Rafael D. Malgor

A systematic review of symptomatic duodenal perforation by inferior vena cava filters

OBJECTIVE A systematic review of the literature on symptomatic duodenal perforation caused by inferior vena cava (IVC) filters. METHODS Three databases, PubMed MEDLINE, Web of Sciences, and Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), reference lists of review articles and conference proceedings were searched. All articles containing data on clinical presentation, diagnostic strategy, and available treatment of symptomatic duodenal perforation caused by an IVC filter were included regardless of design, language, size, or length of follow-up. RESULTS Seventy-two articles were selected for full-text screening, being 21 case reports were selected. The median age was 46 years old (range, 21-83 years old). Abdominal pain was reported in 11 patients and gastrointestinal bleed in 5 patients. The indications for IVC filter placement in this cohort of patients were contraindication of anticoagulation and recurrent pulmonary embolism (PE) despite therapeutic levels in 8 and 5 patients, respectively. Three different imaging modalities were obtained in 9 patients (43%) before confirming the diagnosis. All but 1 patient underwent open approach through laparotomy with or without removal of the filter. No PEs or deaths were reported and only 1 patient had a severe clinical complication of IVC and bilateral iliac vein thrombosis with massive lower extremities edema. CONCLUSIONS Duodenal perforation caused by IVC filters is a rare complication that frequently requires extensive workup. Excellent outcomes with low complication rate have been reported in cases where an open procedure was performed with either extraction of the filter or removal of the offending struts.

A systematic review for the screening for peripheral arterial disease in asymptomatic patients

BACKGROUND Peripheral arterial disease (PAD) is common and associated with significant morbidity and mortality. PAD can be detected through a noninvasive measurement of the ankle-brachial index (ABI). METHODS We conducted a systematic review of several electronic bibliographic databases for studies that evaluated ABI as a screening test for PAD in asymptomatic individuals. We conducted random-effects meta-analysis, reporting pooled hazard ratios (HRs) when appropriate. RESULTS We included 40 individual studies, 2 systematic reviews, and 1 individual-patient data meta-analysis. We found no studies comparing ABI screening with no screening in terms of patient-important outcomes (mortality, amputations). The yield of PAD screening averaged 17% (range, 1%-42%) and was 1% to 4% in lower risk populations. Patients with PAD had higher adjusted risk of all-cause mortality (HR, 2.99; 95% confidence interval, 2.16-4.12) and of cardiovascular mortality (HR, 2.35; 95% confidence interval, 1.91-2.89). Data on benefits, harms, and cost-effectiveness of screening were limited; however, ABI screening was associated with additional prognostic information and risk stratification for heart disease. The overall quality of evidence supporting screening was low. CONCLUSIONS The current available evidence demonstrates that PAD is common in patients with multiple cardiovascular risk factors and is associated with significant morbidity and mortality, but it does not support the benefit of routine ABI screening.

Diagnosis of venous disease with duplex ultrasound

The advent of duplex ultrasound (DU) has changed vascular practice over the years. Venous anatomy, valve function and obstruction can be evaluated in real time using DU. It is a low cost, portable, non-invasive, safe and operator-friendly device that can be used for diagnosis, treatment guidance and follow-up. This paper defines the patterns, location and characteristics of venous reflux and also provides insightful information on acute and chronic venous obstruction.

A Systematic Review of Pulmonary Embolism in Patients With Lung Cancer

Pulmonary embolism (PE) is increasingly recognized as causing significant morbidity and mortality in modern societies; however, little is known about PE in patients with lung cancer. We systematically reviewed Medline, Web of Science, and the Cochrane Library databases and selected 26 studies, including 2 randomized controlled trials, and 4 prospective, 18 retrospective cohort, and 2 case-control studies. Overall incidence of PE was 3.6%. Pulmonary embolism abbreviated survival in 2 studies when the diagnosis was synchronous with lung cancer. Venous thromboembolism prophylaxis, treatment, and surveillance are inconsistently reported. Clinical outcome data pertaining to this topic are limited and of overall poor methodologic quality.

Persistent Abdominal Pain Caused by an Inferior Vena Cava Filter Protruding Into the Duodenum and the Aortic Wall

Inferior vena cava (IVC) filter placement has increased dramatically over the past 2 decades. Symptomatic duodenal perforation by IVC filters with involvement of the aorta is a very rare, but challenging, complication. We report a case of persistent atypical right upper quadrant pain secondary to duodenal and aortic perforation by an IVC filter treated with cavotomy for filter removal, primary repair of the duodenum, and extraction of prongs from the aorta.

