Right femoral vein and right dorsal artery thrombosis in childhood acute myeloid leukemia: A case report.

BACKGROUND: It is rare for newly diagnosed (de novo) or newly treated acute myeloid leukemia (AML) complicated with thrombotic complications, especially combined arterial and venous thrombosis. METHODS: We reported a 13-year-old boy diagnosed with AML and leukocytosis, who developed right femoral vein and right dorsal artery thrombosis during chemotherapy. After treatment with low molecular weight heparin, diosmin, and alprostadil, symptoms were relieved. Unfortunately, the child suffered from coagulopathy afterward, which was unexpectedly caused by vitamin K deficiency. RESULTS: After supplementation with vitamin K and prothrombin complex concentrate, coagulation function recovered. CONCLUSION: For childhood AML patients with high thrombotic risks, close monitoring during anticoagulant treatment was necessary. Concomitantly, we should be alert to past medication history and combined medication use, especially those that may lead to vitamin K deficiency, secondary bleeding, and coagulation disorders. Rational use of antibiotics, anticoagulants, and antitumor drugs must be guaranteed.

Evolution of deep vein thrombosis treatment from leeches to mechanical thrombectomy.

Deep vein thrombosis (DVT) is one of the most common diseases in developed countries with significant socioeconomic consequences. The severity of DVT lies in the potential for life-threatening pulmonary embolism and the development of chronic venous insufficiency, referred to as post-thrombotic syndrome. Virchow contributed to the understanding of the pathophysiological events that lead to thrombosis by describing three basic risk mechanisms. The first therapeutic attempts in the 17th century included venepuncture and the application of leeches. The first anticoagulant drug was heparin, which entered clinical practice after 1935. Subsequent commercialization of oral vitamin K antagonists (warfarin) and the advent of low molecular weight heparin along with compression therapy allowed the expansion of outpatient treatment of DVT. Recently, new oral anticoagulants have been introduced, leading to improved safety due to lower risk of bleeding complications and simplification of the treatment process. The next step in the development of therapeutic options are invasive methods of early thrombus removal, which significantly shorten the process and aim to reduce the occurrence of late complications. These methods include local catheter-directed thrombolysis using tissue plasminogen activator, mechanical thrombectomy and their combination called pharmaco-mechanical thrombectomy. The latter is currently used in patients with acute ilio-femoral DVT.

Comparing Safety and Efficacy of Rivaroxaban with Warfarin for Patients after Successful Stent Placement for Chronic Iliofemoral Occlusion: A Retrospective Single Institution Study.

OBJECTIVE: The aim was to compare the safety and effectiveness of rivaroxaban and warfarin as anticoagulants for treating patients with post-thrombotic syndrome (PTS) with chronic iliofemoral venous occlusion undergoing iliofemoral venous stenting. METHODS: This single institution retrospective study analysed patients with PTS with chronic iliofemoral venous occlusion who were prescribed rivaroxaban or warfarin for one year after successfully undergoing iliofemoral venous stenting. The primary safety and efficacy endpoints were bleeding complication rate and primary patency rate at one year. Secondary outcomes included Villalta score, symptom recurrence rate, ulcer healing rate, and clinically driven target lesion revascularisation (CD-TLR) rate during follow up. RESULTS: From January 2016 to December 2017, 154 legs from 154 patients were included in this study (69 in rivaroxaban group and 85 in warfarin group). The groups were well matched for patient demographics, clinical characteristics, and procedural details. There was no significant difference between the rivaroxaban group and warfarin group in bleeding complication rate (10% vs. 16%, p = .23, hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.25 - 1.37) at one year, as well as major bleeding complication rate (0% vs. 2%, p = .20, HR 0.16, 95% CI 0.01 - 2.61) and minor bleeding complication rate (10% vs. 14%, p = .40, HR 0.67, 95% CI 0.27 - 1.66). The primary patency rate was higher in the rivaroxaban group at one year (84% vs. 71%, p = .049, HR 0.50, 95% CI 0.26 - 0.96) and at two years (79% vs. 63%, p = .037, HR 0.52, 95% CI 0.29 - 0.93). At a mean follow up of 24 months (range 1 - 42 months), the rivaroxaban group had a significantly lower post-operative Villalta score (4.87 ± 3.51 vs. 6.88 ± 5.85, p = .010, t = 2.64, 95% CI 0.50 - 3.52), lower rate of symptom recurrence (4% vs. 32%, p < .001), lower CD-TLR rates (3% vs. 13%, p = .039), and higher ulcer healing rate (90% vs. 59%, p = .004) than the warfarin group. CONCLUSION: For PTS patients with chronic iliofemoral venous occlusion undergoing iliofemoral venous stenting, rivaroxaban probably exhibited similar safety but superior efficacy to warfarin. However, further prospective control studies with large sample size are necessary to confirm the results.

