Venous Flow In Patients Research Articles

Changes in venous drainage after posterior cranial vault distraction and foramen magnum decompression in syndromic craniosynostosis.

The authors' objective was to measure the effect of posterior cranial vault distraction (PCVD) plus foramen magnum decompression (FMD) on dural sinus volume and venous flow in patients with syndromic craniosynostosis. The volumes of the sagittal, straight, transverse, and sigmoid sinuses of 5 consecutive patients with syndromic craniosynostosis who underwent PCVD+FMD were calculated in cubic centimeters with T2-weighted volumetric MRI sequences before surgery, immediately after surgery, and after the end of the distraction process. Tridimensional reconstructions of phase-contrast magnetic resonance angiography (PC-MRA) images were obtained with multiplanar reconstruction (MPR). The average total volume of all dural sinuses increased immediately after surgery (from 10.06 cm3 to 12.64 cm3) and continued to increase throughout the 30-day distraction period (from 12.64 cm3 to 14.71 cm3) (p = 0.04), except that the right sigmoid sinus remained stable after the initial increase. The most important increases were observed for the left transverse sinus (+113.2%), right transverse sinus (+104.3%), left sigmoid sinus (+91.3%), and sagittal sinus (+41.8%). Less important modifications were evident for the right sigmoid sinus (+33.7%) and straight sinus (+23.4%). Significant improvements in venous flow were noted on the tridimensional reconstructions of the PC-MRA images. Venous obstruction grading score improved in 4 patients (average [range] 2.4 [ 2-5]) (p = 0.023) and remained stable in 1 patient. All patients had chronic tonsillar herniation (CTH) (mean [range] 16.6 [8-26] mm), and 3 had syringomyelia. CTH showed improvement on the last follow-up MRI evaluation in 4 patients (mean [range] 10.5 [0-25] mm) and worsened from 15 mm to 19 mm in 1 patient. Syringomyelia improved in 2 patients and remained unchanged in 1. This study has provided the first radiological evidence of the impact of craniofacial surgery on dural sinus anatomy and venous drainage. The venous anomalies described in patients with syndromic craniosynostosis are not static, and PCVD+FMD triggers a dynamic process that can lead to significant modifications of intracranial venous drainage. The traction exerted by the distracted bone flap onto the occipitoparietal dura mater adherent to the inner calvaria may account for the enlargement of the dural sinus throughout the distraction period. The impact of these modifications on venous pressure, intracranial pressure, CTH, and hydrocephalus remains to be determined.

Versatility of Vein Grafts in Hand Neurovascular Reconstruction – Clinical Cases and Literature Review

Injuries to the upper limb may determine unexpected simple or complex soft tissue defects, due to different types of underlying injury mechanism, clean cut/stabs, crushing, torsion, avulsion or mixed types, which pose a challenge for the reconstructive surgeon. Ideally, all arterial, venous and nervous lesions, in the distal upper limb should be repaired in an end-to-end technique, outside of injury zones, with healthy ends, in a tension free manner. However, situations arise where, either a tension-free repair is not possible, or a considerable defect is met, often representing a challenge to the surgeon. Therefore, a timely decision is imposed in order to find the most favorable approach to restore limb or segment perfusion, ensuring efficient venous return, as well as providing a sensate repair. Usage of vein grafts represents an essential tool comprised in the reconstructive surgeon’s armamentarium, with high versatility in nerve, arterial and venous reconstruction. Not only does it provide an ideal solution, with high adaptability to each case, but it also may enhance short- and long-term outcome, offering an optimal reconstructive option in any upper limb trauma situation, regardless of etiology. We aim to describe our therapeutic strategies in a series of challenging trauma cases involving digital structures from the upper limb. Interposed vein grafts were used to re-stablish sensate function in a patient with a collateral digital nerve defect, but also to bridge vital digit arterial defect in a torsion-avulsion thumb amputation, as well as re-establishing venous flow in patients with Urbaniak II finger degloving injury.

