The Effect of Smoking Cessation on the Technical Success of Endovascular Treatment for Thromboangiitis Obliterans.

PURPOSE: To show that smoking cessation improves the technical success of lower extremity endovascular treatment in patients with thromboangiitis obliterans (TAO), or Buerger disease. MATERIALS AND METHODS: One hundred two patients with TAO who underwent endovascular treatment for chronic limb-threatening ischemia or severe claudication of lower extremities in a tertiary hospital between 2015 and 2022 were included in this retrospective study. Data on serum cotinine levels were available for the last 45 patients, and 38 patients constituted the study population. Per the institution's protocol, patients were instructed to quit smoking 15 days before the intervention. However, cotinine levels showed that some of the patients continued smoking. Technical and recanalization successes were assessed as the primary end points. The secondary end point was the improvement in Rutherford scores at the 1-month follow-up. The McNemar test was used to compare the proportion of recanalized arteries after the intervention. RESULTS: Thirty-seven men and 1 woman (mean age, 42.9 years ± 10.1) were evaluated. The overall technical success rate was 86.8% in the study group. The technical success rate was significantly higher in the nonsmoker group (n = 24 [96%]) than in the smoker group (n = 8 [61.5%]; P = .006). One-month clinical data were available for 100% of the patients. The Rutherford category of the nonsmoker group was significantly lower at the 1-month follow-up. In addition, the Wilcoxon signed-rank test revealed lower Rutherford scores after the intervention in the nonsmoker group. The adverse event rate was 8%. One (2.7%) patient in the smoker group underwent a minor amputation. CONCLUSIONS: Cessation of smoking before endovascular therapy improved technical success and recanalization rates in patients with TAO.

Examining the Hepatic Immune System in Children With Liver Disease With Fine Needle Aspiration.

OBJECTIVES: Liver biopsy is the standard in diagnosing liver diseases. Yet, it provides little space to perform comprehensive immune profiling of the liver. Hence, we explored whether fine needle aspirates (FNAs) could be used to elucidate the hepatic immunity in children. METHODS: We enrolled 74 children undergoing diagnostic (n = 17) or protocol biopsy (n = 57) following liver transplantation (LT). Matched blood and FNAs were obtained. Additionally, explant liver tissue was collected from children (n = 14) undergoing LT. Immune cells were isolated from peripheral blood, FNAs and explanted livers. Immune-phenotypical profiling was done by flow cytometry. RESULTS: Biopsied patients (58% female) were at a median age of 46 months (interquartile range [IQR]: 12-118) and LT patients (71% female) were 48 months (IQR: 21-134, P = 0.78) old. CD69+, a hallmark of tissue-resident immune cells was expressed in 1.3% of CD3+ T cells from blood being higher in FNA (20%) and tissue (49%, P < 0.001). CD4+ T-cell frequencies in tissue (13%) and FNAs (20%) were lower compared to blood (35%, P < 0.001) whereas CD8+ T cells in tissue (33.5%) and FNA (32%) were higher than in blood (25%, P < 0.01). Mucosal associated invariant T cells were enriched in liver tissue (8.8%) and in the FNA (4.4%) compared to blood (1.7%, P < 0.001). Whereas the percentage of total Tregs (CD4+CD25+FOXP3+CD127low/-) decreased, the proportion of activated Tregs (CD4+CD45RA-FOXP3high) increased in FNA and explant. Breg (CD19+CD20+CD24highCD38high) frequencies were similar in all groups. CONCLUSION: FNA is a practical method to sample the liver immune system collecting even small cell subsets such as regulatory T/B cells.

Assessment of posterior accessory great saphenous vein of the leg using ultrasonography: a preliminary study.

