Factors associated with ablation-related thrombus extension following microfoam versus radiofrequency saphenous vein closure.

OBJECTIVE: Polidocanol endovenous microfoam ablation (MFA) is approved by the US Food and Drug Administration for great saphenous vein (GSV) closure, yet there are few published data on the subsequent risk of ablation-related thrombus extension (ARTE). Recent societal practice guidelines recommend against routine postprocedure duplex ultrasound (DU) examination after thermal ablation of the GSV in asymptomatic patients. At present, limited data do not allow this recommendation to extend to MFA. Our aim is to identify characteristics and outcomes associated with ARTE following MFA vs radiofrequency ablation (RFA). METHODS: A retrospective review of a prospectively maintained database was conducted of patients who underwent MFA and RFA closure of incompetent above-knee GSVs. Patients treated for isolated tributary vein treatment or did not have a postprocedure DU examination within 48 to 72 hours were not included. Patients were classified into two groups: ARTE and no ARTE. Demographic data, Clinical, Etiologic, Anatomic and Pathophysiologic class, Venous Clinical Severity Score, operative details, postprocedure (48-72 hours) DU findings, and adverse events were analyzed. Variables that were significant on univariate analysis were evaluated using multivariate logistic regression with the primary outcome being development of ARTE. RESULTS: Between June 2018 and February 2023, 800 limbs were treated with either MFA (n = 224) or RFA (n = 576). Ninety-six GSVs treated with MFA met the study criteria. One hundred fifty successive GSVs treated with RFA during the same period were included as a comparison group. There was no statistically significant difference in baseline demographics between the two groups. Six patients (2.4%) demonstrated ARTE on postoperative DU examination at 48 to 72 hours (MFA, n = 5 [5.2%]; RFA, n = 1 [0.7%]; P = .02). Saphenous vein ablation with MFA (P = .045) and a vein diameter of >10 mm (P = .017) were associated with ARTE on both univariable and multivariable analysis. All patients who developed ARTE were treated with oral anticoagulants (mean, 15.6 days). Body mass index, Clinical, Etiologic, Anatomic and Pathophysiologic class, Venous Clinical Severity Score, microfoam volume, operative time, and prior deep venous thrombosis were not predictive of ARTE. CONCLUSIONS: ARTE after above-knee GSV closure occurred more frequently after MFA. Our results suggest that a saphenous vein diameter of >10 mm may be associated with ARTE. Despite this finding, all patients with ARTE were treated with short-term anticoagulation with no related complications. Until larger studies with high-risk subgroups have been studied after MFA, DU examination should be performed routinely after this procedure and patients with ARTE anticoagulated until the thrombus retracts caudal to the saphenofemoral junction or is no longer present on DU examination. Current societal guidelines recommending against routine post-thermal ablation DU examination should not be applied to similar patients after saphenous nonthermal MFA ablation.

Surgical decompression among Paget-Schroetter patients with subacute and chronic venous occlusion.

