Mobeen A. Sheikh

Endovascular stenting of nonmalignant superior vena cava syndrome

Superior vena cava (SVC) syndrome is associated with advanced malignancy of the chest. Extensive experience is published in the literature regarding the use of endovascular intervention for symptomatic relief in these individuals with limited survival. Symptomatic SVC obstruction may occur from benign conditions that may not alter life expectancy. There are few data regarding endovascular therapy in this setting. We retrospectively analyzed our experience using endovascular intervention for benign SVC obstruction in 19 patients. In our series, the mean age was 46.4 years; 58% were female and 14/19 cases were due to an intravascular device. All patients experienced symptomatic relief. Median follow‐up was 28.8 months. Three patients required secondary procedures to maintain patency. Four patients had procedural complications, which did not affect the outcomes. One patient died from complications of anticoagulation at 24 months. Endovascular procedures aimed at relieving SVC stenosis seem to be effective in patients with benign disease.

Isolated internal jugular vein thrombosis: risk factors and natural history

Deep venous thrombosis (DVT) involving the upper extremities, chest, and neck has become appreciated as a significant cause of morbidity, especially in individuals with central venous access devices (CVAD). Like DVT involving the leg and pelvic veins, axillo-subclavian vein thrombosis can result in pulmonary embolism, post-thrombotic syndrome, and venous limb gangrene. Data relating to the natural history of internal jugular vein thrombosis (IJVT) is lacking. Risk factors, treatment patterns, and clinically relevant outcomes were retrospectively assessed in 74 consecutive patients with isolated IJVT. All patients (median age 66 years; range 36-80) had CVAD-associated IJVT, 22 (29.7%) had a history of cancer, and 14 (18.9%) had a history of prior DVT. Thirty-two (43.2%) were treated with systemic anticoagulation, 2 (2.7%) received a superior vena cava filter, and 40 (54.1%) received no specific therapy. Of the patients who underwent serial imaging, 7/40 (17.5%) had thrombus propagation. Two (2.7%) patients were diagnosed with pulmonary embolism, 8 (10.8%) were diagnosed with malignancy during a median follow-up of 20 months (range 18-24), and 3/53 (5.7%) suffered a recurrent DVT. Outcomes similar to those seen in leg DVT were observed. The most effective treatment strategy remains to be determined, but anticoagulant treatment was associated with a trend towards reduced all-cause mortality.

Usefulness of Postexercise Ankle-Brachial Index to Predict All-Cause Mortality

Peripheral arterial disease predicts future cardiovascular events and all-cause mortality. Conventional methods of assessment might underestimate its true prevalence. We sought to determine whether a postexercise ankle-brachial index (ABI), not only improved peripheral arterial disease detection, but also independently predicted death. This was an observational study of consecutive patients referred for ABI measurement before and after the fixed-grade treadmill or symptom-limited exercise component to a noninvasive vascular laboratory from January 1990 to December 2000. The subjects were classified into 2 groups. Group 1 included patients with an ABI of ≥0.85 before and after exercise, and group 2 included patients with a normal ABI at rest but <0.85 after exercise. A total of 6,292 patients underwent ABI measurements with exercise during the study period. Propensity score matching of the groups was performed to minimize observational bias. Overall mortality, as determined using the United States Social Security death index, was the end point. The 10-year mortality rate of groups 1 and 2 was 32.7% and 41.2%, respectively. An abnormal postexercise ABI result independently predicted mortality (hazard ratio 1.3, 95% confidence interval 1.07 to 1.58, p = 0.008). Additional independent predictors of mortality were age, male gender, diabetes, and hypertension. After the exclusion of patients with a history of cardiovascular events, the predictive value of an abnormal postexercise ABI remained statistically significant (hazard ratio 1.67, 95% confidence interval 1.29 to 2.17, p <0.0001). In conclusion, our results have shown that the postexercise ABI is a powerful independent predictor of all-cause mortality and provides additional risk stratification beyond the ABI at rest.

Complications of Vena Cava Filters

Publisher Summary This chapter explores the thrombonic complications of vena cava filters. Venous thromboembolism (VTE) is optimally treated by anticoagulation. When anticoagulation must be withheld, inferior vena cava (IVC) interruption affords protection against major embolic events likely to be life threatening. IVC interruption has historically progressed from cava ligation to plication, caval clips, surgically inserted caval umbrellas and filters, and finally, to percutaneously inserted filters. Currently available devices include permanent filters that once deployed remain in place indefinitely, and optionally retrievable filters that may be left in place permanently or may be removed within a specified time frame (weeks to months depending on the device). Complications associated with the historic methods of caval interruption and devices have driven, and will continue to encourage, the modification and design of devices that have limited endothelial cell interactions, require smaller deployment tools, and use imaging friendly materials with reduced thrombogenicity. Current accepted indications for IVC filter use include contraindications to anticoagulation (active bleeding or recent hemorrhage), complications of anticoagulation, or thromboembolism (pulmonary embolism or recurrent/propagation of deep venous thrombosis) despite adequate anticoagulation.

Images in vascular medicine. Ectopic filter.

The patient is a 50-year-old male Jehovah’s Witness, with spina bifida, who recently underwent spinal fusion surgery. His postoperative course was complicated by a wound infection, which required in-hospital management and eventual surgical debridement with hardware replacement. It was during this admission that a past medical history of lower extremity deep vein thrombosis with subsequent filter placement in 1980 was elicited. However, no formal documentation of this event was available at that time. Additional medical problems included chronic renal failure and hypertension. Computed axial tomography (CAT) of the abdomen, performed to rule out obstructive causes for the worsening of his renal failure, serendipitously revealed the ‘ectopic’ location of his vena caval filter (Panel A, arrow). A scout view on CAT showed another view of the location of the filter (Panel B, arrow). Also visible is the hardware placed during his multiple spinal surgeries. Complications related to vena caval filters have been elucidated in the literature. These complications may occur at any stage, ranging from those occurring at the time of insertion, to months or years later. The early complications are usually peri-procedural and relate to those occurring at the procedure site, problems with the delivery systems, malpositioning and incomplete opening. Most of the delayed complications reported have been related to the recurrence of pulmonary embolism, inferior vena cava penetration, caval thrombosis and filter migration. There are also isolated case reports of related miscellaneous complications such as cardiac dysrhythmias3 and pericardial tamponade4 from migration to the heart, small bowel volvulus from caval perforation,5 phlegmasia cerulea dolens after filter placement6 and other rare complications. However, we found no studies or reports of filters in the location shown in Panels A and B, and it is thought that the filter may have been inadvertently placed in the hepatic vein.