Clinical Impact of Severe Obesity in Patients with Lymphoedema.

OBJECTIVE: With the rate of obesity increasing worldwide, patients with lymphoedema with and without a concomitant diagnosis of severe obesity (SO) were compared in regard to their baseline demographics, health related characteristics, treatment plans, and patient outcomes. METHODS: This was a retrospective observational cohort study. The IBM MarketScan database was examined (2013 - 2019) for patients with a new diagnosis of lymphoedema. Of 60 284 patients with lymphoedema identified, 6 588 had SO defined by a body mass index > 40 kg/m2. The demographics and other characteristics of SO were compared with patients with lymphoedema without SO. RESULTS: SO and lymphoedema diagnosis increased two fold from 2013 to 2019. The lymphoedema SO+ group was younger (57.8 vs. 60.8 years, p < .001) and with a higher proportion of men (37.7% vs. 24.9%, p < .001) than the lymphoedema SO- group. More comorbidities were observed in the lymphoedema SO+ group than the lymphoedema SO- group: diabetes 46.0% vs. 24.9 % (p < .001), heart failure 18.3% vs. 7.4% (p < .001), hypertension 75.0% vs. 47.6% (p < .001), and renal disease 24.8% vs. 11.9% (p < .001). Use of diuretics in the lymphoedema SO+ group was greater: 57.6% vs. 38.0% (p < .001). Patients with lymphoedema SO+ had higher risk of cellulitis: 34.5% vs. 13.5% (p < .001). Specific lymphoedema treatment was given more often to lymphoedema SO-: 66.3% vs. 64.3% (p = .003). This was significant for manual lymphatic drainage (46.6% vs. 40.0%; p < .001) and physical therapy (55.4% vs. 51.6%; p<.001), but not for compression garments (18.2% vs. 17.7%; p = .38). However, more patients with lymphoedema SO+ received pneumatic compression device treatment: 20.9% vs. 13.7% (p < .001). CONCLUSION: There was an increase in SO associated lymphoedema. Patients with lymphoedema SO+ have over a two and half fold increase in cellulitis incidence, with a significant increase in medical resource use and cost. Despite this, patients with lymphoedema and SO receive less specific therapy such as compression, which has proven to reduce cellulitis incidence.

Luminal Changes in Patients with Inferior Vena Cava Filters and Development of Chronic Venous Disease.

BACKGROUND: This study aimed to analyze the luminal changes in the iliocaval veins and their effects on the development of signs and symptoms of chronic venous disease manifesting from inferior vena cava (IVC) filter placement. METHODS: This was a retrospective observations study; deidentified patients with an IVC filter placed with subsequent luminal changes were included. All patients had a computerized tomography (CT) scan with or without ultrasound and those who underwent an intervention for the obstruction had also venography and intravascular ultrasound (IVUS). The diameter of IVC and iliac veins was measured from the near wall to the far wall. IVC diameters measured less than 12 mm were considered to be retractions. Signs and symptoms of chronic venous disease were obtained from patient charts and were reported according to the highest CEAP class. The data were analyzed using descriptive statistics, presenting diameter changes as a mean with standard deviation and a range of diameters included. RESULTS: Overall, 76 patients were included in this study, of whom 66 had occlusion of the IVC or the Iliac veins. Luminal changes of the IVC were observed in all patients. A total of 58 patients presented with chronic post-thrombotic changes in both the IVC and iliac veins. There were 4 patients that had a luminal reduction with no filling defects or post-thrombotic changes. Average IVC diameter and iliac vein diameter was measured to be 8.3 ± 1.4 mm and 4.6 ± 1.4 mm, respectively. Patients most frequently presented with extremity swelling, but other signs such as venous ulceration or skin damage were observed. CONCLUSIONS: Permanent luminal changes of the IVC and iliac veins were observed as a result of IVC filter placement and such patients commonly present with signs and symptoms of chronic venous disease. Together, with other known filter complications, these observations add more reasons for a timely retrieval. When such changes occur, patients' appropriate symptoms can be successfully treated. The permanent changes made by filter placement in the IVC and iliac veins further support filter retrieval in a timely fashion. The luminal changes induced by filter placement should be recognized early, particularly in symptomatic patients who can be safely treated with endovenous procedures.

