Venous Collaterals Research Articles

Extra-hepatic portal vein obstruction leading to portal cavernoma cholangiopathy without liver dysfunction

In adults, EHPVO mainly occurs following thrombosis, while in children it may be related to congenital malformations and/or neonatal umbilical venous catheterization. EHPVO leads to the cavernous transformation of the portal vein in the absence of recanalization. Portal cholangiopathy (also referred to as portal biliopathy) is common in patients with long-standing chronic PVT. It is due to compression of the large bile ducts by the venous collaterals (portal cavernoma) that form in patients with chronic PVT. Typically, symptoms of portal cholangiopathy include jaundice, biliary colic and pruritus.

PO-01-091 VEIN OF MARSHALL ETHANOL ABLATION AND LATERAL MITRAL ISTHMUS LINE TO IMPROVE EFFICACY OF PERSISTENT AF ABLATION

The optimal approach to ablation of persistent AF has not been well-established, and current strategies are only modestly successful. To assess the efficacy of additional vein of Marshall (VOM) ethanol ablation and lateral mitral isthmus ablation in addition to standard persistent AF ablation strategies using a stepwise approach. Sixty -Five consecutive patients undergoing ablation for persistent AF were included. . All patients underwent PVI with RF ,left atrial roof ablation with confirmed roof line block, and cavotricuspid isthmus ablation were performed. VOM ethanol ablation with concomitant lateral mitral annular ablation ( from the LA endocardium and Coronary sinus as needed) to achieve block were attempted in all patients. Patients underwent follow-up ambulatory monitoring and in -office and telephonic follow-up in a closed health delivery system for at least 12 months f/u from procedure. A total of 38 of 65 patients had successful Vom ethanol injection. .35 of these patients achieved successful mitral annular block. 27 patients did not receive therapy due to venous collateralization (29)%, inability to cannulate, vessel (29%) VOM not identified (19%) and target vessel dissection or extravasation (23%.) With an average follow up of 12 months, patients with successful VOM ethanol ablation and lateral mitral line had an 82% clinical arrhythmia- free survival. In patients with unsuccessful VOM attempt, the arrhythmia free survival was 58%. All patients were off antiarrhythmic drugs, and had only one procedure. One patient with successful VOM ethanol ablation was readmitted with pericarditis without effusion managed with colchicine. The addition of VOM ethanol ablation and lateral mitral isthmus ablation is associated with an improved arrhythmia-free survival in persistent AF ablation.

Portal Venous Remodeling Determines the Pattern of Cirrhosis Decompensation: A Systems Analysis.

As liver disease progresses, scarring results in worsening hemodynamics ultimately culminating in portal hypertension. This process has classically been quantified through the portosystemic pressure gradient (PSG), which is clinically estimated by hepatic venous pressure gradient (HVPG); however, PSG alone does not predict a given patient's clinical trajectory regarding the Baveno stage of cirrhosis. We hypothesize that a patient's PSG sensitivity to venous remodeling could explain disparate disease trajectories. We created a computational model of the portal system in the context of worsening liver disease informed by physiologic measurements from the field of portal hypertension. We simulated progression of clinical complications, HVPG, and transjugular intrahepatic portosystemic shunt placement while only varying a patient's likelihood of portal venous remodeling. Our results unify hemodynamics, venous remodeling, and the clinical progression of liver disease into a mathematically consistent model of portal hypertension. We find that by varying how sensitive patients are to create venous collaterals with rising PSG we can explain variation in patterns of decompensation for patients with liver disease. Specifically, we find that patients who have higher proportions of portosystemic shunting earlier in disease have an attenuated rise in HVPG, delayed onset of ascites, and less hemodynamic shifting after transjugular intrahepatic portosystemic shunt placement. This article builds a computational model of portal hypertension which supports that patient-level differences in venous remodeling may explain disparate clinical trajectories of disease.