OBJECTIVE: Management of Paget-Schroetter syndrome (PSS) with first rib resection (FRR) and venoplasty is successful in re-establishing subclavian vein (SCV) patency in most cases. However, in cases with subacute or chronic venous occlusion, SCV patency may not be achieved. Thus, the role for FRR remains controversial in cases of subacute or chronic SCV occlusion. Our goal is to determine whether FRR is beneficial in PSS patients with subacute or chronic SCV occlusion. METHODS: A prospectively maintained thoracic outlet syndrome (TOS) database was searched for patients undergoing FRR who were identified as having SCV occlusion on preoperative venography between 2012 and 2021. Preoperative and postoperative venous patency were determined by venography. Standardized functional outcomes were assessed using the Quick Disability Arm, Shoulder, Hand (QuickDASH-QDS) and Somatic Pain Scale (SPS) before and after FRR. The Derkash outcome score was recorded after FRR. RESULTS: Over the study period, 966 TOS operations were performed; of these, 401 were for venous TOS, and 33 patients were identified with subacute or chronic preoperative SCV occlusion verified by venography. The median age was 29 years, with 73% men. Eighteen patients had attempted thrombolysis; eight were performed at our institution, and ten performed at a referring facility. The median time from the symptom onset of SCV occlusion to FRR was 78 days for all patients. For the group that achieved venous patency after FRR, the time from SCV occlusion to FRR was 71 days, and it was 106 days for the group that remained occluded after FRR. All underwent postoperative venography and percutaneous attempt at SCV recanalization. Recanalization was successful in 64% (21) and unsuccessful in 36% (12). All patients experienced improvement in SPS and QDS. For all patients, the average SPS improved from 1.69 preoperatively to 0.25 postoperatively and the average QDS improved from 27.63 preoperatively to 10.19 postoperatively (P > .05). For patients who were successfully recanalized, the final SPS was 0.18 and the final QDS was 11.22 (P > .05). In patients who failed to achieve recanalization, the final SPS was 0.40 and the final QDS was 9.06 (P > .05). All postoperative Derkash outcome scores were excellent and good, with none fair or poor. CONCLUSIONS: In patients with subacute or chronic preoperative SCV occlusion, surgical decompression and postoperative angioplasty resulted in re-establishing SCV patency in 64% of patients. Symptomatic patients clinically improve after surgical decompression regardless of whether venous patency is successfully re-established. These results indicate that symptomatic patients with PSS should be considered for TOS decompression even if their SCV is occluded in the subacute or chronic presentation.

Surgical Missteps in the Management of Venous Thoracic Outlet Syndrome Which Lead to Reoperation.

BACKGROUND: Surgical management of spontaneous subclavian thrombosis due to venous thoracic outlet syndrome (vTOS) results in durable relief of symptoms. The need to reoperate is rare. We report our experience with reoperation for vTOS. METHODS: Patients evaluated for vTOS between 1996 and 2016 were identified in a prospective database. Data recorded included demographics, initial presentation, initial surgery, recurrent presentation, reoperation, and final outcomes. RESULTS: In all, 261 patients were evaluated for vTOS, of these, 246 patients underwent first rib resections. Ten (3.8%) patients required evaluation for recurrent vTOS symptoms. Prior management included thrombolysis (4) and anticoagulation alone (6). Prior surgical approaches included infraclavicular (2), supraclavicular (2) and transaxillary (6). One operation was complicated by a hemothorax, and one a brachial plexus injury. Indication for reoperation included congestive symptoms (6) and recurrent thrombosis (4). Evaluation included chest X-rays (10), venogram (8), intra-venous ultrasound (2), and computed tomography venography (3). Significant compression by remaining rib segments were identified in all: inadequate resection of the anterior first rib (7), inadequate resection of posterior rib segment (1), and erroneous resection of second rib (2). Reoperations include 7 transaxillary approaches, 1 medial claviculectomy, and 1 paraclavicular decompression. One phrenic nerve palsy occurred following paraclavicular decompression. All underwent postoperative venography and angioplasty. At final evaluation, 8 veins are patent and congestive symptoms resolved, and 1 crushed stent could not be reopened despite decompression. CONCLUSIONS: The incidence of reoperation for first rib resection in cases of vTOS is low and appears largely due to missteps during the initial operation. Awareness of potential errors including inadequacy of resection, intraoperative disorientation, and misunderstanding of the limitations of surgical approaches will result in fewer reoperations.

Contemporary outcomes of elective iliocaval and infrainguinal venous intervention for post-thrombotic chronic venous occlusive disease.

