterior tibial vein (n = 1), anterior tibial vein (n = 2), and peroneal vein (n = 9). PMTs were achieved in 11 (92%) patients. Successful lysis (grade II and grade III lysis) was achieved in all patients with PMT. Four (33%) patients had residual venous occlusion over the popliteal vein. No intraoperative complications or bleeding events occurred in any of the patients. PMT via BTK puncture seems to be a safe and effective approach for treating lower extremity DVT. It is reserved for highly select patients with a low risk of bleeding and is performed at centers that have experience with this procedure.

Rare Association of Takayasu Arteritis and Antiphospholipid Syndrome with Severe Thrombocytopenia

The association of Takayasu arteritis (TA) with antiphospholipid syndrome (APS) has rarely been described in the literature. This paper reports the first documented case of TA and APS in a 24-year-old woman in Bangladesh. This patient had claudication pain in upper and lower limbs for four years and Raynaud’s phenomenon in right hand for eight months. During the course of her illness, she suddenly developed deep vein thrombosis in left superficial femoral, popliteal and posterior tibial veins. Conventional angiography revealed total occlusion of right subclavian artery and 60-70% stenosis of right common iliac artery. CT angiography of right upper limb also supported these findings along with increased wall thickening in the 2nd part of right subclavian artery and moderate narrowing of the 1st part of right axillary artery. She had persistently positive anticardiolipin antibodies in high titers, positive lupus anticoagulant (LA), prolonged activated partial thromboplastin time (APTT) and severe thrombocytopenia. We started high dose prednisolone (1mg/kg daily). Her platelet count increased rapidly. Based on review of 10 case reports, we considered the rare association of TA and APS. Both conditions should be determined promptly for the sake of early institution of the appropriate therapy. Bangabandhu Sheikh Mujib Med. Coll. J. 2023;2(1): 59-63

Case Report on Challenging Deep Vein Thrombosis

In pregnancy, venous thromboembolism (VTE) remains a leading cause of direct maternal mortality. It is approximatelyfive times more common in pregnant women, with an incidence of 0.5-2 in 1000. The highest risk of deep venous thrombosis(DVT) leading to pulmonary embolism (PE) is during the postnatal period, especially after a cesarean section. A clinician who doesnot treat pregnant women regularly may not routinely identify pregnancy-specific risk factors for VTE. In patients with DVT,treatment with anticoagulation is associated with a high risk of bleeding during the immediate postpartum state, and patients dowell with monitored anticoagulation and proper supportive treatment, as described in this case report. We are reporting a caseof a 20-year-old primigravida who presented with labor pains at 39 (+6) weeks of gestation at Sree Balaji Medical College andHospital, Chrompet, Chennai. The patient had no comorbidities and did not report any past or family history of VTE. An emergencycesarean section was performed due to fetal distress, and on the first postoperative day, she developed swelling pain andtenderness in the left lower limb. Color Doppler ultrasound showed left anterior tibial vein thrombosis, following whichanticoagulant therapy was started with low molecular weight heparin. The patient was closely monitored for signs of bleeding orPE and was eventually discharged on oral anticoagulation. In conclusion, all women should be assessed for the risk factors of DVTduring the antenatal period, and early ambulation in the postoperative period is crucial to prevent such deadly complications.

The effect of the A82G mutation in the MMP-12 gene and C634G mutation in the VEGF-A gene on the course of lower limb varicose veins and the risk of disease recurrence