Percutaneous irreversible electroporation in locally advanced pancreatic cancer – a review and a case report

Background. The results of local destruction methods in locally advanced pancreatic cancer (LAPCa) are contradictory. Radiation therapy is the most commonly used. Other methods are used much less frequently, irreversible electroporation (IRE) is one of them. Most authors indicate an acceptable level of complications and mortality, but without an improvement in long-term results. The results of two meta-analyses have been published, the authors indicate the possibility of using the IRE in selected patients. The authors also point out that minimally invasive methods of using the IRE be preferred. Some experience has been gained in the use of percutaneous access for IRE in LAPCa. Computed tomography, ultrasound guidance can be used for navigation. The level of complications can reach 50 %. Mortality with percutaneous access, as a rule, is absent or does not exceed 5 %. Long-term results are the same with the results of open IRE.Aim. To share authors experience of using percutaneous irreversible electroporation in pancreatic cancer, because there are no references to the use of percutaneous IRE in LAPCa in Russia.Materials and methods. The IRE was performed for 53-year female patient with LAPCa after successful induction therapy. A step-by-step pulse effect of electrodes installed under ultrasound control on the tumor infiltrate was carried out. Magnetic resonance imaging, computed tomography and other types of studies were used for diagnostic purposes.Results. The involvement of the common hepatic artery and portal vein remained after the induction therapy, which did not allow performing pancreatoduodenal resection. Ultrasonic navigation and flat-detector computed tomography allowed to install the electrodes adequatly and safely. The impact zone almost completely blocked the infiltrate zone, a more optimal location of the electrodes was limited by the wide network of venous collaterals. Magnetic resonance imaging data performed before and after the procedure showed no progression of the disease within more than three months after the procedure, including in the affected area. Tumor shrinkage was noted as a partial response.Conclusion. The first experience confirmed the safety and the absence of subsequent complications when using the percutaneous access method of IRE for LAPCa. Follow-up monitoring of the patient will allow to say more correctly about the possibility of the method to provide long-term local control.

Endoscopic ultrasound-guided vascular interventions: An expanding paradigm.

Endoscopic ultrasound (EUS) has expanded its arena from a mere diagnostic modality to an essential therapeutic tool in managing gastrointestinal (GI) diseases. The proximity of the GI tract to the vascular structures in the mediastinum and the abdomen has facilitated the growth of EUS in the field of vascular interventions. EUS provides important clinical and anatomical information related to the vessels' size, appearance and location. Its excellent spatial resolution, use of colour doppler with or without contrast enhancement and ability to provide images "real-time" helps in precision while intervening vascular structures. Additionally, structures such as venous collaterals or varices can be dealt with optimally using EUS. EUS-guided vascular therapy with coil and glue combination has revolutionized the management of portal hypertension. It also helps to avoid radiation exposure in addition to being minimally invasive. These advantages have led EUS to become an upcoming modality to complement traditional interventional radiology in the field of vascular interventions. EUS-guided portal vein (PV) access and therapy is a new kid on the block. EUS-guided portal pressure gradient measurement, injecting chemotherapy in PV and intrahepatic portosystemic shunt has expanded the horizons of endo-hepatology. Lastly, EUS has also forayed into cardiac interventions allowing pericardial fluid aspiration and tumour biopsy with experimental data on access to valvular apparatus. Herein, we provide a comprehensive review of the expanding paradigm of EUS-guided vascular interventions in GI bleeding, portal vein access and its related therapeutic interventions, cardiac access, and therapy. A synopsis of all the technical details involving each procedure and the available data has been tabulated, and the future trends in this area have been highlighted.

RETROAORTIC LEFT RENAL VEIN OR POSTERIOR NUTCRACKER SYNDROME: A RARE ANOMALY

The term "Retroaortic Left Renal Vein" refers to a left renal vein that passes behind the abdominal aorta, and this anomaly is a rather unusual occurrence. It has been suggested that retroaortic left renal vein may cause symptoms such as haematuria and abdominal or ank pain. Urological symptoms are likely due to increased pressure in the left renal vein secondary to the posterior nutcracker phenomenon. We describe a highly uncommon case of a 35 year old woman who was admitted via the emergency department due to left sided ank pain for several days. A thorough examination with Contrast-enhanced CT revealed left renal vein compressed in between abdominal aorta and anterior margin of L1 lumbar vertebral body causing severe compression and mild proximal dilatation of left renal vein, with multiple venous collaterals majorly draining into the hemiazygos vein and the rest in inferior vena cava. The left gonadal vein appeared dilatated. These features were suggestive of posterior nutcracker syndrome

Collaterals in congenital heart disease: when and how to treat?