Ten-year trends in iliofemoral deep vein thrombosis treatment and referral pathways.

OBJECTIVES: Iliofemoral deep venous thrombosis is associated with an increased risk of developing post-thrombotic syndrome resulting in reduced quality of life. As there is debate about best management practices, this study aimed to examine the referral and treatment pathways for patients presenting with iliofemoral deep venous thrombosis over an 11-year period at our institution. METHODS: We conducted a retrospective review of patients diagnosed with lower limb deep vein thrombosis between 2010 and 2020. Ultrasound report findings were reviewed for the presence of iliofemoral deep venous thrombosis with acute, occlusive, or proximal clot. Multiple factors were extracted, including patient demographics, risk factors, diagnostic methods, interventions, referrals, and details of follow-up. The CaVenT and ATTRACT trials studied the benefit of thrombolysis in the early phase of iliofemoral deep venous thrombosis management as compared to anticoagulation alone. An analysis was conducted of patients requiring thrombolysis to determine whether these trials impacted physician practice patterns for thrombolysis. Data were organized and examined by year for trends in treatment and referral pathways. RESULTS: The review yielded 2792 patients assessed for lower limb deep venous thrombosis by ultrasound. Four hundred and sixty-seven (16.7%) patients were confirmed to have an occlusive iliofemoral deep venous thrombosis. The average age was 62.7 years (18-101 years). Half (50.4%) of the patients were male. The most common etiology for clot was malignancy-induced hypercoagulable state (39.0%). There was no difference in incidence of iliofemoral deep venous thrombosis diagnosed by ultrasound per year, with an average of 42.5 per year and a peak of 61. There was a trend towards increased rates of computed tomography imaging, ranging between 9.1% and 52.9%. The rate thrombolysis per year ranged between 1.8% and 8.9%, with a range of 4.3% (n = 20) to 8.9% (n = 5) in 2018. The use of pharmacomechanical thrombolysis increased, from 25% (n = 1) in 2010-2012 to 87.5% (n = 7) in 2018-2020. The rate of inferior vena cava filter insertion alone decreased from 18.2% in 2010 (n = 4) to 5.9% (n = 1) in 2020. The length of thrombolysis treatment also decreased, from 100% of patients (n = 4) receiving treatment duration greater than 24 h in 2010-2012 to 0% (n = 0) in 2018-2020. About 45% of patients receiving thrombolysis (n = 9) had venous stenting. No difference in treatment outcomes were observed, with greater than 87.5% of patients reaching intermediate to full resolution of clot burden. No patients experienced intracranial hemorrhage. CONCLUSIONS: The results of this analysis highlight the change in practice in our institution over time. The low rate of intervention likely reflects the current lack of consensus in published guidelines. It is important for future work to elicit the most appropriate management pathways for patients with iliofemoral deep venous thrombosis.

Closed incisional negative pressure therapy may reduce surgical site infection rate following endophlebectomy with complementary polytetrafluoroethylene arteriovenous fistula of the common femoral vein.

OBJECTIVE: Surgical desobliteration or endophlebectomy of the common femoral vein during deep venous recanalization with complementary polytetrafluoroethylene (PTFE) arteriovenous fistula (AVF), may lead to higher rates of surgical site infection (SSI). It has been reported that closed incisional negative pressure wound therapy (cINPT) may decrease SSI rates after different surgical procedures. The aim of this study was to determine the potential effect of cINPT on the SSI rate of femoral endophlebectomy with a complimentary PTFE AVF. METHODS: Patients with recanalization of the femoral-iliac veins and femoral endophlebectomy with a complementary PTFE AVF and postoperative cINPT were identified. SSI, patency, and complication rates were analyzed. RESULTS: This study included 65 patients with a mean age of 41 ± 14 years. The mean procedure time was 240 ± 11.9 minutes. Primary patency rate was 69.2% and secondary patency rate was 78.4%. SSI classified as Szilagyi I, II, and III occurred in 7.6% (n = 5), 3% (n = 2), and 7.6% (n = 5), respectively, with an overall SSI rate of 18.2%. Surgical wound revision with the application of a vacuum pump was required in 10.7% (n = 7). A multivariate analysis showed that the duration of the surgical procedure (P = .003) as well as lymphatic fistulas (P = .044) to have a significant impact on the SSI rate. CONCLUSIONS: Endophlebectomy with complementary PTFE AVF of the femoral vein is related to an increased rate of lymphatic leakage and SSI. Lymphatic fistula and the duration of surgery could be assessed as relevant influencing factors of SSI. Application of cINPT in this surgical setting may reduce the SSI rate. Despite this potential improvement, SSI rates still limit the clinical success of a deep venous recanalization.

