A Stepwise Haemostasis Intraoperative Protocol Driven Reduction of Haematoma Rate Following Symptomatic Carotidendarterectomy.

INTRODUCTION: Carotid endarterectomy (CEA) for symptomatic stenosis reduces further stroke risk. Post-CEA haematoma increases the risk of complications including stroke. There are few studies considering protocols aimed at reducing post-CEA haematoma rates. Presented are the outcomes of a protocol developed to reduce this surgical complication. METHOD: The protocol was implemented in 112 consecutive CEA. It involves stepwise additional measures to ensure haemostasis before wound closure. Attention to bleeding points is followed by light compression for 10 min. Protamine is then given if haemostasis has not been achieved. If after 20 min the problem persists Tranexamic acid is given. Following a further 20 min if haemostasis is not yet achieved a platelet transfusion is undertaken. Haematoma rates, return to theatre for post-operative haematoma and other complications were compared with 100 consecutive pre-protocol introduction CEA cases. RESULTS: Of 112 CEA patients, 19 received protamine, 8 protamine and tranexamic acid. One case required platelet transfusion. Neck haematoma rate fell from 10 to 3 cases (P = .02, OR: 0.25 [95% CI .07-.94]), of which returned to theatre for haematoma evacuation fell from 6 to 1 case (P = .03, OR: 0.14 [95% CI .02-1.19]). 30 day stroke and death rate reduced from 5% to 1.8% (P = .11, OR: 0.35 [95% CI .07-1.82]). CONCLUSION: The stepwise haemostasis intraoperative protocol can reduce post-CEA haematoma rates.

A clinical guide to deep venous stenting for chronic iliofemoral venous obstruction.

BACKGROUND: An increase in endovenous interventions for deep venous pathologies has been observed. This article aims to provide an overview of the role of venous stenting in the management of chronic conditions affecting the deep venous system of the lower limbs, with a focus on intervention relating to the vena cava and iliofemoral venous segments. METHODS: An overview of the literature on the minimally invasive venous stenting procedures that are being increasingly used in the management of chronic conditions affecting the deep venous system of the lower limbs. RESULTS: We discuss key areas of interest to a venous specialist practicing in this area, including diagnostic imaging in chronic deep venous disease, with a focus on the use of intravascular ultrasound examination in this context; the treatment of chronic venous outflow obstruction, including the rationale and structural indications for stenting, current guidance regarding stent placement, and fundamental points to consider during decision-making (endophlebectomy and stenting, stenting across the inguinal ligament, optimal sizing of venous stents, extension of venous stenting to beyond the common femoral vein confluence, the role of thrombolysis useful in chronic venous disease, and arteriovenous fistulae); outcomes and initial reports of stenting; and the future of venous stents. CONCLUSIONS: Deep venous stenting has become a key treatment option for chronic (thrombotic or nonthrombotic) obstructive venous disease. Dedicated venous stents and intravascular ultrasound examination represent important technological advances in the minimally invasive treatment of symptomatic chronic deep venous obstruction, which previously required open surgical reconstruction.

Clinical outcomes and overview of dedicated venous stents for management of chronic iliocaval and femoral deep venous disease.

OBJECTIVES: Venous stenting of the lower extremities has grown in popularity and is now considered a key component of the primary treatment strategy for the management of pathologically obstructive or stenotic lesions of the deep venous system. This review aims to provide an overview of the role of venous stenting in the management of chronic conditions affecting the deep venous system of the lower limbs. METHODS: An overview of venous stents design and current role of stenting procedure in individuals presenting with Chronic Venous Insufficiency (CVI) and presenting the current trials of dedicated venous stenting in management of chronic deep venous lesions. This review provides a focused insight on venous stent design, physical properties and the available dedicated venous stents selected studies with their related patency outcome based on selective literature search of the PubMed database and Cochrane library. CONCLUSIONS: Dedicated venous stent technology is advancing at a rapid pace alongside the increased undertaking of endovascular deep venous stent reconstruction in the management of iliocaval vein pathologies. The ideal design(s) for venous stents remain unknown, although it is hoped that the presence of new dedicated venous stents in clinical practice will allow the generation of experience and data to advance our understanding in this area.

The management and referral of iliofemoral deep venous thrombosis in North West London.

