Underwent Duplex Ultrasonography Research Articles

Association of Age-Related Spontaneous Internal Jugular Vein Reflux with Cognitive Impairment and Incident Dementia.

It remains unclear whether changes in the venous circulation contribute to cognitive decline. This study aimed to clarify whether the spontaneous jugular vein reflux (JVR) is associated with cognitive impairment and incident dementia. Patients with any evidence of cerebral vessel disease on magnetic resonance imaging (MRI) were consecutively enrolled between October 2015 to July 2019. We employed carotid duplex sonography to measure the internal jugular vein (IJV). The subjects were classified into two groups based on the degree of JVR on either side: none, mild (JVR(-) group) and moderate, severe (JVR (+) group) JVR. They underwent both the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment-Japanese (MoCA-J) global tests. Their cognitive status was prospectively assessed until March 2023. 302 patients with an MMSE score ≥24 underwent duplex sonography of the IJV. Among them, 91 had spontaneous JVR on either side. Both MMSE and MoCA-J were significantly lower in patients with JVR (+) group than in the JVR (-) group. After the adjustment for risk factors and MRI findings, intergroup differences in MoCA-J remained significant. Among the cognitive subdomains, median executive function and memory scores were significantly lower in the JVR (+) group than in the JVR (-) group. During the median 5.2-year follow-up, 11 patients with incident dementia were diagnosed. Patients with severe JVR were significantly more likely to be diagnosed with dementia (log-rank test, p = 0.031). Spontaneous IJV reflux especially severe JVR, was associated with global cognitive function, and potentially with incident dementia.

Mycophenolate mofetil in giant cell arteritis.

Giant cell arteritis (GCA) is a systemic granulomatous vasculitis affecting the large arteries. Abnormal lymphocyte function has been noted as a pathogenic factor in GCA. Mycophenolate mofetil (MMF) inhibits inosine monophosphate dehydrogenase and is therefore a highly lymphocyte-specific immunosuppressive therapy. We aimed to assess the efficacy of MMF for inducing remission in GCA. Seven patients (5 female, 2 male) with GCA under therapy with MMF and who were treated at the outpatient clinic for rare inflammatory systemic diseases at Hannover Medical School between 2010 and 2023 were retrospectively included in the study. All patients underwent duplex sonography, 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET), magnetic resonance imaging (MRI), and/or biopsy to confirm the diagnosis. The primary endpoints were the number of recurrences, CRP levels at 3-6 and 6-12 months, and the period of remission. All patients in this case series showed inflammatory activity of the arterial vessels in at least one of the imaging modalities: duplex sonography (n = 5), 18F-FDG PET (n = 5), MRI (n = 6), and/or biopsy (n = 5). CRP levels of all patients decreased at the measurement time points 3-6 months, and 6-9 months after initiation of therapy with MMF compared with CRP levels before MMF therapy. All patients with GCA in this case series achieved disease remission. The results of the present case series indicate that MMF is an effective therapy in controlling disease activity in GCA, which should be investigated in future randomized controlled trials.

Correlation of Clinical Class with Duplex Ultrasound Findings in Lower Limb Chronic Venous Disease

BackgroundThis study investigated the distribution of valve incompetence in patients with chronic venous disease (CVD) and its correlation with the clinical category of the clinical, etiological, anatomical, and pathophysiological (CEAP) classification.MethodsIn total, 1,386 limbs with clinically suspected CVD were categorized according to the CEAP classification and consecutively underwent duplex ultrasonography between April 2017 and December 2020.ResultsThere were 362 limbs in male patients and 1,024 limbs in female patients. The limbs were classified as C0s–C1 (608 limbs, 43.8%), C2 (727 limbs, 52.5%), or C3–C6 (51 limbs, 3.7%). The prevalence of saphenous vein incompetence in CEAP C0s–C1 limbs was 43.6%. The saphenofemoral junction (SFJ) was competent in 37% of CEAP C2–C6 limbs. The CEAP C3–C6 category was not correlated with reflux patterns of the saphenous vein system (Cramer’s V=0.07), incompetent SFJ (Cramer’s V=0.07), deep vein reflux (Cramer’s V=0.03), or the distribution of incompetent segments in the great saphenous vein (GSV) (Cramer’s V=0.11).ConclusionDuplex ultrasonography is necessary to formulate a proper treatment plan for limbs categorized as CEAP C0s–C1. The SFJ was competent in more than one-third of CEAP C2–C6 limbs with GSV reflux; as such, flush ligation of the GSV may be unnecessary in these patients. The CEAP C3–C6 category showed no correlations with reflux patterns of the saphenous vein system, SFJ reflux, deep vein reflux, or the distribution of incompetent segments in the GSV.

