Vein Obstruction Research Articles

Transhepatic therapeutic cardiac catheterization: a new option for the pediatric interventionalist.

We evaluate the efficacy and safety of percutaneous transhepatic (TH) venous access for interventional cardiac catheterization. A retrospective review of all TH therapeutic catheterizations between January 1994 and September 1998 was performed. Patient demographics, pre- and postcatheterization hemoglobin and liver function studies, and complications were evaluated. TH access was performed for 30 interventional catheterizations in 25 patients with a median age of 39 months (range, 1 day to 41 years) and weight of 13.2 kg (3.1-87.0 kg). Indications for TH access were bilateral obstructed femoral veins (n = 15), obstructed femoral veins and superior vena cava (n = 3), Greenfield filter (n = 2), and presumptive improved route for intervention via TH access (n = 5). TH interventions were successful in 29/30 procedures (97%). Interventions via TH sheath sizes of 4-14 Fr included pulmonary angioplasty +/- stent (n = 11), radiofrequency ablation (n = 4), atrial septal defect device occlusion (n = 2), coil occlusion of pulmonary artery pseduoaneurysm (n = 2), Fontan fenestration device occlusion (n = 2), pulmonary valvuloplasty (n = 2), stent dilation of the superior vena cava (n = 2), and one each of device retrieval, Fontan baffle stent placement and subsequent redilation, Fontan fenestration dilation, transseptal mitral valvuloplasty, and cardiac biopsy. There were no changes in pre- and post-TH hemoglobin levels (mean +/- SD, 12.9+/-2.2 vs. 11.9+/-1.9 gm/dL; P = NS) or alanine transferase (34.0+/-27.5 vs. 43.4+/-18.2 IU/L; P = NS). One patient developed important intraperitoneal bleeding and required exploratory laporatomy. Percutaneous TH access is safe and effective as a route for interventional catheter procedures for patients with limited venous access.

Transhepatic therapeutic cardiac catheterization: A new option for the pediatric interventionalist

We evaluate the efficacy and safety of percutaneous transhepatic (TH) venous access for interventional cardiac catheterization. A retrospective review of all TH therapeutic catheterizations between January 1994 and September 1998 was performed. Patient demographics, pre- and postcatheterization hemoglobin and liver function studies, and complications were evaluated. TH access was performed for 30 interventional catheterizations in 25 patients with a median age of 39 months (range, 1 day to 41 years) and weight of 13.2 kg (3.1–87.0 kg). Indications for TH access were bilateral obstructed femoral veins (n = 15), obstructed femoral veins and superior vena cava (n = 3), Greenfield filter (n = 2), and presumptive improved route for intervention via TH access (n = 5). TH interventions were successful in 29/30 procedures (97%). Interventions via TH sheath sizes of 4–14 Fr included pulmonary angioplasty ± stent (n = 11), radiofrequency ablation (n = 4), atrial septal defect device occlusion (n = 2), coil occlusion of pulmonary artery pseduoaneurysm (n = 2), Fontan fenestration device occlusion (n = 2), pulmonary valvuloplasty (n = 2), stent dilation of the superior vena cava (n = 2), and one each of device retrieval, Fontan baffle stent placement and subsequent redilation, Fontan fenestration dilation, transseptal mitral valvuloplasty, and cardiac biopsy. There were no changes in pre- and post-TH hemoglobin levels (mean ± SD, 12.9 ± 2.2 vs. 11.9 ± 1.9 gm/dL; P = NS) or alanine transferase (34.0 ± 27.5 vs. 43.4 ± 18.2 IU/L; P = NS). One patient developed important intraperitoneal bleeding and required exploratory laporatomy. Percutaneous TH access is safe and effective as a route for interventional catheter procedures for patients with limited venous access. Cathet. Cardiovasc. Intervent. 47:41–45, 1999. © 1999 Wiley-Liss, Inc.

Treatment of chronic obstruction of the axillary, subclavian, and innominate veins

Of 79 patients seen at the University of Minnesota with symptomatic chronic obstruction of the axillary subclavian or innominate vein, 65 were considered surgical candidates. Etiology of the obstruction was as follows: Group A (n = 45), previous subclavian effort thrombosis; Group B (n = 14), stenosis caused by occupation or sport activities; and Group C (n = 6), long segments (4–7.2 cm) of obstruction caused by chronic intraluminal placement of devices (catheters, pacemaker, or defibrillator leads).

