[Endovascular treatment of a patient with post-thrombotic disease and obstruction of a cava filter]. / Éndovaskuliarnoe lechenie bol'nogo s posttromboticheskoi bolezn'iu i obstruktsiei kava-fil'tra.

Balloon angioplasty and stenting have increasingly been gaining widespread application for treatment of post-thrombotic alterations in the system of the vena cava. Endovascular ultrasonographic examination makes it possible with the utmost degree of reliability to determine both the extension and degree of the narrowing of venous segments, thus proving a possibility of choosing a venous stent of an appropriate diameter. Restoration of an adequate venous lumen leads to normalization of blood flow and elimination of venous hypertension. However, unsolved as yet remains the problem concerning proper management of post-thrombotic obstructions of the inferior vena cava at the level of a cava filter. Owing to a wide variety of configurations of cava filters to deploy, there are no common approaches to elimination of such obstruction. Presented herein is a clinical case report regarding successful endovascular treatment of a patient diagnosed with post-thrombotic disease secondary to endured thrombosis. The findings of both phlebography and endovascular ultrasonographic examination made it possible to diagnose obstruction of the left common iliac vein, external iliac vein, and inferior vena cava to the level of the cava filter previously deployed. In the segment of the inferior vena cava at the level of the cava filter also revealed was a pronounced luminal narrowing exceeding 90% of its diameter. We carried out stenting of the common and external iliac veins, inferior vena cava, and the cava filter. Swelling of the left leg subsided spontaneously within 2 weeks and the first postoperative month was accompanied by gradual disappearance of the previously existing feeling of heaviness in the lower limbs and a dramatic decrease in fatigue by the end of the working day.

[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.

Device-based Therapy for Hypertension.

Hypertension continues to be a major contributor to global morbidity and mortality, fuelled by an abundance of patients with uncontrolled blood pressure despite the multitude of pharmacological options available. This may occur as a consequence of true resistant hypertension, through an inability to tolerate current pharmacological therapies, or non-adherence to antihypertensive medication. In recent years, there has been a rapid expansion of device-based therapies proposed as novel non-pharmacological approaches to treating resistant hypertension. In this review, we discuss seven novel devices-renal nerve denervation, baroreflex activation therapy, carotid body ablation, central iliac arteriovenous anastomosis, deep brain stimulation, median nerve stimulation, and vagal nerve stimulation. We highlight how the devices differ, the varying degrees of evidence available to date and upcoming trials. This review also considers the possible factors that may enable appropriate device selection for different hypertension phenotypes.

Combination of factor Xa inhibition and antiplatelet therapy after stenting in patients with iliofemoral post-thrombotic venous obstruction.

OBJECTIVES: Studies addressing optimal postprocedural pharmacological management after endovascular stenting of iliofemoral post-thrombotic venous obstruction are lacking. We report our early clinical experience with a combination of rivaroxaban and clopidogrel in patients after iliofemoral post-thrombotic venous obstruction stenting. METHODS: Demographic, procedural, and follow-up data of nine patients (seven women; mean age of 32 ± 11 years) undergoing 10 procedures for iliofemoral post-thrombotic venous obstruction performed between August 2012 and January 2014 were retrospectively reviewed. After endovascular intervention, all patients were administered 20 mg rivaroxaban once daily (s.i.d.) and 75 mg clopidogrel s.i.d. or every second day depending on the individual drug responsiveness for at least six months. The adenosine diphosphate-induced platelet aggregation (platelet aggregation, in aggregation units × min) was assessed on a Multiplate analyzer. Patency was verified venographically at procedure end and was evaluated with duplex ultrasound in regular follow-ups. RESULTS: Iliofemoral venous flow was successfully re-established by percutaneous endovascular angioplasty and stent implantation in nine left-sided and one bilateral iliofemoral post-thrombotic venous obstruction. Under dual treatment strategy of rivaroxaban and clopidogrel with platelet aggregation control (median (range): 285 aggregation units × min (192; 402)), none of the patients experienced restenosis or stent thrombosis, respectively. After a median follow-up of 14 months (range: 6-26 months), the primary patency rate was 100% and no in-stent restenosis, stent occlusion or relevant minor or major bleeding occurred. CONCLUSION: Combined factor Xa inhibition and tailored antiplatelet therapy after stenting of iliofemoral post-thrombotic venous obstruction were safe and performed favorably in terms of vessel patency.