PURPOSE: To assess the frequency and anatomic distributions of the posterior accessory great saphenous vein of the leg (PAGSVL) and its insufficiency rate using ultrasonography (US) in patients who presented with clinical, etiologic, anatomic, and pathophysiologic (CEAP) scores of 1 and above. METHODS: A prospective US study on 200 limbs of 100 consecutive patients with CEAP scores of 1 and above. RESULTS: Right PAGSVL was seen in 45 % (45 cases), whereas left PAGSVL was seen in 54 % (54 cases) of the patients [49.5 % (99 limbs) in total] (p < 0.05). PAGSVL insufficiency was present in 6 % (6 cases) of the patients [6 limbs in total (6.06 %)]. The type of PAGSVL joining to the great saphenous vein (GSV) was above the knee level in 4 % (4 limbs), at the knee level in 14 % (14 limbs), and below the knee level in 74 % of patients (74 limbs). The relationship between posterior tibial perforators and PAGSVL was seen in 3.03 % of cases (3 limbs). There was no statistically significant relationship between PAGSVL insufficiency and the presence of posterior tibial perforators (p = 0.55) or between the presence of PAGSVL and the GSV insufficiency. CONCLUSION: PAGSVL was seen in half of the limbs with CEAP scores of 1 and above. The frequency of PAGSVL was more common in the left limbs than the right limbs. There was no statistically significant relationship between the presence of PAGSVL, GSV insufficiency, and different CEAP scores. The PAGSVL often joined to the GVS below the knee, but could also join above the knee.

Comparing 1470- and 980-nm diode lasers for endovenous ablation treatments.

The purpose of this study was to compare the effectiveness of 1470- and 980-nm lasers with regard to power output, complications, recanalization rates, and treatment response. We prospectively evaluated the effectiveness of endovenous laser ablation (EVLA) in a total of 152 great and small saphenous veins from 96 patients. Lasers were randomly used based on the availability of the units. Patients were clinically evaluated for Clinical Etiologic Anatomic Pathophysiologic (CEAP) stage and examined with Doppler ultrasound. Treatment response was determined anatomically by occlusion of the vein and clinically by the change in the venous clinical severity score (VCSS). Seventy-eight of the saphenous veins underwent EVLA with a 980-nm laser and 74 underwent EVLA with a 1470-nm laser. Treatment response was (68) 87.2 % in the 980-nm group and (74) 100 % in the 1470-nm group (p = 0.004). The median VCSS decreased from 4 to 2 in the 980-nm group (p < 0.001) and from 8 to 2 (p < 0.001) in the 1470-nm group. At 1-year follow-up, seven veins treated with 980 nm and two veins treated with 1470 nm were recanalized (p = 0.16); the average linear endovenous energy density (LEED) was 83.9 (r, 55-100) J/cm and 58.5 (r, 45-115) J/cm, respectively (p < 0.001). Postoperative minor complications occurred in 23 (29.4 %) limbs in the 980-nm group and in 19 (25.6 %) limbs of the 1470-nm group (p = 0.73). EVLA with the 1470-nm laser have less energy deposition for occlusion and better treatment response.

Tunnelled central venous catheter-related problems in the early phase of haematopoietic stem cell transplantation and effects on transplant outcome.

OBJECTIVE: Haematopoietic stem cell recipients need central venous catheters (CVCs) for easy administration of intravenous fluid, medications, apheresis, or dialysis procedures. However, CVCs may lead to infectious or non-infectious complications such as thrombosis. The effect of these complications on transplantation outcome is not clear. This manuscript presents the complication rates of double-lumen tunnelled CVCs and their effect on transplantation outcome. MATERIALS AND METHODS: Data from 111 consecutive patients, of whom 75 received autologous and 36 received allogeneic peripheral blood stem cell transplantations, were collected retrospectively. The data were validated by the Record Inspection Group of the related JACIE-accredited transplantation centre. RESULTS: Thrombosis developed in 2.7% of recipients (0.9 per 1000 catheter days). Catheter-related infection was identified in 14 (12.6%) patients (3.6 per 1000 catheter days). Coagulase-negative Staphylococcus was the most common causative agent. Engraftment time, rate of 100-day mortality, and development of grade II-IV graft-versus-host disease were not found to be associated with catheter-related complications. CONCLUSION: These results indicate that adverse events related with tunnelled CVCs are manageable and have no negative effects on transplant outcome.

Ultrasound-guided supraclavicular brachial plexus block for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas.