Comparative outcomes of catheter-directed thrombolysis plus rivaroxaban vs rivaroxaban alone in patients with acute iliofemoral deep vein thrombosis.

BACKGROUND: Since novel oral anticoagulants (NOACs) have been introduced in the past decade, the first option of deep vein thrombosis (DVT) treatment is toward NOACs. However, aggressive and early thrombus removal strategy is widely used for treating acute iliofemoral DVT. Consequently, optimal treatment duration, efficacy, and safety of rivaroxaban alone or in combination with catheter-directed intrathrombus thrombolysis (CDT) in acute iliofemoral DVT patients should be investigated. METHODS: Patients with recent acute iliofemoral DVT treated with combined CDT-rivaroxaban (CDT) or rivaroxaban alone (control) were followed for mean (standard deviation) of 25.7 (2.5) months. DVT evolution, treatment efficacy and safety, and predisposing factors for patency and postthrombotic syndrome (PTS) development were analyzed through duplex ultrasonography, plethysmography, venography, and computed tomographic venography. RESULTS: 43.2%, 64.9%, 75.7%, and 72.2% of the CDT patients showed complete patency at 3, 6, 12, and 24 months of treatment compared with the control patients having 8.5%, 36.2%, 55.3%, and 57.4% of cumulative patency at 3, 6, 12, and 24 months, respectively (p = 0.001, 0.017, 0.088, and 0.081, respectively). The p value of the log-rank test comparing patency rates of the two groups was 0.009. The median (interquartile range, IQR) Villalta scores at 24 months were 3 (2-5) and 6 (4-8) in CDT and control patients, respectively (p = 0·001). PTS and bleeding events during therapy were, respectively, found in 35.1% and 63.8% (p = 0.017) and in 27% and 17% of CDT and control patients (p = 0.4). The Kaplan-Meier curve analysis of cumulative patency at 24 months for 6 months of rivaroxaban treatment was significant (p = 0.016). CONCLUSION: Treatment therapy and treatment duration with rivaroxaban alone or in combination with CDT are potentially associated with vein patency at 24 months, and a 6-month lysis rate and obstructive vein can influence PTS development. A larger randomized trial is warranted to confirm these findings.

Use of a Muscle Pump Activator Leads to Improved Lower Limb Edema, Lower Limb Blood Flow, and Urine Output Compared With Standard TED Stockings and Compression Devices Following Kidney Transplant: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to evaluate the effects of using thromboembolic deterrent (TED) stockings and intermittent pneumatic compression (IPC) vs a muscle pump activator (MPA) device on limb edema and patient satisfaction after transplant. METHODS: In this single-center randomized controlled trial, 118 patients were randomly assigned to wear TED + IPC (n = 64) or the MPA device (n = 54) from postoperative days 1 to 6. We measured patients' weight and lower leg and thigh circumferences daily. Ultrasonography of the allograft and lower limbs was carried out on postoperative days 1 and 5 to assess resistive index in the transplanted kidney and flow in the femoral vein. We monitored urine output and serum creatinine level. RESULTS: We observed a significant increase in calf and thigh circumference from baseline in the TED + IPC group but not in the MPA group (2.3 [SD, 1] cm vs 0.25 [SD, 0.8] cm, respectively, P < .002). Ultrasonography showed higher femoral vein velocities in the MPA group than the TED + IPC group (0.5 [SD, 0.2] cm, P < .001). The mean total urine output in 6 days was higher in the MPA group than the TED + IPC group (P = .05), which corresponded to large change in TED + IPC weight of 6.2 kg vs 2.1 kg in the MPA group (P = .04). Patients were more satisfied with the use of the MPA device than TED + IPC. No major complications were encountered in either group. CONCLUSIONS: This is the first study to show that the use of an MPA device in the immediate postoperative period following kidney transplant leads to decreased lower limb edema and increased total urine output. Patients were more satisfied with the use of the MPA device than TED + IPC.

Endovenous Laser Ablation with 1,470-nm Diode with Tumescence Anesthesia and Saphenofemoral Ligation: Propensity Score Match Comparison.