Surgical treatment of varicose veins and venous malformations in Klippel–Trenaunay syndrome

Background Klippel–Trenaunay syndrome (KTS) is a mixed mesenchymal malformation characterised by varicose veins, venous and capillary malformations, and hypertrophy of soft tissue and bone. The purpose of this study was to evaluate the surgical outcomes in KTS patients to provide standards for comparison with endovenous therapy. Methods The clinical data of consecutive patient with KTS who underwent open venous surgical treatment between January 1987 and December 2008 were reviewed. Demographics, clinical presentation, operative data, and clinical outcomes were recorded. Follow-up information was obtained from the medical records, mailed questionnaires and phone calls. Descriptive statistics, the Kaplan–Meier method and Log-rank statistics were used where appropriate. Results Twenty-seven females and 22 males, (mean age 26.5 years, range 7.7–55.8) were included in this study. All had varicose veins, 36 (73%) had limb hypertrophy, and 33 (67%) had capillary malformations, with two of three clinical features present in all. The most frequent symptom was pain (N = 43, 88%). Forty-nine patients underwent operations on 53 limbs. Stripping of the GSV, small and accessory saphenous and lateral embryonic veins was performed in 17 (32%), 10 (19%), 9 (17%), and 15 (28%) limbs, respectively. Two patients developed deep vein thrombosis, one had pulmonary embolism (PE), and one patient had peroneal nerve palsy. Freedom from disabling pain at 1, 3 and 5 years was 95%, 77% and 59%, respectively, and freedom from secondary procedures was 78% at 3 years, and 74% at 5 years. At the last follow-up visit, the venous clinical severity score had decreased from 9.48 ± 3.27 to 6.07 ± 3.20 (P < 0.001). Conclusions In selected symptomatic patients with KT syndrome, open surgical treatment is safe and durable. Three-fourths of the patients remain free of disabling pain at five years, but secondary procedures are required in one-fourth of the patients. These data can serve as standards for comparison of endovenous therapy for KT syndrome.

Diagnosing Common Carotid Artery Agenesis Using Duplex Ultrasound

The complete absence of a common carotid artery, also known as common carotid artery (CCA) agenesis, is a well-described yet extremely rare congenital anomaly. Most carotid system anomalies are related to origins of the external or internal carotid arteries. All such anomalies are typically asymptomatic unless associated with a concomitant arterial lesion that results in a workup for symptomatic intracerebral pathology or a focal neurological deficit. The literature is scant on the topic, being limited to singular case reports. We report 3 cases of CCA agenesis and provide the readers with insightful data on the available literature.

Reporting the impact of inferior vena cava perforation by filters

Background Perforation of the inferior vena cava by filters struts is a known complication. The goal of our review is to assess the impact of inferior vena cava perforation by filters based on an open, voluntary national database. Methods We reviewed 3311 adverse events of inferior vena cava filters reported in Manufacturer and User Facility Device Experience database from January 2000 to June 2011. Outcomes of interest were incidence of inferior vena cava perforation, type of filter, clinical presentation, and management of the perforation, including retrievability rates. Results Three hundred ninety-one (12%) cases of inferior vena cava perforation were reported. The annual distribution of inferior vena cava perforation was 35 cases (9%), varying from seven (2%) to 70 (18%). A three-fold increment in the number of adverse events related to inferior vena cava filters has been noted since 2004. Wall perforation as an incidental finding was the most common presentation (N = 268, 69%). Surrounding organ involvement was found in 117 cases (30%), with the aorta being the most common in 43 cases (37%), followed by small bowel in 36 (31%). Filters were retrieved in 97 patients (83%) regardless of wall perforation. Twenty-five (26%) cases required an open procedure to remove the filter. Neither major bleeding requiring further intervention nor mortality was reported. Conclusions Inferior vena cava perforation by filters remains stable over the studied years despite increasing numbers of adverse events reported. The majority of filters involved in a perforation were retrievable. Filter retrieval, regardless of inferior vena cava wall perforation, is feasible and must be attempted whenever possible in order to avoid complications.

Pattern and types of non-saphenous vein reflux.

Venous reflux often originates from saphenous trunks and their tributaries. In about 10% of the patients reflux derived from non-saphenous veins (NSV) such as those located in the buttock, posterolateral thigh, vulva, lower posterior thigh, popliteal fossa, knee or along the peripheral nerves such as the tibial and sciatic nerve. It is also important to note that patients who had saphenous vein stripping or ablation have higher odds of presenting with NSV reflux. The majority of patients with NSV reflux have varicose veins and lower extremity oedema; however, about 10% of those patients present with skin damage. This paper analyses the patterns and types of NSV reflux for diagnosis and treatment purposes.

Stratifying risk: asymptomatic carotid disease

O acidente vascular encefalico gera custos significativos na area da saude e representa um problema social e economico. A instabilidade da placa carotidea aterosclerotica e responsavel por um terco dos acidentes vasculares encefalicos embolicos. O grau de estenose tem sido usado para justificar, deliberadamente, intervencoes carotideas em milhares de pacientes no mundo todo. No entanto, o risco anual de acidente vascular encefalico em doenca carotidea assintomatica e baixo. A morfologia da placa e sua mobilidade tem ganhado importância na elucidacao dos eventos embolicos cerebrovasculares e retinais. Esta revisao proporciona aos leitores uma analise critica e inteligente da estratificacao de risco da doenca carotidea assintomatica com o intuito de auxiliar na selecao de potenciais candidatos a intervencao carotidea.