Interventional Treatment of Access Site Complications During Transfemoral TAVI: A Single Center Experience.

Introduction: Transcatheter aortic valve implantation (TAVI) has rapidly developed over the last decade and is nowadays the treatment of choice in the elderly patients irrespective of surgical risk. The outcome of these patients is mainly determined not only by the interventional procedure itself, but also by its complications.Material and Methods: We analyzed the outcome and procedural events of transfemoral TAVI procedures performed per year at our institution. The mean age of these patients is 79.2 years and 49% are female. All the patients underwent duplex ultrasonography of the iliac arteries and inguinal vessels before the procedure and CT of the aorta and iliac arteries.Results: Transfemoral access route is associated with a number of challenges and complications, especially in the patients suffering from peripheral artery disease (PAD). The rate of vascular complications at our center was 2.76% (19/689). Typical vascular complications (VC) include bleeding and pseudoaneurysms at the puncture site, acute or subacute occlusion of the access vessel, and dissection or perforation of the iliac vessels. In addition, there is the need for primary PTA of the access pathway in the presence of additional PAD of the common femoral artery (CFA) and iliac vessels. Balloon angioplasty, implantation of covered and uncovered stents, lithoplasty, and ultrasound-guided thrombin injection are available to treat the described issues.Conclusion: Interventional therapy of access vessels can preoperatively enable the transfemoral approach and successfully treat post-operative VC in most of the cases. Training the heart team to address these issues is a key focus, and an interventional vascular specialist should be part of this team.

Markers of atherosclerosis lipoprotein-associated phospholipase A2 and E-selectin and vascular risk factors in patients with carotid stenosis

The aim of this study is to evaluate serum level biomarkers of atherosclerosis lipoprotein-associated phospholipase A2 and E-selectin in patients with atherosclerotic carotid stenosis with different clinical manifestation in associated with vascular risk factors.
 Materials and methods: A total 106 patients with atherosclerotic carotid stenosis (74 men and 32 women, aged from 31 to 74 years, mean 62.6±0.9) were included: with acute ipsilateral atherothrombotic stroke (35), history of stroke and carotid endarterectomy (41) and 30 patients with asymptomatic carotid stenosis. The control group consist of 20 health subjects without cardiovascular disease. All participants underwent duplex sonography. Lipoprotein-associated phospholipase A2 and E-selectin was measured using commercially available (ELISA) kit.
 Results: The level of lipoprotein-associated phospholipase A2 was in general 55.664±3.537 ng/ml, which was significantly higher (M-W U=10, p=1.023136´10-11 <0.05) than in the control group (9.296±0.935 ng/ml). Level was significantly higher in groups of symptomatic patients who underwent carotid endarterectomy (p=0.04893), and proportion patients with high degree stenosis >70 % was greater in this group. The level of E-selectin in the study patients was significantly higher (7.653±0.246 pg/ml) than in the control group (3.101±0.503 pg/ml) p<0.05. No association the serum level of lipoprotein-associated phospholipase A2 and E-selectin with common stroke risk factor such as hypercholesterinemia, smoking and body mass index were found, but positive correlation of lipoprotein-associated phospholipase A2 with E-selectin was significant (p=0.00085).
 Conclusions: Increasing plasma level lipoprotein-associated phospholipase A2 and E-selectin in patients with the carotid atherosclerotic stenosis were observe. Statistically significant correlation between the level of lipoprotein-associated phospholipase A2 and E-selectin were found in symptomatic carotid atherosclerotic stenosis

Peripheral Vascular Resistance in Cerebral Arteries in Patients With Carotid Atherosclerosis - Substudy Results of the Atherosclerotic Plaque Characteristics Associated With a Progression Rate of the Plaque and a Risk of Stroke in Patients With the Carotid Bifurcation Plaque Study (ANTIQUE).

Transcranial color-coded duplex sonography (TCCS) enables to measure blood flow characteristics in cerebral vessels, including vascular resistance and pulsatility. The study aims to identify factors influencing pulsatility (PI) and resistance (RI) indices measured using TCCS in patients with carotid atherosclerosis. Self-sufficient patients with atherosclerotic plaque causing 20-70% carotid stenosis were consecutively enrolled to the study. All patients underwent duplex sonography of cervical arteries and TCCS with measurement of PI and RI in the middle cerebral artery, neurological, and physical examinations. Following data were recorded: age, gender, height, weight, body mass index, systolic and diastolic blood pressure, occurrence of current and previous diseases, surgery, medication, smoking, and daily dose of alcohol. Univariant and multivariant logistic regression analysis were used for identification of the factors influencing RI and PI. Totally 1863 subjects were enrolled to the study: 139 healthy controls (54 males, age 55.52 ± 7.05 years) in derivation cohort and 1724 patients (777 males, age 68.73 ± 9.39 years) in validation cohort. The cut off value for RI was 0.63 and for PI 1.21. Independent factors for increased RI/PI were age (odds ratio [OR]=1.108/1.105 per 1 year), occurrence of diabetes mellitus (OR=1.767/2.170), arterial hypertension (OR=1.700 for RI only), width of the carotid plaque (OR=1.260 per 10% stenosis for RI only), and male gender (OR=1.530 for PI only; P ˂.01 in all cases). The independent predictors of increased cerebral arterial resistance and/or pulsatility in patients with carotid atherosclerosis were age, arterial hypertension, diabetes mellitus, carotid plaque width, and male gender.

