Safety and efficacy of combined dilation/stenting of venous abnormalities, including complete obstructions, during lead extractions in patients with congenital heart disease.

INTRODUCTION: Management of transvenous leads in patients with congenital heart disease (CHD) can be complicated by venous obstructions and residual shunts. We present our experience performing concurrent lead extraction and dilation/stenting of venous pathways, including patients with complete venous obstruction. METHODS: All cases of concurrent lead extraction and recanalization of vena cavae/baffles between 2017 and 2021 at Boston Children's Hospital were retrospectively included and reviewed for safety and efficacy. RESULTS: Eight patients, 4 female, median 38.5 years of age (range 16.7-49 years) and 81.6 kg weight (range 41.3-97.8 kg) at time of procedure were included. All patients had CHD, a majority (n = 7) having transposition of the great arteries palliated via atrial switch. All leads were removed in their entirety, with most patients having two leads extracted (n = 7). Median lead dwell time was 13.8 years (range 3.6-35.3 years). Three patients had complete obstructions, three required stenting of their innominate veins and three required recanalization of their femoral vessels. Median procedure time was 9.8 h (range 5.4-12.8 h). Complications included blood transfusion (n = 2), arrhythmia (n = 3), pleural effusion (n = 1), and pressure ulcer (n = 1). There were no cardiac perforations, venous tears, or deaths. CONCLUSION: Lead extraction along with dilation and stenting of venous anomalies, though long in duration, proved effective with minimal complications. This combined procedure can safely and effectively resolve complete obstructions secondary to transvenous leads.

Results of Palliative Stenting in Malignant Superior Vena Cava Syndrome Analyzing Self-Expanding Stainless Steel and Nitinol Venous Bare Metal Stents.

PURPOSE: The purpose was to analyze the technical, clinical, and survival outcomes of our patients with malignant superior cava vein syndrome (SVCS) treated with endovascular approach and analyze the efficacy of different stent types used. MATERIAL AND METHODS: It is an observational, retrospective, single-center study. From 2006 to 2023, 42 patients (32 male, 10 female, mean age 62 years, age range, 41-87 years) underwent percutaneous stent placement for malignant SVCS. One stainless steel stent (Wallstent) and 2 venous nitinol stent type (Sinus-XL, Venovo) were used. Follow-up mean was 276 days. RESULTS: A total of 53 stents were deployed. Clinical success was 97.6% in less 24 hours. Technical success was achieved in 97.6%. No complications were found except 1 patient died during the procedure due to stent migration and atrial dissociation (2.3%). Overall intraprocedural stent migration rate was 11.9% (18.8% stainless steel stent, 9.6% nitinol stent, p>0.05). Overall survival rates were 87.8%, 41.99%, and 34.12%, and overall primary patency rates were 100%, 93.3%, 91.6% at 1, 6, and 12 months, respectively. CONCLUSIONS: Endovascular treatment is a safe and effective therapeutic option for SVCS with high technical and clinical success rates and low complication and recurrence rates. CLINICAL IMPACT: The malignant superior cava vein syndrome is a rare clinical entity treated classically with radiation and chemotherapy with a slower response, or surgical bypass, which is an aggressive surgical technique. Endovascular treatment offers a low-invasive technique with quick clinical resolution and good permeability results. However, further studies are lacking to deal with procedure technical characteristics, stent type used, technical complications, and medium- and long-term patency studies. This study aims to evaluate all these items, analysing self-expanding stainless steel and nitinol venous bare metal stents, and add value to endovascular treatment, confirming the good results of this technique.

Computed tomography predictors of increased transvenous lead extraction difficulty.

