Percutaneous Transluminal Angioplasty Alleviate Pediatric Postthrombotic Syndrome: A Case Report and Literature Review.

PURPOSE: Postthrombotic syndrome (PTS) is one of the long-term sequelae of deep vein thrombosis (DVT), and effective symptom management in pediatric PTS remains a challenge, with interventional therapy rarely explored in this population. We present a successful case of interventional treatment pediatric PTS, resulting in a remarkable amelioration of her symptoms. CASE REPORT: This case features a 6-year-old girl diagnosed with hyperinsulinemia, leading to a hypoglycemic coma. Following a mini-pancreatic partial pancreatectomy, she required further intensive care in the pediatric intensive care unit. It was during this period that left lower extremity DVT was identified, prompting warfarin anticoagulation therapy. During the anticoagulation period, she had several bleeding events and was switched to anticoagulation with low molecular heparin. One month later, the left common iliac vein and external iliac vein was found to be completely occluded. Over time, she experienced a gradual onset of lower limb swelling and pain, which, after 6 months, was accompanied by perineal edema and venous claudication. As a result, she underwent successful percutaneous transluminal angioplasty. In addition, the anticoagulation regimen was adjusted to rivaroxaban. At the 8-month follow-up, we observed significantly improvement in her postoperative lower extremity swelling and symptoms related to venous occlusion had completely disappeared. Moreover, vascular imaging confirmed improvement in stenosis and uninterrupted blood flow. CONCLUSIONS: In our review of pediatric PTS studies, we observed limited options to alleviate symptoms, and interventional treatments have not been reported. Our case study, demonstrating the safe and effective use of percutaneous transluminal angioplasty, helps to illuminate this area and alleviate pediatric PTS symptoms. CLINICAL IMPACT: This case validates the efficacy and safety of using percutaneous transluminal angioplasty (PTA) for the treatment of postthrombotic syndrome (PTS) in pediatric patients. This interventional approach offers significant symptomatic relief and improves quality of life, especially in cases where traditional anticoagulation therapies fail or lead to complications. The successful case presented emphasizes the necessity of considering endovascular interventions for children with moderate to severe PTS, particularly when conservative management is ineffective. This research underscores the potential for PTA to be adopted in clinical practice, offering a promising new approach for managing pediatric PTS.

Role of platelet count in a murine stasis model of deep vein thrombosis.

Platelets are core components of thrombi but their effect on thrombus burden during deep vein thrombosis (DVT) has not been fully characterized. We examined the role of thrombopoietin-altered platelet count on thrombus burden in a murine stasis model of DVT. To modulate platelet count compared to baseline, CD1 mice were pretreated with thrombopoietin antisense oligonucleotide (THPO-ASO, 56% decrease), thrombopoietin mimetic (TPO-mimetic, 36% increase), or saline (within 1%). Thrombi and vein walls were examined on postoperative days (POD) 3 and 7. Thrombus weights on POD 3 were not different between treatment groups (p = .84). The mean thrombus weights on POD 7 were significantly increased in the TPO-mimetic cohort compared to the THPO-ASO (p = .005) and the saline (p = .012) cohorts. Histological grading at POD 3 revealed a significantly increased smooth muscle cell presence in the thrombi and CD31 positive channeling in the vein wall of the TPO-mimetic cohort compared to the saline and THPO-ASO cohorts (p < .05). No differences were observed in histology on POD 7. Thrombopoietin-induced increased platelet count increased thrombus weight on POD 7 indicating platelet count may regulate thrombus burden during early resolution of venous thrombi in this murine stasis model of DVT.