The Relationship between the Blood Flow Volume of the Arteriovenous Fistula and its Early Effect on the Pulmonary Artery Pressure and the Left Ventricular Dimensions and Functions

Abstract Background Cardiovascular complications are leading cause of the death in hemodialysis patients. One of these complications is pulmonary hypertension which complicates chronic renal failure in 12–45% of cases and causes an increase in all-cause mortality of 2-3 folds in the dialysis population. Another complication is left ventricular hypertrophy which is a strong predictor of morbidity and mortality in patients with ESRD. Arteriovenous fistulas increase cardiac output and lead to significant increases in both the mass and the diameter of the left ventricular wall in the long-term duration. There is evidence that A-V fistula creation is a major risk factor for developing a new onset Congestive Heart Failure Aim of the Work Our study aimed to assess the relationship between blood flow volume of arteriovenous fistula (AVF) and its effect on the Pulmonary Artery Pressure (PAP) and the Left Ventricular (LV) dimensions and functions and to find out the cut off value of the AVF blood flow volume above which the cardiac dimensions and functions start to get affected. Methods and Results The study included 50 individuals selected from Internal Medicine and Nephrology outpatient clinics and inpatient wards at Ain Shams University Hospitals during the period from November 2016 until October 2018 who underwent full echocardiography studies once at the beginning of the study and once after 3 months and also underwent Duplex sonography on arteriovenous fistula to measure blood flow rate. The results showed that after 3 months the only significant changes were the ejection fraction (P-value of 0.029), the fractional shortening (P-value of 0.009), and the E/A ratio (p-value of 0.005). Also, the results showed a correlation between AVF blood flow volume and LV internal dimensions. Left ventricular end-diastolic diameter (LVEDD) and Left ventricular end-systolic diameter (LVESD) increased significantly in patients with AVF blood flow volume of 1010 ml/min or above and 1120 ml/min or above respectively. Surprisingly, PASP showed no statistically significant change in our study. Conclusion Our study concluded that high flow AVF affect cardiac dimensions and functions. We proved that a cut off value of AVF blood flow volume affecting LV dimensions and functions can be reached and in our study, a value of 1010 ml/min or above affected the LVEDD and a value of 1120 ml/min or above affected the LVESD. Surprisingly, in our study, the PASP did not show a positive correlation with AVF blood flow volume.

Does Tranexamic Acid Increase the Incidence of Thromboembolism After Spinal Fusion Surgery?

This was a retrospective analysis of prospectively collected data. To investigate the incidence of thromboembolism in patients who received tranexamic acid (TXA) after lumbar spine fusion and determine the diagnostic value of lower limb duplex sonography as a screening test. TXA is effective in reducing blood drainage in spine fusion surgery but some studies have reported increased incidence of venous thromboembolism associated with TXA. One hundred twenty-two patients who underwent lumbar fusion for degenerative spinal disease received intravenous TXA in doses equivalent to 10 mg/kg for 48 hours after surgery. As a control group, 85 patients received intravenous administration of the same amount of normal saline. D-dimer levels were checked on the day of admission and the seventh postoperative day (POD#7). All patients underwent duplex sonography on POD#7, and patients with abnormal results were further evaluated with computed tomography angiography and pulmonary arterial angiography. None of the patients showed symptoms of deep vein thrombosis (DVT). Suspicious signs of DVT were observed in 5 patients in the TXA group and 4 patients in the control group in lower limb duplex sonography. Finally, DVT was confirmed by computed tomography angiography in one of 122 patients (0.8%) in the TXA group and in one of 85 patients (1.2%) in the control group. D-dimer levels on POD#7 were higher in the patients with DVT than in patients without DVT. Average postoperative blood drain was 421.3±133.1 mL in the TXA group and 635.2±151.2 mL in the control group (P<0.001), which showed TXA was effective to reduce postoperative hemorrhage. The incidence of thromboembolism after using TXA in lumbar fusion surgery was 0.8%, as comparable as the incidence of thromboembolism in the control group. Lower limb duplex sonography is not recommended for screening test of DVT because of high false-positive rate. Level III.

