Niels Bækgaard

Long-Term Results using Catheter-directed Thrombolysis in 103 Lower Limbs with Acute Iliofemoral Venous Thrombosis

OBJECTIVES The long-term outcome of catheter-directed thrombolysis (CDT) in patients with acute iliofemoral venous thrombosis (IFVT) is evaluated in this study. MATERIAL AND METHODS Patients presenting for treatment with IFVT between June 1999 and May 2007 were considered for treatment using CDT. The following inclusion criteria were used: first episode of IFVT, age below 60 years, age of thrombus <14 days and open distal popliteal vein. Ultrasonography (US) was used to verify the diagnosis. The popliteal vein was punctured under local anaesthesia using US guidance, and a multi-side-hole catheter with tip occlusion was placed in the thrombus. A solution of r-TPA was infused either continuously or using the pulse spray technique together with heparin. Any occlusion or residual stenosis in the iliac vein system was treated by stenting. Compression stockings and anticoagulation treatment were given for at least 12 months. Patients with severe thrombophilias were treated for longer periods. The patients were assessed by colour-duplex US for assessment of patency and valve function after 6 weeks, 3, 6 and 12 months and afterwards on a yearly basis. RESULTS A total of 101 patients with 103 extremities affected by iliofemoral venous thrombosis were included (median age; 29 years, 78 women, and 79 had left-sided thrombosis). A stent was inserted in 57 limbs. The median follow-up time was 50 months (range 3 days-108 months). At 6 years, 82% of the limbs had patent veins with competent valves and without any skin changes or venous claudication. CONCLUSION Treatment with CDT for IFVT achieves good patency and vein function after 6 years of follow-up in this highly selected group of patients. We suggest that results from future studies should be presented as Kaplan-Meier plots using venous patency without reflux as the main outcome, since it is an early indicator of the clinical outcome.

Postthrombotic syndrome and quality of life in patients with iliofemoral venous thrombosis treated with catheter-directed thrombolysis

BACKGROUND Postthrombotic syndrome (PTS) is a common complication after iliofemoral venous thrombosis, often resulting in poor quality of life (QOL) among the affected patients. This study assessed development of PTS and its effect on QOL among patients treated for iliofemoral venous thrombosis by catheter-directed thrombolysis. METHODS Patients admitted with an iliofemoral venous thrombosis and treated with catheter-directed thrombolysis at Gentofte University Hospital from 1999 to 2008 were invited to participate. Duplex ultrasound imaging was used to assess venous patency and valve function. Each patient completed the generic Short-Form 36-item (SF-36) health survey assessment, producing physical component (PCS) and mental component summary (MCS) scores, and the disease-specific Venous Insufficiency Epidemiological and Economic Study (VEINES)-Quality of Life (QOL)/Symptoms (Sym), questionnaires to assess QOL. PTS was assessed using the Villalta scale. RESULTS The study included 109 patients. Median follow-up was 71 months. PTS developed in 18 patients (16.5%) and of those, initial thrombolysis was successful in 13. Patients with PTS had significantly worse mean ± standard deviation scores than patients without PTS on VEINES-QOL (34.2 ± 9.6 vs 53.1 ± 6.6; P < .0001), VEINES-Sym (34.0 ± 8.8 vs 53.2 ± 6.6; P < .0001), SF-36 MCS (44.2 ± 15.5 vs 52.3 ± 11.0; P = .005), and SF-36 PCS (42.3 ± 9.1 vs 53.5 ± 7.8; P < .0001) subscales. Patients with reflux or chronic occlusions, or both, had significantly lower mean ± SD scores than patients with patent veins without reflux on VEINES-QOL (43.5 ± 14.3 vs 51.0 ± 8.8; P = .044) and SF-36 PCS (47.2 ± 10.9 vs 52.4 ± 8.5; P = .049) scales. CONCLUSION PTS was associated with worse QOL, although only a few patients developed PTS after catheter-directed thrombolysis of iliofemoral venous thrombosis. Patients with patent veins and sufficient valves have higher QOL scores than patients with reflux and occluded veins.

Flash pulmonary edema in patients with renal artery stenosis--the Pickering Syndrome.