Right atrial bypass grafting for central venous obstruction associated with dialysis access: Another treatment option

Purpose: Central venous obstruction is a common problem in patients with chronic renal failure who undergo maintenance hemodialysis. We studied the use of right atrial bypass grafting in nine cases of central venous obstruction associated with upper extremity venous hypertension. To better understand the options for managing this condition, we discuss the roles of surgery and percutaneous transluminal angioplasty with stent placement. Methods: All patients had previously undergone placement of bilateral temporary subclavian vein dialysis catheters. Severe arm swelling, graft thrombosis, or graft malfunction developed because of central venous stenosis or obstruction in the absence of alternative access sites. A large-diameter (10 to 16 mm) externally reinforced polytetrafluoroethylene (GoreTex) graft was used to bypass the obstructed vein and was anastomosed to the right atrial appendage. This technique was used to bypass six lesions in the subclavian vein, two lesions at the innominate vein/superior vena caval junction, and one lesion in the distal axillary vein. Results: All patients except one had significant resolution of symptoms without operative mortality. Bypass grafts remained patent, allowing the arteriovenous grafts to provide functional access for 1.5 to 52 months (mean, 15.4 months) after surgery. Conclusion: Because no mortality directly resulted from the procedure and the morbidity rate was acceptable, this bypass grafting technique was adequate in maintaining the dialysis access needed by these patients. Because of the magnitude of the procedure, we recommend it only for the occasional patient in whom all other access sites are exhausted and in whom percutaneous dilation and/or stenting has failed. (J Vasc Surg 1999;29:472-8.)

Total anomalous pulmonary venous connections and consideration of the fontan or one-ventricle repair

There is now a considerable literature that babies with right atrial isomerism have a poor outcome. The reasons for this are complex and multifactorial, but may be related at least in part to intrinsically small and abnormal pulmonary veins. We reviewed a series of consecutive patients seen at a single institution and found that babies with right atrial isomerism, severe pulmonary outflow tract obstruction or atresia, and total anomalous obstructed pulmonary veins had a grim outlook, especially those requiring operation in the neonatal period. Others have reported a similarly concerning outcome.

Atypical post burn oedema presenting with obstruction of veins at the thoracic inlet

A case of atypical oedema of the non-burned area following electrical burns over the back and buttocks causing venous obstruction at the thoracic inlet is reported.

Case # 10: Venous Ulcer Due to Secondary (Postthrombotic) Obstruction of the Deep Veins

Case # 10: Venous Ulcer Due to Secondary (Postthrombotic) Obstruction of the Deep Veins

Stent implantation in the palliative treatment of obstruction of the upper inflow veins in patients with bronchial carcinoma

Stent implantation in the palliative treatment of obstruction of the upper inflow veins in patients with bronchial carcinoma

Management and outcome of infants and children with right atrial isomerism.

To assess the current results and outcome of surgery in infants and children with right atrial isomerism and complex congenital heart disease. Tertiary referral centre. 20 consecutive children with right atrial isomerism and complex congenital heart disease underwent surgery over a 6 year period between August 1987 and July 1993. The results and outcome were analysed according to age, presentation, and surgical procedures. Patients were divided into two groups depending on age at presentation and initial surgery: group A comprised 11 patients who required surgical intervention in the first month of life (mean age 5 days); and group B comprised nine patients who required initial surgical intervention after the first month of life (mean age 6.8 months). Seven (64%) of the 11 patients in group A had obstructed pulmonary venous drainage and ten (91%) had pulmonary atresia. There were seven early deaths (64%), including the five patients who required systemic to pulmonary artery shunt and simultaneous repair of obstructed pulmonary veins. The long-term survival rate in this group was 18% (two of 11). Pulmonary venous obstruction was present in two (22%) of the nine patients in group B and four (44%) had pulmonary atresia. There were no early deaths. One patient died after a second palliative procedure. There was one late sudden death. Four patients had a Fontan operation with no deaths. Two of the remaining three patients meet the Fontan criteria. The long-term survival rate in this group was 78% (seven of nine). Surgical management of patients with right atrial isomerism who have complex congenital heart disease carries a high mortality and remains palliative. The overall survival rate was 45% (nine of 20); 18% in patients requiring surgery in the first month of life (group A) and 78% in patients requiring surgery after the first month of life (group B) (P < 0.001). Of the total of 20 patients, nine were potential candidates for a Fontan operation. Seven of these have undergone a Fontan procedure with five survivors.

