Venous Segments Research Articles

Analyse de la distribution anatomique de 172 thromboses veineuses des membres inférieurs chez 996 jeunes femmes en contexte hormonal. Impact sur l’exploration écho-Doppler

To analyze localizations of duplex ultrasonography-diagnosed lower-limb venous thrombosis in young women in hormonal periods in order to optimize the ultrasound exploration. From 42,018 standardized ultrasonography report forms, incremented in a database (January 2001 - July 2013), those performed for a first diagnosis of venous thrombosis in women ≤ 45 years were selected (n = 996). Among those, diagnosed venous thrombosis (n = 172) were classified into three groups: oral contraception (n = 74), pregnancy (n = 39) and post-partum period (n = 59). Clinical symptoms and thrombosis distribution were analyzed. In the contraception group, pulmonary symptoms at presentation were much more frequent than in the obstetrical group: 69% vs 20% (P < 0.001). The thrombosis was limited to the iliac veins in 31% (23/74) and to the left internal iliac vein in six patients. During pregnancy, the thrombosis was limited to the iliac veins in 28% (11/39), and to the left internal iliac vein in two patients. In the post-partum period, superficial venous thromboses were found more frequently (37/59). Among the 22 deep venous thromboses, nine were limited to the proximal segment, including four in the vena cava coming from a right ovarian vein thrombosis. Duplex ultrasonography in young women taking oral contraception, as during pregnancy, must target iliac venous segments, especially on the left side, otherwise one thrombosis out of three may be missed; in the post-partum period, the inferior vena cava and superficial veins are to be explored too.

Percutaneous transluminal balloon angioplasty in stenosis of native hemodialysis arteriovenous fistulas: technical success and analysis of factors affecting postprocedural fistula patency.

We aimed to determine the predictors of technical success and patency after percutaneous transluminal angioplasty (PTA) of de novo dysfunctional hemodialysis arteriovenous fistulas (AVF). We performed a retrospective analysis of first time PTA in 228 patients (129 men, 99 women; mean age, 56.8±14.6 years). Anatomical (location, length, grade, and number of stenoses) and clinical variables (sex, age, prior AVF, diabetes mellitus, AVF age, side, and location) were reviewed. A total of 330 stenoses were found in 228 patients. PTA was technically successful in 96.3% of the stenoses (n=319). Clinical success was achieved in 97.2% (n=321). Early dysfunction (within six months) was positively correlated with patient age (P < 0.001) and diabetes (P < 0.005). Older age (P < 0.001) and diabetes (P = 0.002) were associated with a lower primary patency rate. Patient age (P %lt; 0.001), presence of diabetes (P = 0.023), length of stenosis (P = 0.003), early recurrence (P = 0.003) and presence of residual stenosis (P = 0.014) were associated with a lower secondary patency rate. Patency of dysfunctional hemodialysis fistulas can be maintained safely with continuous follow-up and repeated interventions without shortening the venous segment by surgical revision. Percutaneous approach to hemodialysis access stenosis is an alternative to the conventional surgical approach and PTA is an effective treatment method for dysfunctional AVF.

Thoracic central venous evaluation: comparison of first-pass direct versus delayed-phase indirect multidetector CT venography

PurposeThe purpose was to compare first-pass and delayed-phase thoracic computed tomography (CT) venography for the evaluation of suspected central thoracic venous pathology. Material and methodsCT images and medical records of all patients who underwent thoracic CT venography over a 5-year period were retrospectively reviewed. Both first-pass (18s) and delayed-phase (60s) venous images were obtained in all patients. The images were reviewed in random order by three readers using a semiquantitative visual grading scheme for image quality, including artifacts and the uniformity of venous enhancement. In addition, enhancement was quantitatively evaluated. The presence and type of venous pathology, and overall diagnostic confidence were recorded and compared. Reference verification was performed when available. ResultsEighteen patients formed the study group, mean age 49.5years and 28% male. Dual-arm injection was successful in 72% of exams. All readers reported more streak artifacts on first-pass imaging than delayed imaging (72%–94% vs. 27%–44%, respectively; P<.05). First-pass imaging had significantly higher measured enhancement across all central venous segments than delayed imaging (mean HU range 212–906 HU vs. 173–414 HU; P<.05) but also had significantly more heterogeneous enhancement (mean S.D. range 75–1058 HU vs. 67–378 HU; P<.05). For overall diagnosis, reader agreement, accuracy, and confidence levels were higher for delayed-phase images (P<.05). ConclusionIndirect thoracic CT venography using delayed-phase imaging alone may be sufficient for evaluating clinically suspected central venous abnormality.