PURPOSE: To evaluate prospectively the efficacy and safety of ultrasound (US)-guided supraclavicular brachial plexus block (BPB) for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas. MATERIALS AND METHODS: US-guided supraclavicular BPB was performed before endovascular treatment of dysfunctional hemodialysis fistulas in 40 consecutive patients. After BPB, standard interventional procedures were performed for treatment of dysfunctional hemodialysis fistulas. A visual analog scale (0-10) was used to assess pain related to performance of BPB immediately after the endovascular procedure. Patient satisfaction and operator satisfaction during the procedure were also assessed after the procedure. RESULTS: Satisfactory regional anesthesia and analgesia were achieved in all patients without a need for supplemental intravenous analgesia. The mean onset time for complete block was 5.4 minutes ± 2.6. Pain scores were 0 (no pain) in 26 patients and 1-3 (mild, annoying pain) in 14 patients. The patient's satisfaction with pain control was recorded as satisfied (very well) in all cases. The operator's satisfaction with this anesthetic technique was also recorded as satisfied (very well) in all cases. Complications related to the block procedure did not occur in any patient. CONCLUSIONS: US-guided supraclavicular BPB can be used safely to provide analgesia during endovascular treatment of dysfunctional hemodialysis fistulas in adult patients.

Short-term central venous catheter complications in patients with sickle cell disease who undergo apheresis.

Patients with sickle cell disease (SCD) are prone to develop thrombosis and infection due to their inflammatory and immune deficiency state. These patients require red cell exchange therapy for treatment or prevention of hemoglobin S associated complications. Owing to vascular access problems, adult patients need central venous catheterization (CVC) for exchange procedures. Procedure related complications have been reported for long-term CVCs in pediatric patients. However, short-term CVC complications in adult patients are not clear. This report represents the results of documented complications of short-term CVCs in patients with SCD who undergo apheresis. A total of 142 non-tunneled catheters with average median diameter of 9 F (range 8-16 F) were implanted for apheresis. The catheters were mainly inserted through the right internal jugular vein (66.2 %). Total days of catheter were 412. Results were reported as a complication rate and event according to 1,000 catheter days and compared to a control group including 37 healthy stem cell donors. In the patient group, 1 (1 %) hematoma and 1 (1 %) infection were observed for internal jugular vein catheterization (3.7 hemorrhages and 3.7 infections according to 1,000 catheter days), whereas four (8.9 %) cases of thrombosis and 1 (2.2 %) infection (27 and 6.9 according to 1,000 catheter days) developed in femoral vein. There was a significant difference in terms of thrombosis (P = 0.009). In the control group, only individual developed thrombosis in internal jugular vein. Short-term CVC inserted through to the internal jugular vein seems to be safer than femoral vein in patients with SCD.

Effect of Portal Vein Types on Estimated Remnant Volume in Living Donor: Preoperative CT Assessment.

PURPOSE: The aim of this study is to examine the effect of portal vein types on the ratio of the right-left lobe liver volumes, as well as the insufficient estimated remnant liver volume (ERLV) during the preoperative assessment of donor candidates for right-lobe liver transplantation. MATERIALS AND METHODS: The preoperative abdominal CT examinations of the donor candidates in a single institution between December 2018 and May 2022 were retrospectively evaluated. Portal vein types are divided into 3; classical anatomy was considered type 1, PV trifuction was considered type 2, and if the first branch arising from the main portal vein is the right posterior branch, it was accepted as type 3. Other configurations were defined as type 4. The total, right-left lobe liver volumes, the ERLV, and the portal vein variations were noted. The chi-square test was performed to assess the correlation between portal vein types, the ratio of the right-left lobe volumes, and the ERLV ratio below 30%. Tamhane's T2 post hoc tests were performed for pairwise comparison to assess the right-left lobe volume ratio among groups. RESULTS: 287 donor candidates (mean age, 35 years ± 8.2; 174 men) were evaluated. The volume ratio of median volume of the right and left lobe was significantly higher in candidates with type 3 portal veins compared to those with type 1 portal veins (2 (1.3-3.5) and 2.1 (1.6-3.2), respectively, p = 0.017). The ERLV ratio below 30% was significantly higher in donor candidates with type 3 portal veins (42.9%) compared to those with type 1 and 2 portal veins (24.6%, 20%)) respectively, p = 0.030). CONCLUSION: Due to its propensity to result in insufficient ERLV in the donor, the presence of a type 3 portal vein should be evaluated during the preoperative evaluation. Secondary abstract: This study suggests that donor candidates with type 3 portal vein exhibit a notable rise in the frequency of insufficient remnant liver volume during the preoperative assessment.

