Extended anticoagulation for venous thromboembolism: A survey of the American Venous Forum and the European Venous Forum.

OBJECTIVE: Extended anticoagulation therapy should always be considered after standard treatment of an unprovoked episode of venous thromboembolism (VTE). It can also be considered for selected patients with provoked VTE. However, the evidence-based protocols suggested by some clinical guidelines and risk assessment tools to guide this practice are limited and ambiguous. The goal of the present survey research was to analyze current practices in applying extended anticoagulation therapy for patients with VTE among members of the American Venous Forum (AVF) and European Venous Forum (EVF). METHODS: An online survey was created by the AVF Research Committee. The survey consisted of 16 questions to identify the country of practice, specialty, experience of the participating physicians, and their clinical practice patterns in applying extended anticoagulation therapy for VTE patients. The survey was distributed via e-mail to the members of the AVF and EVF. RESULTS: A total of 144 practitioners, 48 AVF members (33%) and 96 EVF members (66%), participated in the survey. Most of the respondents identified themselves as vascular specialists with primary certification in vascular surgery (70%), vascular medicine or angiology (9%), and venous disease or phlebology (3%). Of the 144 respondents, 72% believed that the risk of VTE recurrence will generally overweigh the risk of bleeding for patients with unprovoked VTE. Extended anticoagulation therapy might be used by 97% of providers. Different patterns in real world clinical practice were identified. More than one half of the practitioners estimated the VTE recurrence and bleeding risk subjectively. The antithrombotic drugs most commonly used for secondary prophylaxis were rivaroxaban, apixaban, warfarin, dabigatran, and aspirin, in decreasing order of frequency. Among the reasons selected for not regularly considering extended anticoagulation therapy were the lack of specific clinical practice guidelines (24%), lack of reported evidence (9%), and absence of valid VTE and/or bleeding risk prediction calculators (8%). Twelve participants (8%) stated that extended anticoagulation therapy would not be beneficial for most patients with VTE. Ten participants (7%) indicated that prescribing extended anticoagulation therapy was outside the scope of their specialty. CONCLUSIONS: Different practice patterns exist regarding extending anticoagulation therapy beyond the standard treatment for patients with VTE. Major gaps in knowledge remain a serious challenge at least partially explaining the inaccuracy and inconsistency in long-term VTE management. Appropriately designed studies are needed to evaluate risk stratification tools when contemporary best medical therapy is used, accurately predict VTE recurrence and its long-term outcomes, and tailor safe and effective secondary prophylaxis.

Comparison of Recent Practice Guidelines for the Management of Patients With Asymptomatic Carotid Stenosis.

Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German-Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients.The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German-Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German-Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.

Common femoral vein obstruction secondary to femoral sheath lipoma.

Common femoral vein obstruction secondary to femoral sheath lipomas are rare. We describe the case of a 49 year-old male that presented to the clinic with a 3 month history of progressive right lower extremity pain, edema and discoloration. Venous duplex imaging was consistent with proximal venous obstruction and led to Computerized Tomographic Venography (CTV) which demonstrated a large mass obstructing the external iliac vein (EIV) and common femoral vein (CFV) consistent with a femoral sheath lipoma. Surgical exploration revealed a large well encapsulated lipoma in the right femoral sheath posterior to the CFV and external iliac vein causing near occlusion. We present an overview of the diagnosis and surgical management of symptomatic femoral vein obstruction caused by a large femoral sheath lipoma.

Targeted gene expression analysis of human deep veins.