A case of Pulmonary Veno-occlusive Disease

Pulmonary veno-occlusive disease is a rare cause of pulmonary hypertension in which the primary abnormality is obliterative obstruction of pulmonary veins, especially venules. Clinicaly, we should suspect this disease in the case of congestive cardiac failure with pulmonary hypertension, chronic interstitial pulmonary edema, and normal or elevated wedge pressure on cardiac catheterization. We experience a case of pulmonary hypertension due to pulmonary veno-occlusive disease. A 55-years -old woman developed progressive dry cough and dyspnea for 3 months. Physical examination showed normal heart sounds, diffuse crackles in the whole lung fields. The liver was not palpable and pitting edema was absent. The diagnosis was made by chest HRCT, 2-D echocardiography, normal pulmonary capillary wedge pressure on cardiac catheterization, and confirmed by thoracoscopic lung biopsy. This patient was treated with vasodilator(calcium antagonist) and with mild symptomatic improvement. We reported a case of pulmonary veno-occlusive disease with review of literatures.

Safety and efficacy of extended urokinase infusion plus stent deployment for treatment of obstructed, older saphenous vein grafts

This study was designed to determine the safety and efficacy of extended, continuous infusion of urokinase plus stent deployment to treat older saphenous vein bypass grafts obstructed by both thrombus and atheromatous material. Thirty patients with angiographic evidence of thrombus and atheromatous material obstructing older vein grafts (mean age 8.3 years) underwent the combined interventions of urokinase infusion and stent deployment. The continuous infusion of urokinase was administered directly into each obstructed vein graft over a mean of 20.5 ± 8.1 hours (median dose 2.2 ± 0.7 million units). Stents were deployed at the sites of atheromatous obstruction either before (5 patients) or after (25 patients) infusion of urokinase. Twenty-eight of the 30 patients were successfully treated with the combined interventions (success rate 93.3%). In these 28 patients, percent diameter stenosis at the site of obstruction decreased from 86.0% to −0.2% and Thrombolysis in Myocardial Infarction trial flow increased from 1.0 to 2.5. Two patients (6.7%) developed stent thrombosis followed by myocardial infarction (1 with Q-wave infarction, 3.3%) and congestive heart failure. Minor complications included non-Q-wave myocardial infarction (5 patients, 16.7%) and access-site hemorrhage (5 patients, 16.7%). At 2-week follow-up, anginal symptoms were decreased in all 28 successfully treated patients. At 7.2 ± 3.7-month follow-up, 5 of the 28 successfully treated patients (17.9%) had reacceleration of angina and angiographically documented restenosis at the site of stent deployment. Thus, the combined interventions are highly efficacious in treating older vein grafts obstructed by both thrombus and atheromatous material, but are also associated with significant procedural complications including stent thrombosis, myocardial infarction, and access-site hemorrhage.

Liver transplantation in patients with Budd-Chiari syndrome.

Patients with Budd-Chiari syndrome (obstruction of the hepatic veins) and associated hepatic insufficiency may be candidates for orthotopic liver transplantation (OLT). In our series of 405 OLT patients, 3 were transplanted due to Budd-Chiari syndrome (0.7%). The indication for liver transplantation in these patients was severe hepatic insufficiency (chronic in two and acute in the third one). Morphologic study of the obstructions revealed apparently different causes, including thrombi, membranous webs in hepatic veins, and hydatid cyst compression. The surgical technique employed in these transplantations was similar to that for other etiologies. Due to its implications for the future course of OLT, it is important to determine the exact etiology of Budd-Chiari syndrome in the pretransplant period and to treat the patients with early and long-term anticoagulant therapy to avoid syndrome recurrence.

Internal mammary compartment: window to the mediastinum.