Venous Claudication: a Scoping Review of the Pathophysiology and Clinical Importance.

OBJECTIVE: Venous claudication (VC) is under studied, often being excluded from clinical trials and scales. The purpose of this scoping review was to give a historical perspective of VC and analyse the prevalence, pathophysiological aspects, and clinical implications. METHODS: An extensive search of the books and databases (PubMed, MEDLINE, Scopus, and Cochrane) was performed from inception until October 2021. Studies were considered eligible provided they reported on the topics of interest, whereas strict exclusion criteria with regards to the studied sample of patients, year of publication, or location of the obstruction could not be applied, because of the limited relevant literature. RESULTS: Twenty nine articles were included. VC is found almost exclusively in patients with iliofemoral obstruction. Prevalence was reported in seven studies having a wide range from 10.6% to 74.0%. Dominant findings include increased venous volume and pressure. Pressure in capillaries also rises subsequently causing compartment oedema and increased intramuscular pressure resulting in tissue ischaemia and hypoxia. The time required for the venous pressure to return to the pre-exercise levels in the affected limbs is prolonged compared with normal (39.1 ± 14.4 seconds vs. 1.1 ± 1.1 seconds). CONCLUSION: VC is an important symptom of venous outflow obstruction that is under studied, and merits further recognition. Better understanding of the pathophysiology will be achieved through investigations at tissue level. Diagnosis and improvement after treatment should be reported in an objective and standardised manner.

Prevalence of Inferior Vena Cava Anomalies and Their Significance and Impact in Clinical Practice.

OBJECTIVE: To evaluate the prevalence of inferior vena cava (IVC) anomalies in an asymptomatic healthy population and symptomatic patients. METHODS: This was a multicentre retrospective observational study This study was conducted by reviewing the computed tomography (CT) images of 1 000 individuals from South Korea taken for a general medical check up (group A) and 1 000 patients from the USA who visited with various symptoms for which CT was required (group B). A third group of 800 patients with deep vein thrombosis (DVT) and CT from two US centres were used for comparison (group C). Twenty-eight patients with anatomical changes in the IVC due to intervention, extrinsic compression, trauma, other rare conditions, and poor image quality were excluded. RESULTS: The mean age ± standard deviation of each group was 50 ± 6, 54 ± 11, and 54 ± 15 years in groups A, B, and C, respectively. In group A, duplication was the most common anomaly (10 cases, 1.0%), followed by left sided IVC (four cases, 0.4%), hypoplasia (three cases, 0.3%), and megacava (one case, 0.1%). In group B, the most common IVC anomaly was hypoplasia in six cases (0.6%); duplication in three patients, left sided IVC in three patients, aplasia in two patients, web formation in two patients, and megacava in two patients. In group C, hypoplasia was the most common type (32 cases, 4.0%). The prevalence of hypoplasia in patients younger than 50 years of age was significantly higher compared with older patients (12.7% [14/110] vs. 5.3% [10/190]; p = .027). The risk of hypoplasia or aplasia was significantly higher in patients with DVT (odds ratio [OR] 17.032, 95% confidence interval [CI] 5.243 - 55.321), especially in patients with iliofemoral DVT (OR 34.211, 95% CI 10.323 - 113.378). CONCLUSION: In the normal group, IVC duplication was the most common variation, while hypoplasia was most common in patients with iliofemoral DVT, especially in younger ones.

A systematic review on endovascular repair of isolated common iliac artery aneurysms and suggestions regarding diameter thresholds for intervention.

