Mohammad E. Barbati

What predicts outcome after recanalization of chronic venous obstruction: hemodynamic factors, stent geometry, patient selection, anticoagulation or other factors?

In this review we evaluated the effect of different suggested factors associate with the outcome after recanalization of chronic venous obstruction (CVO). Hemodynamic factors: Based upon literature no clear suggestions can be made to identify the risk of stent occlusion in association with the hemodynamic effects. However it is evident that ensuring optimal in- and outflow of the stented tract is key in maintaining the patency. Patient selection: Noninvasive imaging modalities are used to divide patients in three subgroups based on the place and extension of post-thrombotic changes. Moreover it should be noted that AV fistula in selected patients can reduce the risk of thrombosis or re-occlusion. Geometry: Excessive oversizing of the stent and stent compression from outside are considered to be associated with stent occlusion. Additionally, overlapping rigid stents, unnatural angel between stents and in-stent kinking are other geometrical factors related to worse outcome after venous recanalization. Anticoagulation: Adequate peri-and postoperative anticoagulation has a crutial role in stent patency. There is no data regarding the duration of anticoagulation therapy and recommendations vary between 6 weeks to 6 months. Result: impaired inflow or outflow, presence of a hypercoagulability, total number of treated segments and use of stents designed for implantation in arterial system are associated with decreased stent patency.

Arteriovenous fistula geometry in hybrid recanalisation of post-thrombotic venous obstruction

Introduction Post-thrombotic obstruction can be adequately treated by percutaneous transluminal angioplasty and stenting. When post-thrombotic trabeculations extend below the femoral confluence, proper inflow can be facilitated by endophlebectomy and creation of an arteriovenous fistula. The aim of this study was to investigate whether it is more favourable to place the arteriovenous fistula at the cranial or caudal end of the endophlebectomy to prevent stenosis or occlusion. Methodology We retrospectively analysed the clinical data of all patients who underwent a hybrid procedure in our two centres. Demographics, interventional details and post-operative imaging were collected. Results Data on 42 limbs with cranially and 23 limbs with caudally placed arteriovenous fistulas were collected. Post-thrombotic disease of the profunda femoral vein alone or in combination with the femoral vein was observed more often in the cranial group. The caudal group more often received a smaller sized and straight polytetrafluoroethylene fistula, while the cranial group comprised a significantly higher amount of stented segments. Logistic regression showed that only reduced femoral inflow (hazard ratio 2.934 (95%CI, 1.148–7.494)) was a significant predictor of stent stenosis and/or occlusion. Logistic regression for risk of occlusion showed a significant influence of stent-related complications (hazard ratio 4.691 (95%CI, 1.205–18.260)) and a tendency towards influence of arteriovenous fistula geometry in favour of the cranially placed fistula. Conclusion Placement of the arteriovenous fistula in the cranial part of the endophlebectomy during hybrid recanalisation may result in a more favourable outcome, yet this tendency was not statistically significant. Moreover, femoral inflow is pivotal in maintaining patency and should thus be adequately assessed pre-operatively.

Interventional treatment of postthrombotic syndrome.