Comparison of ultrasound guidance with the traditional palpation and fluoroscopy method for the common femoral artery puncture.

OBJECTIVES: To compare the success and complication rates of ultrasound-guided or palpation-guided punctures of the common femoral artery in a prospective randomized study. BACKGROUND: Percutaneous femoral arterial access is sometimes difficult to perform and is the source of complications. It has not been established whether ultrasound-guided puncture of the common femoral artery is the standard practice for angiography. MATERIALS AND METHODS: Two hundred and eight patients were randomized into two groups. One had ultrasound-guided puncture and the other had palpation-guided puncture of the common femoral artery. The technical success, first pass success rate, total number of attempts required for access, time to sheath insertion, pain during puncture, and access-related complication were compared. RESULTS: Technical success tended to be higher and the complication rates tended to be lower in the ultrasound-guided group but the difference did not reach statistical significance (P = 0.052 and P = 0.052). The first pass success rate was higher, total number of attempts required for access and time to sheath insertion were lower in the ultrasound-guided group. Atheromatous plaques on the common femoral artery, iliac artery obstructive lesion, previous ipsilateral puncture of the common femoral artery, obesity, and blood pressure during puncture did not change the outcome. CONCLUSIONS: Ultrasound guidance improves secondary outcomes of the common femoral artery puncture when compared to palpation-guided puncture. Technical success and complication rates seem lower in the presence of ultrasound guidance but larger study populations are needed to verify the result.

Which patients with advanced cancer and biliary obstruction benefit from biliary stenting most? An analysis of prognostic factors.

BACKGROUND: Patients with advanced cancer may present with obstructive jaundice. Biliary stenting is the treatment of choice. However, which patients benefit most is not well-defined, yet. Our aim was to delineate the clinical factors affecting prognosis. MATERIAL AND METHODS: Charts of 140 patients with advanced cancer who underwent biliary stenting were retrospectively analyzed. Their median age was 63.5 years. Of these patients, 73 (52.1 %) were male, 32 (22.9 %) had ECOG PS 1 and 81 (57.9 %) had PS 2. The most frequent cancer types were cholangiocellular cancer (64, 45.7 %) and pancreatic cancer (36, 25.7 %). RESULTS: Median overall survival (OS) was 141 (95 % CI, 100.7-185.3) days. Female patients lived longer (161.0 vs. 124.0 days) (p = 0.036). Those patients with colorectal cancer lived the longest (667.0 days), followed by cholangiocellular (211.0 days), and gastric cancers (106.0 days) (p = 0.004). The distribution of primary diagnosis differed significantly between sexes: cholangiocellular cancer was present in 22 (30.1 %) out of 73 men and 42(62.7 %) out of 67 women (chi-square p < 0.001). There was a trend for longer overall survival if ALT (p = 0.08) and AST (p = 0.06) were normalized after stent insertion. Of the 137 patients, 63 (45.5 %) did not experience any complication. In 74 patients with complications, there were 39 (28.5 %) episodes of cholangitic infections and 35 (25.5 %) biliary obstructions. In three patients, we could not find data on infections. CONCLUSION: Underlying malignancy, hence the natural biology and the therapeutic expectations are probably the most important factors which must be considered during decision-making.

Ultrasound-guided retrograde tibial access through chronically occluded tibial arteries: a last resort recanalization technique.

PURPOSE We aimed to demonstrate the feasibility of ultrasound (US)-guided retrograde tibial access through chronically occluded tibial arteries as a bailout endovascular recanalization procedure in patients with critical limb ischemia (CLI). METHODS Fifty-one CLI patients with failed conventional antegrade tibiopedal recanalization required retrograde tibiopedal access in the same session. In all of these patients, the target tibial artery was chronically occluded in at least the distal half of the cruris. Access attempts were made under real-time US by a single operator experienced in image-guided vascular access procedures. Fluoroscopy was used only as an adjunct during advancement of a 0.018 inch guidewire. If access to the artery was successful by the retrograde route, the occluded artery was usually predilated with a 2 mm balloon, and the standard endovascular treatment was mostly performed through the antegrade route. RESULTS Patients had athereosclerosis (n=35) or Buerger's disease (n=32) and presented with Rutherford category IV and category V. Successful placement of a guidewire in the occluded artery lumen was achieved in 81% of all patients, whereas, treatment success, i.e. angiographic demonstration of in-line flow at the end of procedure, was achieved in 49%. No significant procedure-related complications were observed. Of 33 limbs with initially successful endovascular treatment, 6 required minor and 1 required major amputation during follow-up. CONCLUSION US-guided retrograde access through completely occluded tibial arteries is difficult but feasible. Half of the tibial arteries that could not be recanalized otherwise were converted to successful recanalization by this method.