OBJECTIVE: Our aim was to systematically review results of endovascular aneurysm repair for isolated common iliac artery aneurysms (CIAA) regarding outcomes and to determine if changes should be made to current diameter threshold recommendations for intervention. METHODS: A comprehensive systematic review was performed according to the PRISMA guidelines. PubMed, Scopus, and the Cochrane Central databases were searched. RESULTS: Twenty-one studies were deemed eligible and provided data for 879 patients and 981 isolated CIAA treated with endovascular repair. The majority of the patients (90.8%) were males. The weighted mean age of the patients was 71.7 years (range, 37-91 years). The weighted mean diameter for the CIAA was 41. mm 1 (range, 15-110 mm) and for ruptured aneurysms 58.4 mm. The overall technical success rate was 97.6%. The perioperative mortality rate was 0.7%. Secondary patency rates were reported in only four studies and varied between 96.7% and 100%. The overall morbidity rate was 14%, ranging from 0% to 25%. Most of the studies did not report long-term or adequate follow-up data. Rupture of an isolated CIAA at <4 cm diameter was extremely low. CONCLUSIONS: Endovascular treatment of isolated CIAA is feasible and safe with a low mortality and excellent technical success rates. Consideration of increasing the diameter threshold for intervention of CIAA to 4 cm should be considered. Studies with longer follow-up and reliable long-term results are needed.

High prevalence of abdominal aortic aneurysms in patients with lung cancer.

BACKGROUND: Lung cancer and abdominal aortic aneurysms (AAAs) possess multiple shared risk factors. Whereas both have screening guidelines in place, they vary in methodology despite having significant overlap in populations of patients screened. METHODS: Our hospital system's Lung Cancer Program database was used to identify patients diagnosed with primary lung cancer within the past 15 years. Demographic and risk factor data were obtained, and patients' original positron emission tomography-computed tomography scans were re-read for measurements of the abdominal aorta (aortic diameter ≥3.0 cm). A cancer-free control group was obtained for comparison. Multilinear regression modeling was used to evaluate the independent associations of multiple variables on the presence of AAA. RESULTS: Among 814 patients with primary lung cancer, 90 (11.1%; 95% confidence interval [CI], 8.9%-13.3%) had AAA compared with 4 of 200 (2%; 95% CI, 0.1%-3.9%) in the control group (P = .0001). Patients who smoked were more likely than nonsmokers to have AAA (11.9% [95% CI, 9.8-14.6] vs 2.2% [95% CI, 0.1-8.1]; P = .0021). In patients with AAA, 12% (11/90) had aneurysms that required treatment, and 76.6% had early-stage lung cancer. Women in our study also had a high prevalence of AAA (4.6%). Logistic regression analysis showed male sex (odds ratio [OR], 3.70; P <.001), increasing age (OR, 1.07 per year; P <.001), smoking amount (OR, 1.01 per pack-year; P = .004), and hypertension (OR, 2.30; P = .020) to be independent risk factors for AAA. CONCLUSIONS: Patients with lung cancer have a high prevalence of AAA. If future studies can demonstrate a reduction in AAA mortality by screening for AAA and lung cancer simultaneously, it may prove worthwhile to extend the low-dose computed tomography scan through the lower abdomen in select patients.

A Systematic Review and Pooled Meta-Analysis on the Incidence and Temporal Occurrence of Type II Endoleak Following an Abdominal Aortic Aneurysm Repair.