Current Outcomes of Femoral Endovenectomy With Concomitant Iliofemoral Vein Stenting for the Management of Chronically Occluded Iliofemoral Vein Stents

Management of post-thrombotic iliofemoral venous occlusive disease may require stent extension across the inguinal ligament into the common femoral vein. Chronic occlusion of these stents represents a unique and growing challenge in patients with C5-C6 venous disease (Fig 1). The purpose of the study is to report 1-year outcomes of femoral endovenectomy and old stent excision with concomitant iliofemoral vein recanalization when performed to restore iliofemoral venous flow in patients with chronically occluded iliofemoral stents.

Large-volume cell-free and concentrated ascites reinfusion therapy improves venous flow in patients with liver cirrhosis.

Hemodynamic change after total paracentesis was investigated because it might lead to various complications. Although cell-free and concentrated ascites reinfusion therapy (CART) is safer and more effective than total paracentesis in theory, hemodynamic change after CART has been never reported. And previous studies did not mention hemodynamics of the venous system. We investigated the hemodynamic change, including that of the venous system, before and after CART using color Doppler ultrasonography and fast Fourier transform analysis. Twenty-eight patients with tensive cirrhotic ascites underwent ultrasonography the day before and after total volume CART. The diameter and velocity of the main, right, and left portal vein; inferior vena cava (IVC); and right renal vein were measured using ultrasonography. A total of 11.8 ± 4.4L of ascites (range 3.6-20.9 L) was filtered and concentrated to 0.85 ± 0.40L (range 0.36-1.50 L). The diameter of the IVC increased from median 13.5 ± 5.4mm (range 4-25mm) to 18.5 ± 4.1mm (range 7-29mm) (p = 0.007). The diameter of the right segmental renal vein significantly increased after KM-CART [from 5.0 ± 1.0 (4-8)mm to 7.0 ± 2.0 (3-10) mm] (p = 0.011). Hemodynamic change of the portal venous system was not significant. The time to the next CART in patients with an IVC diameter ≥ 20mm and < 20mm was 86days and 20.5days (p = 0.035), respectively. Tensive ascites results in venous congestion in patients with cirrhotic ascites. CART improved venous flow, but it did not change the hemodynamics of the portal venous system.

CA125 but not NT-proBNP predicts the presence of a congestive intrarenal venous flow in patients with acute heart failure.

Intrarenal venous flow (IRVF) measured by Doppler ultrasound has gained interest as a potential surrogate marker of renal congestion and adverse outcomes in heart failure. In this work, we aimed to determine if antigen carbohydrate 125 (CA125) and plasma amino-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated with congestive IRVF patterns (i.e., biphasic and monophasic) in acute heart failure (AHF). We prospectively enrolled a consecutive cohort of 70 patients hospitalized for AHF. Renal Doppler ultrasound was assessed within the first 24-h of hospital admission. The mean age of the sample was 73.5 ± 12.3 years; 47.1% were female, and 42.9% exhibited heart failure with preserved ejection fraction. The median (interquartile range) for NT-proBNP and CA125 were 6149 (3604-12330) pg/mL and 64 (37-122) U/mL, respectively. The diagnostic performance of both exposures for identifying congestive IRVF patterns was tested using the receiving operating curve (ROC). The cut-off for CA125 of 63.5 U/mL showed a sensibility and specificity of 67% and 74% and an area under the ROC curve of 0.71. After multivariate adjustment, CA125 remained non-linearly and positively associated with congestive IRVF (P-value = 0.008) and emerged as the most important covariate explaining the variability of the model (R2: 47.5%). Under the same multivariate setting, NT-proBNP did not show to be associated with congestive IRVF patterns (P-value = 0.847). CA125 and not NT-proBNP is a useful marker for identifying patients with AHF and congestive IRVF patterns.

Focal nodular hyperplasia: new findings at Doppler ultrasonography.