BackgroundPostthrombotic syndrome (PTS) is the development of symptoms and signs of chronic venous insufficiency following deep vein thrombosis (DVT) and has a significant negative effect on the quality of life. The current understanding is that the clinical manifestation of PTS is related more to venous obstruction than it is to venous reflux. The use of interventional techniques for the treatment of venous obstruction and/or venous occlusion has rapidly increased in recent years.ObjectiveThis article summarizes the current concept of endovenous and hybrid interventions and presents the optimized treatment of choice in patients with chronic symptomatic venous obstruction.MethodsWe performed a systematic literature search in the Medline database to identify relevant studies on the treatment of patients with PTS.ResultsA meta-analysis of the relevant studies showed that this minimally invasive procedure is an effective treatment option with low morbidity and no mortality. Use of the newly developed dedicated venous stents showed promising results with good mid-term patency rates and a significant decrease in related symptoms.ConclusionInterventional therapy for the treatment of symptomatic chronic venous obstruction has become the method of choice in recent years. More studies are needed to evaluate the long-term success rate of dedicated venous stents.ZusammenfassungHintergrundDas postthrombotische Syndrom (PTS) als Langzeitfolge der tiefen Beinvenenthrombose (TVT) kann zu einer erheblichen Beeinträchtigung der Lebensqualität führen. Nach neuerem Erkenntnisstand trägt die obstruktive Komponente mehr zur Entstehung der Symptomatik bei als die refluxive. Interventionelle Verfahren zur Beseitigung der venösen Obstruktion/Okklusion haben im letzten Jahrzehnt rasant an Bedeutung zugenommen.ZielsetzungIn diesem Beitrag wird die endovaskuläre bzw. Hybridbehandlung der symptomatischen chronisch-venösen Obstruktion und unser Konzept zur Optimierung derselben dargestellt.MethodenDie elektronische Datenbank „medline“ wurde systematisch nach Artikeln in deutscher oder englischer Sprache durchsucht, welche die Behandlung des PTS thematisieren.ErgebnisseAlle zugrundeliegenden Studien zeigen, dass es sich bei dieser wenig invasiven Operation um eine effektive Behandlungsmethode ohne Mortalität mit wenig Morbidität handelt. Die Offenheitsraten sind gut. Es lässt sich ein signifikanter Rückgang der Beschwerden erzielen. Unsere Kurzzeitergebnisse mit speziellen venösen Stents sind erfolgversprechend.SchlussfolgerungDie interventionelle Therapie zur Behandlung der symptomatischen chronisch-venösen Obstruktion hat sich in den letzten Jahren zur Therapie der Wahl entwickelt. Die im Kurzzeitverlauf nachgewiesenen Vorteile der speziellen venösen Stents sollten anhand von kontrollierten Vergleichsstudien evaluiert werden.

The Treatment of Post-Thrombotic Syndrome

BACKGROUND Post-thrombotic syndrome (PTS) arises in 20-50% of patients who have sustained a deep vein thrombosis and markedly impairs their quality of life. METHODS This review is based on pertinent publications retrieved by a selective literature search in PubMed and the Cochrane Library, and on the guidelines of the German Societies of Phlebology and Vascular Surgery (Deutsche Gesellschaft für Phlebologie, Deutsche Gesellschaft für Gefässchirurgie). RESULTS The treatment options are conservative treatment with compression and patient exercises, endovascular recanalization with stent angioplasty, and open bypass surgery of the iliac obstructions. The endovascular techniques yield patency rates of 73 to 100%, with thrombotic stent occlusion and hematoma as potential complications. The open operations have only been documented in studies with small case numbers (3 to 85 cases per study, patency rates 58 to 100%). The complications of these invasive procedures can include thrombotic bypass occlusion, hematoma, and wound infection. There have been randomized trials of conservative treatment, but not of surgical treatment. The American Heart Association, in its guidelines, gives the same weak recommendation for all surgical methods (IIb). CONCLUSION All conservative options should be exhausted as the first line of treatment. If PTS symptoms persist and markedly impair the patients quality of life, the possible indication for surgery should be considered. As PTS hardly ever leads to death or limb loss, its treatment should be as uninvasive as possible. Endovascular recanalization is an attractive option in this respect. A conclusive evaluation of the role of endovascular procedures in PTS must await randomized trials of this form of treatment and of the optimal stent configuration.