BACKGROUND: The aim in this study was to systematically review the literature to identify the time of occurrence of a newly diagnosed Type II endoleak (T2E) following an endovascular aneurysm repair (EVAR) for an infrarenal abdominal aortic aneurysm (AAA) and its potential impact on aneurysmal sac diameter changes. METHODS: A comprehensive systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible studies were identified through a search of PubMed, Scopus and Cochrane until January 2020. A meta-analysis was conducted with the use of a random effects model. The I-square statistic was used to assess for heterogeneity. RESULTS: Thirty-three observational studies were deemed eligible and provided data for 2643 T2E detected following EVAR. A total of 1432 (54.2%) T2E were diagnosed before 30 days follow-up, while 1035 (39.1%) T2E were diagnosed beyond 30 days following EVAR. A total of 222 (8.4%) T2E were diagnosed after 12 months of follow-up. A pooled meta-analysis of 6 studies, showed that early diagnosed T2E had a statistically significant higher odds of resolving as compared to those detected late (OR: 2.41; 95% CI: 1.14-5.09; P = 0.021; I2 = 68.9%). Sac expansion was documented in 313 (29%) T2E. The ruptured endoleaks were 14 (1.1%). CONCLUSIONS: The occurrence of a T2E is a dynamic process detected throughout the lifetime of a patient with 8% detected beyond 12 months following EVAR. Long-term follow up is required with future prospective studies with consist reporting on changes in sac diameter, the thrombus characteristics. Long-term outcomes are needed to optimize management of patients with a newly diagnosed T2E.

Can we predict and prevent the postthrombotic syndrome?

Postthrombotic syndrome (PTS) remains one of the major late complications of deep vein thrombosis (DVT) with a reported prevalence from 10 to 50%. Many factors were found to be related with the development and severity of PTS such as ipsilateral recurrent DVT, advanced age, obesity, ilio-femoral DVT and primary chronic venous disease presence. Some PTS prediction models have been proposed based on risk factor weight. However, it is still difficult to predict which patient with DVT will develop PTS and thus, the clinical application of these models remains limited. Among the identified problems the heterogeneity of the DVT patient population together with the variety of PTS clinical presentations and difficulties concerning PTS severity assessment should be mentioned. Difficulties on the implementation of the specific and objective PTS identification method have also the significant influence on the research focusing on PTS prevention modalities including risk factor modification, compression treatment, anticoagulation and invasive DVT treatment. In this review, the current approach and knowledge on PTS prediction and prevention are presented, including the conservative and invasive DVT treatment possibilities.

Venous Thromboembolism and Bleeding Events With Chemoprophylaxis in Abdominoplasty: A Systematic Review and Pooled Analysis of 1596 Patients.

BACKGROUND: Many plastic surgeons avoid the administration of venous thromboembolism (VTE) chemoprophylaxis out of concern for surgical bleeding in abdominoplasty. Although previous studies have attempted to address the relationship between abdominoplasty and bleeding or VTE, poor reporting techniques remain a challenge. As a result, there has been a lack of reliable data to guide clinical practice. OBJECTIVES: The authors sought to determine the prevalence of bleeding and VTE in abdominoplasty with and without chemoprophylaxis. METHODS: A systematic review was performed following PRISMA guidelines utilizing PubMed, CINAHL, and Cochrane Central. Patient demographics, comorbidities, risk category (if available), bleeding events, VTE events, and chemoprophylaxis information were recorded. RESULTS: Across 10 articles, 691 patients received chemoprophylaxis in the setting of abdominoplasty: 68 preoperatively, 588 postoperatively, and 35 received both; 905 patients did not receive chemoprophylaxis. A total of 96.8% of patients were female, 73% underwent concomitant liposuction, and none were clearly risk stratified. The overall incidence of VTE and bleeding was 0.56% (9/1596) and 1.6% (25/1596), respectively. Compared with no chemoprophylaxis, chemoprophylaxis was not associated with increased incidence of bleeding (1.3% [9/671] vs 0.91% [8/881], P = 0.417) or decreased incidence of VTE (0.87% [6/691] vs 0.33% [3/901], P = 0.187). CONCLUSIONS: The prevalence of bleeding in abdominoplasty was low. Chemoprophylaxis was not associated with increased risk of bleeding or decreased risk of VTE, though the lack of risk stratification and heterogeneity of the cohort precludes firm conclusions. This study underscores the importance of utilizing validated risk-stratification tools to guide perioperative decision-making.

Ischemic Stroke Occurs Less Frequently in Patients With COVID-19: A Multicenter Cross-Sectional Study.