The aim of our study was to explore the features of focal nodular hyperplasia (FNH) at Doppler ultrasonography, analyzing specifically the presence of intratumoral venous flow in patients with an established diagnosis of FNH. Previous studies showed that using a venous Doppler spectrum, intratumoral vessels are often depicted in hepatocellular adenoma (HCA) but less frequently in FNH. Forty-five FNHs from thirty-three consecutive patients (26 female, 7 male; mean±SD age: 40±13) underwent color Doppler ultrasonography and spectral analysis according to a standardized protocol. FNH diagnosis was established by the presence of typical behavior at contrast-enhanced ultrasound (CEUS) associated with another imaging technique (contrast-enhanced computed tomography [ceCT] or contrast-enhanced magnetic resonance [ceMR]). A biopsy was performed when imaging was inconclusive. All data concerning Doppler analysis were reviewed by two more operators, blinded to the final diagnosis, and the interobserver agreement for the presence of venous Doppler signal was determined by Cohen's Kappa. Of the 33 patients, 24 had a single solitary focus, and 9 had multiple foci. Lesion diameter ranged between 1.2 and 8.9 cm (mean ± SD 3.2±1.6 cm). The central feeding artery with the typical arterial spectrum was detected in all 45 lesions, whereas the spoke-wheel sign was observed in 18 cases (40%). A venous Doppler signal was detected in 35 FNHs (77.8%), and in 60% of them, it was identified in the center of the lesion. Venous Doppler signal located in the center of the lesion suspected to be a hypervascular benign lesion cannot be considered a typical HCA feature since it has been detected in a high percentage of FNH cases.

Feasibility of a novel atrioventricular delay optimization method using transmitral and pulmonary venous flow in patients with sequential ventricular pacing or cardiac resynchronization therapy.

BackgroundAlthough several echo-Doppler methods were proposed to optimize atrioventricular (AV) delay in patients with sequential ventricular pacing, “echo-guided” AV optimization has not been widely adopted clinically. A combination of trasmitral flow (TMF) and pulmonary venous flow (PVF) measurements may be beneficial to further optimize AV delay to achieve better cardiac function. The aim of this study was to assess the feasibility and usefulness of AV delay optimization by combined use of TMF and PVF.MethodsA total of 32 patients after sequential ventricular pacemaker implantation were enrolled and studied. The optimal AV delay was defined as the timing to minimize the duration between PVF reversal (a) wave and the duration of the “A” wave of TMF. Stroke volume was measured at the “optimized” AV delay (AVDOPT) and was compared with that obtained at shorter (AVDOPT − 50 ms) and longer (AVDOPT + 50 ms) AV delays.ResultsAV optimization was feasible in 27 of 32 patients (87 %). Stroke volume at AVDOPT was significantly higher than that at shorter or longer AV delay (63 ± 18 ml vs. 57 ± 15 ml vs. 56 ± 16 ml, P = 0.001).ConclusionsAV delay optimization using TMF and PV flow was feasible. Usefulness of this method requires further investigation with a larger study population.

Roles of cyclooxygenase 2 and hepatic venous flow in patients with HHT or hepatopulmonary syndrome

BackgroundHereditary hemorrhagic telangiectasia (HHT) and hepatopulmonary syndrome are disorders characterized by the development of multiple pulmonary arteriovenous malformations (PAVM). Presentation of the hypothesisCOX2 may be at the origin of a cascade of pro inflammatory events to favour angiogenesis and PAVM development. Testing the hypothesisHHT and hepatopulmonary syndrome mouse models may be used to show its effects on PAVM formation. Anti COX-2 therapy could also be tested in human individuals, particularly in patients presenting a hepatopulmonary syndrome or HHT with small PAVM. Implication of the hypothesisPAVMs are one of the main causes of morbidity in patients presenting with HHT disease, owing to the risks of rupture as well as paradoxical embolism exposing to stroke and/or cerebral abscess. Percutaneous embolization has become the treatment of choice of PAVM. Anti COX2 may prevent from PAVM development and subsequent related complications and avoid either surgery and/or percutaneous embolization and thus subsequent related complication.

Coiling of central venous catheter in right internal jugular vein.