Is thromboprophylaxis really justified among Indian population with femur shaft fractures treated with IM nailing?

Introduction: Venous thromboembolism (VTE), which consists of deep vein thrombosis (DVT) and pulmonary embolism, is one of the most common preventable cause of morbidity and mortality after trauma. Though most of the western countries have their guidelines for thromboprophylaxis in these patients, India still does not have these. The increasing detection of VTE among Indian population, lack of awareness, underestimation of the risk, and fear of bleeding complications after chemical prophylaxis have made deep vein thrombosis (DVT) a serious problem, hence a standard guideline for thromboprophylaxis after trauma is essential. There are many studies for thromboprophylaxis in patients underwent Joint replacement surgery. But there are no clear guidelines regarding the prophylaxis for VTE for trauma surgeries. Amongst all fracture pattern femur shaft is most notorious for incidence of fat embolism. Materials and Methods: We carried out a Prospective Randomised study to determine the incidence of DVT. Present study included 105. Patients having Diaphyseal fracture of Femur undergoing intramedullary Interlocking Nailing. All the patients underwent duplex ultrasonography between preoperatively, 3rd Postoperative day and 6 weeks postoperative. Results: Only six patients (7.8%) showed sonographic evidence of DVT and the majority of them resolved without treatment. There were 2 case of pulmonary embolism out of which one patient died because of Pulmonary embolism. Conclusion: DVT following fractures of Femur in Indian patients is not as common as reported in the Western literature. A high level of suspicion and close clinical monitoring is mandatory, routine chemoprophylaxis is perhaps not justified in every patient undergoing femur fracture surgeries. More trials involving a larger number of patients and at multi centers, in future, would be required to confirm the findings of our study.

Prevalence and Predictors of DVT in Medical ICU Patients Undergoing Diagnostic Duplex Ultrasonography

SESSION TITLE: Hematology/Oncology in the ICU SESSION TYPE: Original Investigation Slide PRESENTED ON: Monday, October 30, 2017 at 04:30 PM - 05:30 PM PURPOSE: Deep vein thrombosis (DVT) is a recognized but preventable cause of morbidity and mortality in the ICU. There is limited data on the risk of DVT or predisposing factors among non-surgical ICU patients with multiple medical comorbidities. Our aim is to retrospectively examine the prevalence and risk factors for proximal DVT and potential effect on clinical outcomes in critically ill medical patients in which diagnostic duplex ultrasonography (DUS) was performed. METHODS: Retrospective case-control study examining the prevalence of DVT in 678 patients admitted to two tertiary care level academic Medical ICUs (MICU) from July 2014 to July 2015 in the Bronx, NY. Persons with a diagnosis of proximal DVT on DUS were compared to a cohort of patients without DVT. Sequential Organ Failure Assessment (SOFA) scores were calculated for all patients to assess disease severity and comparability. Primary outcomes were ICU length of stay and mortality. Secondary outcomes were need for invasive mechanical ventilation (IMV), hemodialysis, sepsis, SOFA scores, vasopressor/inotrope use, central venous catheter (CVC) placement, history of DVT and malignancy. Stepwise logistic regression analysis was utilized to determine predictors of DVT occurrence. RESULTS: Of the 678 patients admitted to the MICU, 245 (36%) patients underwent duplex ultrasonography (DUS) to evaluate for DVT. 141 (57%) were male, mean age was 64.4±16.7 years, and BMI 29.8±11.5 kg/m2. Dyspnea (31%) and immobility (23%) were the most common indications for DUS testing. The prevalence of DVT was 19% (47) amongst tested patients. Of the patients with DVT, we noted increased rates of CVC placement (25% vs.15% p=0.05), and vasopressor/inotrope use (26% vs.16% p=0.05) compared to persons without DVT on DUS. Those on routine DVT thromboprophylaxis, chemical or mechanical, had fewer DVTs (15% vs 29% p=0.01). Between cases and controls, there were no significant differences in the need for IMV, hemodialysis, sepsis, SOFA scores, and history of malignancy. There were also no significant differences in ICU length of stay (DVT:4.4±6 days vs no DVT:4.8±59 days p=0.35) or mortality (DVT:10.6% vs no DVT:11.8% p=0.34). Stepwise regression modeling demonstrated a prior history of DVT was a significant predictor for development of DVT (OR 5.68, 95% CI [1.81, 17.83] p<0.01). CONCLUSIONS: A significant percentage of patients tested had proximal DVT even with appropriate use of DVT thromboprophylaxis. A history of DVT in a patient was the sole predictor for development of DVT on DUS testing in our MICU population. Our study demonstrated vasopressor/inotrope use and the central venous catheters used for medication delivery were associated with presence of DVT. Sepsis was not an independent risk factor for DVT. CLINICAL IMPLICATIONS: Despite the use of universal, guideline-recommended thromboprophylaxis, critically ill patients still demonstrate high rates of DVT. In the presence of known risk factors elicited from our cohort - history of DVT, CVC placement, and use of vasopressors/inotropes - our study highlights the need for targeted screening via DUS in the medical ICU. Further studies with larger patient populations are needed to fully elucidate the impact of acute DVT on morbidity and mortality in the medical ICU. DISCLOSURE: The following authors have nothing to disclose: Charlisa Gibson, Mai Colvin, Michael Park, Qingying Lai, Gavin Harris, Chirag Shah, Matthew Langston No Product/Research Disclosure Information

