Editor's Choice - Factors Associated with Long-Term Outcome in 191 Patients with Ilio-Femoral DVT Treated With Catheter-Directed Thrombolysis.

OBJECTIVE: To identify factors associated with long-term treatment success after catheter-directed thrombolysis (CDT) for acute deep venous thrombosis (DVT) involving the ilio-femoral vein. MATERIAL AND METHODS: This was a non-randomised observational cohort study. From 1999 to 2013, 191 consecutive patients (203 limbs) attending a tertiary vascular centre at Gentofte University Hospital, Denmark underwent CDT. All patients had ultrasonically verified acute ilio-femoral DVT with open distal popliteal vein and calf veins. Patients were seen in the outpatient clinic 6 weeks, 3, 6, and 12 months, and annually thereafter following the DVT. Successful outcome was defined as patent deep veins without reflux on Duplex ultrasound scanning (DUS). Data were collected prospectively as per protocol and analysed retrospectively. RESULTS: Median age was 27 years (range 14-74 years) and overall median lysis time was 56 h (range 22-146 h). A stent was placed in 106 limbs (52%). Six patients had major bleeding. The median follow-up was 5 years (range 1 month-14.3 years). The cumulative rate of patients with deep patent veins without reflux at 7 years was 79%. Multivariate Cox regression analyses showed that symptom duration >2 weeks (hazard ratio (HR) 2.78, 95% CI 1.14-6.73) and chronic post-thrombotic lesions (HR 19.3, 95% CI 7.29-51.2) were significantly associated with poorer outcome, while the pulse-spray technique (HR 0.15, 95% CI 0.05-0.48) was associated with better outcome. Age, gender, side, IVC atresia, stenting, and lysis duration did not affect outcome. CONCLUSION: In this observational study of CDT for ilio-femoral DVT it was demonstrated that symptom duration less than 2 weeks, absence of chronic post-thrombotic lesions and use of the pulse-spray technique for CDT resulted in better primary patency including normal valve function in the long term.

Carotid endarterectomy after intravenous thrombolysis for acute cerebral ischaemic attack: is it safe?

OBJECTIVES: Intravenous thrombolysis (IVT) has proven effective in the treatment of acute cerebral ischaemic attack in selected cases. In the presence of a carotid artery stenosis, such patients may be candidates for carotid endarterectomy (CEA). Few studies have been made on the safety of CEA performed after IVT. DESIGN: This was a retrospective study. Data including 30 days' follow-up were obtained from medical records and from a vascular registry. MATERIALS: A consecutive series of 306 patients were operated on for symptomatic carotid artery stenosis during a 5-year period. Among these, 22 (7%) patients had been treated with IVT for an acute cerebral ischaemic attack prior to CEA and 284 (93%) patients had CEA only. METHODS: IVT as well as CEA was performed following established guidelines. CEA was performed in median 11 days (25 and 75% percentiles: 7-13 days) after the neurological index event in patients having undergone IVT and 12 days (25 and 75% percentiles: 8-21 days) in patients undergoing CEA only. RESULTS: The 30 days' stroke and death rate was 0% (95% confidence interval (CI): 0-15%) in patients who had IVT before CEA and 2.4% (95% CI: 0.9-4.7%) in patients who underwent CEA only. CONCLUSION: Our experience indicates that CEA performed after IVT for acute cerebral ischaemic attack is safe, confirming existing but sparse publications. However, our series is small and our study possesses a number of limitations. Thus, our results cannot necessarily be transferred to other units, who instead should perform similar studies, preferably together.

Observer agreement of lower limb venous reflux assessed by duplex ultrasound scanning using manual and pneumatic cuff compression in patients with chronic venous disease and controls.