OBJECTIVE: Endothelial-derived molecules involved in thrombosis and hemostasis have been investigated mainly in arteries and in experimental animals. The actual presence and integral function of these molecules in the human deep venous system have received less attention. Our aim was to evaluate the expression of certain prothrombotic and antithrombotic genes in the normal human deep veins of the lower extremities. METHODS: Macroscopically intact and competent valve-containing segments of human deep veins were prospectively collected from patients who had undergone above-knee amputation. Vein samples were separated into four zones: zone 1, postvalve (downstream, proximal) vein wall; zone 2, the valve cusp; zone 3, prevalve (upstream, distal) vein wall; and zone 4, vein wall within the valve cusp (cusp removed). Real-time quantitative polymerase chain reaction for principal genes involved in coagulation, fibrinolysis, and inflammation was performed to quantify messenger RNA. Selected protein gene products were measured by the western blot assay. One additional valve-containing segment underwent mass spectrometry analysis to investigate global differences in the proteome between the study zones. RESULTS: Seventeen valve-containing vein segments were analyzed. Significant upregulation of antithrombotic (protein C receptor [PROCR], thrombomodulin [THBD], tissue factor pathway inhibitor [TFPI]), prothrombotic (con Willebrand factor [VWF]), and proinflammatory (selectin P [SELP], intercellular adhesion molecule 1 [ICAM1]) genes was found in the valve cusp compared with the vein wall (P < .05). PROCR and THBD demonstrated the highest level of upregulation in the valve cusp. PROCR, serpin peptidase inhibitor, clade E, member 1 (SERPINE1), and SELP were upregulated in the valve cusp at the protein level (P < .05). Messenger RNA composition in the vein wall within the valve cusp was similar to the prevalve and postvalve vein wall for all genes, except for two times overexpressed ICAM1 (P < .05). Substantial differences within the proteome between the study zones were observed with mass spectrometry. CONCLUSIONS: The biological properties of the valve cusp, vein wall within the valve cusp, and vein wall beyond the valve cusp are different. The endothelium of the valve cusps of a normal competent deep venous valve may be naturally less thrombogenic compared with the vein wall. The endothelium of the valve cusp may have a higher potential to interact with white blood cells compared with the vein wall. Mass spectrometry demonstrates substantial differences in the proteome between the vein wall and the valve cusps that were not anticipated before. (J Vasc Surg Venous Lymphat Disord 2021;9:770-80.) CLINICAL RELEVANCE: Deep vein thrombosis (DVT) is a major cause of mortality, morbidity, and impaired quality of life. Multiple risk factors have been identified, although their relative weight and pathophysiologic interactions remain obscure. Many patients with multiple risk factors for DVT never develop this condition. Conversely, in numerous cases DVT cannot be attributed to any known clinical risk factor. The molecular mechanisms that initiate DVT are unclear. An improved understanding of the normal biology of human deep veins will serve as an important foundation for new hypotheses of the pathogenesis of DVT. The latter may suggest new projects on novel therapeutic strategies.

Contemporary nationwide trends and in-hospital outcomes of adjunctive stenting in patients undergoing catheter-directed thrombolysis for proximal deep venous thrombosis.

OBJECTIVE: Outflow venous stenting as an adjunct to catheter-directed thrombolysis (CDT) is performed to prevent recurrent thrombosis and to reduce the risk of post-thrombotic syndrome. Historical data show that stenting improves outcomes of surgical thrombectomy in patients with iliofemoral deep venous thrombosis (DVT), and recent observational data suggest that stenting improves long-term outcomes of CDT. However, the impact of stenting during CDT on acute safety outcomes is unknown. We sought to investigate the contemporary trends, safety outcomes, and resource utilization of adjunctive stent placement in patients undergoing CDT. METHODS: Patients with proximal lower extremity and caval DVT were identified within the National Inpatient Sample from January 2005 to December 2013. From this data set, we stratified our patients into three groups: patients who received CDT alone, patients who received CDT plus angioplasty, and patients who received CDT plus angioplasty with stenting. We used an inverse probability treatment weighting algorithm to create three weighted cohorts. Cochran-Armitage test was used to evaluate the trends of stent placement among patients treated with CDT. The primary outcome was a composite end point of all-cause mortality, gastrointestinal bleed, or intracranial hemorrhage. RESULTS: A total of 138,049 patients were discharged with a principal diagnosis of proximal and caval DVT; 7097 of these patients received CDT (5.1%). From this group, 2854 (40.2%) were treated with CDT alone, 2311 (32.6%) received adjunctive angioplasty alone, and 1932 (27.2%) received adjunctive angioplasty and stent. Adjunctive stenting had a significantly lower rate of primary composite outcome compared with CDT alone (2.7% vs 3.8%; P = .04). Stent placement was associated with a similar length of stay compared with angioplasty and CDT alone groups (6.8 vs 6.9 vs 7.1 days, respectively; P = .94) and higher in-hospital charges ($115,164.01 ± $76,985.31 vs $98,089.82 ± $72,921.94 vs $80,441.63 ± $74,024.98; P < .001). CONCLUSIONS: This nationwide study suggests that one in four patients undergoing CDT is treated with adjunctive stent placement in the United States. This observational study showed that adjunctive stenting does not adversely affect the acute safety outcomes of CDT; however, it was associated with increased hospital charges.