Classification of reflux patterns in patients with great saphenous vein insufficiency and correlation with clinical severity.

PURPOSE: This study aims to establish a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency and to evaluate the relationship between this classification, the demographics, and severity of clinical findings. METHODS: This is a retrospective study from prospectively collected data of 503 patients who had the complaint of varicose vein. All patients had complete physical examination and their medical history was recorded. Lower limbs of all patients were examined with Doppler ultrasonography. A total of 787 limbs with great saphenous vein insufficiency were included in the analysis. The reflux patterns of great saphenous vein insufficiency were classified into 4 types as: type 1, great saphenous vein reflux without involvement of malleolar region and saphenofemoral junction (SFJ); type 2, reflux involving malleolar region with competent SFJ; type 3, reflux involving SFJ with competent malleolar region; and type 4, reflux involving both the SFJ and the malleolar region. We evaluated the association between the classification of great saphenous vein insufficiency and age, sex, body mass index (BMI), disease duration, clinical, etiological, anatomical and pathophysiological elements (CEAP) classification and venous clinical severity score (VCSS). RESULTS: The mean age of the patients was 45.3±11.7 years, with a male-to-female ratio of 2:3. The most common reflux pattern in patients with great saphenous vein insufficiency was type 3 (48.9%), while 14.8% of patients had type 1, 10.4% had type 2, and 25.7% had type 4. Patients with type I reflux pattern were younger in age (p = 0.002), had lower BMI (p = 0.002), fewer number of children (p = 0.008), as well as milder clinical severity score (p = 0.002) compared to other reflux types. Duration of disease symptoms was not significantly correlated with the reflux patterns, but VCSS increased with the involvement of malleolar region as in type 2 compared to type 1 (2.82±1.67 vs. 2.74±2.31), and further increased with the involvement of SFJ as in type 3 (4.13±2.92 vs. 2.82±1.67). Patients with diffuse reflux pattern (type 4) had the most severe clinical presentation (4.59±2.9). CONCLUSION: We developed a clinically applicable classification of reflux patterns in patients with great saphenous vein insufficiency based on the involvement of malleolar region and/or SFJ. We showed an association between weight, BMI, VCSS, CEAP classification and the extent of insufficiency.

Non-occlusive hepatic artery hypoperfusion syndrome and imaging findings: a systematic review.

Non-occlusive hepatic artery hypoperfusion syndrome (NHAHS), in other words, splenic steal, is a rare disorder that can arise following liver transplantation. After liver transplantation, its frequency has been defined as between 0.6 and 10.1%. The diversion of flow from hepatic to splenic arteries results in low perfused hepatic artery which causes elevated liver enzymes, hyperbilirubinemia, and graft dysfunction. This may result from a high resistance in the hepatic arteries, enlarged splenic arteries, a limited hepatic arterial flow due to high portal flow, or a discordance of the graft size and hepatic arterial flow. There may be a need for some prophylactic and/or posttransplant treatment procedures. We aimed to describe pre and post-treatment imaging findings of NHAHS.

Atherosclerotic risk factors and segmental distribution in symptomatic peripheral artery disease.

PURPOSE: To determine the distribution of atherosclerotic peripheral artery disease (PAD) and associated risk factors in patients who have undergone pelvic and lower-limb angiography. MATERIALS AND METHODS: Records of 626 consecutive patients (88 women, 538 men; mean age, 62 years; age range, 31-85 y) with PAD were retrospectively reviewed. Severity of limb ischemia was staged according to Rutherford classification of PAD. The arterial system was divided into three segments including aortoiliac, femoropopliteal, and crural segments. PAD was defined as a greater than 50% stenosis or occlusion of any segment. Univariate and multivariate analyses were used to determine associations between segmental arterial disease and patient demographics, medical history, and angiographic findings. RESULTS: Of the 626 patients, 400 (64%) had multisegmental disease, the most common form of which was combined femoropopliteal and crural disease (25%). A significant association was found between severity of limb ischemia and distribution of PAD. Intermittent claudication was significantly associated with aortoiliac disease (odds ratio, 2.15; P < .001), whereas critical limb ischemia was associated with crural disease (odds ratio, 2.5; P = .001) on multivariate analysis. Significant associations were found between smoking and aortoiliac, femoropopliteal, and multisegment disease; between diabetes mellitus and crural disease; and between age and femoropopliteal and multisegment disease. CONCLUSIONS: PAD was multisegmental in most of the patients in this study group. Different clinical risk factors predict the involvement of different arterial segments. Severity of limb ischemia was significantly associated with the distribution of PAD.