Safety and Feasibility of Subcutaneous Purse-String Suture of the Femoral Vein After Electrophysiological Procedures on Uninterrupted Oral Anticoagulation

The aim of this study was to compare safety and feasibility of a subcutaneous purse-string suture (PSS) with manual compression (MC) to gain hemostasis in patients after multiple femoral venous punctures undergoing electrophysiological procedures on uninterrupted oral anticoagulation (OAK). A total of 784 patients who underwent catheter ablation for atrial fibrillation (n= 564) or (a)typical atrial flutter (n= 220) were assessed. Four hundred sixty-two patients received PSS (58.9%) and 322 patients (41.1%) received MC to gain hemostasis. All patients were on uninterrupted full-dose OAK. During the procedure, weight-adapted heparin was applied. Venous sheath diameter were 8Fr (n= 2)/11.5Fr (n= 1) for left atrial or 8Fr (n= 1)/6Fr (n= 2) for right atrial procedures. No protamine was administered at the end of the procedure. After PSS, patients' had 6hours of bed rest compared with 10hours after MC (sheath removal after 4hours followed by a bandage for 6hours). PSS was removed the following day. All patients underwent duplex sonography of the access site the following day. Using the PSS, hemostasis was achieved in 453 of 462 patients (98%). MC leads to hemostasis in all 322 patients. No difference was found between the 2 approaches regarding hematomas (<5cm or >5cm), arterio-venous fistulas, or pseudoaneurysms. No major complication such as ipsilateral leg ischemia, the need of vascular surgery, or deep vein thrombosis occurred. In conclusion, PSS is a safe and effective way to gain immediate hemostasis after multiple punctures of the femoral vein in patients undergoing catheter ablation on OAK. PSS avoids MC and leads to shorter patient immobilization.

Prevalence and risk factors for atherosclerotic carotid stenosis and plaque: A population-based screening study.

Atherosclerotic carotid stenosis (ACS) is a major cause of ischemic stroke. Screening for asymptomatic ACS is important to identify the patients who require longitudinal surveillance, medication, or endovascular surgery. The aim of this study was to assess the prevalence and risk factors for ACS and carotid plaque (CP) in Korea using a population-based screening study.We recruited participants during visits to several community welfare centers in Korea. The baseline characteristics of the study population were collected. All patients underwent duplex ultrasonography to examine their bilateral carotid arteries. ACS was defined as the presence of plaque with ≥50% vessel diameter reduction and peak systolic velocity (PSV) ≥125 cm/s or PSV ratio ≥2.0. CP was defined as the presence of plaque with <50% vessel diameter reduction. The Mann–Whitney test, χ2 test, Fisher exact test, and logistic regression were used in the statistical analysis.A total of 3030 participants were enrolled in this study (male 43.7% and female 56.3%). The prevalence of ACS and CP was 1.1% and 5.7%, respectively. Significant risk factors for CP included age ≥80 years (odds ratio [OR], 8.11; 95% confidence interval [CI], 3.45–18.93), male sex (OR, 2.16; 95% CI, 1.29–3.61), hypertension (OR, 1.72; 95% CI, 1.21–2.45), and hyperlipidemia (OR, 1.84; 95% CI, 1.30–2.62). The presence of ACS was significantly associated with age (OR, 1.07; 95% CI, 1.03–1.12), hypertension (OR, 3.16; 95% CI, 1.34–7.46), and being an ex-smoker (OR, 6.81; 95% CI, 1.66–27.93) or current smoker (OR, 6.97; 95% CI, 1.78–27.31) after adjusting for confounding factors.This population-based screening study revealed that ACS was uncommon and had a prevalence of 1.1% in the study population. Age, hypertension, and smoking were risk factors for ACS. Further investigations into the prevalence and risk factors of ACS are required, as are studies on the cost-effectiveness of a national screening program.

Duplex Ultrasonography Has Limited Utility in Detection of Postoperative DVT After Primary Total Joint Arthroplasty.