BACKGROUND: Patients with iliofemoral deep venous thrombosis are at risk for development of post-thrombotic syndrome. Iliac vein stenting has been shown to significantly improve clinical outcomes in patients with venous outflow obstruction, although many studies include a heterogeneous population with several different venous pathologic processes. Our objective was to evaluate the results of iliocaval and infrainguinal venous intervention for venous outflow obstruction due to post-thrombotic chronic venous occlusive disease. METHODS: All patients treated at a single institution for symptomatic iliocaval venous occlusive lesions with and without infrainguinal extension between 2008 and 2015 were retrospectively analyzed. Nonthrombotic iliac vein lesions were excluded from analysis. All patients with symptomatic post-thrombotic occlusion of the iliac vein or inferior vena cava (IVC) and a Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) score of 3 or greater were included. Demographics of the patients, presence of IVC filters at presentation, presenting CEAP score, postintervention CEAP score, primary and secondary patency, wound healing and subjective clinical improvement outcomes, and procedural details were recorded in a database. RESULTS: There were 105 patients with symptomatic iliocaval venous occlusive lesions identified, of which 31 patients (42 limbs) met inclusion criteria. Presenting symptoms included pain or swelling (100%); venous claudication (81%); and CEAP class 3 (76%), 4 or 5 (14%), or 6 (10%). All patients presented with either subacute (>30 days [35%]) or chronic (>90 days [65%]) iliocaval venous thrombosis. Procedural technical success with venous recanalization was achieved in 100% of cases and in 46% of IVC filter retrieval attempts. Overall clinical improvement was achieved in 84% of patients; complete clinical resolution was obtained in 42% and a decrease in CEAP score in 65%. At a mean follow-up of 14.7 months (range, 2-49 months), primary and secondary 1-year patency was 66% and 75% overall, and primary patency was equivalent between patients requiring isolated iliac venous stenting and those requiring infrainguinal stent extension (68% vs 65%, respectively; P = .74, not significant). Patients who presented with IVC filters had a higher rate of complete clinical resolution if the filter could be removed (100%) compared with those patients in whom the filter could not be removed (17%; P < .01). CONCLUSIONS: Treatment of chronic venous occlusive disease with iliocaval and infrainguinal venous stenting is associated with acceptable 1-year patency rates, healing of venous ulcers, and a significant reduction in symptoms and CEAP score. Patients who underwent successful removal of indwelling IVC filters showed improved clinical outcomes compared with those in whom the IVC filter could not be removed.

Contemporary outcomes after venography-guided treatment of patients with May-Thurner syndrome.

OBJECTIVE: Patients with May-Thurner syndrome (MTS) present with a spectrum of findings ranging from mild left leg edema to extensive iliofemoral deep venous thrombosis (DVT). Whereas asymptomatic left common iliac vein (LCIV) compression can be seen in a high proportion of normal individuals on axial imaging, the percentage of these persons with symptomatic compression is small, and debate exists about the optimal clinical and diagnostic criteria to treat these lesions in patients with symptomatic venous disease. We evaluated our approach to venography-guided therapy for individuals with symptomatic LCIV compression and report the outcomes. METHODS: All patients with suspected May-Thurner compression of the LCIV between 2008 and 2015 were analyzed retrospectively. Patients with chronic iliocaval lesions not associated with compression of the LCIV were excluded from analysis. Criteria for intervention included LCIV compression in the setting of (1) leg edema/venous claudication with associated venographic findings (collateralization, iliac contrast stagnation, and contralateral cross cross-filling), or (2) left leg deep venous thrombosis. Outcome measures included presenting Clinical, Etiology, Anatomy, Pathophysiology (CEAP) score, postintervention CEAP score, primary patency, and secondary patency. Technical success was defined as successful stent implantation without intraoperative device complications, establishment of in-line central venous flow, and less than 30% residual LCIV stenosis. RESULTS: Of the 63 patients evaluated, 32 (51%) had nonthrombotic MTS and presented with leg edema (100%) or venous claudication (47%). Thirty-one patients (49%) had thrombotic MTS and presented with acute (26%) or chronic (71%) DVT, leg edema (100%), or venous claudication (74%). The mean presenting CEAP score was 3.06 and 3.23 for nonthrombotic and thrombotic MTS, respectively. Forty-four patients (70%) underwent successful intervention with primary stenting (70%) or thrombolysis and stenting (30%); 14 nonthrombotic MTS patients were treated conservatively with compression therapy alone, and 5 thrombotic MTS patients were treated with lysis or angioplasty alone. Clinical improvement and decrease in CEAP score occurred in 95% and 77% of stented patients compared with 58% and 32% of nonstented patients. Complete symptom resolution was achieved in 48% of patients overall, or 64% of stented patients and only 21% of nonstented patients. Complications included two early reocclusions. Primary and secondary 2-year patency rates were 93% and 97% (mean follow-up, 20.3 months) for stented patients. CONCLUSIONS: Venography-guided treatment of MTS is associated with excellent 1-year patency rates and a significant reduction in symptoms and CEAP score. Treating symptomatic MTS patients on the basis of physiologically relevant venographic findings rather than by intravascular ultrasound imaging alone results in excellent long-term patency and clinical outcomes but may result in undertreatment of some patients who could benefit from stent implantation.