BACKGROUND AND PURPOSE: The impact of coronavirus disease 2019 (COVID-19) on the occurrence of ischemic stroke has been the subject of increased speculation but has not been confirmed in large observational studies. We investigated the association between COVID-19 and stroke. METHODS: We performed a cross-sectional study involving patients discharged from a healthcare system in New York State, from January to April 2020. A mixed-effects logistic regression analysis and a propensity score-weighted analysis were used to control for confounders and investigate the association of COVID-19 with ischemic stroke. Similar techniques were used to detect the impact of concurrent COVID-19 infection on unfavorable outcomes for patients with stroke. RESULTS: Among 24 808 discharges, 2513 (10.1%) were diagnosed with COVID-19, and 566 (0.2%) presented with acute ischemic stroke. Patients diagnosed with COVID-19 were at one-quarter the odds of stroke compared with other patients (odds ratio, 0.25 [95% CI, 0.16-0.40]). This association was consistent in all age groups. Our results were robust in sensitivity analyses, including propensity score-weighted regression models. In patients presenting with stroke, concurrent infection with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) was associated with higher case-fatality (odds ratio, 10.50 [95% CI, 3.54-31.18]) and a trend towards increased occurrence of discharge to rehabilitation (odds ratio, 2.45 [95% CI, 0.81-1.25]). CONCLUSIONS: Using a comprehensive cross-section of patients from a large NY-based healthcare system, we did not identify a positive association between ischemic stroke and COVID-19. However, patients with stroke with COVID-19 had worse outcomes compared with those without, with over a 9-fold increase in mortality. Although no definitive conclusions can be reached from our observational study, our data do not support the concerns for an epidemic of stroke in young adults with COVID-19.

A Comprehensive Review of the Pathophysiology and Clinical Importance of Iliac Vein Obstruction.

OBJECTIVE: The purpose of this comprehensive review is to give a historical account of iliac vein compression and to analyse the pathophysiological aspects and their clinical implications. METHODS: An extensive search of the databases was performed from inception until 2019. The patterns, length and site of compression, wall and luminal changes, and anatomical variations were some of the factors recorded and analysed. RESULTS: Twenty-seven studies were included in this review, divided into cadaveric, histological, and imaging. According to the literature 22%-32% of the asymptomatic population shows "spurs" at the origin of the left common iliac vein (LCIV). Imaging studies also show the presence of direct and indirect compression signs such as the presence of collateral venous flow in axial, transpelvic, or ascending lumbar collaterals, and >50% compression in 37%-44% of the asymptomatic population. In patients without thrombosis it is unknown what produces the signs and symptoms, as the obstruction pre-exists their development. Haemodynamic evaluation is found in only a few studies often including patients with previous deep vein thrombosis. Furthermore, most of the tests are performed with the patient in the supine position and therefore the haemodynamic information is relatively poor. CONCLUSION: Patients with venous obstruction have various clinical presentations from being asymptomatic to having venous claudication and skin damage. Obstruction should be placed into clinical context, together with other contributing factors. Proper evaluation and clinical judgement are important in selecting patients for treatment. Given that such selection is not always clear, further work is needed.

Ultrasonography for the diagnosis of extra-cranial carotid occlusion - diagnostic test accuracy meta-analysis.