Clinical Significance of Venous Graft Size and Run-Off Segment for Peripheral Bypass Patency

Aim: To analyze the one-year-patency of infrainguinal arterial reconstructions in relation to venous graft diameter and length and the run-off segment, when arteries above the proximal anastomosis of the reconstruction are not diseased. Material and Methods: We compared retrospectively for two-year period the diameter, the length of the used vein and the run-off segment in 107 consecutively constructed infrainguinal autovenous bypasses – 54 patent (not less than 1 year) and 53 failed bypasses Diameter of the vein was measured at the narrowest part of the vein (in all cases this was the area of the distal anastomosis). Аll bypassеs are made with translocated nonreversed vein and the length of the vein was measured after the completion of reconstruction. Volume and pressure of blood flow were measured below the distal anastomosis by the means of ultrasound transit-time flowmetry. For the assessment of run-off segment Fourier analyses of flow and pressure were used and alteration of the amplitudes after intragraft infusion of Prostaglandines was calculated. Results: We compared the alteration in amplitudes in failed and patent for at least 1 year bypasses and estimated that ratio below 2 before and after medicamentous vasodilatation, sets the reconstruction in the group of threatened, as well as graft diameter below 3.5 mm and length over 40 cm. Conclusion: Hemodynamic assessment of blood flow below distal anastomosis defines the necessary vein lenght, that is why run-off segment has the most important significance for the patency of the infrainguinal autovenous reconstructions. Shorter grafts with diameter over 3.5 mm do not guarantee longer patency if distal anastomosis is constructed above diseased run-off segment.

Posterior Tibial Vein Aneurysm: Case Report

Venous Aneurysm (VA) is a focal dilatation that communicates with a normal venous segment through a single channel, non-related to a varicose segment, pseudoaneurysm or arteriovenous1 fistula. Most venous aneurysms are congenital, although they may also be acquired by trauma or inflammation2. Single venous aneurysms are rare and usually appear as incidental findings on physical tests or imaging studies, yet little reported in the medical literature. However, they may be remembered as a rare cause of Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT)3. Primary aneurysm of the posterior tibial vein is an extremely rare clinical entity. Only four cases have been described in the literature, all related to complications1,4-6. The objective of this study is to report a case of asymptomatic posterior tibial vein aneurysm with a conservative approach.

Pilot/Feasibility Metrics, Real-Time Remote Monitoring, and Inter-Observer Agreement on Veno-Occlusion in a National Multicenter Randomized Controlled Trial of Pediatric Venous Thromboembolism: Findings from the Pilot/Feasibility Phase of the Kids-DOTT Trial