Sir, We read with interest the article written by Goyal et al.[1] describing a case of coiling of central venous catheter (CVC) in left subclavian vein. The authors have reported it as a rare complication, and we do not agree with this statement. Malatinský et al.[2] in 1976 presented a series of 378 radiographically controlled CVC placements and reported pure loop formations (coiling) in 2.9% of the cases. Supraclavicular subclavian approach was used in the majority of the patients and the authors explain this as a reason for relatively low incidence rates in their series as compared to other studies.[2] We report a case of coiling of central venous catheter in right internal jugular vein (IJV) in a 36-year-old patient admitted postoperatively in intensive care unit (ICU) following evacuation of large extradural hematoma. The CVC was placed in the operation theatre under ultrasound guidance. Intraoperatively the waveform was damped, and the flow of fluids was slow, but it was considered secondary to rotation of the neck and labeled as “positional”. Just after admission to the ICU a “flush test” was performed, and it was positive; 5–10 mL of normal saline was injected with force using a syringe and fluid thrill was felt in the ipsilateral neck region with the palmer aspect of the hand.[3] Subsequent chest X-ray confirmed coiling of CVC in right IJV [Figures ​[Figures1a1a and ​andbb]. Figure 1 (a) Chest X-ray anteroposterior view with coiled central venous catheter in right internal jugular vein, (b) Coiled central venous catheter after removal Factors predisposing to coiling and catheter malpositions are: Retrograde venous flow secondary to IJV valve incompetence in patients with chronic obstructive pulmonary disease, primary pulmonary hypertension and prior cannulations and catheterizations of the IJV[4,5] Retrograde venous flow in patients with high intrathoracic and intrabdomical pressures Seldinger technique: The catheter is inserted over the guidewire and placed in the central vein. During this procedure sometimes the guidewires are removed before the CVC are properly positioned in the superior vena cava. Resistance encountered in inserting the CVC then leads to excessive pressure applications, which then predisposes to malpositioning. Common sites of resistance are the junction of first rib and clavicle for the subclavian vein and the junction of venous tributaries for the IJV and brachiocephalic vein.

Endovascular treatment of postpartum deep venous thrombosis: report of three cases

Pregnancy and the postpartum period are generally considered as contraindications for thrombolysis. We evaluate in this report the safety and effectiveness of using ultrasound-accelerated catheter-directed thrombolysis (UACDT) in treating three symptomatic postpartum deep vein thrombosis (DVT). UACDT was performed using a recombinant human tissue plasminogen activator (alteplase) which was delivered using the EKOS EkoSonic® system. Postprocedure venography was repeated after treatment which include stenting if stenosis was present. The treatment was successful in all three cases of iliofemoral DVT and symptom relief was achieved in all cases. Minor bleeding at the catheter insertion site in one patient was observed but none of the patients suffered from major bleeding or symptomatic pulmonary embolism. UACDT is a safe and effective treatment for restoration of the venous flow in patients with postpartum iliofemoral DVT. Residual venous obstruction should be treated by angioplasty and stent insertion to avoid early re-thrombosis.

Abstract No. 264: Transarterial embolization with cyanoacrylate for severe arterioportal shunts causing hepatofugal portal flow complicated by hepatocellular carcinoma

To evaluate the clinical efficacy and safety of N-butyl cyanoacrylate (NBCA) embolization in the treatment of severe arterioportal shunts (APS) presenting with hepatofugal portal venous flow in patients with hepatocellular carcinoma (HCC). Between January 2006 and January 2010, 12 patients with unresectable HCC accompanied by severe APS with hepatofugal portal venous flow who underwent transarterial APS embolization with NBCA were defined as the TAE group; and 11 patients in the similar situations who did not receive APS embolization but adjunctive intra-arterial chemotherapy due to the technique limitation between July 2000 and December 2005 were set as a control group. The change of APS, survival rates and procedure related complications of each group were analyzed. The occlusion rate of APS after initial treatment in the TAE group was 83.3% (10/12). The long term APS improvement with hepatopetal portal flow was achieved in 80% (8/10) patients who underwent follow-up angiography in the TAE group. The survival rates in the TAE group were 67% at 6 months, 40% at 1 year, 15% at 2 years, whereas those in the control group were 0 at 6 months(P<0.05). The median survival time in the TAE group was 275 days, which was significantly longer than that of 107 days in the control group after using multivariate Cox regression analysis (P=0.001, hazard ratio= 9.04, 95% confidence interval 2.38, 34.33). There were no major complications related to the interventional treatments in both groups. The preliminary experience in our series suggests NBCA embolization may be an effective and safe therapy in the clinical management of severe APS accompanied with HCC, and may also improve patient's survival.