BACKGROUND: The aim of this study is to compare 2 groups of patients treated for great saphenous vein (GSV) reflux with open surgical saphenofemoral ligation (SFL) and endovenous laser ablation (EVLA). METHODS: Consecutive patients with primary unilateral GSV reflux undergoing EVLA treatment since 2014 were enrolled, and another series of patients treated with SFL was considered. The patients were stratified according to treatment and the results were compared using the propensity score (1:1). The covariables were age, gender, body mass index, CEAP (Clinical class, Etiology, Anatomy and Pathophysiology) staging, and GSV and saphenofemoral junction diameters. Primary outcomes were GSV occlusion or recurrent groin varicose veins at 1 year after treatment. Secondary outcomes included vein thrombosis, hyperpigmentation, paresthesia, postoperative pain, analgesic requirement, and ecchymosis assessed at discharge and CEAP stage and quality of life (QoL) assessment 1 month after surgery. RESULTS: A total of 123 patients were included in the study: 59 were treated with EVLA and 64 with SFL. At 12 months, we observed 10 recurrent groin varicose veins after SFL (15.6%) and 6 GSV recanalization after EVLA (10.2%, P = 0.369). Extra-saphenous recurrent varicose veins were observed in 36 patients (29.3%): 20 in the open group (31.2%) and 16 in EVLA group (27.1%, P = 0.615). After matching procedure 74 patients were analyzed (37 patients by group), logistic regression model showed that the risk of outcome was not associated with the surgical treatment (odds ratio 1.76, 95% confidence interval 0.52-6.01). CONCLUSIONS: Both techniques to treat saphenous impairment have demonstrated to be safe, with good results in terms of efficacy and symptomatic improvement at follow-up. EVLA with 1,470 nm seems to have lower rates of recurrence and good perceived QoL. Tumescent anesthesia is a good option with good results and may be extended to open surgical ligation.

Treatment of deep vein thrombosis with rivaroxaban and its potential to prevent the post-thrombotic syndrome.

BACKGROUND: The study was initiated following the observation of complete recanalization of thrombus in subjects with DVT treated with rivaroxaban after 1-2 weeks. The aim of this observational retrospective study was to evaluate clinically and by means of echo color Duplex, the fibrinolytic effect of rivaroxaban in patients with recent and previous DVT. To accomplish this two populations of patients were evaluated. METHODS: Group 1 was comprised of 31 patients (ranging in age 52-73 years) with popliteal-femoral DVT (12 months ago) treated with standard anticoagulant therapy. In these patients, we found a complete superficial femoral recanalization and partial recanalization of the popliteal vein (30% of residual thrombus). The patients had normal creatinine clearance and liver function. The patients were switched from warfarin to rivaroxaban due to a lack of compliance with warfarin therapy. Group 2 was comprised of 22 patients (ranging in age 65-82 years) with previous popliteal-femoral DVT and documented complete common femoral veins recanalization who presented with a recent superficial femoral vein re-thrombosis (1 week before). The patients had normal creatinine clearance and liver function. The patients switched from warfarin to rivaroxaban due to a lack of compliance with warfarin therapy. RESULTS: In group 1, all patients exhibited the complete recanalization of the popliteal veins after 4 weeks of rivaroxaban therapy. In group 2, all patients exhibited the complete recanalization of the popliteal veins after 4 weeks, and the complete recanalization of the acute re-thrombosis of the superficial femoral veins after 2 weeks of rivaroxaban therapy. No adverse events for both groups were observed. CONCLUSIONS: Our results suggest that rivaroxaban could have a pro-fibrinolytic effect not only on recent thrombus but also on organized thrombus that results in a complete recanalization of affected veins. It is proposed that this lytic effect will preserve venous valve structure and lead to a reduction of incidence of post-thrombotic syndrome in rivaroxaban treated patients.

Autologous blood reinfusion during iatrogenic acute hemorrhagic cardiac tamponade: Safety and feasibility in a cohort of 30 patients.

BACKGROUND: Iatrogenic hemorrhagic pericardial tamponade (IHPT) represents a life-threating condition requiring emergency pericardiocentesis. In this clinical context, reinfusion of pericardial blood can stabilize the patient and sustain hemodynamic conditions. AIMS AND METHODS: We reviewed all cases of IHPT occurred at our hospital over a 10 years span. In all patient autologous blood reinfusion through a femoral vein was performed. RESULTS: In our clinical experience of 30 consecutive patients with hemorrhagic cardiac tamponade, this technique was successful to limit blood transfusions, to prevent further clinical worsening and bridge patients with intractable bleeding, to cardiac surgery. No major adverse reactions were directly related to blood autotransfusion. CONCLUSION: In the complex clinical scenario of acute tamponade occurring during catheter-based cardiac procedures, autotransfusion of pericardial blood through a femoral vein is safe and effective. It can be a useful trick up the sleeve of the interventional cardiologist.