OBJECTIVES: The study aimed to evaluate observer agreement between two experienced ultrasound operators examining deep venous reflux assessed by duplex ultrasound (DU) using either manual or pneumatic cuff compression. In addition, the two methods were compared with each other with regard to immediate "eyeballing" and direct measurements of reflux time from Doppler flow curves. DESIGN: This was a case control study. MATERIAL AND METHODS: Cases were found among patients admitted to our department with deep venous thrombosis of the iliac, femoral or popliteal veins during the period 1999-2006. Controls were departmental staff. DU was used to assess valve function in the common femoral, femoral and popliteal veins in the standing position using manual and pneumatic cuff compression. The investigators were blinded to the other's observations. Observer agreement was assessed using the Rasch model for binary items. RESULTS: Twenty patients and 20 controls participated in the study and were analysed by the Rasch model. Quantitative measurement was found to be more reliable than "eyeballing", and cuff compression was more reproducible in identifying reflux than manual compression. We found that assessment by manual measurement by one investigator functioned at a lower level of expertise than for the other investigator. CONCLUSIONS: Cuff measurements were more accurate in diagnosing deep venous reflux than manual measurements, and measurement was more accurate than "eyeballing". The fact that assessment by manual compression by one investigator functioned at a lower level of expertise suggests that cuff measurement might be the optimal assessment method, especially in the difficult cases.

Long-term results using catheter-directed thrombolysis in 103 lower limbs with acute iliofemoral venous thrombosis.

OBJECTIVES: The long-term outcome of catheter-directed thrombolysis (CDT) in patients with acute iliofemoral venous thrombosis (IFVT) is evaluated in this study. MATERIAL AND METHODS: Patients presenting for treatment with IFVT between June 1999 and May 2007 were considered for treatment using CDT. The following inclusion criteria were used: first episode of IFVT, age below 60 years, age of thrombus <14 days and open distal popliteal vein. Ultrasonography (US) was used to verify the diagnosis. The popliteal vein was punctured under local anaesthesia using US guidance, and a multi-side-hole catheter with tip occlusion was placed in the thrombus. A solution of r-TPA was infused either continuously or using the pulse spray technique together with heparin. Any occlusion or residual stenosis in the iliac vein system was treated by stenting. Compression stockings and anticoagulation treatment were given for at least 12 months. Patients with severe thrombophilias were treated for longer periods. The patients were assessed by colour-duplex US for assessment of patency and valve function after 6 weeks, 3, 6 and 12 months and afterwards on a yearly basis. RESULTS: A total of 101 patients with 103 extremities affected by iliofemoral venous thrombosis were included (median age; 29 years, 78 women, and 79 had left-sided thrombosis). A stent was inserted in 57 limbs. The median follow-up time was 50 months (range 3 days-108 months). At 6 years, 82% of the limbs had patent veins with competent valves and without any skin changes or venous claudication. CONCLUSION: Treatment with CDT for IFVT achieves good patency and vein function after 6 years of follow-up in this highly selected group of patients. We suggest that results from future studies should be presented as Kaplan-Meier plots using venous patency without reflux as the main outcome, since it is an early indicator of the clinical outcome.

Muscle mitochondrial function in patients with type 2 diabetes mellitus and peripheral arterial disease: implications in vascular surgery.

OBJECTIVES: (1) To review the available information on mitochondrial function in type 2 diabetes mellitus (T2DM) and peripheral arterial disease (PAD) obtained by non-invasive phosphorus magnetic resonance spectroscopy ((31)PMRS), near-infrared spectroscopy (NIRS) in vivo and respirometry on mitochondria isolated from muscle biopsies in vitro (2) to evaluate the usefulness of such data in the diagnosis, treatment and prognosis of these patients. DESIGN: Review. SEARCH STRATEGY: PubMed (http://www.ncbi.nlm.nih.gov/PubMed) and manual literature search. MAIN RESULTS: Fifty-three articles were retrieved, which included (31)PMRS, 15, NIRS, 11, Combined, 1 and Respirometry, 2 and background literature, 24. CONCLUSION: Muscle mitochondrial function is impaired in both T2DM and PAD patients, but differently. Patients suffering from both pathological conditions will display more serious impairment of the mitochondrial function. Mitochondrial function and the degree of ischaemic disease as evaluated by (31)PMRS and NIRS are well correlated. The NIRS technique appears to determine the degree of PAD better than (31)PMRS. It is argued that systematic testing of mitochondrial function may be a useful prognostic tool with PAD and T2DM, but clinical studies are needed.

Thrombus age is ideally measured by history or MRV prior to thrombus removal.