Extra-cranial venous flow in patients with multiple sclerosis

Introduction Recently, a chronic state of impaired venous drainage from the central nervous system, termed chronic cerebrospinal venous insufficiency (CCSVI) was claimed to be a pathologic condition exclusively seen in patients with multiple sclerosis (MS), suggesting that cerebral venous congestion plays a significant role in the pathogenesis of MS. This hypothesis has gained enormous attention among patients and physicians but has been questioned since. Methods Twenty seven patients with MS and 32 healthy controls underwent color extra cranial Doppler exam aimed to detect four parameters of abnormal venous flow: no Doppler-detected flow in the IJV or vertebral veins (VV), reflux in the internal jugular veins (IJVs), venous flow stenosis in the IJVz (cross sectional area < 0.3 cm) or reverted postural control in the IJV. Results Except for one healthy patient, blood flow direction in the IJVs was normal in all subjects. When aiming to detect at least one parameter of abnormal venous flow per subject, two parameters or three parameters no significant difference was found between subjects and controls (p = 0.707, 0.62, 0.849 respectively). Conclusion We found no evidence to suggest that MS patients have excess of CCSVI. In addition we failed to observe a typical venous flow pattern in MS patients. Until carefully designed controlled studies to investigate CCVSI have been completed, invasive and potentially dangerous endovascular procedures as therapy for MS should be discouraged.

Catheter-Directed Thrombolysis with a Continuous Infusion of Low-Dose Urokinase for Non-Acute Deep Venous Thrombosis of the Lower Extremity

ObjectiveWe wanted to evaluate the feasibility of catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for treating non-acute (less than 14 days) deep venous thrombosis of the lower extremity.Materials and MethodsThe clinical data of 110 patients who were treated by catheter-directed thrombolysis with a continuous infusion of low-dose urokinase for lower extremity deep venous thrombosis was analysed. Adjunctive angioplasty or/and stenting was performed for the residual stenosis. Venous recanalization was graded by pre- and post-treatment venography. Follow-up was performed by clinical evaluation and Doppler ultrasound.ResultsA total of 112 limbs with deep venous thrombosis with a mean symptom duration of 22.7 days (range: 15-38 days) were treated with a urokinase infusion (mean: 3.5 million IU) for a mean of 196 hours. After thrombolysis, stent placement was performed in 25 iliac vein lesions and percutaneous angioplasty (PTA) alone was done in five iliac veins. Clinically significant recanalization was achieved in 81% (90 of 112) of the treated limbs; complete recanalization was achieved in 28% (31 of 112) and partial recanalization was achieved in 53% (59 of 112). Minor bleeding occurred in 14 (13%) patients, but none of the patients suffered from major bleeding or symptomatic pulmonary embolism. During follow-up (mean: 15.2 months, range: 3-24 months), the veins were patent in 74 (67%) limbs. Thirty seven limbs (32%) showed progression of the stenosis with luminal narrowing more than 50%, including three with rethrombosis, while one revealed an asymptomatic iliac vein occlusion; 25 limbs (22%) developed mild post-thrombotic syndrome, and none had severe post-thrombotic syndrome. Valvular reflux occurred in 24 (21%) limbs.ConclusionCatheter-directed thrombolysis with a continuous infusion of low-dose urokinase combined with adjunctive iliac vein stenting is safe and effective for removal of the clot burden and for restoration of the venous flow in patients with non-acute lower extremity deep venous thrombosis.