Aim: creation of a method for predicting the development of varicose veins of the lower extremities and its recurrence.Object and methods. 2 independent studies of patients with C2-C6 varicose veins of the lower extremities (CEAP-classifier) were conducted. In the first, with ultrasound diagnosis of the main veins of the lower extremities and genomic analysis of blood samples, 75 participants (men 20, women 55), mean age 43.7 ± 5.9 years. All patients were randomized into two groups: group I (n = 17) – with recurrent varicose veins; Group II (n = 58) – applied with varicose veins for the first time. The 2nd study involved 44 (men 10, women 34), mean age 55.5 ± 2.7 years. Similarly, patients were divided into groups – I (5) and II (39 people). All patients of the first stage of the study underwent real-time PCR with allele-specific primers to determine the A82G mutation in the MMP-12 gene (matrix metalloproteinase-12) and the second stage C634G in the VEGF-A gene (endothelial fibroblast growth factor – A).Results of the study. In patients of both groups I and II, having the MMP-12 gene in the heterozygous variant, dilatation of the tibial and popliteal veins was present (6.4 ± 0.3 mm and 10.7 ± 0.24 mm, respectively) with the presence reflux and slowing down the evacuation of blood from the deep venous system. In patients of group I, the MMP-12 gene was found in 80 % of cases, as A/A (homozygous) and A/G (heterozygous variation), while in group II only in 33.3 % of cases. Pearson's goodness-of-fit criterion χ2 = 10.4 (the critical value of the criterion is 6.63), p &lt; 0.01. The frequency of recurrence of varicose veins and mutation of the MMP-12 gene according to the Spearman test was 1.0 with the number of degrees of freedom 23, p &lt; 0.05. In the 2nd study, a correlation was found between groups I and II of patients with the C/C genotype (Pearson's coefficient χ2 = 0.79, p &lt; 0.11) and a correlation in the duration of the disease between groups of patients with the C/C genotype (homozygous variation) and C /G (heterozygous variation) – Pearson correlation coefficient χ2 = 0.92 (p &lt; 0.01).Conclusion. The revealed relationship between the MMP-12 gene polymorphism and the frequency of varicose vein recurrence is a predictor of the development of structural changes in the vein wall, and a mutation in the VEGF-A gene occurs with a long history of the disease.

Canalis cruropopliteus - the overlooked canal of Wenzel Gruber

It is widely known that the popliteal fossa and the lower leg are connected by a canal, containing the neuro-vascular bundle to the posterior leg region, containing the tibial nerve and the posterior tibial artery and veins. The existence of this canal has not been duly recognized in literature, even though it has been named by Wenzel Gruber in 1871, and its contents, walls, entrance, and exits have been extensively described by him in 1878. In the present paper, we would like to pay a homage to the work of this prominent anatomist, which retains its significance for contemporary surgical practice. The cruropopliteal canal, canalis cruropopliteus, as named by him, and having been assigned a multitude of terms in practice, deserves to regain its eponymous name – Gruber’s canal. The history, and the anatomy with its clinical implications are discussed herein. We hereby recommend that the original name of this canal be included in anatomical textbooks and specialized literature.

Proximity of percutaneous tibial nerve stimulation needle insertion to surrounding anatomic structures: a cadaveric study