Deep vein thrombosis (DVT) is a pathology in which blood clots form in the deep veins of our body. Usually occurring in the legs, these clots can be dangerous if they dislodge and travel to the heart and are pumped into the lungs. Often these clots do not travel and heal where they formed. However, as the body heals the clot it may also cause damage to the vein wall and predispose the patient to future clots, i.e., the biggest risk factor for a second clot is the first clot. DVT can also cause symptoms of pain, swelling, and redness in the long-term, leading to post-thrombotic syndrome where the initial symptoms of the clot persist for a long time. All blood clots have common components of red blood cells, white blood cells, platelets, and fibrin in varying concentrations. Humans maintain a platelet count between 150 and 400 thousand platelets per microliter of our blood. However, diseases like cancer or medications like chemotherapy can cause a change in our body's platelet count. The effect of a changing platelet count on the size (clot burden) of DVT clot and how platelet count could affect DVT as the clot heals is not fully understood. Studying this might help us develop better targets and treat patients with a wide range of platelet counts who experience DVT. In this study, we intentionally decreased, left unchanged, and increased platelet counts in mice and then created a DVT to study what the effect of low, normal, and high platelet counts, respectively, would be on the clot burden. We observed that mice with higher platelet counts had a higher clot burden during the early part of the healing process of the clot. Within this study, we can conclude that higher platelet counts may lead to higher clot burden in DVT which furthers our understanding of how platelet count affects clot burden during DVT.

Time-Restricted Salutary Effects of Blood Flow Restoration on Venous Thrombosis and Vein Wall Injury in Mouse and Human Subjects.

BACKGROUND: Up to 50% of patients with proximal deep vein thrombosis (DVT) will develop the postthrombotic syndrome characterized by limb swelling and discomfort, hyperpigmentation, skin ulcers, and impaired quality of life. Although catheter-based interventions enabling the restoration of blood flow (RBF) have demonstrated little benefit on postthrombotic syndrome, the impact on the acuity of the thrombus and mechanisms underlying this finding remain obscure. In experimental and clinical studies, we examined whether RBF has a restricted time window for improving DVT resolution. METHODS: First, experimental stasis DVT was generated in C57/BL6 mice (n=291) by inferior vena cava ligation. To promote RBF, mice underwent mechanical deligation with or without intravenous recombinant tissue plasminogen activator administered 2 days after deligation. RBF was assessed over time by ultrasonography and intravital microscopy. Resected thrombosed inferior vena cava specimens underwent thrombus and vein wall histological and gene expression assays. Next, in a clinical study, we conducted a post hoc analysis of the ATTRACT (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) pharmacomechanical catheter-directed thrombolysis (PCDT) trial (NCT00790335) to assess the effects of PCDT on Venous Insufficiency Epidemiological and Economic Study quality-of-life and Villalta scores for specific symptom-onset-to-randomization timeframes. RESULTS: Mice that developed RBF by day 4, but not later, exhibited reduced day 8 thrombus burden parameters and reduced day 8 vein wall fibrosis and inflammation, compared with controls. In mice without RBF, recombinant tissue plasminogen activator administered at day 4, but not later, reduced day 8 thrombus burden and vein wall fibrosis. It is notable that, in mice already exhibiting RBF by day 4, recombinant tissue plasminogen activator administration did not further reduce thrombus burden or vein wall fibrosis. In the ATTRACT trial, patients receiving PCDT in an intermediate symptom-onset-to-randomization timeframe of 4 to 8 days demonstrated maximal benefits in Venous Insufficiency Epidemiological and Economic Study quality-of-life and Villalta scores (between-group difference=8.41 and 1.68, respectively, P<0.001 versus patients not receiving PCDT). PCDT did not improve postthrombotic syndrome scores for patients having a symptom-onset-to-randomization time of <4 days or >8 days. CONCLUSIONS: Taken together, these data illustrate that, within a restricted therapeutic window, RBF improves DVT resolution, and PCDT may improve clinical outcomes. Further studies are warranted to examine the value of time-restricted RBF strategies to reduce postthrombotic syndrome in patients with DVT.

Antithrombotic Therapy After Venous Interventions: AJR Expert Panel Narrative Review.

Interventions for thrombotic and nonthrombotic venous disorders have increased with technical advances and more trained venous specialists. Antithrombotic therapy is essential to clinical and procedural success; however, postprocedural therapeutic regimens exhibit significant heterogeneity due to limited prospective randomized data and incomplete mechanistic understanding of the critical factors driving long-term patency. Postinterventional antithrombotic therapy for thrombotic venous disorders should adhere to existing venous thromboembolism management guidelines, which include 3-6 months of therapeutic anticoagulation at minimum and consideration of extended therapy in patients with higher risk of thrombosis because of procedural or patient factors. The added benefit of antiplatelet agents in the acute and intermediate period is unknown, having shown improved long-term stent patency in some retrospective studies. Dual- and/or triple-agent therapy should be limited based on individual risks of thrombosis and bleeding. The treatment of nonthrombotic disorders is more heterogeneous, though patients with limited flow, extensive stent material, or underlying prothrombotic states such as malignancy or chronic inflammation may benefit from single-agent or multiagent antithrombotic therapy. However, the agent, dose, and duration of therapy remain indeterminate. Future prospective studies are warranted to improve patient risk stratification and standardize postprocedural anti-thrombotic therapy in patients receiving venous interventions.