Abstract Aim. We report the prevalence of flash pulmonary edema in patients consecutively referred for balloon angioplasty of unior bilateral renal artery stenosis (PTRA), and describe the characteristics of this special fraction of the patients. We further report two unusual cases. Methods and material. Review of medical records from 60 patients consecutively referred for unior bilateral PTRA from 2004–2005 in Copenhagen County. Results. Eight out of 60 patients had one or more episodes of flash pulmonary edema before PTRA. Compared with the remaining patients, they had a higher prevalence of bilateral stenosis (50% vs 27%) and coronary artery disease (75% vs 28%). However, only one of eight had severe systolic dysfunction of the left ventricle. After PTRA, two recurrences of flash pulmonary edema were observed. One was caused by severe restenosis and did not recur after aorto-renal bypass surgery. The other one was caused by rapid atrial fibrillation and did not recur after pacemaker and medical treatment. Conclusion. Flash pulmonary edema can be observed in patients with unilateral as well as bilateral stenosis. The prognosis is usually excellent upon treatment of the stenoses. Recurrences are rare unless restenosis occurs, and therefore, regular control, e.g. by Doppler-ultrasound examination is recommended.

Acute Iliofemoral Venous Thrombosis in Patients with Atresia of the Inferior Vena Cava Can Be Treated Successfully with Catheter-directed Thrombolysis

PURPOSE To assess the effectiveness and clinical outcomes of catheter-directed thrombolysis in patients with atresia of the inferior vena cava (IVC) and acute iliofemoral deep vein thrombosis (DVT). MATERIALS AND METHODS From 2001 to 2009, 11 patients (median age, 32 y) with atresia of the IVC and acute iliofemoral DVT in 13 limbs were admitted for catheter-directed thrombolysis. Through a multiple-side hole catheter inserted in the popliteal vein, continuous pulse-spray infusion of tissue plasminogen activator and heparin was performed. Thrombolysis was terminated when all thrombus was resolved and venous outflow through the paravertebral collateral vessels was achieved. After thrombolysis, all patients received lifelong anticoagulation and compression stockings and were followed up at regular intervals. RESULTS Ultrasound or computed tomography revealed absence of the suprarenal segment of the IVC in two patients, and nine were diagnosed with absence of the infrarenal segment of the IVC. Median treatment time was 58 hours (range, 42-95 h). No deaths or serious complications occurred. Overall, complications were observed in four patients, one of whom required blood transfusion. Three patients were diagnosed with thrombophilia. Median follow-up was 37 months (range, 51 d to 96 mo). All patients had patent deep veins and one developed reflux in the popliteal fossa after 4 years. No thromboembolic recurrences were observed during follow-up. CONCLUSIONS Catheter-directed thrombolysis of patients with acute iliofemoral DVT and atresia of the IVC is a viable treatment option, as reasonable clinical outcomes can be obtained.

Excellent long-term results with iliac stenting in local anesthesia for post-thrombotic syndrome

Background Only 20% of iliac veins will recanalize on anticoagulation (AC) treatment alone and may, therefore, develop venous obstruction after iliofemoral deep venous thrombosis (DVT). A considerable number of these patients will suffer from post-thrombotic syndrome (PTS) leading to impaired quality of life in more than 50%. Endovascular treatment for iliac vein obstruction using stents is known to alleviate PTS symptoms in selected patients. Purpose To report the Danish long-term results of endovascular treatment with iliac stenting. Material and Methods From 2000 to 2013 consecutive patients were evaluated and 19 patients with severe venous claudication were identified and subsequently underwent angioplasty and stenting. AC treatment was prescribed for 6 months, and knee-high class II compression stocking recommended for 1 year. Scheduled follow-up was done in the outpatient clinic at 6 weeks, 3 months, and annually thereafter. Results Nineteen patients, all women, all with left-sided iliac vein obstruction, and all with severe PTS symptoms were included. The median follow-up time was 81 months (range, 1–146 months; mean, 69 months). Primary patency rate of the inserted iliac stent was 89% (17/19) and 16 patients (84 %) had almost or total symptom relief at follow-up. Conclusion Endovascular stenting of iliac obstruction in local anesthesia is minimally invasive and shows excellent long-term outcomes for patients suffering from PTS.

Which criteria demand additive stenting during catheter-directed thrombolysis?