Feasibility of complex transfemoral electrophysiology procedures in patients with inferior vena cava filters.

BACKGROUND: The presence of inferior vena cava filters (IVCFs) has been considered a relative contraindication to electrophysiology (EP) procedures that require transfemoral venous placement of multiple catheters and/or long sheaths. There are inadequate data related to complex EP procedures in this population. OBJECTIVE: The purpose of this study was to describe the experience of a single high-volume center with respect to complex EP procedures in patients with IVCFs. METHODS: Patients with IVCFs undergoing complex EP procedures between 2004 and 2018 were identified. Clinical characteristics, IVCF type, procedural findings, and complications were analyzed. RESULTS: Fifty complex ablation procedures were performed in 40 patients (mean age 63.8 ± 10.9 years; 68% men). The mean IVCF dwell time was 69.1 ± 19.1 months, and 48 patients (96%) were on chronic oral anticoagulation. Procedures included ablation of atrial fibrillation (n = 21), ventricular tachycardia (n = 20), supraventricular tachycardia (n = 3), cavotricuspid isthmus flutter (n = 3), supraventricular tachycardia and cavotricuspid isthmus flutter (n = 1), and transvenous lead extraction (n = 3). Twenty procedures included quadripolar catheters (mean 1.4 ± 0.75), and 33 procedures involved deflectable decapolar catheters (mean 1.7 ± 0.47). Long sheaths were used in 35 cases (mean 1.63 ± 0.49) and intracardiac echocardiography in 38. In 4 cases (involving 3 patients), the IVCF was occluded and could not be crossed. There were no procedural complications related to the IVCF. CONCLUSION: The substantial majority of IVCFs in patients presenting for complex EP procedures were patent and easily crossed under fluoroscopic guidance. The presence of an IVCF should not discourage operators from performing procedures that require transfemoral deployment of multiple catheters and/or sheaths.

Rivaroxaban or vitamin-K antagonists following early endovascular thrombus removal and stent placement for acute iliofemoral deep vein thrombosis.

BACKGROUND: The optimal anticoagulant following catheter-based therapy of acute iliofemoral deep vein thrombosis (IFDVT) is unknown. METHODS: From the Swiss Venous Stent registry, an ongoing prospective cohort study, we performed a subgroup analysis of patients with acute IFDVT who underwent catheter-based early thrombus removal followed by nitinol stent placement. Duplex ultrasound and Villalta scores were used to determine patency rates and incidence of the post-thrombotic syndrome (PTS) in patients treated with either rivaroxaban (n = 73) or a vitamin K-antagonist (VKA; n = 38) for a minimum duration of 3 months. RESULTS: Mean follow-up duration was 24 ±â€¯19 months (range 3 to 77 months). Anticoagulation therapy was time-limited (3 to 12 months) in 56% of patients (47% in the rivaroxaban group and 58% in the VKA group, p = 0.26), with shorter mean duration of anticoagulation in the rivaroxaban group (180 ±â€¯98 days versus 284 ±â€¯199 days, p = 0.01). Overall, primary and secondary patency rates at 24 months were 82% (95%CI, 71-89%) and 95% (95%CI, 87-98%), respectively, with no difference between the rivaroxaban (87% [95%CI, 76-94%] and 95% [95%CI, 85-98%]) and the VKA group (72% [95%CI, 52-86%] and 94% [95%CI, 78-99%]; p > 0.10 for both). Overall, 86 (86%) patients were free from PTS at latest follow-up, with no difference between the rivaroxaban and the VKA groups (57 [85%] versus 29 [88%]; p = 0.76). Two major bleeding complications (1 in each group) occurred in the peri-interventional period, without any major bleeding thereafter. CONCLUSIONS: In patients with acute IFDVT treated with catheter-based early thrombus removal and venous stent placement, the effectiveness and safety of rivaroxaban and VKA appear to be similar. CLINICAL TRIAL REGISTRATION: The study is registered on the National Institutes of Health website (ClinicalTrials.gov; identifier NCT02433054).

Pilot study evaluating the efficacy of exergaming for the prevention of deep venous thrombosis.