Background: The correct diagnosis of internal carotid artery (ICA) occlusion is crucial as it limits unnecessary intervention, whereas correct identification of patients with severe ICA stenosis is paramount in decision making and selecting patients who would benefit from intervention. We aimed to evaluate the accuracy of ultrasonography (US) in the diagnosis of ICA occlusion. Methods: We conducted a systematic review in compliance with the Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) of diagnostic test accuracy studies. We interrogated electronic bibliographic sources using a combination of free text and thesaurus terms to identify studies assessing the diagnostic accuracy of US in ICA occlusion. We used a mixed-effects logistic regression bivariate model to estimate summary sensitivity and specificity. We developed hierarchical summary receiver operating characteristic (HSROC) curves. Results: We identified 23 studies reporting a total of 5,675 arteries of which 722 were proven to be occluded by the reference standard. The reference standard was digital subtraction or cerebral angiography in all but two studies, which used surgery to ascertain a carotid occlusion. The pooled estimates for sensitivity and specificity were 0.97 (95% confidence interval (CI) 0.94 to 0.99) and 0.99 (95% CI 0.98 to 1.00), respectively. The diagnostic odds ratio was 3,846.15 (95% CI 1,375.74 to 10,752.65). The positive and negative likelihood ratio were 114.71 (95% CI 58.84 to 223.63) and 0.03 (95% CI 0.01 to 0.06), respectively. Conclusions: US is a reliable and accurate method in diagnosing ICA occlusion. US can be used as a screening tool with cross-sectional imaging being reserved for ambiguous cases.

Correlation between pelvic congestion syndrome and body mass index.

OBJECTIVE: Previous studies of men suggested that patients with varicocele may be leaner than the normal population. No such work exists in women with pelvic congestion syndrome (PCS). This study evaluated the correlation between body mass index (BMI) and PCS. METHODS: A case-control study at a single institution was performed of women who had the objective diagnosis of PCS. Data were prospectively collected for 100 consecutive patients with PCS. BMI was calculated for every patient and categorized into normal weight (BMI <25), overweight (BMI 25-29.9), and obese (BMI >30). Diagnosis of PCS was made by ultrasound and venography. Mean BMI was compared with that of the general female population of the United States from 1999 to 2002. Furthermore, analyses included comparison of patients with and without ovarian vein dilation and pelvic varices. RESULTS: There were 100 women with a median age of 44 years (range, 24-73 years). The mean BMI of the study group was 25 ± 5.6 kg/m2. The cohort was categorized into 59 women with normal BMI, 23 overweight women, and 18 obese women. The study cohort's BMI was less than that of the general U.S. female population (P = .02). The majority of the study group were white with lower BMI (P < .0001). Leg varicosities were more prevalent in obese patients (100% obese vs 81% normal BMI; P = .01). Patients with ovarian vein dilation had significantly lower BMI (24.1 ± 5.6 kg/m2 and 26.7 ± 5.4 kg/m2; P = .036). No differences were identified for pelvic varices or reflux. CONCLUSIONS: Women with PCS are more likely to have a normal BMI with ovarian vein dilation compared with obese women, who are more frequently affected by leg varicosities.

Clinical characteristics and outcome of isolated infrarenal aortic stenosis in young patients.

OBJECTIVE: The objective of this study was to identify young patients with isolated infrarenal aortic atherosclerotic stenosis and to determine the clinical characteristics and midterm results of angioplasty and stenting. METHODS: Data from patients younger than 50 years with significant infrarenal aortic stenosis and at least 1 year of follow-up were prospectively collected. Patients with coexistent suprarenal or iliofemoral disease and Takayasu arteritis were excluded. All patients were treated with percutaneous transluminal angioplasty (PTA), primary stenting, or both. Pressure gradient was measured intraoperatively before and after the intervention. Every patient was monitored postoperatively with clinical examination, ankle-brachial index, and duplex ultrasound during follow-up. RESULTS: There were 51 patients, of whom 34 were excluded. Seventeen patients ranging in age from 37 to 49 years (mean, 43.7 years) met the study criteria, and they were all female. Fifteen patients had both history of hyperlipidemia and smoking with a mean of 53.2 pack-years. Fourteen patients were claudicants, whereas seven patients presented with distal embolization. Six patients were treated with primary stenting; four had PTA plus stent and seven had PTA alone. The length of the stenotic segments treated was <2 cm in 7, between 2 and 4 cm in 8, and >4 cm in 2. The mean follow-up for this cohort was 4.2 years. Mean pressure gradient before intervention was 49.06 ± 12.75 mm Hg, decreasing to 6.13 ± 2.06 mm Hg after intervention with a mean reduction of 42.75 ± 11.59 mm Hg. Mean ankle-brachial indices before the intervention were 0.67 ± 0.07, increasing to a mean of 0.92 ± 0.06 after the procedure. Stenosis developed in three patients during follow-up, requiring reintervention for a primary assisted patency of 100%. CONCLUSIONS: Isolated infrarenal aortic stenosis in young patients is primarily a disease of women. Most of these patients are heavy smokers with hyperlipidemia. PTA alone or with stenting has favorable midterm results.