Many factors are known to be important in order to achieve optimal results after thrombus removal for iliofemoral DVT. Not much is published in the literature about timing the treatment, though many guidelines recommend treatment within 14 days. This time span lies within the phrase of acute DVT according to the definition given in many reporting standards. This article will highlight the value of information acquired from patients directly regarding onset of symptoms versus information acquired from imaging with the purpose of a more precise selection of patients for catheter-directed thrombolysis for iliofemoral DVT. What is the value of clinical information acquired from patients and does the information from imaging have additional value?

Prophylactic antibiotics in amputation of the lower extremity for ischemia. A placebo-controlled, randomized trial of cefoxitin.

Of 152 patients who were scheduled for an amputation for ischemia, seventy-seven were randomly assigned to perioperative prophylaxis with cefoxitin (Mefoxin) and seventy-five patients, to injections of a placebo. The patients were followed for twenty-one days or, in the case of wound complications, to the end of treatment. An infected wound occurred in 38.7 per cent of the patients in the placebo group and 16.9 per cent of those in the antibiotic group (p less than 0.005). Clostridial infection occurred in eight patients in the placebo group and in none in the antibiotic group (p = 0.003). Three of the patients with clostridial infection died of gas gangrene. A multivariate analysis showed that the absence of antibiotic prophylaxis increased the risk of infection by a factor of 3.3 (p = 0.004) and increased the need for reamputation by a factor of 4.5 (p = 0.003). We concluded that amputation patients should have prophylaxis with a broad-spectrum antibiotic given perioperatively.

MRI mapping of postreconstructive edema following femoropopliteal bypass surgery.

We have used T1 MR images to map the distribution of water contributing to the edema which follows femoropopliteal bypass surgery. Spin-echo images and true parametric T1 images were made at the same time. The spin-echo images were used to identify the tissue anatomy. The extra fluid contributing to the edema distributes in two phases: a volume equivalent to 5% of the leg volume is distributed throughout the leg tissue, while the excess fluid collects in a localized annulus lying adjacent to the fascia. The T1 in the annulus can be as high as 4 sec, indicating build up of free fluid in this region. Although most of this free fluid lies in the subcutaneous fat, there is a component which lies underneath the fascia in the muscle compartment.

Evaluation of patients with thoracic aortic dissection by intraarterial digital subtraction angiography.

In 17 patients (mean age 60 years) a thoracic aortic dissection could be revealed by intraarterial digital subtraction angiography with exact delineatin of the proximal and distal extent. Furthermore a visualisation of the true and false lumen and hereby especially the blood flow and its direction in the false lumen could be made. The disclosure of the intimal flap could be seen in patients with flow in both channels, separating the true and the false lumen. In 4 patients the entry could be seen sharply as a hole, but not corresponding to the proximal extent. In 11 patients the entry was seen over a longer area and in 2 patients neither entry nor reentry could be seen. The most distal part of the intimal flap might correspond to the reentry. One anonymous artery, five renal arteries and one coeliac trunc were involved by the dissection. The exact anatomical and pathophysiological nature of the dissection made it possible to decide whether or not the patients should be operated upon and if so, what kind of operation should be chosen.

Intraluminal calcification of the abdominal aorta.

A patient who had no evidence of atherosclerotic disease and had never been hypertensive, presented with symptoms usually associated with gallstone disease. A large intraluminal calcification in the juxtarenal aorta was found to be the probable cause of these symptoms. The aorta was otherwise free of atherosclerotic changes. Although it could not be identified with certainty, this calcification could have developed secondary to a single ulcerated atheroma.

Diagnosis of acute aortic occlusion by computer tomography.

We present a case of acute aortic occlusion, which was diagnosed immediately with CT. Since a prompt diagnosis is essential we recommend contrast enhanced CT as a quick procedure to confirm diagnosis and to exclude dissecting thoracic aneurysm and genuine abdominal aneurysm.

[Thoracoabdominal aortic aneurysms. Treatment, complications and early results]. / Torakoabdominale aortaaneurismer. Behandling, komplikationer og tidlige resultater.