Quality of life after pharmacomechanical catheter-directed thrombolysis for proximal deep venous thrombosis.

BACKGROUND: After deep venous thrombosis (DVT), many patients have impaired quality of life (QOL). We aimed to assess whether pharmacomechanical catheter-directed thrombolysis (PCDT) improves short-term or long-term QOL in patients with proximal DVT and whether QOL is related to extent of DVT. METHODS: The Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) trial was an assessor-blinded randomized trial that compared PCDT with no PCDT in patients with DVT of the femoral, common femoral, or iliac veins. QOL was assessed at baseline and 1 month, 6 months, 12 months, 18 months, and 24 months using the Venous Insufficiency Epidemiological and Economic Study on Quality of Life/Symptoms (VEINES-QOL/Sym) disease-specific QOL measure and the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary general QOL measures. Change in QOL scores from baseline to assessment time were compared in the PCDT and no PCDT treatment groups overall and in the iliofemoral DVT and femoral-popliteal DVT subgroups. RESULTS: Of 692 ATTRACT patients, 691 were analyzed (mean age, 53 years; 62% male; 57% iliofemoral DVT). VEINES-QOL change scores were greater (ie, better) in PCDT vs no PCDT from baseline to 1 month (difference, 5.7; P = .0006) and from baseline to 6 months (5.1; P = .0029) but not for other intervals. SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 2.4; P = .01) but not for other intervals. Among iliofemoral DVT patients, VEINES-QOL change scores from baseline to all assessments were greater in the PCDT vs no PCDT group; this was statistically significant in the intention-to-treat analysis at 1 month (difference, 10.0; P < .0001) and 6 months (8.8; P < .0001) and in the per-protocol analysis at 18 months (difference, 5.8; P = .0086) and 24 months (difference, 6.6; P = .0067). SF-36 PCS change scores were greater in PCDT vs no PCDT from baseline to 1 month (difference, 3.2; P = .0010) but not for other intervals. In contrast, in femoral-popliteal DVT patients, change scores from baseline to all assessments were similar in the PCDT and no PCDT groups. CONCLUSIONS: Among patients with proximal DVT, PCDT leads to greater improvement in disease-specific QOL than no PCDT at 1 month and 6 months but not later. In patients with iliofemoral DVT, PCDT led to greater improvement in disease-specific QOL during 24 months.

Direct Oral Anticoagulants and Cancer-Associated Thrombosis Management. Where Do We Stand in 2019?

Direct oral anticoagulants (DOACs) are now widely used for the management of venous thromboembolism (VTE) that now includes cancer-associated thrombosis. This review summarizes recent data on VTE prophylaxis and treatment, new challenges, guidelines, and updates as well as the current place for DOACs on the emerging cancer-associated VTE management landscape.

The contemporary hybrid operative procedure for incapacitating post-thrombotic iliofemoral and vena caval obstruction improves procedural outcomes.