BACKGROUNDSuccessful completion of investigator-initiated pediatric venous thromboembolism (VTE) trials has been hampered when key assumptions in trial design have often not been met during trial execution. Unfortunately, pilot/feasibility (P/F) studies have rarely been conducted and reported prior to implementation of the definitive trials. METHODSThe Kids-DOTT trial is a multicenter, parallel-cohort randomized controlled trial (RCT) evaluating efficacy and safety of shortened (6 weeks) versus conventional (3 months) duration of anticoagulation in pediatric provoked VTE. The Kids-DOTT design included a pre-specified P/F phase consisting of the first 100 subjects enrolled. Quality assurance methods included real-time remote monitoring of patient eligibility criteria immediately prior to enrollment, as well as measurement of inter-observer agreement of mutually-blinded, central versus local radiologic assessments of complete thrombus veno-occlusion (yes/no) at 6 weeks post-diagnosis (a key randomization criterion in the trial). P/F metrics included: screened:enrolled ratio; radiologic inter-observer agreement (measured by percent agreement and kappa statistic); frequency of protocol violations pertaining to eligibility criteria and randomization procedures; proportion of the enrolled population comprising the non-randomized parallel cohorts; and rates of withdrawal/loss to follow-up. The blind was maintained for all P/F analyses. RESULTSScreened:enrolled ratio was approximately 6:1, of which 4% was due to declined consent. During the last 6 months of the P/F phase, with an average of 15 open centers, 24 subjects were enrolled. Protocol violations due to missed randomization occurred in 3% of subjects (3/92) who have reached the 6-week (randomization) visit. There were no eligibility violations and no improper randomizations. During the two most recent years of the trial, 14% of subjects were allocated to the observational, parallel cohorts on completely veno-occlusive thrombosis or persistent antiphospholipid antibody positivity; remaining subjects comprised the RCT population. Inter-observer agreement in the determination of complete veno-occlusion at 6-week imaging (n=71 adjudicated to date) was 97% (95% confidence interval, 89-100%) with Κ=0.79 (95% CI, 0.50-1.0), indicating “substantial agreement” (Landis-Koch criteria). Complete veno-occlusion, as defined by absence of flow throughout a venous segment (e.g. femoral vein; subclavian vein), was observed at 6 weeks in 6% of adjudicated patients (4/71). Rate of withdrawal/loss-to-follow-up prior to primary endpoint assessment was 10% (10/97). CONCLUSIONSThe P/F phase of the Kids-DOTT trial has provided novel multicenter feasibility data demonstrating substantial inter-observer agreement in radiologic determination of complete thrombus veno-occlusion, and a rate of completely veno-occlusive thrombosis of 6% at 6 weeks following diagnosis of provoked venous thrombosis. In addition, it has defined recruitment and retention rates on the trial that have facilitated determination of the required number of participating sites (40) to complete timely accrual. Kids-DOTT is now continuing toward completion of the definitive RCT, targeted for 2018. DisclosuresGoldenberg:Eisai Inc: Research Funding. Off Label Use: Anticoagulants for pediatric venous thrombosis, all of which are off-label for this (pediatric) indication despite their use in the pediatric standard of care. .

The ROX coupler: creation of a fixed iliac arteriovenous anastomosis for the treatment of uncontrolled systemic arterial hypertension, exploiting the physical properties of the arterial vasculature.

Uncontrolled hypertension, whether due to drug resistance or poor adherence and persistence, remains a problem in many patients. The ROX coupler is a novel technology designed to reduce arterial blood pressure consequent to the predicted physical effects of reducing vascular resistance and improving arterial compliance. This article describes the technical aspects of the device and implantation procedure, results from a preclinical study, patient selection criteria, and potential complications of this therapy for uncontrolled hypertension. The coupler is a self-expanding, stent-like device that exploits the mechanical effects of the creation of a low-resistance, high-compliance venous segment to the central arterial tree, and can be implanted in a standard catheterization laboratory under fluoroscopic guidance. Preclinical studies were conducted in sheep with acute or chronic hypertension. The devices were implanted in the aorta for up to 12 months. The anastomoses were evaluated for patency, healing, conformation into the artery and vein, and complications. Deployment of the anastomotic device in ovine aortas for up to 12 months showed optimal anastomotic patency in all animals with proper healing and conformation of the device into the artery and the vein. There was no significant residual mural thrombus and minimal to moderate intimal thickening at the vein outflow, consistent with expected arterialization. A novel arteriovenous coupler for percutaneous placement in the iliac vasculature is under clinical investigation as a potential treatment modality for selected patients with uncontrolled hypertension. Initial results from patients with uncontrolled hypertension are expected in Autumn 2014.

Changes in the diameter and valve closure time of leg veins in primigravida women during pregnancy.