BACKGROUND: Post-thrombotic syndrome is a common complication of iliofemoral deep venous thrombosis (IFDVT). Existing evidence and National Institute for Health and Care Excellence guidelines suggest that this can be reduced by prompt thrombolytic therapy or thrombectomy. We aimed to evaluate the characteristics of IFDVT patients and to identify whether patients are being offered the recommended treatment pathway. METHODS: A multicenter cross-sectional study was conducted across eight hospital sites in the North West London region, of which two were hub hospitals in their local vascular service networks. Patients with proximal DVT were identified using International Classification of Diseases, Tenth Revision coding during a 1-year period. Data on demographics, diagnostic methods used, interventions, and referrals were extracted from electronic and paper medical records. RESULTS: During the study period, 132 patients with IFDVT were identified (mean age, 59.4 years; 55% female); 75% of these patients had an IFDVT. In this cohort, the biggest predisposing factors were previous DVT (n = 35), malignant disease (n = 35), and immobility (n = 20). In total, 104 patients were administered anticoagulation, and 88 of these patients received anticoagulation within 24 hours. The cases of 45 patients were either discussed with or promptly referred to a vascular service, after which 20 patients were treated solely with anticoagulation, whereas 20 patients received thrombolysis of varying methods. CONCLUSIONS: A significant proportion (56%) of symptomatic IFDVT patients are not being appropriately referred to or discussed with vascular services. Of these, 43% would have been eligible for consideration of early thrombus removal. Adherence to the National Institute for Health and Care Excellence guidelines could be improved by increasing awareness among emergency department colleagues.

A systematic review of paediatric deep venous thrombolysis.

OBJECTIVES: The aim was to assess the effectiveness and safety of catheter-directed thrombolysis in children with deep venous thrombosis and to evaluate its long-term effect. METHOD AND RESULTS: EMBASE, Medline and Cochrane databases were searched to identify studies in which paediatric acute deep venous thrombosis patients received thrombolysis. Following title and abstract screening, seven cohort studies with a total of 183 patients were identified. Technical success was 82% and superior in regional rather than systemic thrombolysis (p < 0.00001). One cohort study identified significant difference in thrombus resolution at one year between thrombolytic and anticoagulant groups (p = 0.01). The complication rate was low, with incidence rates of major bleeding, pulmonary embolism and others at 2.8%, 1.8% and 8.4%, respectively. The overall post-thrombotic syndrome rate was 12.7%. The incidence of re-thrombosis ranged from 12.3% to 27%. CONCLUSION: Thrombolysis for paediatric deep venous thrombosis is an effective and relatively safe therapeutic option, lowering the incidence of post-thrombotic syndrome and deep venous thrombosis recurrence.

A systematic review on the use of deep venous stenting for acute venous thrombosis of the lower limb.

OBJECTIVES: The aim is to evaluate venous stent patency, the development of post-thrombotic syndrome, recurrence, quality of life and the optimal post-procedural anticoagulation regimen in the treatment of iliofemoral deep venous thrombosis. METHOD AND RESULTS: EMBASE and Medline databases were interrogated to identify studies in which acute deep venous thrombosis patients were stented. Twenty-seven studies and 542 patients were identified. Primary, assisted primary and secondary patency rates 12 months after stent placement ranged from 74 to 95, 90 to 95 and 84 to 100%, respectively. The observed post-thrombotic syndrome rate was 14.6%. The incidence of stent re-thrombosis was 8%. In 26% of studies, patients received additional antiplatelet therapy. Quality of life questionnaires employed in 11% of studies, demonstrating an improvement in the chronic venous insufficiency questionnaire (22.67 ± 3.01 versus 39.34 ± 6.66). CONCLUSION: Venous stenting appears to be an effective adjunct to early thrombus removal; however, further studies are needed to identify optimal anticoagulant regimen and effect on quality of life.

Post Thrombotic Syndrome.

Venous insufficiency following deep venous thrombosis is known as the post thrombotic syndrome. Whilst its presentation and symptoms can vary slightly between individuals, it can have a profound effect on quality of life. Symptoms range from mild limb swelling to severe intractable ulceration. A number of scoring systems have been developed to help monitor the disease progression, response to treatment as well as to classify patients for research purposes.Treatment involves a combination of therapies, including compression stockings, venous stenting for out flow obstruction and in some instances deep venous bypass. A considerable effort is made in preventing post thrombotic syndrome with a number of trials looking into the effect of prompt and stable anticoagulation, the effect of compression stockings, the effect of exercise and the outcomes following early thrombus removal strategies such as catheter directed and pharmacomechanical thrombolysis.