Differences in portal hemodynamics between whole liver transplantation and living donor liver transplantation

The aim of this study was to investigate the differences in portal hemodynamics between whole liver transplantation and living donor liver transplantation (LDLT). Twenty patients who underwent LDLT (the L group) and 42 patients who underwent whole liver transplantation (the W group) were enrolled, and colored Doppler ultrasonography was performed preoperatively and on postoperative days (PODs) 1, 3, 5, 7, 30, and 90. The changes in the portal blood flow velocity (PBV) and portal blood flow volume (PBF) were monitored. The graft and spleen sizes were measured with angiographic computed tomography, and upper endoscopy was used to measure esophageal varices on PODs 14, 30, and 90. Although the portal venous pressure (PVP) decreased after graft implantation, it was higher in the L group with a smaller graft size ratio (25.7 ± 5.1 cm H₂O for the L group and 18.5 ± 4.6 cm H₂O for the W group, P < 0.05). PBF and PBV increased in both the W and L groups on POD 1 after transplantation; however, the PBF and PBV peaks were significantly higher in the W group. The postoperative PVP and graft volume were greatly related to PBF on POD 1. Grafts in the L group regenerated rapidly after the operation, and the volume increased from 704 ± 115 to 1524 ± 281 mL as early as 1 month after transplantation. A rapid improvement in splenomegaly was observed in both groups. An improvement in esophageal varices was observed in the W group on POD 14 after transplantation, whereas no change was observed in the L group. The portal venous flow in patients with portal hypertension showed a high perfusion state after LDLT, but in contrast to whole liver transplantation, the PVP elevation after LDLT postponed the closing time of the collateral circulation and affected the recovery from splenomegaly.

Role of splanchnic hemodynamics in liver regeneration after living donor liver transplantation

The aim of this study was to investigate the changes in splanchnic hemodynamics after LDLT and their relationship with graft regeneration. Eighteen patients with LDLT December 2006 and June 2008 were enrolled, and color Doppler ultrasonography was performed preoperatively and on postoperative days (PODs) 1, 3, 5, 7, 30, and 90 after transplantation. The changes in the portal blood flow mean velocity (PBV) and portal blood flow volume (PBF) were monitored, and their effects on hepatic function were observed simultaneously. Graft sizes were measured on PODs 7, 30, and 90 after the operation. The regeneration rates of grafts were calculated. PBF increased in the recipient group from 1081.17 +/- 277.50 to 2171.44 +/- 613.15 mL/minute, and PBV increased from 15.01 +/- 5.67 to 56.00 +/- 22.11 cm/s; they were both significantly higher than those in the donor group (P < 0.01). On POD 1, serum aspartic aminotransferase, alanine aminotransferase, and total bilirubin all peaked; however, these indices in patients with PBF/graft weight (GW) > 300 mL/minute . 100 g were significantly higher than those in patients with PBF/GW < 300 mL/minute . 100 g. Livers in the recipient group regenerated rapidly. The graft regeneration rate reached 119.40% +/- 28.21% as early as 1 month post-transplantation. PBF and PBV on PODs 1 and 3 were greatly related to liver regeneration at 30 days. The portal venous flow in patients with portal hypertension after LDLT showed a high perfusion state, which could promote graft regeneration, but PBF/GW after the operation should be controlled below 300 mL/minute . 100 g in order to protect grafts from hyperperfusion injury.

Pattern of pulmonary venous flow in patients with ostium secundum atrial septal defect

The purpose of this study is to determine the possible influence of a left to right atrial shunt over the pulmonary venous flow pattern in children with ostium secundum atrial septal defect (ASD). Complete two-dimensional, spectral Doppler and colour flow Doppler examination were undertaken to examine the pulmonary vein flow pattern in 74 patients with ASD. This group was compared with a control group of 49 non-cardiological patients of similar ages and gender. Ultimately, pulmonary venous flow patterns changed. Pulmonary vein systolic velocities were significantly increased and diastolic velocities decreased in the ASD patient group compared with the control group. The right ventricular (RV) systolic function, evaluated by tricuspid annular displacement and tricuspid annular systolic velocity, was increased in patients with ASD. No left ventricular dysfunction was detected in the patient study group. Patients with ASD show changes in the pattern of pulmonary venous flow with an increase in systolic velocity and a decrease in diastolic velocities. This could be caused by an increase in the RV systolic function, which creates a vacuum effect against not only blood from the superior and inferior vena cavae, but also blood from the pulmonary vein through the ASD.