OBJECTIVE: Current prophylactic protocols fail to prevent deep venous thrombosis (DVT) in a significant minority of patients, and it remains one of the leading causes of preventable death. We therefore quantified the efficacy of novel game-based exercises (exergaming) to augment femoral venous parameters relative to ankle movement and muscle flexion. METHODS: Healthy volunteers were recruited to perform a series of ankle and foot exercises using a wireless foot sensor (LEGSys; BioSensics LLC, Watertown, Mass) to navigate a computer cursor sequentially on a screen to the center of 200 circular targets. A single ultrasound technician (W.A.M.) measured each patient's mean flow volume, peak flow velocity, mean flow velocity, and cross-sectional area of the right femoral vein at baseline and obtained immediate postexercise (PEX), 5-minute PEX, and 15-minute PEX measurements. Electromyography (EMG) was performed at baseline and during the exercise. Baseline demographics and medical and surgical comorbidities were also recorded. The primary end point was the difference between baseline and immediate PEX mean flow volume estimates. We secondarily explored the association of baseline characteristics and EMG measurements with femoral vein parameters. RESULTS: Fifteen healthy subjects (53% male; 28.1 ± 4.6 years) completed the exergaming task within a mean of 4 minutes, 2 ± 21 seconds. Immediately after exercise, the femoral vein mean flow volume, mean velocity, and peak systolic velocity increased by 49%, 53%, and 48%, respectively (P < .02 for each). Mean flow volume and velocity remained significantly elevated 5 minutes after exercise (P < .04 for each). Plantar flexion and dorsiflexion velocities and EMG frequency and intensity were not significantly correlated with PEX mean flow volume estimates (P > .05). Subgroup analysis revealed that women (P < .01) and Hispanics (P < .01) exhibited significantly slower PEX responses. Subjects with the largest improvements in mean flow volume had lower peak plantar flexion velocities (P < .01). CONCLUSIONS: Exergaming increases mean flow volume, mean flow velocity, and peak systolic velocity within the femoral vein by approximately 50% above baseline. Exergaming represents a novel and potentially attractive method of DVT prevention by augmenting femoral vein mean volume flow and capitalizing on biofeedback. Less forceful but more uniform contractions were found to be most effective at augmenting venous blood flow. Exergaming will require further validation in larger study bases, among patients at higher risk of DVT.

One-year results of the use of endovenous radiofrequency ablation utilising an optimised radiofrequency-induced thermotherapy protocol for the treatment of truncal superficial venous reflux.

Background In previous in vitro and ex vivo studies, we have shown increased thermal spread can be achieved with radiofrequency-induced thermotherapy when using a low power and slower, discontinuous pullback. We aimed to determine the clinical success rate of radiofrequency-induced thermotherapy using this optimised protocol for the treatment of superficial venous reflux in truncal veins. Methods Sixty-three patients were treated with radiofrequency-induced thermotherapy using the optimised protocol and were followed up after one year (mean 16.3 months). Thirty-five patients returned for audit, giving a response rate of 56%. Duplex ultrasonography was employed to check for truncal reflux and compared to initial scans. Results In the 35 patients studied, there were 48 legs, with 64 truncal veins treated by radiofrequency-induced thermotherapy (34 great saphenous, 15 small saphenous and 15 anterior accessory saphenous veins). One year post-treatment, complete closure of all previously refluxing truncal veins was demonstrated on ultrasound, giving a success rate of 100%. Conclusions Using a previously reported optimised, low power/slow pullback radiofrequency-induced thermotherapy protocol, we have shown it is possible to achieve a 100% ablation at one year. This compares favourably with results reported at one year post-procedure using the high power/fast pullback protocols that are currently recommended for this device.

[Clinical efficacy of electric stimulation of crural muscles in comprehensive treatment of post-thrombotic disease]. / Klinicheskaia éffektivnost' élektricheskoi stimuliatsii myshts goleni v kompleksnom lechenii posttromboticheskoi bolezni.