OBJECTIVE: Chronic, post-thrombotic iliofemoral and inferior vena caval obstruction is associated with debilitating morbidity. Venoplasty and stenting are often successful; however, in the presence of a diseased or occluded common femoral vein (CFV), failure is common. A hybrid operative procedure of open surgical CFV endovenectomy and endoluminal recanalization or bypass of the obstructed iliofemoral and vena caval segments has been developed and modified. The purpose of this report was to assess the technical evolution of this procedure on operative complications. METHODS: Thirty-one patients undergoing CFV endovenectomy and proximal ipsilateral endoluminal reconstruction (iliac, inferior vena caval) or contralateral outflow were analyzed. The initial techniques of patient management were compared with the present contemporary techniques, evaluating procedural complications and failures. The contemporary procedure evolved to include routine axial imaging, preoperative venography through the popliteal vein, preoperative passage of a guidewire or catheter into the patent vena cava, placement of an ipsilateral popliteal vein sheath for intraoperative and postoperative anticoagulation, routine patch closure, routine arteriovenous fistulas, routine completion intravascular ultrasound, and long-term anticoagulation with warfarin to a target international normalized ratio of 3.0 to 4.0. Procedure-related complications were compared between the initial and contemporary techniques. RESULTS: Of 17 patients treated with the early techniques, 15 (88%) had major complications: 5 iliofemoral thromboses, 4 major wound bleeds, 4 wound infections, and 2 CFV stenoses requiring reintervention. One iliac vein rupture treated with a stent graft thrombosed. Of 14 patients treated with the contemporary techniques, 2 (14%; P = .006) had major complications: 1 bleed and 1 infected seroma. One intraoperative iliac vein rupture, treated with a second stent relining the first, remains patent. CONCLUSIONS: Contemporary hybrid operative techniques for incapacitating post-thrombotic iliofemoral and vena caval obstruction increase procedural success and reduce complications compared with the initial approach. The contemporary techniques are recommended for patients undergoing hybrid operative management of post-thrombotic iliofemoral and vena caval occlusion involving the CFV.

Venous Compression Syndromes.

Venous compression syndromes occur due to extrinsic compression causing complications of venous hypertension or venous thrombosis. This review focuses on 4 venous compression syndromes involving the left common iliac vein, subclavian vein, left renal vein, and popliteal vein. Clinical presentation, diagnostic methods, and management options are reviewed. When properly diagnosed and treated, long-term consequences can be avoided.

Hybrid operative thrombectomy is noninferior to percutaneous techniques for the treatment of acute iliofemoral deep venous thrombosis.

OBJECTIVE: Hybrid operative thrombectomy (HOT) is a novel technique for the treatment of acute iliofemoral deep venous thrombosis (IFDVT) and is an alternative to percutaneous techniques (PTs) that use thrombolytics. In this study, we compare perioperative and intermediate outcomes of HOT vs PT as interventions for early thrombus removal. METHODS: From July 2008 to May 2015, there were 71 consecutive patients who were treated with either PT (n = 31) or HOT (n = 40) for acute or subacute single-limb IFDVT. HOT consisted of surgical thrombectomy with balloon angioplasty with or without stenting by a single incision and fluoroscopically guided retrograde valve manipulation to extract the thrombus. PT included catheter-directed thrombolysis with or without pharmacomechanical thrombectomy using the Trellis-8 system (Bacchus Vascular, Santa Clara, Calif). Patients who presented with bilateral DVT (n = 4), inferior vena cava involvement (n = 8), or venous gangrene (n = 1) were excluded. Perioperative outcomes, quality measures, and thrombus resolution were compared between the two treatment groups. Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification, Villalta score, and venous duplex ultrasound at intermediate follow-up were also analyzed. RESULTS: The left limb was the most common site of the IFDVT overall. Technical success (≥50% resolution) was 100% for both groups, and >80% resolution was achieved in all patients treated with HOT. There were eight major bleeding events in the PT group compared with three in the HOT group (P = .04). PT patients had a significantly longer length of stay (13 vs 10 days; P = .028) compared with HOT. At 2-year duplex ultrasound examination, there was no difference between HOT and PT in mean reflux times at the femoral-popliteal segment. At 2 years, 85% and 87% of the patients (HOT vs PT, respectively) had not developed post-thrombotic syndrome, and there was no difference between the groups for mean Villalta score (2.1 ± 1.9 vs 2.3 ± 2; P = .79). CONCLUSIONS: PT and HOT have demonstrated good outcomes in the perioperative and intermediate periods. HOT is noninferior to PT as a technique for early thrombus removal and has the advantages that thrombus resolution is established in one operation and length of stay is significantly decreased. HOT avoids thrombolytic therapy, which may reduce major bleeding events.