Percutaneous tibial nerve stimulation is a third-line treatment for overactive bladder and urgency urinary incontinence. During the procedure, a needle is inserted cephalad to the medial malleolus and posterior to the tibia. In recent years, permanent implants and leads have been developed for insertion into the medial ankle via a small incision. There are many important structures present in the medial compartment of the ankle, including the great saphenous vein, saphenous nerve, tibial nerve, posterior tibial vessels, and tendons of the posterior compartment leg muscles. The primary objective of this study was to identify the proximity of the percutaneous tibial nerve stimulation needle placed per Food and Drug Administration-approved device instructions to nearby important anatomic structures. The secondary objectives were to identify the proximity of the tibial nerve to the needle site, identify clinically relevant ankle anatomic structures, and confirm the tibial nerve and posterior tibial vasculature by histologic analysis. Detailed medial ankle dissections were performed bilaterally on 10 female lightly embalmed anatomic donors (cadavers) obtained from the Willed Body Program at the University of Louisville. A pin was inserted at the percutaneous tibial nerve stimulation needle site, and the medial ankle was minimally dissected so the surrounding anatomic structures were visible but not disrupted. The shortest distance from the pin to the selected structures of the medial ankle region was measured. On completion of each dissection and set of measurements, tissue was harvested for histologic examination. The distances between the pin and each structure were assessed using means and standard deviations. A paired t test was used to assess the difference in the locations between the left and right ankles. Statistical analysis was performed on left-sided, right-sided, and combined measurements. An 80% prediction interval was found to represent the expected range of values for the measurement of a new cadaver or patient, and the 95% confidence interval of the mean was computed to characterize the average distance across all cadavers or patients. The medial ankle of 10 adult female lightly embalmed cadavers were examined bilaterally. Dissections were completed from October 2021 to July 2022. Of note, 80% prediction intervals for the tibial nerve, the posterior tibial artery or vein, and the flexor digitorum longus tendon had a lower range of 0.0 mm from the pin and extending to 12.1, 9.5, and 13.9 mm, respectively. Moreover, 2 of the structures were found to be asymmetrical between the right and left ankles. The great saphenous vein was further from the pin on the left (20.5 mm [standard deviation of 6.4 mm] on the left vs 18.1 mm [standard deviation of 5.3 mm] on the right; P=.04). The calcaneal (Achilles) tendon was further from the pin on the right side (13.2 mm [standard deviation of 6.8 mm] vs 7.9 mm [standard deviation of 6.7 mm]; P=.04). Tibial neurovascular structures were confirmed with microscopic analysis. The anatomic structures within the medial ankle lie unexpectedly close to the percutaneous tibial nerve stimulation needle site as noted per Food and Drug Administration-approved device instructions. There is a possibility that some medial ankle structures are not symmetrical. It is crucial that practitioners understand medial ankle anatomy when performing percutaneous tibial nerve stimulation or permanent device insertion.

Our Experience with Posterior Approach for Posterior Tibial Plateau Fractures.

Introduction: Posterior tibial plateau fractures are a rare type of fractures. Most surgeons are accustomed to operate in the supine position, however, surgery in the posterior knee region and operating in prone position can be challenging because of the presence of neurovascular structures including the tibial nerve, popliteal artery and vein, common peroneal nerve and, also challenging to achieve effective reduction and fixation, thus, it is less commonly performed. Materials and methods: Between February and September 2022 four posterior tibial plateau fractures were diagnosed and operated in our clinic within a six months follow-up (2 female and 2 male with mean age of 48.5 years). All were diagnosed with X-rays and CT scans. All of the fractures were on the right leg. Posterior "S shape" approach in prone position was used to reduce the tibial condyle and fix it with a plate. In fracture patterns that include lateral plateau impressions, the posterior "S shape" approach may not be sufficient to perform open reduction and internal fixation of the lateral condyle, so an additional anterolateral approach was made and additional locking plate was placed. Radiographic evaluation included reduction quality and satisfactory alignment of the bone axis. Results: All fractures healed within 6 months, without secondary displacement. Throughout the follow-up period, there were no incidences of post-traumatic osteoarthritis of the knee. No patient complained of knee instability. Conclusion: The direct dorsal approach allowed for adequate open reduction and internal fixation, and early clinical results are promising. However, in fracture patterns that include lateral plateau impressions, the posterior "S shape" approach may not be sufficient to perform open reduction and internal fixation of the lateral condyle, so an additional anterolateral approach should be made and additional locking plate to be placed.

Natural history and role of anticoagulation in the management of endovenous glue-induced thrombus