BACKGROUND: The ability of computed tomography (CT) characteristics to predict the difficulty of transvenous lead extraction (TLE) is an evolving subject. OBJECTIVE: To identify CT characteristics associated with increased TLE difficulty. METHODS: All consecutive patients undergoing TLE at the University of California San Diego from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Registry. Patients underwent cardiac-gated chest CT scans with intravenous contrast; all scans were reviewed by a single radiologist. Lead extraction was performed per standard institutional protocol with the initial use of a laser sheath and crossover to a mechanical sheath as needed. Multivariable linear and logistic regression analyses were performed to identify predictors of individual lead-removal fluoroscopy time and mechanical sheath use, as markers of extraction difficulty. RESULTS: A total of 343 patients were analyzed. The mean age of the study population was 63.8 ± 15.4 years; 71% were male. The mean lead dwell-in duration was 8.6 ± 5.7 years. In multivariable linear regression analysis, venous occlusion detected on CT was independently associated with higher individual lead-removal fluoroscopy time (p = 0.004), when adjusting for clinical characteristics such as lead dwell time. In multivariable logistic regression analysis, calcification and venous occlusion were independently associated with a higher need for mechanical sheath use during TLE (odds ratio:5.08, p < 0.001, 95% CI: 2.54-10.46) and (odds ratio:3.72, p < 0.001, 95% CI: 1.89-7.35), respectively. CONCLUSION: In patients undergoing TLE, venous occlusion identified by chest CT is associated with increased fluoroscopy time. Patients with lead-associated calcification or venous occlusion detected by chest CT are each five and three times more likely to require crossover from laser to a mechanical sheath.

Comparison of Metabolic, Ionic, and Electrolyte Responses to Exhaustive Low-Load Strength Training With and Without Blood Flow Restriction and High-Load Resistance Training.

Low-load blood-flow-restriction resistance training (LL-BFR-RT) is gaining popularity, but its physiological effects remain unclear. This study aimed to compare LL-BFR-RT with low-load resistance exercise (LL-RT) and high-load resistance exercise (HL-RT) on metabolism, electrolytes, and ions in the lower extremities by invasive catheter measurements, which are crucial for risk assessment. Ten healthy men (27.6 ± 6.4 years) completed three trials of knee-extensor exercises with LL-RT (30% 1RM), LL-BFR-RT (30% 1RM, 50% limb occlusion pressure), and HL-RT (75% 1RM). The exercise protocol consisted of four sets to voluntary muscle failure with 1 min of rest between sets. Blood gas analysis was collected before, during, and after each trial through intravenous catheters at the exercising leg. LL-BFR-RT had lower total workload (1274 ± 237 kg, mean ± SD) compared to LL-RT (1745 ± 604 kg), and HL-RT (1847 ± 367 kg, p < 0.01), with no difference between LL-RT and HL-RT. Pain perception did not differ significantly. Exercise-induced drop in oxygen partial pressure, lactate accumulation and electrolyte shifts (with increased [K+]) occurred during under all conditions (p < 0.001). Creatine kinase and lactate dehydrogenase increased significantly 24- and 48-h postexercise under all three conditions (p < 0.001). This study, using invasive catheter measurements, found no significant differences in metabolic, ionic, and electrolyte responses among LL-BFR-RT, LL-RT, and HL-RT when exercised to voluntary muscular failure. LL-BFR-RT reduced time to failure without specific physiological responses.

Utility of covered stents as a bypass for the treatment of central venous occlusion: a case report.

BACKGROUND: Central venous occlusion (CVO) is difficult to treat with percutaneous transluminal angioplasty because the guidewire cannot pass through the occluded segments. In this study, we devised a new method for establishing an extra-anatomic bypass between the right subclavian vein and the superior vena cava via a covered stent to treat whole-segment occlusion of the right brachiocephalic vein (BCV) with calcification. CASE PRESENTATION: We present the case of a 58-year-old female patient who complained of right arm swelling present for 1.5 years. Twelve years prior, the patient began hemodialysis because chronic glomerulonephritis had progressed to end-stage renal disease. During the first 3 years, a right internal jugular vein (IJV)-tunneled cuffed catheter was used as the dialysis access, and the catheter was replaced once. A left arteriovenous fistula (AVF) was subsequently established. Owing to occlusion of the left AVF, a new fistula was established on the right upper extremity 1.5 years prior to this visit. Angiography of the right upper extremity revealed complete occlusion of the right BCV and IJV with calcification. Because of the failure to pass the guidewire across the lesion, we established an extra-anatomic bypass between the right subclavian vein and the superior vena cava with a covered stent. Angiography confirmed the patency of whole vascular access system. After 3 months of follow-up, the patient's AVF function and the bypass patency were satisfactory. CONCLUSIONS: As a new alternative for the treatment of long, angled CVO with or without calcification, a covered stent can be used to establish an extravascular bypass between central veins.