Cilostazol May Improve Maturation Rates and Durability of Vascular Access for Hemodialysis.

Cilostazol is effective in controlling pathophysiological pathways similar or identical to those involved in nonmaturation and failure of the arteriovenous access. This case-control study examined whether cilostazol would improve maturation rates and durability of vascular access for hemodialysis. The treatment group included 33 patients who received cilostazol for ≥30 days prior to creation of a dialysis access and continued with cilostazol therapy for ≥60 days after surgery. The matched (gender, age, race, diabetes, and the year of surgery) control group included 116 patients who underwent the same procedure but did not receive cilostazol prior to and at least 3 months after surgery. Primary outcomes were maturation and, for those that matured, time of functioning access, defined as the time from the first use to irreparable failure of the access. Secondary outcomes were time to maturation, complications, and time to first complication. Study group patients were 3.8 times more likely to experience fistula maturation compared to the controls (88% vs 66%, RR = 3.8, 95% confidence interval: 1.3-11.6, P = .016). Fewer patients in the study group had complications (76% vs 92%, P = .025), and the time from construction of the fistula to the first complication was longer (345.6 ± 441 days vs 198.3 ± 185.0 days, P = .025). Time to maturation was similar in both groups (119.3 ± 62.9 days vs 100.2 ± 61.7 days, P = .2). However, once matured, time to failure was significantly longer in the treatment group (903.7 ± 543.6 vs 381.6 ± 317.2 days, P = .001). Multivariate analysis confirmed that the likelihood of maturation was significantly higher in the treatment group patients. These results suggest that dialysis access patients may benefit from preoperative and postoperative cilostazol therapy. If confirmed by a randomized trial, this treatment will have a major beneficial impact on patients dependent on a well-functioning access for their hemodialysis.

Program requirements for fellowship education in venous and lymphatic medicine.

Background In every field of medicine, comprehensive education should be delivered at the graduate level. Currently, no single specialty routinely provides a standardized comprehensive curriculum in venous and lymphatic disease. Method The American Board of Venous & Lymphatic Medicine formed a task force, made up of experts from the specialties of dermatology, family practice, interventional radiology, interventional cardiology, phlebology, vascular medicine, and vascular surgery, to develop a consensus document describing the program requirements for fellowship medical education in venous and lymphatic medicine. Result The Program Requirements for Fellowship Education in Venous and Lymphatic Medicine identify the knowledge and skills that physicians must master through the course of fellowship training in venous and lymphatic medicine. They also specify the requirements for venous and lymphatic training programs. The document is based on the Core Content for Training in Venous and Lymphatic Medicine and follows the ACGME format that all subspecialties in the United States use to specify the requirements for training program accreditation. The American Board of Venous & Lymphatic Medicine Board of Directors approved this document in May 2016. Conclusion The pathway to a vein practice is diverse, and there is no standardized format available for physician education and training. The Program Requirements for Fellowship Education in Venous and Lymphatic Medicine establishes educational standards for teaching programs in venous and lymphatic medicine and will facilitate graduation of physicians who have had comprehensive training in the field.

Primary venous insufficiency increases risk of deep vein thrombosis.