Sturge-Weber syndrome: A unified pathophysiologic mechanism

According to a new, unifying view of the pathogenesis of Sturge-Weber syndrome and related syndromes, signs and symptoms all arise from localized primary venous dysplasia, with effects of venous hypertension transmitted to nearby areas via persisting communicating venous passageways and compensatory collateral venous channels. Port-wine stains result from a vascular disorder rather than a neural disorder. Symptoms depend upon the extent and location of the venous dysplasia. This hypothesis is supported by published data and by original observations and Doppler ultrasonographic studies of orbital venous flow in patients with the Sturge-Weber syndrome. This new understanding of underlying pathophysiology also elucidates the mechanism for tissue hypertrophy. Therapies aimed at obliterating port-wine stains to minimize the cosmetic blemish will reduce collateral venous blood-flow passageways. In some instances, this reduction may worsen blood stasis within the brain and potentially exacerbate neurologic symptoms.

Interobserver agreement on ultrasound measurements of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with previous venous thrombosis

Interobserver agreement on ultrasound measurements of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with previous venous thrombosis

Abnormalities of pulmonary venous flow in patients with lone atrial fibrillation†

Mechanisms underlying lone atrial fibrillation (LAF) are poorly defined. We sought to investigate indices of left atrial (LA) function in patients with recurrent LAF, in comparison with that in healthy subjects. Investigations were performed in 42 patients aged 51.8 +/- 8.7 at least 30 days after the last episode of LAF and in 38 healthy controls. Each subject underwent echocardiographic evaluation including left ventricular parameters and LA function indices. LA ejection fraction served as a measure of LA systolic performance, and acceleration (SAT) and deceleration time (SDT) of systolic phase of pulmonary venous flow (PVF) corresponded to LA relaxation and compliance, respectively. Patients with LAF showed significantly lower values of SAT (179.1 +/- 63.2 vs. 199.2 +/- 45.1 ms, P < 0.02) and higher values of SDT (250.8 +/- 81.6 vs. 211.7 +/- 57.3 ms, P < 0.01) when compared with controls. No significant differences were found with respect to other measured parameters. The combination of SAT < 185 ms and SDT > 239 ms showed a positive predictive value of 92% in the identification of patients prone to LAF. This study suggests that (i) patients with LAF have abnormalities of the systolic phase of PVF and (ii) Doppler estimation of PVF seems to be very valuable in the evaluation of patients with LAF.

Interobserver agreement on ultrasound measurements of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with previous venous thrombosis

Introduction In patients with new symptoms in a leg previously affected by deep vein thrombosis (DVT), the presence of thrombus on ultrasound cannot be assumed to be due to recurrent thrombosis. Several parameters have been suggested to differentiate between acute and chronic thrombus on ultrasound, including measurement of residual vein diameter during compression, thrombus echogenicity and Doppler assessment of venous flow, but studies on the reproducibility of these measurements are sparse. Objective To determine interobserver agreement on measurement of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with residual thrombus in the veins of the lower limb. Materials and methods Patients with previous proximal DVT who had a high likelihood of residual thrombosis, but without symptoms of recurrent DVT, had ultrasound examinations independently performed by two examiners on the same day. Interobserver agreement on measurement of residual vein diameter, thrombus echogenicity and Doppler venous flow was evaluated. Results We determined that interobserver agreement on these measurements was moderate. The mean difference between paired measurements of residual vein diameter was 2.2 mm (95th centile, 8.0 mm). When both examiners agreed residual thrombus was present, 54% of the variance of the measurement of residual vein diameter was accounted for by the paired measurements. The weighted kappa coefficient for thrombus echogenicity was 0.01 and for Doppler venous flow was 0.51. Conclusions The error associated with ultrasound measurements of residual vein diameter, thrombus echogenicity and flow appears to be considerable.