Caffeine Abstinence in Habituated Users: Cardiovascular Responses to Exercise With Blood Flow Restriction.

CONTEXT: Blood flow restriction resistance exercise studies often require caffeine abstinence to avoid cardiovascular effects that could change the blood flow restriction stimulus. However, effects may be attenuated for habituated users. OBJECTIVE: To compare cardiovascular responses to blood flow restriction resistance exercise when habituated users consume or abstain from caffeine. DESIGN: Thirty participants completed a 3-visit within-subject study beginning with familiarization and caffeine intake questionnaire. METHODS: Visits 2 and 3 consisted of blood flow restriction resistance exercise (3 sets bicep curls to failure, 30% 1-repetition max, 40% arterial occlusion pressure [AOP]), following participants' normal caffeine consumption (CAFF) or abstaining (ABS). AOP, systolic (SBP) and diastolic (DBP) blood pressure, and heart rate were measured preexercise and postexercise. Prevalues and preexercise to postexercise change scores for SBP, DBP, AOP (all millimeters of mercury), heart rate (in beats per minute), and repetitions were compared between conditions. Results are represented as mean (SD). RESULTS: Preexercise AOP was similar for CAFF (137.8 [14.4]) and ABS (137.1 [14.9], BF10 = 0.2), although pre-SBP was higher for CAFF (115.4 [9.8]) than ABS (112.3 [9.4], BF10 = 1.9). Pre-DBP was similar between conditions. The exercise-induced change in AOP was greater for CAFF (18.4 [11.2]) than ABS (13.2 [14.9]), though evidence was anecdotal (BF10 = 0.7). Exercise-induced changes in SBP, DBP, and heart rate were similar between conditions (all BF10 ≤ 0.40). More repetitions were completed for CAFF (63 [26]) than ABS (57 [17], BF10 = 2.1). CONCLUSIONS: The findings of this study suggest that for habituated users, maintaining daily caffeine habits will not have substantial effects on common cardiovascular variables relevant to blood flow restriction.

Bridging vascular physiology to vascular medicine: an integrative laboratory class.

Vascular diseases of the legs are highly prevalent and constitute an important part of medical curricula. The understanding of these diseases relies on strongly interwoven aspects of vascular physiology and vascular medicine. We aimed to connect these within a horizontally integrated laboratory class on vascular physiology of the leg that was designed in cooperation between the departments of physiology and vascular surgery. Conceptually, we applied examination techniques of vascular medicine to visualize physiological parameters that are altered by the most frequent diseases. This facilitates integrative discussions on malfunctions, trains diagnostic skills, and bridges to vascular medicine. In four experiments, we use oscillometry and impedance venous occlusion plethysmography to address key aspects of the arterial and venous system of the legs: 1) arterial pulse wave, 2) arterial systolic blood pressure, 3) venous capacitance and venous outflow, and 4) reactive hyperemia. After the experiments, physiological vascular function, the associated diseases, their impact on the recorded parameters, and diagnostic options are discussed. To allow reproduction, we describe the course structure and the experimental setup in detail. We present the experimental data of a cohort of medical students and document learning success and student satisfaction. All experiments were feasible and provided robust data on physiologically and clinically relevant vascular functions. The activity was perceived positively by the students and led to a substantial improvement of knowledge. With this work, we offer a template for reproduction or variation of a proven concept of horizontally integrated teaching of vascular physiology of the leg.NEW & NOTEWORTHY This article presents an integrative laboratory class on vascular physiology bridging to vascular medicine. The four experiments rely on oscillometry and venous occlusion plethysmography. We describe in detail this new class regarding structure, experimental setup, and experimental procedure, and we give insight into the applied materials. Moreover, we present the experimental data of 74 students and a quantitative evaluation of the students' learning success and acceptance.