BACKGROUND: Varicose veins have been recognized as a risk factor for deep vein thrombosis (DVT). However, venous reflux has not carried the same correlation. This study evaluated the association between primary valvular reflux and DVT. METHODS: We performed a nested case-control study with enrollment of outpatients presenting to the vascular laboratory with signs and symptoms of DVT. All patients had a complete bilateral venous duplex examination evaluating for DVT and superficial and deep venous valvular reflux. Eighty-seven patients with confirmed DVT on venous duplex were selected for the study group. The control group was randomly selected from the same cohort in a 4:1 ratio matched by age and gender (n = 348). Groups were compared for the prevalence of deep and superficial reflux. RESULTS: DVT outpatients were 4.7-times more likely to have primary valvular reflux than symptomatic controls (65.5% vs 29.0%; 95% confidence interval [CI], 2.8-7.7; P < .000001). Deep reflux was 2.1-times more prevalent (36.8% vs 21.6%; odds ratio, 2.12; 95% CI, 1.28-3.51; P = .005) and superficial reflux was 4.6-times more prevalent (43.7% vs 14.4%; odds ratio, 4.62; 95% CI, 2.75-7.77; P < .0000001) in DVT patients than in controls. DVT patients were also 2.1-times more likely to have combined deep and superficial reflux than non-DVT patients (13.8% vs 6.6%, 95% CI, 1.08-4.75; P = .044). CONCLUSIONS: The prevalence of primary valvular reflux in patients with DVT is significantly higher than expected. Reflux may be considered as a novel risk factor for DVT. Two-thirds of patients with DVT have pre-existent primary chronic venous disease, which is likely to contribute to post-thrombotic morbidity.

A histological and functional description of the tissue causing chronic postthrombotic venous obstruction.

BACKGROUND: Postthrombotic intraluminal tissue causing postthrombotic syndrome (PTS) has not been well described. This study defines its histological characteristics and assess whether tissue function evolves over time. METHODS: Specimens from 18 common femoral veins (CFV) from 16 patients obtained during CFV endovenectomy and iliocaval recanalization were examined. Phase 1 used hematoxylin and eosin and Masson's trichrome stains for collagen, immunohistochemical, and Von Kossa stains. Phase 2 examined young (≤ one year) and mature (≥10years from acute DVT) specimens to evaluate evolution of endothelial function. Antibodies to four biomarkers were used to examine specific functions of endothelial cells lining neovessels and recanalization channels (RC). RESULTS: Phase 1: Specimens demonstrated 80-90% of collagen type I, 10-20% of collagen type III, and dystrophic calcification. Neovessels and RC were in close proximity to each other. Thrombus and smooth muscle cells were absent, but white blood cells were present. Phase 2: VEGFR2 receptor uptake was more abundant in neovessels than RC and more prominent in younger specimens. Neovascular, nonchannel cells were observed more frequently in young specimens. CD-31 was similar in young and mature specimens. TIE-2 and von Willebrand factor antibodies had greater uptake in mature specimens. CONCLUSION: Tissue causing chronic postthrombotic venous obstruction is predominantly type I collagen. Neovascularization and recanalization occur in close proximity. The biomarker for neovascularization and angiogenesis (VEGFR2) was more prominent in young specimens whereas TIE-2, a stabilizing biomarker and vWF were more frequently observed in mature specimens.

Clinical outcomes and cost-effectiveness of initial treatment strategies for nonembolic acute limb ischemia in real-life clinical settings.

OBJECTIVE: The optimal initial treatment for patients with acute limb ischemia (ALI) remains undefined. Although clinical outcome data are inconsistent, catheter-directed thrombolysis (CDT) with tissue plasminogen activator is increasingly used. Patient-level analysis combining clinical and economic data in a real-life setting is lacking. This study compared clinical outcomes and cost-effectiveness of initial treatment strategies for nonembolic ALI using real-life patient-level data. METHODS: Medical records and data for hospital costs were analyzed for nonembolic ALI patients treated in four hospitals over 3 years. A cost-effectiveness analysis was performed using a decision tree analytic model. All costs were valued based on cost-to-charge ratios. RESULTS: In 205 patients, initial treatments were CDT alone in 68 or with angioplasty in 16, open surgery in 60, endovascular in 33, and hybrid in 28. Although clinical outcomes did not differ significantly among the groups, reintervention rates during hospital stay, readmission rates, and costs were highest in the CDT group. Reintervention was required in 62% of patients after CDT compared with 7% after open surgery, and 16% of the CDT patients needed more than one reintervention. The mean total hospital cost was $34,800 per patient in CDT group compared with $10,677 in open surgery group. CONCLUSIONS: In this real-life study, initial treatment of nonembolic ALI with currently available CDT options was associated with greater health care resource consumption and cost compared with other initial treatment options.