The aim of this study was to monitor the changes that develop in leg veins of primigravida women during pregnancy. Sixty primigravida women volunteered to undergo clinical evaluation and duplex ultrasound examination of both lower limb veins to monitor changes in vein diameter and valve closure time (VCT) during pregnancy and 3 months postpartum by duplex ultrasound. A total of four readings were taken for each subject, one reading for each trimester and the last reading at 3 months postpartum. The mean (± standard deviation) age of participants was 26.82 ± 2.47 years; 39 limbs (32.5%) and 65 limbs (54.2%) developed C1-C3 venous changes during the second and third trimesters, respectively. Three months post partum, 36 limbs (30%) continued to have C1-C2 changes. Only four limbs in four subjects developed varicose veins along the great saphenous vein, and their VCT was more than 1 second. These subjects were found to have a family history of varicose veins. Duplex examinations showed that there was a gradual increase in the diameter and VCT from the second trimester through the third trimester of pregnancy in all examined venous segments. These changes were statistically significant by Friedman and related-samples Wilcoxon signed rank tests within the same legs (P = .001) but not between legs in the same subject (P > .05), even with adjustment for body mass index (P = .001-.049). In primigravida women, lower limb veins showed gradual increase in vein diameter and in VCT starting from the second trimester. These changes reverted to baseline in most cases 3 months after delivery.

Skin colonisation at the catheter exit site is strongly associated with catheter colonisation and catheter-related sepsis.

The commonest mode of catheter colonisation is via the extraluminal route with skin bacteria. Catheter-related sepsis causes significant mortality and morbidity in neonates. Our aim was to study the relationships between culture-positive catheter exit site skin swabs, percutaneous central venous catheter segments and blood to determine the magnitude of associations between exit site skin colonisation, catheter colonisation and catheter-related sepsis. In a prospective study, an exit site skin swab and three formerly in vivo catheter segments (proximal, middle and tip) were taken for culture at catheter removal. In those neonates who were clinically unwell at catheter removal, a peripheral blood culture was also collected. Univariate and multivariate analyses were used to study associations. Skin swabs were culture positive in 39 (21%) of 187 catheter removals. With a culture-positive skin swab, the risk of associated catheter colonisation was nearly eight times higher (OR: 7.84, 95% CI: 3.59-17.15) and the risk of definite catheter-related sepsis with the same organism was nearly 10 times higher (OR 9.86, 95% CI: 3.13-31.00). Culture-positive skin swabs from the catheter exit site were strongly associated with catheter colonisation and with definite catheter-related sepsis with the same organism. These data provide further evidence supporting catheter colonisation via the extraluminal route and highlight the importance of optimising skin disinfection before catheter insertion.

Magnetic resonance direct thrombus imaging differentiates acute recurrent ipsilateral deep vein thrombosis from residual thrombosis

AbstractAccurate diagnostic assessment of suspected ipsilateral recurrent deep vein thrombosis (DVT) is a major clinical challenge because differentiating between acute recurrent thrombosis and residual thrombosis is difficult with compression ultrasonography (CUS). We evaluated noninvasive magnetic resonance direct thrombus imaging (MRDTI) in a prospective study of 39 patients with symptomatic recurrent ipsilateral DVT (incompressibility of a different proximal venous segment than at the prior DVT) and 42 asymptomatic patients with at least 6-month-old chronic residual thrombi and normal D-dimer levels. All patients were subjected to MRDTI. MRDTI images were judged by 2 independent radiologists blinded for the presence of acute DVT and a third in case of disagreement. The sensitivity, specificity, and interobserver reliability of MRDTI were determined. MRDTI demonstrated acute recurrent ipsilateral DVT in 37 of 39 patients and was normal in all 42 patients without symptomatic recurrent disease for a sensitivity of 95% (95% CI, 83% to 99%) and a specificity of 100% (95% CI, 92% to 100%). Interobserver agreement was excellent (κ = 0.98). MRDTI images were adequate for interpretation in 95% of the cases. MRDTI is a sensitive and reproducible method for distinguishing acute ipsilateral recurrent DVT from 6-month-old chronic residual thrombi in the leg veins.