Duplex ultrasound is routinely used to evaluate suspected deep venous thrombosis after total joint arthroplasty. When there is a clinical suspicion for a pulmonary embolism, a chest angiogram (chest CTA) is concomitantly obtained. Two questions were addressed: First, for the population of patients who receive duplex ultrasound after total joint arthroplasty, what is the rate of positive results? Second, for these patients, how many of these also undergo chest CTA for clinical suspicion of pulmonary embolus and how many of these tests are positive? Furthermore, what is the correlation between duplex ultrasound results and chest CTA results? A retrospective chart review was conducted of total joint replacement patients in 2011 at a single institution. Inclusion criteria were adult patients who underwent a postoperative duplex ultrasonography for clinical suspicion of deep venous thrombosis (DVT). Demographic data, result of duplex scan, clinical indications for obtaining the duplex scan, and DVT prophylaxis used were recorded. Additionally, if a chest CTA was obtained for clinical suspicion for pulmonary embolus, results and clinical indication for obtaining the test were recorded. The rate of positive results for duplex ultrasonography and chest CTA was computed and correlated based on clinical indications. Two hundred ninety-five patients underwent duplex ultrasonography of which only 0.7% were positive for a DVT. One hundred three patients underwent a chest CTA for clinical suspicion of a pulmonary embolism (PE) of which 26 revealed a pulmonary embolus, none of which had a positive duplex ultrasound. Postoperative duplex scans have a low rate of positive results. A substantial number of patients with negative duplex results subsequently underwent chest CTA for clinical suspicion for which a pulmonary embolus was found, presumably resulting from a DVT despite negative duplex ultrasound result. A negative duplex ultrasonography should not rule out the presence of a DVT which can embolize to the lungs and thus should not preclude further workup when clinical suspicion exists for a pulmonary embolus.

Duplex Ultrasonography-Detected Positional Vertebral Artery Occlusion in Upper Cervical Rheumatoid Arthritis.

Prospective imaging study. To clarify the frequency of positional vertebral artery (VA) occlusion using duplex ultrasonography in patients with rheumatoid arthritis (RA). Some patients with upper cervical RA develop thromboembolic stroke related to positional and transient VA occlusions; however, whether RA patients have positional VA occlusion without neurological symptoms is unclear. Outpatients with RA were enrolled. Clinical data were collected, and radiograph examinations were performed to measure the anterior atlantodental interval (AADI), the posterior atlantodental interval (PADI), and the Ranawat method. Patients underwent duplex ultrasonography during rotation to the contralateral side of the examination side, flexion, and extension of their neck. If positional VA occlusion was detected, CT angiography was conducted in the neutral position and in the same position that showed VA occlusion on duplex ultrasonography. Clinical and radiological data were compared between the VA occlusion (VAO) group and the non-VAO group. Sensitivity-specificity curve analyses were performed to clarify optimal threshold values of AADI, PADI, and the Ranawat method for predicting positional VA occlusion. Of the 132 RA patients, dynamic duplex ultrasonography showed positional VA occlusion in eight (6%) patients. Patients in the VAO group had a greater AADI (median, 7.4 vs. 2.3 mm; P < 0.001), a shorter PADI (median, 13.7 vs. 19.6 mm; P = 0.002), and a lower Ranawat value (median, 13.7 vs. 16.8 mm; P = 0.006) than those in the non-VAO group. Cut-off values of AADI, PADI, and the Ranawat method for predicting positional VA occlusion were 6.5, 14.0, and 15.5 mm, respectively. A subset of RA patients developed positional VA occlusion associated with cervical spine involvement.

Accuracy of Venous Filling Index on Standing (VFIst) and Pure Regurgitation Index (PRI), a Novel Index Obtained by Air Plethysmography, for Detecting Venous Reflux

To evaluate the accuracy of venous filling index on standing (VFIst) and a new index named pure regurgitation index (PRI), obtained by air plethysmography, for detecting venous reflux. One hundred and sixty-one healthy subjects (161 limbs) and 180 varicose vein patients (180 limbs) were investigated. All subjects underwent duplex ultrasonography for verifying venous reflux and air plethysmography to obtain hemodynamic parameters such as VFIst, VFI in the supine position (VFIsu), and the maximum arterial inflow rate. To evaluate the accuracy of VFIst and PRI (= (VFIst - VFIsu)/body mass index), receiver operating characteristics curves were created. The optimal cut-off value, sensitivity, specificity, and area under the curve, obtained from analyzing the receiver operating characteristics curves, of VFIst vs. PRI were 2.058 mL/s vs. 0.059 mL · m(2)/s · kg, 93.3% vs. 90.3%, 88.8% vs. 91.3%, and 0.954 vs. 0.964, respectively. This study indicates that while both VFIst and PRI are highly accurate indicators of venous reflux, PRI, which is not affected by the arterial inflow rate and body mass index, is slightly superior to VFIst, especially in subjects with greater body mass index.