Venous Thromboembolism Research Priorities: A Scientific Statement From the American Heart Association and the International Society on Thrombosis and Haemostasis.

Venous thromboembolism is a major cause of morbidity and mortality. The impact of the US Surgeon General's The Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism in 2008 has been lower than expected given the public health impact of this disease. This scientific statement highlights future research priorities in venous thromboembolism, developed by experts and a crowdsourcing survey across 16 scientific organizations. At the fundamental research level (T0), researchers need to identify pathobiological causative mechanisms for the 50% of patients with unprovoked venous thromboembolism and to better understand mechanisms that differentiate hemostasis from thrombosis. At the human level (T1), new methods for diagnosing, treating, and preventing venous thromboembolism will allow tailoring of diagnostic and therapeutic approaches to individuals. At the patient level (T2), research efforts are required to understand how foundational evidence impacts care of patients (eg, biomarkers). New treatments, such as catheter-based therapies, require further testing to identify which patients are most likely to experience benefit. At the practice level (T3), translating evidence into practice remains challenging. Areas of overuse and underuse will require evidence-based tools to improve care delivery. At the community and population level (T4), public awareness campaigns need thorough impact assessment. Large population-based cohort studies can elucidate the biological and environmental underpinnings of venous thromboembolism and its complications. To achieve these goals, funding agencies and training programs must support a new generation of scientists and clinicians who work in multidisciplinary teams to solve the pressing public health problem of venous thromboembolism.

Endovascular management of the deep venous thrombosis: A new challenging role for the endovascular specialist in 2020.

Over the last years, the endovascular approach to the management of the acute and chronic deep vein thrombosis (DVT) has gained more and more attention from the scientific community. DVT is the third most common cardiovascular disease after coronary heart disease and stroke, with classic treatment based on anticoagulation. Recent evidences have highlighted the risk of postthrombotic syndrome as high as 30%-50% in proximal ilio-femoral lesions, with irreversible clinical symptoms and impact on the quality of life of the population. Since 2000s, the new concept of thrombus removal in the acute phase has been supported by the introduction of different techniques based on the endovascular ablation of the clot by in-situ fibrinolysis and, more recently, fragmentation and aspiration. In the chronic phase, recanalization of the thrombosed segment is recommended by stent placement to remove the obstruction and eventually reduce the congestion. Immediate technical success of these procedures is widely satisfying, whereas the long-term clinical benefits are still debated. This paper presents an overview of the modern management of the DVT by endovascular approach with regard to the clinical contexts, interventional strategies and clinical outcomes. Endovascular specialist needs to be aware of this incoming challenge, as local expertise is demanded for the modern management of these patients in multidisciplinary theaters.

Incidence and severity of postthrombotic syndrome after iliofemoral thrombosis - results of the Iliaca-PTS - Registry.

Background: Deep venous thrombosis (DVT) and in particular, iliofemoral thrombosis (IFT) can lead to recurrent thrombosis and postthrombotic syndrome (PTS). Data on the prevalence, predictors and outcome of IFT are scarce. Patients and methods: We retrospectively searched our database of outpatients who had presented with DVT and IFT including the iliac veins from 2014 until 2017. In addition, we performed a prospective registry in a subgroup of patients with IFT. These patients received duplex ultrasound, magnetic resonance venography and measurement of symptom-free walking distance using a standardized treadmill ergometry. The severity of PTS was analyzed using the Villalta-Scale (VS) and quality of life was assessed using the VEINES-QOL/Sym Questionnaire. Results: 847 patients were retrospectively identified with DVT and 19.7% (167/847) of these presented with IFT. 50.9% (85/167) of the IFT-patients agreed to participate in the prospective registry. The majority of these patients (76.5%: 65/85) presented with left-sided IFT. In 53.8% (35/65) May-Thurner syndrome was suspected. 27.1% (23/85) underwent invasive therapy. Moderate or severe PTS (VS ≥ 10) occurred in 10.6% (9/85). The severity of PTS is correlated with a reduced quality of life (ρ (CI 95%) = -0.63 (-0.76; -0.46); p < 0.01). None of the patients presented with a venous ulcer at any time. A high body mass index was a significant predictor (OR (CI 95%) = 1.18 (1.05; 1.33), p = 0.007) for the development of clinically relevant PTS (VS ≥ 10) and venous claudication. Conclusions: Every fifth patient with DVT presented with an IFT. The majority developed left sided IFT. Every 10th patient developed moderate or severe PTS (VS ≥ 10). A high body mass index was predictive for the development of PTS and venous claudication.