The purpose of the study was to evaluate clinical efficacy of electromyostimulation (EMS) of the crural muscles as part of comprehensive therapy for post-thrombotic disease in patients with residual venous obstruction in the femoropopliteal segment. We carried out a prospective comparative clinical study enrolling patients having endured a fist episode of clinically unprovoked venous thrombosis of the femoropopliteal segment and completed the standard 6-month course of anticoagulant therapy and presenting with ultrasonographic signs of complete recanalization of the proximal venous segments (stenosis of 20% and more from the vessel's initial diameter), as well as scoring 5 points and more by the Villalta scale. The study included a total of 60 patients (38 men and 22 women, mean age 58.5±11.4 years) subdivided into two groups consisting of 30 patients each. Patients of both the Study and Control Groups underwent comprehensive therapy including wearing a compression knee sock (23-32 mmHg), a course phlebotrophic drugs, and dosed walking (not less than 5,000 steps a day). The Study Group patients were additionally subjected to daily electrical stimulation of the crural muscles with the "Veinoplus VI" unit (three 30-minute sessions a day). The duration of the follow up amounted to 12 months. The criteria for assessing therapeutic efficacy were as follows: severity of the disease by the VCSS and Villalta scales, quality of life as assessed by the CIVIQ-20 questionnaire, and lack of relapses of the venous thrombus. Clinical and instrumental assessment of the patients' condition was carried out monthly, with the disease's severity and quality of life assesses each 6 months. Relapses of venous thrombosis were registered in 7 (23.3%) patients from the Control Group and were not observed in patients undergoing EMS (p=0.011). In 5 cases, thrombosis was asymptomatic and in 4 cases it was presented by reocclusion of the involved venous segments. Patients of the Study Group were found to have a decrease in the disease's severity, reflected in points: VCSS (9.9±1.6 - 7.8 ± 1.6 - 6.1±1.5 (p <0.0001)); Villalta scale (18.9±3.9 - 12.8±4.0 - 8.3±2.7 (p<0.0001)); CIVIQ-20 score (67.8±8.4 - 51.3±8.4 - 40.0±10.5 (p<0.001)). The Control Group patients showed a similar tendency for the disease's severity: 8.1±2.8 - 7.3±2.1 - 7.2±2.1 points by the VCSS (p=0.014); 12.7±6.7 - 10.9±5.6 - 10.2±5.4 points by the Villalta scale (p=0.002), but not for quality of life: 48.2±19.3 - 46.7±17.3 - 47.4±16.2 points by the CIVIQ-20 (p>0.05). On the background of using EMS, the alterations in the studied parameters were characterized by higher velocity and intensity (p<0.05). The use of electromyostimulation as part of comprehensive treatment for post-thrombotic disease makes it possible to efficiently eliminate both subjective and objective signs of venous insufficiency, improve patients' quality of life and decrease the risk for the development of relapsing venous thrombosis.

Elimination of CT-detected gas bubbles derived from decompression illness with abdominal symptoms after a short hyperbaric oxygen treatment in a monoplace chamber: a case report.

We report the case of a 54-year-old male compressed-air worker with gas bubbles detected by computed tomography (CT). He had complained of strong abdominal pain 30 minutes after decompression after working at a pressure equivalent to 17 meters of sea water for three hours. The initial CT images revealed gas bubbles in the intrahepatic portal vein, pulmonary artery and bilateral femoral vein. After the first hyperbaric oxygen treatment (HBO2 at 2.5 atmospheres absolute/ATA for 150 minutes), no bubbles were detected on repeat CT examination. The patient still exhibited abdominal distension, mild hypesthesia and slight muscle weakness in the upper extremities. Two sessions of U.S. Navy Treatment Table 6 (TT6) were performed on Days 6 and 7 after onset. The patient recovered completely on Day 7. This report describes the important role of CT imaging in evaluating intravascular gas bubbles as well as eliminating the diagnosis of other conditions when divers or compressed-air workers experience uncommon symptoms of decompression illness. In addition, a short treatment table of HBO2 using non-TT6 HBO2 treatment may be useful to reduce gas bubbles and the severity of decompression illness in emergent cases.

Venous Thrombosis After Electrophysiology Procedures: A Systematic Review.

BACKGROUND: Femoral venous access for catheter introduction represents the cornerstone of electrophysiology (EP) procedures. Limited data are available regarding postprocedure VTE. The aim of this systematic review is to determine the incidence of DVT and pulmonary embolism (PE) associated with femoral vein catheterization during EP procedures. METHODS: An electronic search was conducted for studies documenting the incidence of DVT and PE after EP procedures. Studies were classified as atrial fibrillation (AF) or non-AF ablation procedures. RESULTS: Two thousand eight-hundred sixty-four studies were evaluated, 16 of which were included in the analysis. The incidence of DVT after AF and non-AF ablations reached as high as 0.33% and 2.38%, respectively, with a pooled incidence of 0% (95% CI, 0%-0.0003%) and 0.24% (95% CI, 0.08%-0.39%), respectively. The incidence of PE was 0.29% after AF ablation and ranged from 0% to 1.67% for non-AF procedures; the pooled incidence after non-AF ablations was 0.12% (95% CI, 0%-0.25%). Asymptomatic DVT was documented in up to 21.2% of patients. Hematomas occurred in 1.05% of AF ablations (95% CI, 0.30%-1.8%) and 0.3% of non-AF ablations (95% CI, 0.09%-0.51%). CONCLUSIONS: A lower incidence of symptomatic DVT and PE was observed after AF ablations as opposed to non-AF ablations, likely due to the use of routine periprocedural anticoagulation. Asymptomatic DVTs appear to be common, although their significance is unclear. Future studies are required to weigh the risk of hematoma against the risk of VTE associated with the use of prophylactic anticoagulation after non-AF ablation procedures.