Diagnostic value of T2*-weighted gradient-echo MRI for segmental evaluation in cerebral venous sinus thrombosis

ObjectiveWe evaluated the diagnostic value of gradient-echo (GRE) imaging in patients with “cerebral venous and sinus thrombosis” (CVST). Materials and MethodsIn total, 130 thrombosed venous segment signal intensities in 45 patients with CVST were analyzed retrospectively using magnetic resonance imaging and magnetic resonance venography. ResultsThe T2* GRE sequence had a diagnostic value for detecting acute and subacute superior sagittal sinus (SSS) thrombosis and thrombosis of the deep veins (DVs), and cortical veins (CVs; P<.05). ConclusionsThe T2* GRE sequence had a high diagnostic value for detecting both acute and subacute SSS, DV, and CV thromboses.

Classification of anatomic involvement of the iliocaval venous outflow tract and its relationship tooutcomes after iliocaval venous stenting.

Iliocaval venous obstruction (ICVO) includes a wide spectrum of iliac vein and vena cava obstructive patterns but anatomic classification is lacking, making comparisons of treatment modalities difficult. The purpose of this study was to propose an anatomic classification for ICVO based on patterns of venous obstruction and to correlate severity to clinically relevant outcomes. A multi-institutional retrospective evaluation of patients with ICVO who underwent venous stenting procedures was performed to identify anatomic patterns of iliocaval obstruction. The sites of venous disease were categorized on the basis of computed tomography or magnetic resonance venography supplemented by contrast venography or intravascular ultrasound. Proposed anatomic classification was defined as follows: type I, stenosis of a single venous segment; type II, stenosis of multiple venous segments; type III, occlusion of a single venous segment; and type IV, occlusion ofmultiple venous segments. Anatomic segments included in the classification scheme were defined as inferior vena cava, common iliac vein, external iliac vein, and common femoral vein. All patients underwent attempted stenting to re-establish normal iliocaval outflow. Outcomes, including initial procedural success and rethrombosis rates within 6months, were determined for each type of ICVO. A consecutive 120 patients with ICVO underwent venography and attempted intervention. The type of ICVO was well distributed across all categories, with type I involvement identified in 42.5% of cases, type II in 19.2%, type III in 13.3%, and type IV in 25%. Procedural success was achieved significantly more often in types I and II ICVO (P= .02). Stent reocclusion was more frequent in type IV ICVO (26.7%) than in type I (7.8%) or type II ICVO (4.3%) (P= .009). On the basis of a proposed anatomic classification, the diversity of ICVO may be stratified according to the severity of venous involvement. The anatomic classification was found to correlate to the technical success and short-term patency of venous intervention. Prospective evaluation is required to further validate the utility of this new anatomic classification system.

Cerebral venous disorders: diagnosis, clinical features

Most reports on vascular pathology of the brain have been devoted to arterial blood flow, while morphometric studies of the brain have demonstrated that approximately 85% of the vascular bed of the brain accounts for venous vessels, 10% accounts for the arteries, and about 5% accounts for capillaries. Nevertheless, only a few studies regarding venous pathology of the brain have been published. Many authors admit that the arterial and venous segments of the vascular bed represent a complex interdependent system, where the venous segment is considered to be a highly organized reflexogenic zone responsible for the development of complex, physiologically important, compensatory reactions that provide the constancy of cerebral blood flow. Venous circulation disorders, cerebral venous dyscirculations (CVDs), as well as thromboses of the intracranial veins and sinuses, comprise a significant part of vascular lesions of the brain. The etiologic and pathogenetic aspects of CVD, as well as of thromboses of the intracranial veins and sinuses, have been analyzed. The issues of diagnosis and management of patients with cerebral venous disorders have been considered. Clinical manifestations and characteristics of progression of this pathology have been presented. Cerebral venous thromboses and CVP are often severe, but potentially treatable diseases. Knowledge of the main clinical symptom complexes makes it possible to timely diagnose this pathology and perform effective differentiated pathogenetic and symptomatic therapy in these patients.

Changes in the diameter and valve closure time of leg veins across the menstrual cycle.