Interventionelle Therapie des postthrombotischen Syndroms

ZusammenfassungHintergrundDas postthrombotische Syndrom (PTS) als Langzeitfolge der tiefen Beinvenenthrombose (TVT) kann zu einer erheblichen Beeinträchtigung der Lebensqualität führen. Nach neuerem Erkenntnisstand trägt die obstruktive Komponente mehr zur Entstehung der Symptomatik bei als die refluxive. Interventionelle Verfahren zur Beseitigung der venösen Obstruktion/Okklusion haben im letzten Jahrzehnt rasant an Bedeutung zugenommen.ZielsetzungIn diesem Beitrag wollen wir die endovaskuläre, bzw. Hybridbehandlung der symptomatischen chronisch-venösen Obstruktion und unser Konzept zur Optimierung derselben darstellen.MethodenDie elektronische Datenbank „medline“ wurde systematisch nach Artikeln in deutscher oder englischer Sprache durchsucht, die die Behandlung des PTS thematisieren.ErgebnisseAlle zugrundeliegenden Studien zeigen, dass es sich bei dieser wenig invasiven Operation um eine effektive Behandlungsmethode ohne Mortalität mit wenig Morbidität handelt. Die Offenheitsraten sind gut. Es lässt sich ein signifikanter Rückgang der Beschwerden erzielen. Unsere Kurzzeitergebnisse mit speziellen venösen Stents sind erfolgversprechend.SchlussfolgerungDie interventionelle Therapie zur Behandlung der symptomatischen chronisch-venösen Obstruktion hat sich in den letzten Jahren zur Therapie der Wahl entwickelt. Die im Kurzzeitverlauf nachgewiesenen Vorteile der speziellen venösen Stents sollten anhand von kontrollierten Vergleichsstudien evaluiert werden.AbstractBackgroundPostthrombotic syndrome (PTS) is the development of symptoms and signs of chronic venous insufficiency following deep vein thrombosis (DVT), which has a significant negative effect on the quality of life. The current understanding is that the clinical manifestation of PTS is more related to venous obstruction than to venous reflux. In the last decade the use of interventional techniques for the treatment of venous obstructions and occlusions has drastically increased.ObjectiveThis article summarizes the current concept of endovenous and hybrid interventions and presents our concept for optimization of the treatment in patients with symptomatic chronic venous obstruction.MethodA systematic literature search in the medline library was performed to identify relevant studies on the treatment of patients with PTS.ResultsA meta-analysis of the relevant studies showed that this minimally invasive operation is an effective treatment option with a low rate of morbidity and no mortality. Use of the newly developed dedicated venous stents showed promising results with good short-term patency rates, as well as a significant decrease of related symptoms.ConclusionEndovenous interventions have become the method of choice in the treatment of symptomatic chronic venous obstruction. More studies are needed to evaluate the long-term success rate of dedicated venous stents.

Wound complications after common femoral vein endophlebectomy: Influence on outcome:

Introduction Venous recanalization of obstructed femoral and iliac veins is associated with good results regarding the feasibility and patency rate. If the common femoral vein with its inflow vessels is involved, open surgical desobliteration or endophlebectomy has been described as a crucial part of the intervention. However, when performing the hybrid procedure, a number of specific complications have been described. We present our results after venous recanalization including an endophlebectomy, focussing on wound complications and its impact on outcome. Material and methods A retrospective analysis of prospective recorded data of all patients who underwent a hybrid procedure for chronic obstruction of iliofemoral veins between 2010 and 2015 was performed. The patients were treated by recanalization of the affected veins combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation. Data assessment focussed on complications and patency rates. Results This study includes 96 patients, thereof 58 females with a mean age of 44.1 years. The mean procedure time was 344 ± 140 min (range 124–663). Median follow-up time was 12.5 months (2–33 months). Primary patency was 62.5% and secondary patency was 90%. Re-intervention due to early occlusion within the first 30 post-intervention days was necessary in 37.5% of all cases. Besides bleeding complications, wound complications, mainly classified as Szilagyi I, occurred in 33% of all patients. A multivariate analysis showed a significant impact of wound complications on primary as well as secondary patency rate (p = 0.032, respectively 0.015). Conclusion Recanalization of obstructed iliac veins and/or the inferior vena cava combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation is a safe and feasible treatment option in the post-thrombotic syndrome. As wound complications are a common and associated with a significant impact on patency rate, further attempts to improve the procedure are crucial.

Effect of a new incision management system (PREVENA®) on wound healing after endophlebectomy of the common femoral vein: a case series

BackgroundNew endovascular techniques facilitate treatment of complex deep vein obstructions in cases of post-thrombotic syndrome. In a relevant number of these patients, endophlebectomy including the implantation of an arteriovenous fistula between the common femoral artery and the femoral vein is indispensable in order to establish a good inflow. These procedures display a high risk of wound complications. Despite conservative efforts to prevent these postoperative complications, wound healing problems occur in more than 20 % of cases. The present case report is the first description of wound dressing using a PREVENA® incision management system in cases of endophlebectomy.Case presentationA single center’s experience with the incision management system PREVENA®, which was used after endophlebectomy and venous stenting in complex hybrid procedures in three white men aged 46 years, 53 years, and 61 years is the subject of this case report. Although the surgical procedures were performed under therapeutical anticoagulation and took a couple of hours, no wound complications occurred.ConclusionsThese encouraging results underline a potential benefit of the incision management system PREVENA® in cases of complex venous recanalization including endophlebectomy of the femoral vein as well as the implantation of an arteriovenous fistula.