Teamwork, communication and safety climate: a systematic review of interventions to improve surgical culture.

OBJECTIVES: To define the target domains of culture-improvement interventions, to assess the impact of these interventions on surgical culture and to determine whether culture improvements lead to better patient outcomes and improved healthcare efficiency. BACKGROUND: Healthcare systems are investing considerable resources in improving workplace culture. It remains unclear whether these interventions, when aimed at surgical care, are successful and whether they are associated with changes in patient outcomes. METHODS: PubMed, Cochrane, Web of Science and Scopus databases were searched from January 1980 to January 2015. We included studies on interventions that aimed to improve surgical culture, defined as the interpersonal, social and organisational factors that affect the healthcare environment and patient care. The quality of studies was assessed using an adapted tool to focus the review on higher-quality studies. Due to study heterogeneity, findings were narratively reviewed. FINDINGS: The 47 studies meeting inclusion criteria (4 randomised trials and 10 moderate-quality observational studies) reported on interventions that targeted three domains of culture: teamwork (n=28), communication (n=26) and safety climate (n=19); several targeted more than one domain. All moderate-quality studies showed improvements in at least one of these domains. Two studies also demonstrated improvements in patient outcomes, such as reduced postoperative complications and even reduced postoperative mortality (absolute risk reduction 1.7%). Two studies reported improvements in healthcare efficiency, including fewer operating room delays. These findings were supported by similar results from low-quality studies. CONCLUSIONS: The literature provides promising evidence for various strategies to improve surgical culture, although these approaches differ in terms of the interventions employed as well as the techniques used to measure culture. Nevertheless, culture improvement appears to be associated with other positive effects, including better patient outcomes and enhanced healthcare efficiency. TRIAL REGISTRATION NUMBER: CRD42013005987.

Sodium valproate-induced congenital cardiac abnormalities in mice are associated with the inhibition of histone deacetylase.

BACKGROUND: Valproic acid, a widely used anticonvulsant drug, is a potent teratogen resulting in various congenital abnormalities. However, the mechanisms underlying valproic acid induced teratogenesis are nor clear. Recent studies indicate that histone deacetylase is a direct target of valproic acid. METHODS: In the present study, we have used histological analysis and RT-PCR assays to examine the cardiac abnormalities in mice treated with sodium valproate (NaVP) and determined the effects of NaVP on histone deacetylase activity and the expression of heart development-related genes in mouse myocardial cells. RESULTS: The experimental data show that NaVP can induce cardiac abnormalities in fetal mice in a dose-dependent manner. NaVP causes a dose-dependent inhibition of hitone deacetylase (HDAC) activity in mouse myocardial cells. However, the expression levels of HDAC (both HDAC1 and HDAC2) are not significantly changed in fetal mouse hearts after administration of NaVP in pregnant mice. The transcriptional levels of other heart development-related genes, such as CHF1, Tbx5 and MEF2, are significantly increased in fetal mouse hearts treated with NaVP. CONCLUSIONS: The study indicates that administration of NaVP in pregnant mice can result in various cardiac abnormalities in fetal hearts, which is associated with an inhibition of histone deacetylase without altering the transcription of this enzyme.