[Endovascular treatment of acute iliofemoral deep venous thrombosis - our results with catheter-directed thrombolysis and AngioJet]. / Az akut proximális mélyvénás thrombosis endovascularis kezelése ­ a lokális katéteres lysissel és az AngioJet-tel szerzett tapasztalataink.

INTRODUCTION: Most of the patients with iliofemoral thrombosis treated with anticoagulants only are affected with postthrombotic syndrome (PTS) that worsens the patients' quality of life. In the acute phase of proximal deep venous thrombosis (DVT) catheter-directed (CDT) and pharmacomechanical thrombolysis may be a reasonable alternative therapeutic method. Our aim was to summarize our results using these methods. METHODS: Since 2009 twenty-four patients with iliofemoral DVT were treated with these endovascular procedures and with stenting at our Institution. RESULTS: The median age of the patients was 35.83 ± 15.9 years, the female: male ratio was approximately 2:1. The mean time between the onset of the symptoms and the procedures was eleven days. CDT alone was performed in 8 patients, thrombus aspiration in addition to CDT using AngioJet device in 16 patients; in 19 cases the procedure was completed with venous stenting. During the follow-up we performed US examinations and estimated the severity of PTS by Villalta-scale. The total recanalization-rate was more than 50%, which even improved during the follow-up. The total lysis time and the amount of used recombinant tissue plasminogen activator decreased significantly by applying the AngioJet. We did not find any severe PTS among our patients during the follow-up visits. CONCLUSION: Our data suggests that these methods can be used efficiently and safely in the treatment of acute iliofemoral DVT.

How to achieve ultrasound-guided femoral venous access: the new standard of care in the electrophysiology laboratory.

PURPOSE: Bedside vascular ultrasound machines are increasingly available. They are used to facilitate safer vascular access across a number of different specialties. In the electrophysiology laboratory however, where patients are frequently anticoagulated and require the insertion of multiple venous sheaths, anatomical landmark techniques predominate. Despite the high number of vascular complications associated with electrophysiological procedures and the increasing evidence to support its use in electrophysiology, ultrasound remains underutilised. A new standard of care is required. A comprehensive technical report, providing a detailed explanation of this important technique, will provide other electrophysiology centres with the knowledge and justification for adopting ultrasound guidance as their standard practice. METHOD: We review the increasing body of evidence which demonstrates that routine ultrasound usage can substantially improve the safety of femoral venous access in the electrophysiology laboratory. We offer a comprehensive technical report to guide operators through the process of ultrasound-guided venous access, with a specific focus on the electrophysiology laboratory. Additionally, we detail a novel technique which utilises real-time colour Doppler ultrasound to accurately identify needle tip location during venous puncture. CONCLUSIONS: The use of vascular ultrasound to guide femoral venous cannulation is rapid, inexpensive and easily learnt. Ultrasound is readily available and offers the potential to significantly reduce vascular complications in the unique setting of the electrophysiology laboratory. Ultrasound guidance to achieve femoral venous access should be the new standard of care in electrophysiology.

Ultrasound-guided cannulation of the femoral vein in electrophysiological procedures: a systematic review and meta-analysis.

AIMS: In an effort to minimize periprocedural stroke risk, increasingly, electrophysiological (EP) procedures are being performed on anticoagulation. The decrease in stroke has been accompanied by an increase in potentially devastating vascular access complications. Ultrasound guidance for femoral vein cannulation reduces complications in other applications. The aim of this study is to determine the utility of real-time two-dimensional (2D) ultrasound guidance for femoral vein cannulation in EP. METHODS AND RESULTS: A comprehensive literature search of Medline, Embase, Google Scholar, and the Cochrane Central Register of Controlled Trials was performed. Five years of conference abstracts from the Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society were reviewed. Two independent reviewers identified trials comparing ultrasound-guided with standard cannulation in EP procedures. Data were extracted on study design, study size, operator and patient characteristics, use of anticoagulation, vascular complication rates, first-pass success rate, and inadvertent arterial puncture. Four trials, with a total of 4065 subjects, were included in the review, with 1848 subjects in the ultrasound group and 2217 subjects in the palpation group. Ultrasound guidance for femoral vein cannulation was associated with a 60% reduction of major vascular bleeding (relative risk, 0.40; 95% confidence interval, 0.28-0.91). Additionally, there was a 66% reduction in minor vascular complications (relative risk, 0.34; 95% confidence interval, 0.15-0.78). CONCLUSION: The use of real-time 2D ultrasound guidance for femoral vein cannulation decreases access-related bleeding rates and life-threatening vascular complications.