[Resection of the Right External Iliac Artery and Vein after Local Recurrence of Cecal Cancer].

A 62-year-old woman was admitted with abdominal pain and distention in July 2013. Computed tomography (CT) revealed a small bowel obstruction caused by an ileocecal tumor, and colonoscopy revealed a type 3 cecal tumor. Because an ileus tube was not effective to relieve her symptoms, she was transferred to the Department of Surgery for an emergency operation. Open resection of the ileocecal tumor along with the right ureter and psoas was performed. Histological examination showed that cancer cells were present in the radial margin. The patient was treated with a post-operative course of chemotherapy (capecitabine and oxaliplatin), but the level of carcinoembryonic antigen was increasing; positron emission tomography (PET) revealed a local cancer recurrence. Although the right external iliac artery and reconstructed right ureter were encased by the tumor, there were no signs of lymph node metastasis or distant metastasis. Because the tumor was localized, we decided to perform a re-excision. Intraoperatively, the right external iliac vein was difficult to separate from the tumor. Therefore, we resected the right ureter, kidney, and right external iliac artery and vein en bloc. The right external iliac artery and vein were replaced with grafts. Histopathologically, the reconstructed right ureter was completely invaded by the tumor, and cancer cells had invaded the nearby adventitia of the artery, but the surgical margin was negative. Four months after the second operation, peritoneal dissemination was detected on PET. The patient was followed-up in an outpatient clinic without chemotherapy.

Alternative cannulation strategy for pediatric ECMO.

Vascular access in children who require extracorporeal membrane oxygenation (ECMO) support can be a challenging endeavor particularly in those who have undergone prior median sternotomies or interventional procedures. We present an alternative cannulation strategy that can be utilized in pediatric patients requiring ECMO that involves utilization of the iliac vein via a retroperitoneal approach.

Whole blood intra-operative salvage and reinfusion in patients undergoing venous thrombectomy.

Concern regarding the risk of disease transmission via blood transfusion together with periodic shortages of homologous blood has stimulated an interest in and the usage of autologous blood. Forty-nine patients had shed blood salvaged during venous thrombectomy. Between 200-3800 ml of blood were salvaged and reinfused using Solcotrans. No patient in this study required an homologous blood transfusion. The haematological parameters studied showed figures within the normal, acceptable range post-reinfusion. No patient experienced a clinical coagulopathy or showed evidence of renal dysfunction. The device is simple to use, safe and effective.

Shifts in external iliac venous pressure under local and general anaesthesia. Their impact on the tactics of venous thrombectomy in iliofemoral thrombosis.

The authors measured the venous pressure in the iliofemoral segment in 12 patients in good general conditions, with a normal patency of the inferior caval vein, profound pelvic veins, and lower limb veins. Examination was performed with Claudy manometer. The resting venous pressure in the external iliac vein was 40--75 mm H2O = 3--5.5 mmHg. During Valsalva's manoeuvre the patients achieved an overpressure 250--1 100 mm H2O = 18--81 mmHg for 20 s. After induction of general anaesthesia and intubation, the anaesthesiologist produced an overpressure of 50 cm H2O in the patient's respiratory circuit for 20 s, but the venous pressure rose only to 90--175 mm H2O = 7-- mmHg. This rise is lesser with a high statistical significance than the overpressure produced in the Valsalva's manoeuvre. In the light of these results the authors discuss the tactics of venous thrombectomy. As a safe prevention of peroperative uplmonary embolism they regard either Valsalva's manoeuvre, carried out under local anaesthesia, or a tourniquet fixation of the clot head during the surgical intervention under general anaesthesia. The anaesthesiologist cannot prevent embolism by restriction of the venous return by producing an overpressure in the respiratory circuit of a patient under general anaesthesia.

[Indications and technics of the surgical treatment in iliaco-femoral thrombophlebitis in the acute phase]. / Indicazioni e tecnica nella terapia chirurgica delle flebotrombosi iliaco-femorali in fase acuta

A personal technique employed in the successful resolution of a case of iliacofemoral phlebothrombosis is described. Attention is drawn to the indications for this type of operation. The technique is not traumatic and can be easily performed, particularly with the aid of a Fogarty catheter. The results obtainable as far as the prevention of lung embolism and postphlebitic syndromes are concerned are also described.