US-guided placement of central vein catheters in patients with disorders of hemostasis.

OBJECTIVE: To prospectively evaluate the technical success and immediate complication rates of temporary central catheter placement in a homogenous patient population with disorders of hemostasis. MATERIALS AND METHODS: One hundred and thirty three temporary central vein catheters inserted under ultrasound guidance in 119 patients with bleeding disorders were analyzed over a 4-year period. Patients were males (n=51; 43%) and females (n=68; 57%) with a mean age of 56.6 years (age range 18-95 years). A catheter was inserted in IJV in 129 (97%) procedures, subclavian vein in 2 (1.5%) procedures and femoral vein in 2 (1,5%) procedures. Thirty-three (24.8%) procedures were performed on bedside. Of 119 patients, 106 (89%) had only one catheter placement and the rest had had more than one catheter placement (range 1-3). RESULTS: Technical success was achieved in all patients (100%). Average number of puncture was 1.01 (range 1-2). One hundred and nineteen insertions (89.5%) were single-wall punctures, whereas 14 insertions were double-wall punctures. Eight (6%) minor complications occurred including oozing of blood around the catheter in five (3.8%) procedures, small hematoma in two (1.5%) procedure and both in one patient. There was no inadvertent arterial puncture or major complications like hemothorax or pneumothorax in any patients. CONCLUSION: US-guided placement of central vein catheters in patients with disorder of hemostasis is safe with high technical success and low complication rates. US guidance for central venous catheterization should be the preferred method in this group of patients, if available in the hospital setting.

Treatment of multiple primary hydatid cysts.

Hydatid disease, which is caused by the parasite Echinococcus granulosis, is endemic in certain parts of the world in which humans and sheep live in proximity. Hydatid cysts occur most often in the liver, and affliction with multiple cysts is rare. We present the case of a 48-year-old woman with 55 hydatid cysts (47 in the liver, 5 in the right lung, and 3 in the left lung). The cysts in the right lung were intact, and those in the left lung had ruptured. A partial cystectomy was performed to excise 34 cysts through a right thoracoabdominal incision. The remaining deeply seated cysts were treated by needle aspiration and the ultrasonographically guided injection of hypertonic saline. This case report indicates that open surgery accompanied by ultrasonographically guided aspiration can effectively treat multiple hydatid cysts in a single laparotomy session.

[Pseudoaneurysm of the internal carotid artery following a tonsil biopsy: endovascular repair with covered stent]. / Tonsil biyopsisine bagli gelisen internal karotis arter psödoanevrizmasi: endovasküler kapli stent ile onarim.

Evaluation and management of peritonsillar masses require specific attention because of their relationship to vital neighboring anatomical structures. A 57-year-old woman developed pseudoaneurysm of the internal carotid artery following a biopsy taken at another center from a mass in the left tonsillar region. She was treated by a multidisciplinary approach and an endovascular covered stent was implanted under local anesthesia in the left internal carotid artery. No recurrence was detected in the neck and the patient was asymptomatic in the postoperative second year.

Ultrasound-Guided Popliteal Sciatic Block Provides Adequate Analgesia During Urgent Endovascular Treatment of Critical Limb Ischemia with Resting Pain.