Many factors are necessary for obtaining satisfactory results after catheter-directed thrombolysis (CDT) for iliofemoral deep venous thrombosis (DVT). Selections of patients, composition of the thrombolytic fluid, anticoagulation per- and post-procedural, recognition and treatment of persistent obstructive lesions of the iliac veins are the most important contributors. Stenting has been known for 15 to 20 years. The first publication on CDT in 1991 was combined with ballooning the iliac vein, an additive procedure which has been abandoned as an isolated procedure. This chapter will discuss selection, indication, such as an iliac compression syndrome, and outcome of iliac stenting in combination with CDT. The reported frequency of stenting used after CDT is very inconsistent, therefore this will be discussed in details. It is concluded that selection for stenting is of the greatest importance, when CDT is used for iliofemoral DVT, but strict criteria for stenting are not available in the existing literature. The potential value of intravascular ultrasound (IVUS) is also discussed.

Pregnancy after catheter-directed thrombolysis for acute iliofemoral deep venous thrombosis

Objective: To assess the safety and efficacy of low-molecular-weight heparin (LMWH) in pregnancy and puerperium in women with previous acute iliofemoral deep venous thrombosis (DVT) treated with catheter-directed thrombolysis (CDT). Materials and methods: Consecutive patients treated for acute iliofemoral DVT using CDT between June 1999 and June 2009 were followed yearly by colour duplex ultrasound scanning. A subgroup of these patients who became pregnant during the follow-up period, three months to 10 years after CDT, was included in the present study. During pregnancy, thromboprophylaxis using LMWH was prescribed according to individual risk assessment, and the women were regularly assessed for adverse events. Women on warfarin had this treatment discontinued before the sixth week of pregnancy in order to prevent potential teratogenic adverse effects. Administration of LMWH was started at international normalized ratio ≤<2.0, and continued during pregnancy, delivery and puerperium. Postnatal, the anticoagulation treatment was converted back to warfarin and LMWH discontinued after a bridging period. Women, who, prior to pregnancy, had discontinued anticoagulation treatment after CDT, were prescribed anticoagulation treatment using LMWH as early in pregnancy as practical. LMWH was continued during pregnancy, delivery and for six weeks postpartum. All women were prescribed graduated compression stockings. Results: A total of 33 women completed 45 pregnancies, 44 singletons and 1 gemelli. In 24 (53%) of the cases, the mother had been treated with adjunctive stenting immediately following the CDT. In nine (21%) of the pregnancies, the mother had been on long-time anticoagulation treatment using warfarin prior to conception due to permanent severe risk factors. Thrombophilia was demonstrated in 31 (69%) of the pregnancies, and in 29 (64%) of the patients, the previous DVT was oestrogen-related. Thromboprophylaxis using tinzaparin was given in 41 (91%) and using dalteparin in four (9%) of the pregnancies. Doses of LMWH during pregnancy were adjusted according to risk assessment. One pregnancy was terminated by induced delivery at week 22 due to fetal malformations, and two of the pregnancies (4%) were complicated by intrauterine fetal death, one in week 39 due to severe fetal infection and one in week 23 due to intrauterine fetal growth restriction caused by severe antiphospholipid syndrome. All but one of the pregnancies was carried out without recurrence of DVT or maternal pulmonary embolism and the mother remained having patent deep veins postnatal. The mother with the antiphospholipid syndrome had a recurrent DVT complicated by iliac stent occlusion. This mother was prior to pregnancy on long-time treatment using warfarin. During pregnancy, she was erroneously treated with LMWH in standard prophylaxis doses instead of therapeutic doses and without adding aspirin. Conclusions: After CDT for acute iliofemoral DVT including adjunctive stenting, pregnancy can be carried out almost uneventful even in women at high risk of thromboembolism. Thromboprophylaxis during pregnancy using LMWH in a dosage adjusted to individual risk assessment, is essential.

Renal graft failure after addition of an angiotensin II receptor antagonist to an angiotensin-converting enzyme inhibitor: unmasking of an unknown iliac artery stenosis

Combined treatment with an angiotensin-converting enzyme (ACE) inhibitor and an angiotensin II (Ang II) receptor blocker (ARB) has been suggested in order to achieve a more complete blockade of the renin-angiotensin-aldosterone system in cardiovascular and renal disease. The present report describes a case of acute renal graft dysfunction following the addition of an ARB to existing ACE inhibition. This unmasked an unknown iliac artery stenosis. The case indicates a possible important role of Ang II generated by non-ACE pathways in this situation.