The purpose of this study was to determine the changes (if any) in the diameter and valve closure time of the lower limb veins in healthy young nulliparous women at different phases of the menstrual cycle. Fifty-three young nulliparous women were asked to undergo clinical evaluations and duplex ultrasound examinations of both lower limb veins to monitor changes in the vein diameter and valve closure time at different phases of their menstrual cycles. The vein diameter on B-mode imaging and valve closure time on pulsed Doppler tracing were calculated at days 1 to 4, 14 to 16, and 25 to 28 of the menstrual cycle. Freidman and related samples Wilcoxon signed rank tests were used to determine time-related changes in venous function. The volunteers' mean age ± SD was 20.60 ± 1.90 years, and their mean body mass index was 23.90 ± 4.90 kg/m(2). There was a gradual increase in the vein diameter and valve closure time at the specified phases of the menstrual cycle. Friedman and related samples Wilcoxon signed rank tests for venous segment diameter and valve closure time changes between the different phases of the menstrual cycle were performed and showed statistical significance for each venous segment within each limb (P = .003-.025). Also, when adjusted for body mass index, statistical significance existed for the same venous segments in the same limbs (P =.001-.049). There was no statistical significance for the same venous segments at the same phase of the menstrual cycle between limbs (related samples Wilcoxon signed rank test: P =.079-.97). During the menstrual cycle, the lower limb veins show an increase in their diameter and valve closure time. These changes are probably mediated by the female sex hormones.

Role of the VEGF 936 gene polymorphism and VEGF-A levels in the late-term arteriovenous fistula thrombosis in patients undergoing hemodialysis.

Vascular access is vital for hemodialysis patients. A major factor that facilitates arteriovenous (AV) fistula failure is stenosis and thrombosis due to intimal hyperplasia developing in the venous segment of AV fistula. It has been reported that VEGF accelerated re-endothelialization, reduction in intimal thickening, and/or mural thrombus formed in the injured vascular structures. In this study, we aimed to identify the effect of the VEGF 936 gene polymorphism and vascular endothelial growth factor-A (VEGF-A) levels in the late period of AV fistula loss in hemodialysis patients. The study was carried out with a patient group of 42 individuals who experienced two or more fistula thrombosis in the late period after the AV fistula operation and also a control group of 38 patients who have not had any AV fistula thrombosis history for 3 years or more. All participants were assessed for VEGF-936C/T gene polymorphism and VEGF-A levels. VEGF-936C/T genotypes were determined in the large proportion in the control group (31.6 %), while VEGF-936C/C genotypes were determined in a large proportion in the patient group (90.5 %). Individuals carrying the VEGF-936C/C genotype had an increased risk of 5.54 for getting AV fistula thrombosis. The VEGF-A levels of patient group (27.3 ± 43.5 pg/ml) were significantly lower than those of the control group (70.7 ± 53.1 pg/ml). There is an increased risk of AV fistula thrombosis in individuals carrying the VEGF-936C/C genotype. The other renal replacement modalities should be considered in patients with this genotype. As a result, it will be possible to prevent the morbidity and mortality due to fistula failure.

Improvements of Venous Tone with Pycnogenol in Chronic Venous Insufficiency: An Ex Vivo Study on Venous Segments

This study evaluated the stretching and dilatation of venous segments ex vivo in subjects with primary varicose veins in comparison with comparable segments from subjects that used the supplement Pycnogenol (150 mg/d) for 3 months before surgery. Subjects with varicose veins and chronic venous insufficiency voluntarily used Pycnogenol for a period of at least 3 months. The segments of veins removed with surgery (in 30 subjects that had used Pycnogenol and in 10 comparable control subjects that had not used the supplement) were compared with normal, unused vein segments harvested for bypass grafting. The segments were suspended and a weight was attached to the distal part of the veins for 3 minutes and dilated with pressurized water. Digital images were recorded; the veins were measured before and after stretching to evaluate elongation. The manipulation of the vein segment was minimal. Tests were completed within 20 minutes after harvesting the veins. All segments were 4 cm long. The stretching test indicated a significantly higher level of passive elongation in control, varicose segments (2.29; 0.65 mm) in comparison with 1.39; 0.2 mm in vein segments from Pycnogenol-using patients. The dilation test showed an average higher dilation (2.19; 0.3 mm) in control varicose veins in comparison with varicose veins from Pycnogenol-using patients (1.32; 0.7 mm) (p < 0.05). Stretching and dilatation were lower in veins from Pycnogenol-using subjects (p < 0.05). The measurement of destretching and the recovery after dilatation indicated a better tone and recovery of the original size/shape in varicose segments from patients using Pycnogenol. Varicose segments had a more significant persistent dilatation and elongation in comparison with normal vein segments. Pycnogenol seems to decrease passive dilatation and stretching and gives vein walls a greater tonic recovery and elasticity that allows the vein to recover its original shape after dynamic stresses.