Lumbar artery pseudoaneurysm in a patient with inferior vena cava filter and history of strenuous physical exercise.

Lumbar artery pseudoaneurysms (LAPs) are a rare complication of inferior vena cava (IVC) filters. The few reports in the literature describe treatment of patients presenting with ruptured LAPs. This case report describes the successful management of a symptomatic LAP because of an IVC filter, which initially presented as a retroperitoneal hematoma resulting from lumbar artery laceration by a filter strut. We hypothesize that the strenuous abdominal exercises performed by the patient may have facilitated IVC penetration by the filter, leading to development of a retroperitoneal hematoma and subsequent LAP. This case suggests that patients with IVC filters should avoid strenuous exercise and underscores the importance of timely retrieval of nonpermanent IVC filters.

Role of coexisting contralateral primary venous disease in development of post-thrombotic syndrome following catheter-based treatment of iliofemoral deep venous thrombosis.

BACKGROUND: It has been reported that early clot removal benefits patients with iliofemoral deep venous thrombosis (DVT) by removing obstruction and preserving valve function. However, a substantial number of patients who had successful clot removal develop post-thrombotic syndrome (PTS). Residual thrombus and rethrombosis play a part in this phenomenon, but the role of coexisting primary chronic venous disease (PCVD) in these patients has not been studied. METHODS: All patients who underwent catheter-based techniques of thrombus removal for symptomatic acute iliofemoral DVT during a 5-year period compose the study group. These patients were assessed for PTS by the Villalta scale, the Venous Clinical Severity Score (VCSS), and the Venous Insufficiency Epidemiological and Economic Study on Quality of Life (VEINES-QOL) questionnaire. The presence of coexisting PCVD was determined by clinical and duplex ultrasound findings in the contralateral leg at the time of the initial DVT diagnosis. Patients who had coexisting PCVD were compared with those without PCVD. RESULTS: Forty patients (40 limbs) were included in the study group. At initial diagnosis, 15 patients (38%) had coexisting symptomatic primary valve reflux in the unaffected limb. After thrombolysis, 9 of 40 limbs (22%) had complete lysis, 29 (73%) had ≥ 50% to 99% lysis, and 2 (5%) had <50% lysis. The mean percentage of lysis in patients with or without PCVD was similar (78% vs 86%; P = .13). Patients without coexisting PCVD had significantly better Villalta score and VCSS compared with those with coexisting PCVD (Villalta score, 2.52 vs 3.27, P = .014; VCSS, 2.96 vs 3.29, P = .005). Forty-five percent of patients (18 of 40) developed PTS. Patients who developed PTS had less clot lysis than those without PTS. This was true for patients with coexisting PCVD (60% vs 85%; P = .025) and in patients without PCVD (75% vs 89%; P = .013). There was no significant difference in the VEINES-QOL score between those with or without PCVD (79.5 vs 80.5; P = .9). Patients who had reflux in the treated limb after lysis had a five times greater chance for development of PTS compared with those who retained normal valve function during follow-up (odds ratio, 5.3; 95% confidence interval, 1.6-17.045). However, in patients with normal veins in the contralateral leg, the chance of development of PTS was 1.5 times higher if reflux was present in the treated limb (odds ratio, 1.49; 95% confidence interval, 0.043-10.253). CONCLUSIONS: Coexisting PCVD is a contributing factor to development of PTS after treatment of iliofemoral DVT with thrombus removal techniques.

Core content for training in venous and lymphatic medicine.

The major venous societies in the United States share a common mission to improve the standards of medical practitioners, the educational goals for teaching and training programs in venous disease, and the quality of patient care related to the treatment of venous disorders. With these important goals in mind, a task force made up of experts from the specialties of dermatology, interventional radiology, phlebology, vascular medicine, and vascular surgery was formed to develop a consensus document describing the Core Content for venous and lymphatic medicine and to develop a core educational content outline for training. This outline describes the areas of knowledge considered essential for practice in the field, which encompasses the study, diagnosis, and treatment of patients with acute and chronic venous and lymphatic disorders. The American Venous Forum and the American College of Phlebology have endorsed the Core Content.