Ovarian Vein Diameter Cannot Be Used as an Indicator of Ovarian Venous Reflux

Previous research into pelvic venous reflux has suggested that the size of the ovarian veins indicates the presence or absence of reflux. It is already known that vessel diameter is not an indicator of reflux in the great saphenous vein. However, to this day, physicians still use vein size to plan treatment of refluxing ovarian veins. The authors aimed to investigate whether or not vessel diameter can be used as an indicator of reflux in the ovarian veins. Nineteen female patients (mean 40.2 years, range 29-60) presenting to a specialist vein unit with leg varicose veins underwent duplex ultrasonography (DUS). All were found to have a significant pelvic contribution to their leg reflux on transvaginal duplex ultrasonography (TVS) and were referred to an interventional radiologist for treatment by transjugular coil embolization. During the procedure, the diameter of the ovarian veins was measured using digital subtraction venography. Thirty-four ovarian veins were measured (17 right, 17 left) and of these 18 were found to be non-refluxing while 16 displayed reflux. The mean diameter of the non-refluxing veins was 7.2 mm (range 3-13 mm)and that of the refluxing veins was 8.5 mm (range 4-13 mm). This difference was found to be insignificant at a 95% confidence level (Student t test, p = .204). There is no significant difference between the diameters of competent and refluxing ovarian veins and, as such, techniques that measure vein diameter may not be suitable for the diagnosis of venous reflux in the ovarian veins.

Primary avalvular varicose anomalies are a naturally occurring phenomenon that might be misdiagnosed as neovascular tissue in recurrent varicose veins.

The objective of this study was to report a phenomenon in patients with primary varicose veins that resembles neovascular tissue in postsurgical recurrences-primary avalvular varicose anomalies (PAVA). Between March 2012 and July 2013, 756 patients (122 men, 634 women) with primary varicose veins (mean age, 53years; range, 18-89years) underwent duplex ultrasonography with retrospective analysis of their reflux patterns. We diagnose PAVA as small, refluxing vessels in legs with primary varicose veins and no history of surgery, trauma, or infection in the area that show one or more of three patterns of distribution: lymph node pattern-PAVA arising directly from groin lymph nodes; peritruncal pattern-PAVA wrapping around the great, small, or anterior accessory saphenous veins; and atypical pattern. PAVA are predominantly found within the saphenous fascia, but components have been found to emerge into the superficial and deep venous compartments. We analyzed results from 1398 legs (756 patients). Sixty-four legs (4.6%) in 58 patients exhibited PAVA, bilateral in six patients and unilateral in 52 patients. Lymph node involvement and peritruncal PAVA were seen in 23.4% and 70.3% of legs, respectively. The small saphenous vein was the most common truncal vein to be involved (48.9% of peritruncal cases). More than one pattern of PAVA could be observed in seven legs. Of the 48 women with PAVA, 42% had concurrent pelvic vein reflux. Neovascularization has been identified as a major cause of clinically recurrent varicose veins. Neovascular tissue has been described after endovenous thermoablation. We suggest that this might represent PAVA undetected preoperatively in some cases. PAVA are thin-walled, serpiginous, incompetent vessels that resemble neovascular tissue. We conclude that neovascularization should be diagnosed as a source of recurrence after endovenous surgery only if PAVA had been actively looked for, and excluded, in the preoperative diagnostic duplex ultrasound examination.

Strip-tract revascularization as a source of recurrent venous reflux following high saphenous tie and stripping: results at 5–8 years after surgery

We have previously reported strip-tract revascularization 1 year following high saphenous ligation and inversion stripping. This study reports the 5-8 year results in the same cohort. Between 2000 and 2003, 72 patients presented with primary varicose veins and had undergone high saphenous ligation and inversion stripping plus phlebectomies with or without subfascial endoscopic perforator surgery. Of the 64 patients who had attended for follow-up at 1 year, 35 patients (male:female, 16:19; 39 legs) underwent duplex ultrasonography 5-8 years after surgery (response rate 55%). Duplex ultrasonography was performed and all strip-tract revascularization and reflux and groin neovascularization was documented. Eighty-two percent of legs of patients showed some evidence of strip-tract revascularization and reflux. Full and partial strip-tract revascularization and reflux was seen in 12.8% and 59% of limbs of patients, respectively, and 10.2% limbs of patients had neovascularization only at the saphenofemoral junction only. Seven limbs of patients showed no revascularization. Five to eight years after high saphenous tie and stripping, 82% of legs of patients showed some strip-tract revascularization and reflux and 12% showed total revascularization and reflux of the stripped great saphenous vein.