The development of collateral circulation is not that rare in patients with congenital heart defects. These collaterals can affect cardiovascular hemodynamics and cause systemic arterial desaturation, which arises the question whether these should be closed. To date, few if any reports have been published on the therapeutic management of collaterals in adult patients with congenital heart disease in heart failure (HF). The focus of this article is to provide a pragmatic approach in the assessment of collateral circulation of the patient with HF. By considering the underlying hemodynamics and overall effects of the collateral circulation, we aim to provide a practical tool useful in clinical decision making. The paper highlights mainly the systemic venous to systemic venous collaterals, systemic venous to pulmonary venous (or pulmonary venous atrium) collaterals, and pulmonary arterio-venous malformations. Systemic venous anomalies are frequent and reported in 20% to 40% of patients who underwent Glenn or Fontan procedure. A reduction in effective pulmonary blood flow, coupled with increasing oxygen demands with growth, as well as a pressure difference between the higher pressure caval venous system and lower pressure atria (so called decompressing collaterals) are potential causes of collateral formation. Whether angiogenesis de novo or reappearance of embryological venous channels is responsible for collateral formation remains to be elucidated.

Conversion of Femoral-Tibial Bypass Surgery into Deep Vein Arterialization in a Patient with Severe Peripheral Artery Disease: Post-Operative Computed Tomography and Angiography Findings

Deep vein arterialization (DVA) is a therapeutic option in “no option” for revascularization chronic limb-threatening ischemia patients, creating an arteriovenous bypass between a proximal artery and a distal deep venous target at the ankle. Imaging plays a crucial role in peripheral arterial disease (PAD) patient management. We present the case of a 71-year-old PAD patient (Rutherford class 5) with focal gangrene of the first and second toes of the right foot, who was admitted to the vascular surgery department to undergo revascularization surgery by femoro-tibial artery bypass. During surgery a DVA was performed because of an unsatisfactory distal artery target. The post-operative computed tomography angiography showed the saphenous graft patency and opacification of distal foot veins. Subsequent angiography documented the presence of a large venous collateral, responsible for extensive early wash-out to leg venous vessels, which was then embolized. After two months, the patient underwent amputation of the right first and second necrotic toes at the level of the metatarsophalangeal joints. The post-operative course was excellent, with disappearance of pain at rest and good trophism of the surgical wound.

Accessory Hepatic Vein Stenting in the Management of Budd-Chiari Syndrome: A Case Report

The Budd-Chiari Syndrome (BCS) is associated with hepatic venous outflow obstruction. A 22-year-old female patient presented with abdominal pain and backache for 12 days, along with generalised weakness. Physical examination revealed pitting pedal oedema and abdominal distension. An abdominal ultrasound with Doppler Ultrasonography (USG) was performed, revealing liver parenchymal disease with gross ascites and occlusion of all three Hepatic Veins (HV), suggestive of BCS. Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) of the liver, as well as a right hepatic venogram using Digital Subtraction Angiography (DSA), showed chronic total occlusion at the ostium. An Accessory Hepatic Vein (AHV) was identified, joining the Right Hepatic Vein (RHV) to the Inferior Vena Cava (IVC). The accessory RHV exhibited high-grade stenosis (approximately 90-95%) at its junction with the IVC. Recanalisation of the AHV (balloon dilatation/stent insertion) was performed. Post-procedure accessory hepatic venogram showed a patent stented segment with a significant reduction in adjacent venous collaterals. No procedure-related complications were observed. The present case highlights the importance of AHV stenting in BCS patients, as it helps maintain normal physiology, in contrast to Direct Intrahepatic Porto-systemic Shunt (DIPS), which alters normal physiology by allowing portal venous blood to mix directly into the systemic circulation, bypassing the liver parenchyma.

Angiographic collateral venous phase: a novel landmark for leptomeningeal collaterals evaluation in acute ischemic stroke

BackgroundAlthough recanalization rates constantly increase (>80%), a favorable clinical outcome is achieved in only 45–55% of patients undergoing mechanical thrombectomy (MT) for anterior circulation stroke. Collateral circulation seems to play...