Thrombus age is ideally measured by history or MRV prior to thrombus removal

Many factors are known to be important in order to achieve optimal results after thrombus removal for iliofemoral DVT. Not much is published in the literature about timing the treatment, though many guidelines recommend treatment within 14 days. This time span lies within the phrase of acute DVT according to the definition given in many reporting standards. This article will highlight the value of information acquired from patients directly regarding onset of symptoms versus information acquired from imaging with the purpose of a more precise selection of patients for catheter-directed thrombolysis for iliofemoral DVT. What is the value of clinical information acquired from patients and does the information from imaging have additional value?

Manuscripts from the European Venous Course

This is already our sixth European Venous Course, with important contributions of a lot of experts in the field. 2012 showed again a further increased interest for the care for patients with venous disease. Patient organizations, physicians, medical institutions, hospitals and industry all identify the burden of this disease for the patients and the socioeconomic impact and acknowledged the importance of a better collaboration. The establishment of the Dutch and European Colleges of Phlebology illustrate this. In these two new “vertical societies”, patient organizations, physicians, medical institutions, hospitals and industry are assembled and members in one new society involved in the care for these patients. The optimization of the quality of care for patients with venous disease is the most important bylaw of these societies. This improved collaboration is essential to speed up the implementation of new technologies, because a lot is happening in varicose vein and deep venous pathology diagnostics and treatment. We are very pleased with the fact that Phlebology agreed again to publish the papers presented during the European venous course in a Supplement of Phlebology. All the important educative contributions for the European Venous Course will now be available for a much bigger audience. We are also still very proud of our, every year well appreciated, venous course book. The program this year concentrates on innovations for varicose veins, how to identify the patterns of reflux and decide on which therapy to chose. Because in a lot of countries reimbursement for varicose vein surgery is a big issue a complete session deals with the cost effectiveness and discusses the macro economical consequences. A lot of time is also spend on the innovative treatments for deep venous pathology, with special attention to deep venous thrombosis, deep venous stenting and the impact on diagnostics and treatment for venous ulcers. Anticoagulation, prophylactic and therapeutic, is changing fast and gets the attention it deserves. Prof. Hugo ten Cate, invited as the keynote speaker, will address the ever-changing issues related to indications and duration of anticoagulation after venous interventions. Finally a session is dedicated to venous malformations. Opinion leaders address the multidisciplinary approach necessary to identify and treat patients with venous malformations. Besides this theoretical information, presented in the Supplement, it is recognized that hands-on training is mostly needed and much appreciated. This is why again the popular venous master classes, in which participants get hands-on training in superficial and deep venous treatments, are organized for three days. Last year we had 7 stations for each master class, but due to the increase interest we now have 11 stations in each master class. We also added a third master class for the more advanced physicians in venous pathology, in which difficult venous cases are discussed with leaders in the field. Parallel to the master classes we have 3 satellite symposia comprehensively addressing important issues in venous disease and the value of a good intuitive electronic patient record combined with a national registry is discussed. As stated before the collaboration with everybody involved is recognized and already led to the establishment of two new societies. This European Venous Course identified this need for many years and is specially designed for all healthcare workers in the field of venous disease like vascular surgeons, dermatologists, phlebologists, angiologists, vascular technicians, nurse practitioners and physician assistants. New is the active involvement of hospital management, boards and industry. The fact that industry is more and more involved shows that there focus on education and training is growing. We are convinced that they are our partners and not our sponsors although it is clear that without their financial support a meeting like this is impossible. Therefore, we are very grateful to our major and regular partners for their contribution and confidence in this European Venous Course. Although new Eucomed rules together with the new standards to ensure the independence of CME activities restrict an intensive collaboration it is our opinion that we should integrate more because our goal to improve the quality of care for the patient with a venous problemis exactly the same. We are convinced that cooperation with industries and healthcare workers in the field of venous disease will positively influence the quality of care and possible new innovations in venous care. Maastricht, Aachen 2013