PURPOSE: To demonstrate feasibility and safety of ultrasound-guided popliteal sciatic nerve block for providing analgesia during urgent endovascular treatment of critical limb ischemia with resting pain. MATERIALS AND METHODS: Ultrasound-guided popliteal sciatic blocks were performed by an interventional radiologist in angiography suite immediately prior to commencement of urgent endovascular treatment of 30 critical limb ischemia patients. Subjective pain levels prior to and following sciatic block were assessed using the visual analog scale (VAS). Need for any supplemental anxiolytics or analgesics during treatment was recorded. Post-procedural evaluation of patient and operator satisfaction levels regarding the intervention was also documented. RESULTS: Ultrasound-guided sciatic block provided adequate analgesia in all patients; VAS scores were 0 (no pain) in 87% and 1-3 (mild to annoying pain) in 13%. Two patients required anxiolytic premedication. Additional analgesia was not required during course of endovascular treatment of any patients. Time necessary to perform sciatic block ranged 3-9 (mean 5.9 ± 1.3) min. Median number of needle attempts was 1 (range 1-3). Onset of satisfactory block ranged from 5 to 20 min (mean 9.4 ± 2.6 min). Mean treatment time was 102.2 ± 36.7 min, and balloon time was 22.4 ± 6.1 min. Patient and operator satisfaction with pain control were very good in all cases. There were no procedure-related complications. CONCLUSIONS: Ultrasound-guided popliteal sciatic block is a feasible and safe alternative for providing adequate analgesia during urgent endovascular treatment of critical limb ischemia with resting pain. LEVEL OF EVIDENCE: Level 4, case series.

A potential therapeutic pitfall in the treatment of venous reflux due to variant planar anatomy of varicose segments.

Purpose To elaborate on a planar anatomic variant of great saphenous vein as a potential therapeutic pitfall in the treatment of venous reflux. Materials and methods Lower extremity veins in 568 limbs with great saphenous vein insufficiency were sonographically mapped. A rather overlooked variation, the saphenous bow, was studied with emphasis on anatomic clarification and its involvement in venous insufficiency. Results This variation, observed in 5.1% (n = 29) of limbs, comprised two segments; one uninterrupted great saphenous vein proper coursing throughout saphenous compartment and one extra-compartmental segment originating distally from and proximally fusing with it. Venous arch remains within compartment only briefly during take-off and re-entry. Extra-compartmental venous arch had reflux either alone (10.3%) or together with intra-compartmental segment (75.9%). Conclusion This variation, part of saphenous segmental aplasia/hypoplasia complex, is associated with venous insufficiency. Meticulous mapping of great saphenous vein territory and identification of such variants during planning stage is indispensable for optimal clinical outcomes of treatment.

Portal venous system aneurysms: imaging, clinical findings, and a possible new etiologic factor.

OBJECTIVE: The aims of this study were to present the prevalence, imaging and clinical findings, and possible causes of portal venous system aneurysms. MATERIALS AND METHODS: From 1998 to 2006, a total of 38 portal venous system aneurysms identified in 25 patients were retrospectively reviewed. The data of seven patients diagnosed using color Doppler sonography or CT before March 2004 were not consecutive, but the data recorded thereafter comprised the analysis of 4,186 consecutive patients who underwent routine abdominal MDCT. The patients were 14 men and 11 women (mean age -/+ SD, 53 -/+ 17 years). RESULTS: The prevalence of portal venous system aneurysm among 4,186 consecutive patients was 0.43%. There were no differences with respect to patient age, patient sex, and intrahepatic or extrahepatic location of aneurysm between those with and those without portal venous system aneurysm. Seven of the 25 patients with portal venous system aneurysm were symptomatic because of portal vein thrombosis, and six of them had recurrence. These patients had significantly larger aneurysms than those without symptoms. Four of those seven symptomatic patients evaluated for thrombophilia had an underlying defect. Other associated findings were splenomegaly (n = 16), portal hypertension (n = 8), cirrhosis (n = 3), psoriasis (n = 2), portal vein variation (n = 1), chronic pancreatitis (n = 1), and cutis laxa (n =1). CONCLUSION: Portal venous system aneurysms were rare in our study group but occurred more frequently than previously thought. All thrombosed aneurysms, most with a recurrence, were symptomatic and larger in patients with symptoms of portal venous system aneurysm than in those without symptoms. There were no differences among patients with portal venous system aneurysm and those without portal venous system aneurysm with respect to patient age and patient sex. Among those with aneurysms, there was no difference between subjects with intrahepatic versus extrahepatic aneurysms. A thrombophilic defect probably played a role in development of thrombosis in the portal venous system aneurysm.