Over a four and a half year period ten patients operated upon for thoraco-abdominal aortic aneurysm. One patient died, and another developed paraparesis. Review of the literature and the experience obtained by using an intraluminal aortic graft for the proximal anastomosis is presented. Reduction of aortic cross-clamping time is essential in reducing complications, of which paraparesis is the most common. The employment of an intraluminal prosthesis whenever possible seems advantageous in achieving this goal. Patients with thoraco-abdominal aortic aneurysms can be treated with an acceptably low mortality and morbidity.

[Percutaneous embolization of vascular abnormalities]. / Perkutan embolisering af karanomalier.

In six male patients, percutaneous embolisation of symptom-producing vascular anomalies was performed with spirals or small particles. After a total of ten treatments, symptom-free states were obtained in half of the patients and definite improvement in the remainder. The results are so promising that this method of treatment will be continued.

[Preoperative evaluation of arteriosclerotic symptoms in the lower extremities by means of intravenous digital subtraction angiography]. / Praeoperativ evaluering af arteriosklerotiske symptomer fra underekstremiteterne ved hjaelp af intravenøs digital subtraktionsangiografi.

Intravenous DSA was performed in 106 patients with symptoms of arterial insufficiency in the lower extremities, requiring treatment according to preceding clinical examination. The examinations were carried out using a 36.5 cm (14 in.) intensifier and a 5.5 F pigtail catheter located centrally. 71% of the examinations were carried out on out-patients. No complications were observed. In 96% of the cases, the intravenous DSA provided sufficient information to make decisions about treatment.

[Post-traumatic pseudoaneurysm of the posterior tibial artery]. / Posttraumatisk pseudoaneurisme på arteria tibialis posterior.

A case of post-traumatic pseudoaneurysm of the posterior tibial artery is presented. The diagnosis was made by ultrasound one week after the trauma, and a vascular reconstruction was performed. The purpose of this case report is to bring attention to this complication to vascular trauma, which may cause delayed symptoms long time after the injury. We suggest that these patients should be treated with vascular reconstruction rather than ligation, thereby preserving the function of this artery.

[Surgical treatment of abdominal aorta aneurysm 1983-1987. A multicenter study. 1266 operations, development and early results]. / Operative behandling af abdominalt aorta-aneurysme 1983-1987. Multicenterundersøgelse. 1,266 operationer, udvikling og tidlige resultater.

During the years 1983-1987, 1,266 operations for abdominal aortic aneurysm (AAA) were carried out in eight surgical departments with vascular surgical function. The activity increased constantly corresponding to 311 patients in 1987 or 50% more than in 1983. During this period the distribution between patients subjected to elective operation and those operated upon as emergencies was very uniform. In the latter group, only a slight increase in the number of AAA patients with rupture was observed. The risk of complications was low with a significant decrease in the need for dialysis. The early mortality was constant for the patients subjected to elective operation remained constant about 5.5%. A marked decrease in the early mortality was observed for the patients operated upon as emergencies with rupture from 63 to 50% and without rupture from 37 to 25%. At the conclusion of the period, ultrasonic scanning became the preoperative investigation of election and introduction of an aortic prosthesis the method of operation of election. Patients with AAA should be recognized so that elective surgery can be offered before a condition endangering life develops.

Which criteria demand additive stenting during catheter-directed thrombolysis?

Many factors are necessary for obtaining satisfactory results after catheter-directed thrombolysis (CDT) for iliofemoral deep venous thrombosis (DVT). Selections of patients, composition of the thrombolytic fluid, anticoagulation per- and post-procedural, recognition and treatment of persistent obstructive lesions of the iliac veins are the most important contributors. Stenting has been known for 15 to 20 years. The first publication on CDT in 1991 was combined with ballooning the iliac vein, an additive procedure which has been abandoned as an isolated procedure. This chapter will discuss selection, indication, such as an iliac compression syndrome, and outcome of iliac stenting in combination with CDT. The reported frequency of stenting used after CDT is very inconsistent, therefore this will be discussed in details. It is concluded that selection for stenting is of the greatest importance, when CDT is used for iliofemoral DVT, but strict criteria for stenting are not available in the existing literature. The potential value of intravascular ultrasound (IVUS) is also discussed.