20 LEAD-RELATED SUPERIOR VENA CAVA SYNDROME IN A PACEMAKER-DEPENDENT PATIENT: A HYBRID PROCEDURE

Abstract We report a case of a 77-years-old man admitted to our department because of facial plethora, prominent venous collateral over the anterior chest wall, marked swelling of the head and upper extremities. His medical history was notable diabetes, non-Hodgkin lymphoma (NHL), eradicated HCV, AV block, for which he underwent placement of a dual-chamber pacemaker 4 years earlier. A superior vena cava (SVC) syndrome lead-related was documented on angio-CT scan and phlebography. After a multidisciplinary team discussion, a treatment strategy was designed to consist of transvenous lead extraction, SVC reconstruction and epicardial pacing placement. At 5 months follow-up, he was completely relieved of symptoms. Conclusion Lead-associated SVC syndrome is a rare condition and there is no standard management protocol. Data are lacking and we need at least a registry to make the treatment homogeneous. In this specific patient, a hybrid procedure based on lead extraction and reconstruction of superior vena cava was safe and effective for the relief of symptoms and maintenance of SVC patency. Heparin alone will not lead to the resolution of the disease if the disease is at an advanced stage. Learning outcomes Patients with lead-induced superior vena cava syndrome often required a multidisciplinary approach. A hybrid procedure based on transvenous lead extraction and reconstruction of superior vena cava is safe and effective to achieve relief of symptoms, maintenance of SVC patency, and adequate pacing.

Duplex and Angiographic-Assisted Evaluation of Outcomes of Endovascular Embolization after Surgical Deep Vein Arterialization for the Treatment No-Option Critical Limb Ischemia Patients.

To report early and mid-term outcomes of the arterialization of the deep venous system in no-option critical limb-threatening ischemia (CLTI) using duplex ultrasound and angiographic evaluation to improve limb perfusion. A single-center prospective study of patients with no-option CLTI treated with hybrid surgical arterialization of the deep venous circulation and staged endovascular embolization of the venous collateral. Embolization was performed using a controlled-release spiral, within two weeks after bypass surgery. Patients were assessed for clinical status, wound healing, median transcutaneous partial pressure of O2 (TcPO2), and post-operative duplex ultrasound evaluating peak systolic velocity (PSV), end diastolic velocity (EDV), and resistance index (RI) to assess foot perfusion and bypass features. Primary endpoint analysis was primary technical success, limb salvage, patency rates, and clinical improvement. Secondary endpoints were 30-day and long-term mortality, major cardiovascular events (MACE), including myocardial infarction or stroke, and serious adverse events (SAE). Five patients with no-option CLTI were treated at our center using the hybrid deep vein arterialization technique. Clinical stage was grade 3 in one patient and grade 4 in the remaining four. Mean age was 65.8 years (range 49-76 years), and two patients were affected by Buerger's disease. Primary technical success was achieved in all patients, and all the bypasses were patent at the angiographic examination. At 30-day and at average follow-up of 9.8 months (range 2-24 months), mortality, major cardiovascular events (MACE), and serious adverse events (SAE) were not reported, with a primary patency and limb salvage rates of 100%. Three patients required minor amputation. Clinical improvement was demonstrated in all patients with granulation, resolution of rest pain, or both. Median TcPO2 values rose from 10 mm Hg (range 4-25) before the procedure to 35 (range 31-57) after surgery, and to 59 mm Hg (range 50-76) after the staged endovascular procedure. In our initial experience, the arterialization of the deep venous circulation, with subsequent selective embolization of the venous escape routes from the foot, seems a feasible and effective solution for limb salvage in patients with no-option CLTI and those in the advanced wound, ischemia, and foot infection (WIfI) clinical stage.

Venous collaterals in acute ischemic stroke patients after endovascular treatments: a novel scoring system using 4D computed tomography angiography.