Can we predict and prevent the postthrombotic syndrome?

Postthrombotic syndrome (PTS) remains one of the major late complications of deep vein thrombosis (DVT) with a reported prevalence from 10 to 50%. Many factors were found to be related with the development and severity of PTS such as ipsilateral recurrent DVT, advanced age, obesity, ilio-femoral DVT and primary chronic venous disease presence. Some PTS prediction models have been proposed based on risk factor weight. However, it is still difficult to predict which patient with DVT will develop PTS and thus, the clinical application of these models remains limited. Among the identified problems the heterogeneity of the DVT patient population together with the variety of PTS clinical presentations and difficulties concerning PTS severity assessment should be mentioned. Difficulties on the implementation of the specific and objective PTS identification method have also the significant influence on the research focusing on PTS prevention modalities including risk factor modification, compression treatment, anticoagulation and invasive DVT treatment. In this review, the current approach and knowledge on PTS prediction and prevention are presented, including the conservative and invasive DVT treatment possibilities.

Endovascular Thrombus Removal for Acute Iliofemoral Deep Vein Thrombosis.

BACKGROUND: The ATTRACT trial (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) previously reported that pharmacomechanical catheter-directed thrombolysis (PCDT) did not prevent postthrombotic syndrome (PTS) in patients with acute proximal deep vein thrombosis. In the current analysis, we examine the effect of PCDT in ATTRACT patients with iliofemoral deep vein thrombosis. METHODS: Within a large multicenter randomized trial, 391 patients with acute deep vein thrombosis involving the iliac or common femoral veins were randomized to PCDT with anticoagulation versus anticoagulation alone (No-PCDT) and were followed for 24 months to compare short-term and long-term outcomes. RESULTS: Between 6 and 24 months, there was no difference in the occurrence of PTS (Villalta scale ≥5 or ulcer: 49% PCDT versus 51% No-PCDT; risk ratio, 0.95; 95% CI, 0.78-1.15; P=0.59). PCDT led to reduced PTS severity as shown by lower mean Villalta and Venous Clinical Severity Scores ( P<0.01 for comparisons at 6, 12, 18, and 24 months), and fewer patients with moderate-or-severe PTS (Villalta scale ≥10 or ulcer: 18% versus 28%; risk ratio, 0.65; 95% CI, 0.45-0.94; P=0.021) or severe PTS (Villalta scale ≥15 or ulcer: 8.7% versus 15%; risk ratio, 0.57; 95% CI, 0.32-1.01; P=0.048; and Venous Clinical Severity Score ≥8: 6.6% versus 14%; risk ratio, 0.46; 95% CI, 0.24-0.87; P=0.013). From baseline, PCDT led to greater reduction in leg pain and swelling ( P<0.01 for comparisons at 10 and 30 days) and greater improvement in venous disease-specific quality of life (Venous Insufficiency Epidemiological and Economic Study Quality of Life unit difference 5.6 through 24 months, P=0.029), but no difference in generic quality of life ( P>0.2 for comparisons of SF-36 mental and physical component summary scores through 24 months). In patients having PCDT versus No-PCDT, major bleeding within 10 days occurred in 1.5% versus 0.5% ( P=0.32), and recurrent venous thromboembolism over 24 months was observed in 13% versus 9.2% ( P=0.21). CONCLUSIONS: In patients with acute iliofemoral deep vein thrombosis, PCDT did not influence the occurrence of PTS or recurrent venous thromboembolism. However, PCDT significantly reduced early leg symptoms and, over 24 months, reduced PTS severity scores, reduced the proportion of patients who developed moderate-or-severe PTS, and resulted in greater improvement in venous disease-specific quality of life. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00790335.