Is the temperature of tumescent anesthesia applied in the endovenous laser ablation important? Comparison of different temperatures for tumescent anesthesia applied during endovenous ablation of incompetent great saphenous vein with a 1470 nm diode laser

We aimed to investigate whether the temperature of tumescent anesthesia is important, if so, to establish an opinion about the ideal temperature. Endovenous laser ablations were performed in 72 patients; 35 patients (Group A) received tumescent anesthesia at +4℃, while other 37 patients (Group B) received tumescent anesthesia at room temperature. The groups were compared in terms of intraoperative pain, postoperative regional pain, ecchymosis, paresthesia, skin burns and necrosis. At month 1, great saphenous vein was evaluated for recanalization and patient satisfaction. The survey on intraoperative pain showed that patients receiving tumescent anesthesia at +4℃ experienced much less pain. Interestingly, statistical analysis showed that this difference was not significant (p = 0.072). No skin burns or necrosis occurred in either group, whereas ecchymosis and paresthesia were the most frequently observed side effects in both groups, but no significant difference was found between the groups. There was no significant difference between pain levels on postoperative days and no significant difference between the groups in terms of satisfaction with endovenous laser ablation procedure and postoperative satisfaction. All venous segments treated with endovenous laser ablation in both groups were occluded. At month 1 no recanalization was observed. We conclude that the temperature of tumescent anesthesia solution is not important, while the proper administration of tumescent solution in adequate amounts ensuring delivery of the fluid to all segments appears to be a more significant determinant for the success of the procedure.

Rosuvastatin Suppresses the Oxidative Response in the Venous Limb of an Arteriovenous Fistula and Enhances the Fistula Blood Flow in Diabetic Rats

Objective: The blood flow in the arteriovenous (AV) fistula is significantly reduced in diabetic patients. Statins are known to mediate pleiotropic effects in the vascular endothelium and attenuate inflammatory responses. This study tested the vascular protective effect of rosuvastatin in an experimental model of AV fistula. Methods: One week after the induction of diabetes mellitus (DM) in rats, a fistula was created in the abdominal aorta and inferior vena cava. Rats received placebo or rosuvastatin (15 mg/kg/day) in chow for 2 weeks. The blood flow in the venous segments of the fistula was measured. The expression of proinflammatory genes and the generation of superoxide in the venous fistula were examined. Results: The blood flow and luminal diameter of the AV fistula was significantly enhanced in animals treated with rosuvastatin. Rosuvastatin attenuated the expression of inducible nitric oxide synthase, NADPH oxidase, and monocyte chemotactic protein-1 in the fistula. The levels of superoxide anions and proinflammatory cytokines were also suppressed in rosuvastatin-treated animals. Neointimal formation in the AV fistula was not affected following treatment with rosuvastatin. Conclusions: We demonstrated that rosuvastatin improves luminal dilatation and blood flow in the AV fistula of subjects with DM. These vascular protective effects of rosuvastatin are most likely mediated by the attenuation of proinflammatory activities in the remodeled vasculature.

Venous Outflow Stenosis of the Brachiocephalic Fistula: A Single Entity, or is the Cephalic Arch Different?