Evolution of type II endoleaks based on different ultrasound-identified patterns.

OBJECTIVE: The objective of this study was to delineate the specific types of waveforms that exist in type II endoleaks (T2ELs) and their effect on aneurysm sac size. METHODS: Patients who underwent an endovascular aneurysm repair and were diagnosed with a T2EL were included in the study. The flow velocity characteristics of the T2ELs were evaluated in detail with duplex ultrasound. Four different flow patterns were identified: high resistance, low flow; low resistance, low flow; low resistance, high flow; and to-fro flow. The type and number of vessels involved, time at detection, evolution, and need for treatment were recorded. The aneurysm sac diameter was monitored with duplex ultrasound. A computed tomography scan was always performed at baseline within 1 month of the procedure and repeated only when symptoms developed or there were changes in the ultrasound examination findings, such as sac enlargement. RESULTS: Of 382 patients who underwent endovascular aneurysm repair in our institution, 56 (14.65%) were found to have a T2EL. There were 52 male and four female patients with a mean age of 74 years (61-86 years). The T2EL was diagnosed within the first month in 32 patients; 9 patients were diagnosed at 3 months, 5 patients at 6 months, 3 patients at 9 months, and 7 patients at 1 year or later. There were 43 patients who had a T2EL involving one vessel; two vessels were involved in 11 patients and three vessels were involved in two patients. During follow-up, several changes were observed for the different types of T2EL. High-resistance, low-flow endoleak was detected in 14 patients; of those, 13 were occluded and 1 converted to high flow. Low-resistance, low-flow endoleak was detected in seven patients; of those, 5 were occluded, 1 remained stable, and 1 converted to high flow with sac enlargement requiring treatment. Low-resistance, high-flow endoleak was found in 13 patients; of those, 8 were occluded, 3 remained stable, and 2 had sac enlargement requiring treatment; 1 patient presented with rupture. Finally, to-fro flow was identified in the majority of the patients (22); of those, 14 occluded, 3 remained stable, and 5 had sac enlargement requiring treatment; 2 patients presented with rupture. No deaths due to T2EL were encountered. CONCLUSIONS: Most of the T2ELs resulted in spontaneous occlusion and were not associated with sac enlargement. A low-resistance, high-flow or to-fro flow T2EL has higher chances of sac enlargement, rupture, and requiring reintervention.

Mechanical and Biochemical Role of Fibrin Within a Venous Thrombus.

BACKGROUND: The physical properties of a venous thrombus are derived from molecular characteristics, including fibrin polymer diameter, density, branching, and cross-linking. Dense thrombi with thin, highly branched fibrin fibres and small pores in the meshwork have been observed to be more rigid, less permeable, and more resistant to lysis. The three dimensional fibrin meshwork acts as the main structure to entrap and capture erythrocytes, platelets and plasma components. Attached factors become integrated into the developing thrombus, co-localise with fibrin deposition and act in either a pro- or anticoagulant capacity. Similarly, factors including blood flow, osmolarity and pH, oxidative stress, platelet and leukocyte recruitment, and thrombin concentration alter thrombus composition, architecture, and its mechanical properties. CONCLUSIONS: Over time, an increase in thrombus cellular composition and a linear decrease in fibrin content as a function of thrombus age is observed. However, little else is known regarding the evolution of fibrin based clots. The role of fibrin in mediating cellular coordination, thrombus maturation, and changes of the venous wall also requires further research. This review discusses the current impact of fibrin on thrombus remodeling and addresses the limitations of the work done in this area.