To determine the role of internal mammary ultrasonography (US) in assessment of the mediastinum. In 66 patients (age range, 2 days to 18 years old; mean age 6.5 years) US imaging with spectral and color Doppler was used to examine the internal mammary region. Forty-four patients were suspected to have mediastinal masses; 22, vascular abnormalities. Five patients had abnormal internal mammary arterial flow (reversed in one). Internal mammary vein flow was reversed or absent in 10 patients with vein obstruction or Glenn shunts. Eight of 23 patients with lymphoma had internal mammary adenopathy. None of six patients with infectious mediastinal adenopathy and no patients with other benign mediastinal masses or vascular abnormalities had visualized internal mammary nodes. US and Doppler imaging of the internal mammary vessels and nodes provide valuable information about the nature of mediastinal masses and vascular disease. Flow pattern in the internal mammary vessels may elucidate abnormalities of central vessels.

Evaluation of Adaptive Changes by Non-Invasive Imaging in Hepatic Vein Outflow Obstruction

Hepatic vein outflow obstruction induces remarkable changes of intra–hepatic blood circulation; the significance of these changes remains uncertain. Six patients with obstruction of the hepatic veins were evaluated by duplex Doppler ultrasound and computed tomography. The adaptive changes secondary to obstruction were analyzed and their significance was correlated with the clinical findings. Four patients presenting unilateral hepatic vein occlusion had unilateral reversed portal flow. Two of them, with lobar liver atrophy and contralateral compensatory hypertrophy required operation; the other two, with normal appearance of the liver, benefitted from conservative treatment. Two patients with bilateral hepatic vein occlusion, intra-hepatic bypasses, bilateral lobar atrophy and caudate lobe hypertrophy, received operations. Intrahepatic unilateral portal flow reversal compensates for unilateral hepatic outflow obstruction. The combination of complete or subtotal hepatic vein obstruction and atrophy–hypertrophy complex predicates advanced disease despite flow reversal or spontaneous shunt.

Subclavian Vein Repair in Patients With an Ipsilateral Arteriovenous Fistula

Management of subclavian vein occlusive disease in persons with an ipsilateral arteriovenous fistula can be challenging. From July 1991 to May 1993, nine patients underwent direct exploration and repair of an obstructed subclavian vein following medial claviculectomy. Eight patients had polytetrafluoroethylene (PTFE) grafts; one patient had a Brescia-Cimino fistula. Intractable arm edema was the major symptom in five of eight. The site of the occlusive disease ranged from the midsubclavian vein to the proximal innominate vein. Pathology varied from a focal occluding web to a long segment of intimal fibroplasia. Five veins were occluded; four were stenotic. Surgical procedures consisted of endovenectomy and vein patch (four), endovenectomy and PTFE patch (one), resection of a focal stricture with end-to-end anastomosis (two), resection with PTFE interposition (one), and end-to-end internal jugular to subclavian vein transposition (one). Postoperative contrast venograms revealed a patent subclavian vein in eight of eight patients. One patient died postoperatively from unrelated causes; two patients died with a functioning fistula 8 and 12 months, respectively, after surgery. Two grafts were removed for infection and one deteriorated graft was abandoned because of repeated thrombosis. Only three of nine original grafts are currently in use, including one in which the ipsilateral subclavian vein rethrombosed. Although stent placement may now be the preferred treatment for subclavian vein stenosis, vein repair may still have a role in the treatment of subclavian vein occlusion, particularly in patients with a Brescia-Cimino fistula.

LIVER TRANSPLANTATION FOR ECHINOCOCCUS GRANULOSUS HYDATID DISEASE

The authors report their experience with 6 patients requiring liver transplantation who suffered with liver infestation by Echinococcus granulosus. One patient presented with acute Budd-Chiari syndrome because obstruction of hepatic veins was produced during the first operation; the other 5 patients received liver transplants for terminal chronic liver disease (2 secondary sclerosing cholangitis, 2 secondary biliary cirrhosis, and 1 postnecrotic cirrhosis of the liver). All the patients had been operated previously on for hydatidosis and were at the end of liver functional disorder. Some of the patients had undergone many operations, making the transplantation procedure even more difficult. One patient required a second transplant for primary graft failure; he died 40 days later from cerebrovascular accident. Another patient died 7 months after transplant from pulmonary embolism. The other 4 patients are alive and in optimal condition 37-65 months after transplantation. Hepatic hydatidosis--in principle, a benign disease--can cause hepatic complications that eventually require liver transplantation. The transplantation procedure is more difficult than usual in these cases. Although postoperative complications are frequent, most patients achieve prolonged survival and a good quality of life.