Prevalence of venous obstructions in (recurrent) venous thromboembolism: a case-control study.

BACKGROUND: The role of venous obstructions as a risk factor for recurrent venous thromboembolism has never been evaluated. This study aimed to determine whether there is a difference in prevalence of venous obstructions between patients with and without recurrent venous thromboembolism. Furthermore, its influence on the development of post-thrombotic syndrome and patient-reported quality of life was assessed. METHODS: This matched nested case-control study included 32 patients with recurrent venous thromboembolism (26 recurrent deep-vein thrombosis and 6 pulmonary embolism) from an existing prospective cohort of deep-vein thrombosis patients and compared them to 24 age and sex matched deep-vein thrombosis patients without recurrent venous thromboembolism. All participants received standard post-thrombotic management and underwent an additional extensive duplex ultrasonography. Post-thrombotic syndrome was assessed by the Villalta-scale and quality of life was measured using the SF36v2 and VEINES-QOL/Sym-questionnaires. RESULTS: Venous obstruction was found in 6 patients (18.8%) with recurrent venous thromboembolism compared to 5 patients (20.8%) without recurrent venous thromboembolism (Odds ratio 0.88, 95%CI 0.23-3.30, p = 1.000). After a median follow-up of 60.0 months (IQR 41.3-103.5) the mean Villalta-score was 5.55 ± 3.02 versus 5.26 ± 2.63 (p = 0.909) and post-thrombotic syndrome developed in 20 (62.5%) versus 14 (58.3%) patients, respectively (Odds ratio 1.19, 95%CI 0.40-3.51, p = 0.752). If venous obstruction was present, it was mainly located in the common iliac vein (n = 7, 63.6%). In patients with an objectified venous obstruction the mean Villalta-score was 5.11 ± 2.80 versus 5.49 ± 2.87 in patients without venous obstruction (p = 0.639). Post-thrombotic syndrome developed in 6 (54.5%) versus 28 (62.2%) patients, respectively (Odds ratio 1.37, 95%CI 0.36-5.20, p = 0.736). No significant differences were seen regarding patient-reported quality of life between either groups. CONCLUSIONS: In this exploratory case-control study patients with recurrent venous thromboembolism did not have a higher prevalence of venous obstruction compared to patients without recurrent venous thromboembolism. The presence of recurrent venous thromboembolism or venous obstruction had no impact on the development of post-thrombotic syndrome or the patient-reported quality of life.

Patency rates, safety and clinical results of the sinus-Obliquus venous stent in the treatment of chronic ilio-femoral venous outflow obstruction - data from the Arnsberg venous registry.

Background: We sought to determine the patency and clinical symptom relief following the usage of the sinus-Obliquus venous stent in the endovascular treatment of venous obstruction of the ilio-femoral track in short-term. Patients and methods: 48 patients (62 % female, mean age 57 years) with chronic unilateral post-thrombotic obstruction (PTO) and non-thrombotic iliac vein obstructive lesions (NIVL) without involvement of inferior vena cava receiving a sinus-Obliquus venous stent was included in the analysis. Clinical improvement determined by the revised venous clinical severity score (rVCSS) as well as the clinical, etiologic, anatomic and pathophysiologic score (CEAP), safety, and stent patency rates were determined at baseline and at 1, 6 and 12 months after stent placement. Ten of the 48 included patients had a venous ulceration. Results: Primary patency rates were 98 % at FU1, 94 % at FU2 and 94 % at FU3, respectively. Secondary patency was 100 % at FU1, 96 % at FU2 and remained 96 % at FU3. At 12 months, the mean rVCSS dropped from 9.0 to 4.8 points (p < 0.001) whereas the mean CEAP improved from 3.45 to 2.96 (p < 0.001). A substantial healing of ulcerations was observed in 8 of 10 patients with initial venous ulceration. There were no relevant safety concerns noticed. Conclusions: Even though long-term studies are missing, the sinus-Obliquus venous stent already showed very promising patency rates at short term, associated with substantial clinical improvement and low device-related complications in both NIVL and PTS.

