Sven Just

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.

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.

Changes in superior mesenteric artery Doppler waveform during reduction of cardiac stroke volume and hypotension

Influence of stroke volume reduction and hypotension on the superior mesenteric artery (SMA) Doppler waveform was evaluated during head-up tilt-induced central hypovolemia in 11 healthy volunteers. During normotensive reduction in stroke volume, peak systolic velocity (pV), mean velocity, pulsatility and resistivity indices decreased, while diastolic velocities increased. During hypotension, a further decrease in pV was accompanied by maintained elevation of diastolic velocities and reduction in pulsatility and resistivity indices. Power of backscattered Doppler wave was elevated throughout the hypovolemia. Alterations in pV and pulsatility indices were closely related to changes in stroke volume, and a negative correlation was found between diastolic velocities and stroke volume. regression analysis showed no significant relation between variations in velocity parameters and blood pressure. Results of the study indicate that alterations in stroke volume induce consequential changes in the SMA Doppler waveform. These changes originate from both direct influence of stroke volume and/or pressure on blood flow velocity, and alterations in SMA peripheral resistance that follow variations in stroke volume. Presented interdependencies should be taken into consideration while studying mesenteric physiology with the use of Doppler technique and while interpreting the duplex results in patients suffering from diseases that may influence flow velocity and mimic or obscure Doppler effects of the SMA stenosis.

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.

Prediction of outcome after femoropopliteal balloon angioplasty by intravascular ultrasound

OBJECTIVE To evaluate intravascular ultrasound (IVUS) as a control procedure after femoropopliteal percutaneous transluminal angioplasty (PTA), and compare it with arteriography. DESIGN Descriptive study. MATERIAL Arteriographic and intravascular ultrasound data obtained from 18 patients (20 limbs) undergoing PTA of the superficial femoral or popliteal artery. The degree of stenosis, the diameter and area of the lumen and the morphological changes in the plaque were related to the short-term patency of the intervention, as evaluated by duplex scan and ankle branchial index. RESULTS Fifteen arteries remained patent. Two occlusions and two stenoses developed during the first 3 months after the intervention and one occlusion occurred after 1 year. The following IVUS parameters were related to a favourable patency: presence of calcification; dissection or plaque rupture and residual stenosis of less than 70%. The arteriographically determined diameter reduction did not show predictive value. CONCLUSION This study shows that in contrast to arteriography, IVUS revealed parameters predictive for patency following PTA.

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.

Quantification of iliac artery stenoses : A methodological comparative study between intravascular ultrasound, arteriography and duplex scanning

Two morphological methods for quantifying the degree of stenoses in the iliac arteries, intravascular ultrasound (IVUS) and arteriography, were compared with duplex scanning, a method of evaluating the haemodynamic importance of the stenosis. A total of 38 patients, 20 women and 18 men, median age 66 y, admitted for either PTA (n=18) or femoro-femoral crossover bypass surgery (n=20), were examined by IVUS, single plane arteriography and duplex scanning. The predictive value, sensitivity, specificity and kappa value of IVUS were higher than the corresponding values for arteriography. Logistic regression analysis found that IVUS had a predictive value (p=0.0003) for diagnosing significant stenosis as defined by duplex scanning, but arteriography did not (p=0.1). However, this difference in usefulness as predictors did not reach significance. The agreement between arteriography and IVUS was relatively good. The conclusion is that IVUS seems to be superior to single-plane arteriography in predicting hemodynamically significant stenoses as defined by duplex scanning.