The natural history of endovenous glue-induced thrombus (EGIT) resolution and the role of anticoagulation (AC) and/or anti-platelet (AP) agents in their management is currently ill-defined. The goal of this investigation is to determine the clinical behavior of EGITs and whether or not AC or AP affects treatment outcomes. We performed a retrospective review of all endovenous ablations utilizing cyanoacrylate glue (CAG) from January 2020 to December 2021 at the Center for Vein Restoration. Patients were divided into two groups: (1) patients who developed an EGIT (EGIT/CAG) and (2) patients treated with CAG and no EGIT development (CAG). Demographics, medical/surgical histories, revised Venous Clinical Severity Score (rVCSS), Chronic Venous Insufficiency Quality of Life Questionnaire (CIVIQ), CEAP, EGIT category, type of anticoagulation, resolution time, location of any deep vein thrombosis (DVT) were analyzed, catheter tip distance, treatment length and proximal thigh diameters were all analyzed. EGITs were categorized as follows: EGIT 1: thrombus extension into the deep vein covering less than 25% of the luminal area; EGIT 2: thrombus between 25% and 49%; EGIT 3: thrombus between 50% and 74%; and EGIT 4: total occlusion. Our protocol is to perform post-procedure duplex scans within 3 to 7days after endovenous ablations to assess for post-intervention DVTs. During the study period, 2374 patients received 4321 CAG procedures. EGITs were observed in 133 patients (3.1%): EGIT 1 (n= 57); EGIT 2 (n= 35); EGIT 3 (n= 19); and EGIT 4 (n= 22). All EGITs were identified by surveillance scanning. No patient presented with limb or pulmonary symptoms suggestive of VTE. The average age, rVCSS, and CIVIQ 20 of the entire cohort was 65.3± 14.2 years, 8.2± 2.8, and 48± 18.3, respectively with 89 females and 44 males. For EGIT 1, 56 of 57 (98%) resolved at 4.2± 5.1weeks, with one patient lost to follow-up. AC/AP regimen included two aspirin (ASA), one Eliquis, 5 Xarelto, and nothing in 49 patients (86%). For EGIT 2, 27 of 35 (77%) resolved at 4.4± 3.4weeks, one was unresolved, six regressed to EGIT 1, and one remained an EGIT 2 at the last follow-up examination. AC/AP regimens included seven ASA, three Eliquis, three Xarelto, one Coumadin, and nothing in 21 patients (60%). For EGIT 3, 12 were in the common femoral vein (CFV), three in the popliteal vein (POPV), one in the external iliac vein, and three in the gastrocnemius veins. Nine of nineteen (47%) resolved at 6± 5.9weeks, four regressed, one migrated to the proximal CFV, three became chronic, and two were lost to follow-up. AC/AP regimens included three ASA, three Eliquis, seven Xarelto, and nothing in six patients (32%). AC/AP compared with no AC/AP had no effect on clot resolution (P= .3). Of the 22 EGIT 4, one was in the CFV, two were in the POPV, and 18 (82%) were remote calf vein DVTs (15 gastrocnemius, one peroneal [PV], and three posterior tibial veins [PTVs]). The CFV EGIT became chronic, one POPV resolved, and one was lost to follow-up. For the gastrocnemius clots, five became chronic, eight resolved, and two were lost to follow-up. For the PTV clots, one resolved, one became chronic, and one was lost to follow-up. The PV clot became chronic. AC/AP regimen included four ASA, five Eliquis, six Xarelto, and nothing in seven patients. AC/AP compared with no AC/AP had no effect on clot resolution (P= .9). The average proximal thigh diameter (millimeters, mm), vein length treated (mm), and catheter distance (mm) from the junction were the following: EGIT 1 (5.9± 2.4, 37.5± 17.6, and 5.2± 1), EGIT 2 (5.9± 1.7, 38± 16.9, 4.79± 0.71), EGIT 3 (5.1± 2.6, 27.9± 16.6, and 5.26± 1.4), and EGIT 4 (5± 1.7, 29.9± 15.8, and 5.39± 2.18), respectively. Treatment length alone was significantly shorter in EGIT 3 and 4, compared with EGIT 1 and 2 (P ≤ .05). Catheter distance from the junction was longer in EGIT 1, 3, and 4 patients compared with CAG patients (P ≤ .02). Regardless of EGIT class or severity, the majority of EGITs are not associated with clot extension or migration and tend to resolve or regress. For EGIT class 1 and 2 patients, AC or AP therapy is not necessary, as 86% and 60%, respectively, resolved with observation alone by 4 weeks. For EGIT 3, 68% resolved or regressed regardless of AC or AP use. The majority of EGIT 4 were remote calf vein DVTs. EGIT 3 and 4 associated with the saphenofemoral/popliteal junction are rare. When compared with CAG patients, proximal thigh diameters and treatment lengths were larger and longer in EGIT 1 and 2 patients. Catheter proximity to the junction was not associated with a higher incidence of EGIT formation.