[Stent placement for filter-related chronic occlusion of the inferior vena cava].

Objective: To assess the technical success rate, stent patency, clinical efficacy and complications of stent placement for filter-related chronic occlusion of the inferior vena cava. Methods: A retrospective analysis was carried out for 12 patients with filter-related chronic occlusion of the inferior vena cava associated with severe post-thrombotic syndrome, who underwent stent placement after ineffective conservative therapy at Nanjing First Hospital from March 2016 to December 2018,9 males and 3 females, aged from 48 to 77 years, mean age 60 years, six had bilateral lower extremity symptoms and six had unilateral lower extremity symptoms.Technical success rate, stent patency, clinical efficacy and complications of stent placement were recorded. Clinical success was defined as relief of symptoms and a decrease in clinical, etiology, anatomy, and pathophysiology (CEAP) score for at least grade 1. Results: Stent placement in the unilateral or bilateral iliocaval occlusion was successful in 11 patients. The cause of technical failure in the single patient with failed stent placement was an inability to cross the occluded left iliacvein and the patient was treated with stent placement in the right iliocaval vein.There were 7 patients with inferior vena cava and unilateral iliocaval stent placement; 5 patients with inferior vena cava and bilateral iliocaval stent placement. Acute stent thrombosis occlusion occurred in 1 case after the operation, the blood flow recanalized after catheter-directed thrombolysis and re-stenting. All patients were followed up for 6 to 24 months, with an average of (13±6) months. During the follow-up period, CTV or venography of lower limbs showed that the blood flow in the stent was unobstructed. At the last follow-up, 12 patients were evaluated as clinically effective. Three patients had transient treatment of lateral lumbar pain during operation, which alleviated by themselves.No significant abdominal pain, severe hemorrhage, symptomatic pulmonary embolism and other complications related to treatment occurred in all patients during perioperative period and follow-up. Conclusion: Stent placement is safe and feasible in the treatment of filter-related chronic occlusion of the inferior vena cava, which can alleviate the clinical symptoms of severe post-thrombotic syndrome.

Standards for recanalisation of chronic venous outflow obstructions.

Postthrombotic syndrome (PTS) is the most common complication after iliofemoral deep vein thrombosis. It reduces quality of life and increases deep vein thrombosis (DVT)-related costs. The clinical symptoms and severity of PTS may vary; the most common symptoms include edema, pain (venous claudication), hyperpigmentation, lipodermatosclerosis, and ulceration. PTS is based on the principle of outflow obstruction, which may be caused by venous hypertension and may lead to valvular damage and venous reflux or insufficiency. Recent technical developments and new stent techniques now allow recanalisation of even complex venous outflow obstructions within the iliac vein and the inferior vena cava. This manuscript gives an overview on the latest standards for venous recanalisation.

Haemostaseological complication management in caval and iliac venous stenting.

Antiplatelet and anticoagulation therapy after venous stenting is still not standardized, data from randomized-controlled trials are missing. Rare prothrombotic disorders and nonresponsiveness to drugs must be taken into account. This case report demonstrates successful haemostaselogical complication management in recurrent rethromboses due to underlying clopidogrel resistance and low responsiveness to anticoagulation with dabigatran after endovascular stent reconstruction of chronic pelvic and caval vein occlusion in a patient with severe postthrombotic syndrome.

Patency and Clinical Outcomes of a Dedicated, Self-Expanding, Hybrid Oblique Stent Used in the Treatment of Common Iliac Vein Compression.