Subcutaneous Radionuclide Venography

Traditional acupuncture points K-3 are physiologically tender points located halfway between the Achilles tendon and the medial malleolus. Recently, the authors developed a new method of radionuclide venography of the lower limbs, namely subcutaneous radionuclide venography (SC-RNV), by subcutaneous injection of Tc-99m pertechnetate at these points. The authors applied this method in a patient with suspected deep vein thrombosis of both lower limbs. For comparison, ascending radionuclide venography by intravenous injection (IV-RNV) of Tc-99m MAA and color Doppler ultrasound were also done. The SC-RNV showed partial obstruction of right popliteal vein and complete obstruction of the left popliteal vein with prominent collateral flows. These results were compatible with the findings of color Doppler ultrasound. However, the IV-RNV showed small narrowing with patency of the left popliteal vein, and normal flow on the right. This suggests that the results of SC-RNV may be different from that of IV-RNV. The benefits of SC-RNV in the detection of deep vein thrombosis are described.

Portopulmonary Shunt by Splenopneumopexy as a Treatment for Portal Hypertension Due to Extrahepatic Portal Vein Obstruction: Case Report

A case of secondary portal hypertension due to extrahepatic portal vein ob struction that was treated by splenopneumopexy approximately nine years ago is presented. The patient was a forty-seven-year-old man suffering from hema temesis. On preoperative portography, the portal trunk could not be visualized, and cavernous transformation of the portal vein and moderate esophageal varices were demonstrated. Splenopneumopexy for management of esophageal varices was accomplished as treatment. After the operation, significant portopulmonary shunt was devel oped and findings of the esophageal varices were improved. Results from pul monary and hepatic function tests after operation were essentially unchanged. For nine years since the operation he has had no episode of recurrent variceal bleeding. Splenopneumopexy, which diverts the portal blood into the pulmonary vein, is one of the shunt procedures used as treatment for portal hypertension. In Japan, endoscopic sclerotherapy is the first choice of treatment for variceal bleeding. However, splenopneumopexy is still useful as a treatment for patients with secondary portal hypertension such as extrahepatic portal vein obstruc tion.

Betrachtungen zur Ausbildung des sekundären Venensystems des Bauchraumes unter besonderer Berücksichtigung der idiopathischen linksseitigen Varikozele

Based on 1,778 radiologic investigations of vena cava inferior, left renal vein and left spermatic vein the anomalies due to incorrect transformations from the first to the second abdominal venous system are presented. A persistent vena cardinalis posterior could be demonstrated in two cases. Varicoceles were seen with and without insufficient valves of the spermatic vein and venous outflow obstruction of the renal vein, respectively. Based on the demonstrated phlebographies disorders of ontogenesis seem to be the cause of the idiopathic left-sided varicoceles.

Total central vein obstruction: Resolution with angioplasty and fibrinolysis

Percutaneous transluminal angioplasty (PTA) has assumed an important role in the chronic management of malfunctioning and failed fistulas [1–8]. Stenotic lesions, most commonly occurring in the venous limbs of such fistulas, are the most common anatomic cause of malfunction [4]. If left untreated, these stenoses may progress to total occlusion. Central vein stenosis has emerged as a serious new medical complication of hemodialysis catheter insertion [5, 6]. Previous publications suggest that the duration of a peripheral fistula is an important associated factor in addition to a previous central vein cannulation [5, 6]. These central vein lesions are not amenable to simple surgical revision or thrombectomy because of their intra-thoracic location [5, 6]. Previous reports have documented the excellent response of subtotal central vein lesions to PTA [2–6]. This study describes a four year experience with patients presenting with total obstruction of their central venous system. To our knowledge, there have been no other reported series detailing the technique for and results of angioplasty of totally obstructed central veins in hemodialysis patients.