A Mobile Compression Device for Thrombosis Prevention in Hip and Knee Arthroplasty

Venous thromboembolic events, either deep venous thrombosis or pulmonary embolism, are important complications in patients undergoing knee or hip arthroplasty. The purpose of this study was to evaluate the effectiveness of a mobile compression device (ActiveCare+S.F.T.) with or without aspirin compared with current pharmacological protocols for prophylaxis against venous thromboembolism in patients undergoing elective primary unilateral arthroplasty of a lower-extremity joint. A multicenter registry was established to capture the rate of symptomatic venous thromboembolic events following primary knee arthroplasty (1551 patients) or hip arthroplasty (1509 patients) from ten sites. All patients were eighteen years of age or older with no known history of venous thromboembolism, coagulation disorder, or solid tumor. Use of the compression device began perioperatively and continued for a minimum of ten days. Patients with symptoms of deep venous thrombosis or pulmonary embolism underwent duplex ultrasonography and/or spiral computed tomography. All patients were evaluated at three months postoperatively to document any evidence of deep venous thrombosis or pulmonary embolism. Of 3060 patients, twenty-eight (0.92%) had venous thromboembolism (twenty distal deep venous thrombi, three proximal deep venous thrombi, and five pulmonary emboli). One death occurred, with no autopsy performed. Symptomatic venous thromboembolic rates observed in patients who had an arthroplasty of a lower-extremity joint using the mobile compression device were noninferior (not worse than), at a margin of 1.0%, to the rates reported for pharmacological prophylaxis, including warfarin, enoxaparin, rivaroxaban, and dabigatran, except in the knee arthroplasty group, in which the mobile compression device fell short of the rate reported for rivaroxaban by 0.06%. Use of the mobile compression device with or without aspirin for patients undergoing arthroplasty of a lower-extremity joint provides a noninferior risk for the development of venous thromboembolism compared with current pharmacological protocols.

Prevalence and risk factors of extra-coronary artery disease in patients with diabetes which confirmed atherosclerosis of coronary arteries

To assess prevalence and risk factors of extra-coronary artery disease (peripheral artery (PA) disease (D) of lower extremities (LE), brachiocephalic arterial (BCA) stenosis (S), renal arterial (RA) S in type 1 and 2 (T1 and T2) diabetes (D) patients (P) with confirmed atherosclerosis of coronary arteries (CA). 100 P (48 with T2D, 18 with T1D, 34 without diabetes - PWD), with hemodynamically significant atherosclerosis of CA confirmed by coronary angiography. All patients underwent duplex ultrasonography of PA LE, BCA, RA. Other studies included assessment of clinical characteristics and measurement of the following parameters: profibrogenic cytokines (transforming growth factor [TGF] beta1, matrix metalloproteinase 9 [MMP9], monocyte chemotactic protein-1 [MCP-1], regulated on activation normal T-cell expressed and secreted [RANTES), markers of endothelial dysfunction (von Willebrand factor [VWF], homocystein [HCYST], plasminogen activator inhibitor-1 [PAI-1], vascular cell adhesion molecule [VCAM], soluble intercellular adhesion molecules-1 [sICAM], vascular endothelial growth factor [VEGF], asymmetric dimethylarginine [ADMAD, N-terminal fragment of pro-brain natriuretic peptide (NT-pro BNP), fibroblast growth factor 23 (FGF-23), and fibrinogen. Portions of P with multivessel CA disease were similar in all three groups (T1D - 88.9, T2D - 85.5, WD - 82.3%). Coexistence of atherosclerosis in 2 or more vascular beds was identified in 85.3% of T2D and in 50% of WD P (p = 0.005). In T1D group 61.1 and 11.1% of P had atherosclerosis in 2 and 3 vascular beds, respectively. Levels of profibrogenic cytokines and factors of endothelial activation (RANTES, MMP-9, PAI-I, VCAM, sICAM, ADMA) were significantly higher in P with diabetes vs P WD. P with diabetes and multifocal atherosclerosis demonstrated significant increases of CRP, fibrinogen, NT-proBNP, VWF, PAI-1, ADMA, sICAM, and decrease of GFR compared with P with atherosclerosis in 1 vascular bed. Logistic regression model identified diabetes, reduced renal function, previous myocardial infarction, smoking, ADMA and fibrinogen as factors associated with presence of multifocal atherosclerosis. Coexistence of atherosclerosis in two or more vascular beds was more frequent in P with diabetes and hemodynamically significant CA atherosclerosis than in PWD. It was associated with renal and cardiac dysfunction, excessive activation of mediators of inflammation, hemostasis, and factors of endothelial damage.