PURPOSE: To investigate the clinical outcomes of a dedicated hybrid oblique nitinol stent that has been specifically designed to treat common iliac vein compression. METHODS: The Bern Venous Stent Registry database was interrogated to identify all patients who had at least 6-month follow-up after treatment with the sinus-Obliquus hybrid stent for common iliac vein compression. The search identified 24 patients (mean age 39±18 years; 20 women) who matched the search criteria. Ten patients had postthrombotic syndrome (PTS), another 10 patients had acute iliofemoral thrombosis after catheter-directed therapy, and 4 patients had nonthrombotic iliac vein compression. Primary treatment success was defined as antegrade flow and stenosis <30% on venography and evidence of a spontaneous Doppler signal in the treated segment. Stent patency was assessed using duplex ultrasound. Clinical outcomes were evaluated using a clinical symptom score (Villalta) and the revised venous clinical severity score (rVCSS) at 3, 6, and 12 months in follow-up. RESULTS: Primary treatment success was achieved in all patients. Mean follow-up was 10±3 months. Primary patency estimates by Kaplan-Meier analysis were 92% at 6 months [95% confidence interval (CI) 71% to 98%] and 83% (95% CI 54% to 95%) at 10 months. Three symptomatic patients underwent reintervention for early and late stent thromboses and the third for in-stent restenosis, resulting in secondary patency of 100%. Overall, all patients had clinical improvement at the latest follow-up; 50% reported complete resolution of symptoms. In patients with PTS, the Villalta score decreased by 6±6 points (p=0.02) and the rVCSS score by 3±1 points (p=0.05). Among deep vein thrombosis patients, none developed PTS. CONCLUSION: In patients with common iliac vein compression, the oblique hybrid nitinol stent appears to provide excellent early patency and clinical outcomes.

A comparison of magnetic resonance venography findings and venous occlusion plethysmography variables in postthrombotic syndrome.

Objective The relation between venous morphology and venous function in postthrombotic syndrome is poorly understood. The aim of this study was to compare obstruction and collateralization as seen with magnetic resonance venography with variables of venous occlusion plethysmography in patients with postthrombotic syndrome. Methods Medical records, magnetic resonance venography and venous occlusion plethysmography data were analyzed in 28 patients (33 legs). Magnetic resonance venography images were scored for degree of obstruction and collateralization in segments of pelvic and abdominal veins and correlated to venous occlusion plethysmography data. Results Obstruction of the inferior vena cava correlated with an overall increase of collaterals ( p < 0.001). The summary scores of collaterals or obstructions did not correlate with venous occlusion plethysmography variables. Relative expelled volume at 4 s correlated inversely with obstruction of the inferior vena cava ( p = 0.045) and vertebral collateralization ( p = 0.033). Conclusions Modest correlations were found between magnetic resonance venography scores and venous occlusion plethysmography variables. Prospective studies with refined scoring and magnetic resonance venography techniques may increase our knowledge further.

[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.

Very long-term risk of moderate-to-severe postthrombotic syndrome after deep vein thrombosis.

BACKGROUND: Postthrombotic syndrome (PTS) refers to manifestations of chronic venous insufficiency after a deep vein thrombosis (DVT). The risk of developing moderate-to-severe PTS in the very long term is largely unknown and particularly in case of distal DVT. Furthermore, the impact of DVT vs other causes of chronic venous insufficiency on long-term manifestations of PTS is also unknown. OBJECTIVES: To assess the very long-term risk of moderate-to-severe PTS after DVT and the role that DVT plays in PTS symptoms. METHODS: Patients with lower-limb DVT enrolled in the multicenter Optimisation de l'interrogatoire dans l'evaluation du risque thromboembolique veineux (OPTIMEV) study underwent a very long-term telephone follow-up. We assessed i) the proportion of moderate-to-severe PTS (assessed with the patient-reported Villalta score) according to DVT extent and ii) the population attributable fraction that DVT plays in patients' moderate-to-severe PTS manifestations. RESULTS: Fourteen years after DVT, moderate-to-severe PTS developed in 35 of 185 patients with distal DVT (18.9%; 95% CI, 13.5%-25.3%), 11 of 47 patients with popliteal DVT (23.4%; 95% CI, 12.3%-38.0%), and 27 of 74 patients with iliofemoral DVT (36.5%; 95% CI, 25.6%-48.5%). The population attributable fraction of DVT in moderate-to-severe symptoms of PTS was 25.7% (-18.1% to 53.3%) in patients with distal DVT, 27.3% (-63.7% to 67.7%) in patients with popliteal DVT, and 43.1% (+0.7%-67.4%) in patients with iliofemoral DVT. CONCLUSION: In the very long term after DVT, a quarter of patients have moderate-to-severe PTS manifestations. However, the impact of the DVT on these manifestations appears nonpredominant and varies according to DVT extent. Distal DVT does not significantly increase the risk of developing moderate-to-severe PTS.