Background: Cephalic Arch Stenosis (CAS) is emerging as an important cause of Brachiocephalic Fistula (BCF) failure. The optimal management strategy for dysfunctional AVF as a result of CAS is yet to be defined. Endovascular management is generally employed as first line treatment based upon success in other venous stenosis sites. We compare the outcomes of angioplasty in CAS to other venous stenoses causing BCF dysfunction. Methods: 62 patients with dysfunctional BCF due to venous segment pathology were identified and proceeded to angioplasty. Lesions were categorized anatomically: 19 CAS, 22 venous outflow, 21 swing segment(<3cm of anastomosis). Anastomotic stenoses were excluded. Endovascular intervention was carried out in a standard fashion; 8-10mm balloon angioplasty at the interventionalist’s discretion. Patients were followed prospectively by regular clinical and venous pressure monitoring of the fistula. Re-intervention was performed on clinical suspicion of recurrence. Results: Mean duration of follow-up was 402 days. Patient demographics were comparable across the three groups except a lower incidence of diabetes in the cephalic arch cohort (15.7% vs. 28.2% vs. 25.0%). Swelling and aneurysmal fistulae were more common presenting complaints in CAS (15.7% vs. 2.6% vs. 0%). Mean length of cephalic arch stenosis was shorter(1.6cm vs.3.1cm vs.2.5cm). Primary patency of cephalic arch angioplasty was 68.8%, 43.7% and 31.0% at 3, 6 and 12 months respectively. Primary assisted patency was 87.5%, 81.0% and 43.0%. There was no significant difference in primary or primary assisted patency compared to other outflow stenoses. 2.3 interventions/ patient were required to preserve the access in the CAS cohort vs. 1.1 interventions/ patient for venous outflow stenosis and 1.3 interventions/ patient for swing segment stenoses. Conclusion: CAS bears a different clinical presentation to other venous outflow stenoses. Despite being shorter, and apparently a more attractive target lesion, the hallmark is a requirement for repeated endovascular intervention when compared to other venous stenoses causing BCF dysfunction

Partial aneurysmectomy for salvage of autogenous arteriovenous fistula with complicated venous aneurysms

One complication of autogenous arteriovenous fistula (AVF) for hemodialysis is the formation of a venous aneurysm (VA). The treatment of massive aneurysmal AVF generally involves ligation or resection with the use of prosthetic interposition. Partial aneurysmectomy, with or without reduction venoplasty, has been suggested to treat such a complicated AVF to maintain an all-autogenous access. The purpose of this study was to describe these procedures and examine their outcomes. From January 2008 to May 2012, 14 patients (64% males) with complicated VAs were treated by partial aneurysmectomy with reduction venoplasty for a diffusely dilated venous segment. Patients with an infected aneurysm or central vein stenosis were not included. The surgical technique and the postoperative outcome were described. Patients were a mean age of 37.2 ± 12.2 years. Twenty-five aneurysms and four diffusely dilated segments (7, 10, 15, and 21 cm in length) were treated. Four patients (29%) presented with one aneurysm, nine (64%) with two aneurysms, and one (7%) with three aneurysms. The main clinical indications for intervention were skin necrosis and erosion with imminent danger of bleeding in nine (64%), stenosis related to aneurysm in one (7%), and high flow associated with multiple aneurysms or massive diffuse venous dilatation in four (29%). The AVFs were a mean age of 42.4 ± 8.8 months and the VAs were a mean age of 16.2 ± 4.2 months at the time of partial aneurysmectomy. The mean aneurysm diameter was 5.3 ± 1.6 cm. The procedures were successful in all patients. The mean operative time was 180.3 ± 51.5 minutes (range, 90-245 minutes), and the mean hospital stay was 2.5 ± 1.2 days. In five patients, a sufficient usable portion of the AVF remained for cannulation and was punctured the day after the procedure; in the remaining nine patients, a tunneled hemodialysis catheter was inserted. The AVFs remained patent, without recurrent aneurysms, and were used continuously for dialysis throughout the follow-up periods, which were a mean of 30.4 ± 14.4 months (range, 6-48 months). Two patients with functioning AVFs died of causes that were not related to the aneurysmectomy procedure. Partial aneurysmectomy is a simple and effective intervention for managing aneurysm-associated complications. It offers the ability to maintain the benefits of an autogenous access while conserving future dialysis sites. Partial aneurysmectomy is recommended as a first-line choice for managing aneurysm-associated complications.