To establish a novel cortical venous collateral score based on four-dimensional computed tomography angiography (4D CTA) and to assess the relationship between the score and clinical outcomes in patients with acute ischemic stroke (AIS) after endovascular treatments (EVTs). This was a retrospective case-control study designed to evaluate all consecutive patients with large vessel occlusion in unilateral anterior circulation who underwent EVTs at a single institution. Two independent neuroradiologists evaluated venous collaterals using different venous collateral scores: a cortical venous collateral score based on 4D CTA (4D-VCS), the prognostic evaluation based on cortical vein score difference in stroke (PRECISE) score, and the cortical vein opacification score (COVES). Spearman correlation analysis was used to analyze the correlation of different venous collateral scoring systems with final infarct volume (FIV), modified Rankin Scale (mRS) score, and artery collateral score. Multivariate logistic regression analysis was used to identify the prognostic value of each model. The areas under the curve (AUC) of the receiver operating characteristic (ROC) curve of the 6 models were compared by the DeLong test. A total of 107 patients were enrolled in the study. The AUC of 4D-VCS was 0.92 [95% confidence interval (CI): 0.85 to 0.96; P<0.0001]. The 4D-VCS was highly correlated with FIV (r=-0.615; 95% CI: -0.737 to -0.473; P<0.001), mRS score (r=-0.706; 95% CI: -0.789 to -0.602; P<0.001), and arterial collateral score (r=0.769; 95% CI: 0.678 to 0.838; P<0.001). There were statistically significant differences between model 1 (AUC, 0.89; 95% CI: 0.81 to 0.94) and model 2 (AUC, 0.94; 95% CI: 0.88 to 0.98) (P=0.025), model 1 (AUC, 0.89; 95% CI: 0.81 to 0.94) and model 3 (AUC, 0.93; 95% CI: 0.87 to 0.97) (P=0.045), model 1 (AUC, 0.89; 95% CI: 0.81 to 0.94) and model 6 (AUC, 0.95; 95% CI: 0.89 to 0.98) (P=0.011), and model 2 (AUC, 0.94; 95% CI: 0.88 to 0.98) and model 5 (AUC, 0.89; 95% CI: 0.82 to 0.94) (P=0.032). The findings of this study suggested that 4D-VCS, a novel measurement of venous enhancement based on 4D CTA, may be accurately used to identify AIS patients with high risk of poor clinical outcome after EVTs.

Venous Outflow and Parenchymal Hemorrhage: A Clogged Drain Problem?

Venous Outflow and Parenchymal Hemorrhage: A Clogged Drain Problem?

THE CLOT THICKENS: THE CASE OF A YOUNG MALE WITH RECURRENT PULMONARY EMBOLISMS

THE CLOT THICKENS: THE CASE OF A YOUNG MALE WITH RECURRENT PULMONARY EMBOLISMS

PAGET-SCHROETTER SYNDROME: "EFFORT THROMBOSIS” DISCOVERED AFTER AIR TRAVEL

PAGET-SCHROETTER SYNDROME: "EFFORT THROMBOSIS” DISCOVERED AFTER AIR TRAVEL

TRANSUDATIVE CHYLOTHORAX AND CHYLOUS ASCITES IN ADVANCED HEART FAILURE

TRANSUDATIVE CHYLOTHORAX AND CHYLOUS ASCITES IN ADVANCED HEART FAILURE

Evolution of Thoracic Duct Congestion after Portal Decompression by TIPS in Cirrhotic Patients.

To evaluate the thoracic duct (TD) diameter on CT scan in a population of cirrhotic patients before and after relief of portal hypertension by transjugular intrahepatic portosystemic shunt (TIPS) insertion. To evaluate the association between the initial TD diameters and the cirrhosis severity, the morphological signs of portal hypertension and the clinical success of TIPS. This retrospective monocentric study included 54 cirrhotic patients who underwent TIPS insertion between 2010 and 2020. Measurements of the TD were performed in CT scan at two distinct points: at the cisterna chyli (CC) and at the terminal TD near the lymphovenous junction. The mean diameter of the TD was 6.4 mm (± 2.9) at the CC and 6.9 mm (± 1.9) near the lymphovenous junction. After TIPS, the mean diameter decreased to 5.1 (± 2.1) at the CC (p < 0.001) and to 4.3 (± 1.5) at the terminal TD (p = 0.001). The initial TD diameter was associated with the presence of voluminous venous collaterals (p = 0.04 at CC and p = 0.04 junction). The initial terminal TD diameter was weakly associated with the largest axis of the spleen (r = 0.126, p = 0.03) and moderately associated with the azygos vein diameter (r = 0.511, p = 0.001). Initial TD diameter was not associated with Child-Pugh score (r = 0.276, p = 0.08 and r = 0.169, p = 0.7) or with clinical success of TIPS on ascites (p = 0.33 and 0.60) or on bleeding (p = 0.13 and 0.99). The diameter of the TD decreases after TIPS, but its initial diameter does not seem to be predictive of the clinical success of TIPS.