Treatment of blunt thoracic aortic injury in Germany—Assessment of the TraumaRegister DGU®

Purpose Using the data delivered by the German Trauma Register DGU® from 2002 till 2013, the value of different therapies of blunt thoracic aortic injury (BTAI) in Germany was analyzed. Methods Prospectively collected data of patients suffering from BTAI were retrospectively analyzed with focus on the different treatment modalities for grade I–IV injuries. Results 821 patients suffering from BTAI were identified: 51.6% (424) grade I injury, 35.4% (291) grade II or III injury and 12.9% (106) grade IV injury (77.5% men [44.94 ± 20.6 years]). The main patterns of injury were high- speed accidents and falls (78.0% [n = 640], 21.8% [n = 171] respectively). Significant differences between grade I and grade II/III as well as IV injuries could be assessed for the incidence of cardiopulmonary resuscitation, a Glasgow Coma Scale score below 8 and a systolic blood pressure below 90 mmHg (p-value: <0.001). In the primary admission subgroup, 44.1% (197/447) of the patients received best medical treatment, 55.9% received surgical intervention (250/447): Thereof 37.2% (93/250) received open surgery and 62.8% (147/250) had been treated by endovascular means. Significantly lower 24-h- and in-hospital-mortality rates were encountered after endovascular treatment for all gradings of BTAI (p-value: <0.001). Yet this subgroup of patients showed the lowest incidence of further severe injuries and cardiac arrest. Conclusion Endovascular therapy became the treatment of choice for BTAI in Germany. Patients who have been treated by surgical means showed the highest survival rate, especially endovascular therapy showed a favorable low mortality rate.

Open Thoracic and Thoraco-abdominal Aortic Repair in Patients with Connective Tissue Disease

Retrospective cross-border, single centre study February 2000 to April 2016 72 aortic operations on 65 patients with CTD 41 male, median age 41 years [range 19–70 years] 56 patients (86%) with previous aortic repair (71 open, 4 endovascular) 33 patients (51%) operated before at the site of the procedure reported here Procedures: 8 emergency operations (11%) Aortic arch revision (n = 1; 1%) Descending thoracic aortic repair (n = 11; 15%) TAAA type I repair (n = 12; 17%), Type II repair (n = 29; 40%) Type III repair (n = 12; 17%) Type IV repair (n = 5; 7%). Ascending aorta and/or the aortic arch (n = 2; 3%) and (n = 8; 11%) 7 patients (10%) underwent staged procedures Median follow-up: 42 months (0.5–180 months)

Blunt Thoracic Aortic Injury in Case of a 15-Year-Old Boy: Difficulties and Possibilities of the Endovascular Approach

BACKGROUND Blunt thoracic aortic injuries (BTAIs) are rare but life threatening. Most BTAI are caused by high-energy trauma. Among children with blunt trauma, the incidence of BTAI is below 1 percent. The present case deals with covered thoracic aortic rupture of a 15-year-old boy. Emphasizing the value and the difficulties of endovascular surgery in children is the motivation for this case report. CASE REPORT We are presenting the case of a 15-year-old boy, who suffered multiple traumata after accident. Beneath multiple fractures and a liver laceration, a thoracic aortic rupture with pseudoaneurysm of the aortic wall was diagnosed. Owing to the comorbidities, an endovascular therapy in combination with a transposition of the left subclavian artery to the common carotid artery was performed. The chronological line-up of the events and the endovascular treatment as well as the in-hospital follow-up are described. DISCUSSION Injury-induced BTAI in pubescent children rarely occurs. Only few cases can be found in literature, none of which were associated with the presented pattern of injury. CONCLUSIONS The optimal treatment for childhood BTAI is a case-by-case decision. We critically discuss the value of endovascular therapy in the present case.