Carotid Bifurcation Geometry as Assessed by Ultrasound is Associated with Early Carotid Atherosclerosis.

BACKGROUND: Atherosclerosis usually develops at geometrically susceptible areas, despite the impact of systemic risk factors on the entire vascular system. The aim of our study was to investigate whether carotid bifurcation geometry as assessed by ultrasound is associated with early carotid atherosclerosis, regardless of the presence of known atherosclerotic risk factors. MATERIAL AND METHODS: A nonrandomized prospective study was undertaken, including subjects of both genders, aged 50-60 years, without known cardiovascular family history, and symptoms and/or signs of cardiovascular disease. Clinical assessment and ultrasound of the carotid bifurcation evaluating geometrical characteristics, ultrasonic biopsy score (UBS), intima-media thickness (IMT), and the presence of plaque were recorded. RESULTS: Two hundred one subjects (95 men/106 women; mean age: 55 years) provided 286 carotid bifurcations associated with atherosclerotic risk factors and 114 without (one poor imaging). While UBS in the right common carotid artery (CCA) was higher in subjects with atherosclerotic risk factors but free of plaque (P = 0.035), larger diameter of the bulb (dBULB) (P < 0.001), lower ratios of internal carotid artery diameter + external carotid artery diameter/diameter of CCA ([dICA + dECA]/dCCA) (P = 0.004), and (dICA2 + dECA2)/dCCA2 (P = 0.025) were independently associated with higher CCA IMT. The presence of plaque among the total 400 carotid bifurcations was associated in the left and right CCA with lower values of bulb diameter/dCCA (dBULB/dCCA) (P = 0.014) and (dICA + dECA)/dCCA (P = 0.001), respectively. Among subjects without atherosclerotic risk factors (n = 114), the presence of plaque in the right CCA was associated with lower values of (dBULB + dECA)/dCCA (P = 0.001) and that in the left with lower values of dBULB/dCCA (P = 0.001). CONCLUSIONS: Different dimensional ratios of the carotid bifurcation assessed by ultrasound are associated with the development of early carotid atherosclerosis independently from the presence of atherosclerotic risk factors. Carotid atherosclerotic process may be side dependent.

Endovascular management of inferior vena cava filter thrombotic occlusion.

Objective Inferior vena cava occlusion is a potentially life-threatening complication related to caval filters. We present our experience with filter-induced inferior vena cava occlusion in order to assess the feasibility, safety, and effectiveness of endovascular management. Methods A retrospective review of all patients undergoing inferior vena cava filter placement over a 60-month study period was performed. From this cohort, a total of 10 cases of inferior vena cava occlusion after filter placement were identified. Demographics, clinical data, procedures, and outcomes were extracted. Patients were followed to the last clinic visit or until they died. Results One-hundred eighty filters were placed by our group practice during the study period. Of those, a total of 10 patients were identified. Overall, there were 7 males; the mean age was 57.1 years (25-78 years). The median time between inferior vena cava filter placement and filter occlusion was 105 days (range 5-4745 days). All patients were clinically symptomatic at the time of their presentation. Nine out of 10 patients were successfully managed endovascularly. Trellis™-8 thrombectomy was the most common endovascular strategy performed ( n = 9). Four patients had balloon angioplasty, two of those with stent placement for chronically occluded inferior vena cava/iliac veins. No thromboembolic complications developed during a median follow-up period of 233 days (range 4-1083 days). Conclusions Endovascular management of inferior vena cava occlusion is feasible, safe, and effective in decreasing thrombus burden in the presence of an inferior vena cava filter. Further studies evaluating long-term inferior vena cava patency and optimal surveillance regimen after endovascular management of filter-related inferior vena cava occlusion are warranted.