Correlation between hepatic venous pressure gradient and portal venous pressure gradient in hepatitis B cirrhosis with different hepatic veins anatomy

PurposeThe hepatic venous pressure gradient (HVPG) has been employed as the gold standard for indicating the portal venous pressure gradient (PPG) in the diagnosis of portal hypertension (PHT). However, little has been reported on whether the HVPG can accurately estimate the PPG in patients with hepatic vein collateral shunts. We aimed to explore the correlation between the HVPG and the PPG in hepatitis B cirrhosis patients with different hepatic vein anatomies. MethodsA total of 461 hepatitis B cirrhosis patients with portal hypertension (PHT) who were treated with a transjugular intrahepatic portosystemic shunt (TIPS) between January 2016 and June 2020 were included. All patients underwent various venous pressure measurements and balloon-occluded compression hepatic venography during the TIPS operation. Agreements were evaluated by Pearson’s correlation and the Bland–Altman method. Disagreements were assessed by paired t tests. ResultsThe correlation coefficient (r) values (P < 0.001) between the HVPG and the PPG of the early (151 patients, 32.8 %), middle (73 patients, 15.8 %), late (46 patients, 10.0 %), portal vein (151 patients, 32.8 %), and no lateral branch development groups (40 patients, 8.7 %) were 0.373, 0.487, 0.569, 0.690, and 0.575, respectively; the determination coefficient (R2) values were 0.139, 0.238, 0.323, 0.475, and 0.330, respectively. According to the Bland–Altman method, agreement was the greatest in the portal vein development group, with the 95 % limits of agreement (95 % LoA, mean differences ± 1.96 SD) being the smallest. The differences were statistically significant (P < 0.05). ConclusionThe correlation between the HVPG and the PPG is the worst in early lateral branch development, followed by middle development, and the influence of lateral branches becomes significantly reduced in late development. Hepatic venous collateral formation is a vital factor for underestimation of the HVPG, which is the most accurate predictor of PPG in patients with portal vein development. Patients with no collateral channel development in the hepatic vein have a higher HVPG than PPG, which is an important reason for overestimation of the HVPG.

Differentiation between anatomical slenderness and acquired stenosis of the internal jugular veins.

Background and PurposesDifferentiating between acquired stenosis (pathologic) and anatomical slenderness (physiologic) of internal jugular vein (IJV) remain ambiguous. Herein, we aimed to compare the similarities and differences between the two entities.MethodsPatients who underwent head and neck computer tomography (CT) and brain magnetic resonance imaging (MRI) were enrolled in this case‐control study from January 2016 through October 2021.Results1487 eligible patients entered final analysis totally. 803 patients had bilateral IJVs imaging without IJV stenosis‐related symptoms and presented in three ways: right IJV slenderness (10.5%, n = 85), left IJV slenderness (48.4%, n = 388), and symmetric IJVs (41.1%, n = 330). In patients with asymmetric IJVs, their bilateral jugular foramina were also asymmetric. All involved asymmetric IJVs presented as slenderness without surrounding abnormal collaterals and credible cloudy‐like white matter hyper‐intensity (WMH). Their cerebral arterial perfusion statuses on brain MR‐PWI maps were normal.In contrast, the major patients with IJV stenosis presented with signs and symptoms such as headaches, head noise, etc. In CE‐MRV maps, local stenosis of the IJV was surrounded by abnormal venous collaterals in contrast to the lack of abnormal venous collaterals for patients with IJV slenderness. And in CTV maps, the caliber of jugular foramina was mismatched with the transverse diameter of IJV. Moreover, in MRI maps of most of these patients, a cloudy‐like WMHs were distributed symmetrically in bilateral periventricular and/or centrum semi vales. These patients also had symmetrical cerebral arterial hypo‐perfusion. Seven patients underwent stenting of the IJV stenosis correction, their WMHs attenuated or disappeared subsequently.ConclusionsImaging features in addition to clinical symptoms can be used to differentiate between physiologic IJV slenderness and pathologic IJV stenosis. Notable imagine‐defining features for IJV stenosis include local stenosis surrounded by abnormal venous collaterals, cloudy‐like WMHs, and mismatch between the transverse diameter of IJV and the caliber of the jugular foramina.