Risk of venous and arterial thromboembolism in patients with giant cell arteritis and/or polymyalgia rheumatica: A Veterans Health Administration population-based study in the United States.

BACKGROUND: Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are systemic inflammatory diseases that primarily affect elderly women. OBJECTIVES: To compare the risk of thromboembolic events and retinal vascular occlusions in GCA and/or PMR with that in osteoarthritis (OA), evaluating a veteran-based population. METHODS: A total of 1535 patients with GCA, 10,265 with PMR, and 1203 with overlapping disease, as well as 39,009 age- and sex-matched patients with OA were identified in this retrospective study. The incidence rate ratios (IRRs) of pulmonary embolism (PE), deep venous thrombosis (DVT), arterial thromboembolism, central retinal artery occlusion, and central retinal vein occlusion were calculated and examined over time. The cumulative incidence was plotted and hazard ratios (HRs) of thromboembolic events were calculated, adjusting for independent risk factors of thromboembolism. RESULTS: Patients with GCA and overlapping disease exhibited higher IRRs for all thromboembolic events compared to patients with OA. Patients with GCA had a higher risk of developing DVT and retinal vascular occlusions than those with overlapping disease (HR: 2.01, 95% confidence interval [CI]: 1.35-2.99, p < 0.001; HR: 2.37, 95% CI: 1.23-4.53, p = 0.009, respectively) or PMR alone (HR: 1.89, 95% CI: 1.50-2.41, p < 0.001; HR: 4.68, 95% CI: 3.10-7.07, p < 0.001, respectively). Patients with GCA had a higher risk of developing PE than those with PMR (HR: 1.55, 95% CI: 1.1-2.18, p = 0.01). CONCLUSION: The risk of thromboembolic events differs between GCA, PMR, and overlapping diseases. Our findings may help predict the risk of thromboembolic events based on disease phenotype.

A Systematic Review and Meta-Analysis of 12-Month Patency After Intervention for Iliofemoral Obstruction Using Dedicated or Non-Dedicated Venous Stents.

BACKGROUND: Endovascular stenting of the deep venous system has been proposed as a method to treat patients with symptomatic iliofemoral outflow obstruction. The purpose of this systematic review and meta-analysis was to compare the effectiveness of this treatment at 1-year following the development of dedicated venous stents. METHOD AND RESULTS: We searched MEDLINE and EMBASE for studies evaluating the effectiveness of venous stent placement. Data were extracted by disease pathogenesis: non-thrombotic iliac vein lesions (NIVL), acute thrombotic (DVT), or post-thrombotic syndrome (PTS). Main outcomes included technical success, stent patency at 1 year and symptom relief. A total of 49 studies reporting outcomes in 5154 patients (NIVL, 1431; DVT, 950; PTS, 2773) were included in the meta-analysis. Technical success rates were comparable among groups (97%-100%). There were no periprocedural deaths. Minor bleeding was reported in up to 5% of patients and major bleeding in 0.5% upon intervention. Transient back pain was noted in 55% of PTS patients following intervention. There was significant heterogeneity between studies reporting outcomes in PTS patients. Primary and cumulative patency at 1 year was: NIVL-96% and 100%; DVT-91% and 97%; PTS (stents above the ligament)-77% and 94%, and; PTS (stents across the ligament)-78% and 94%. There were insufficient data to compare patency outcomes of dedicated and nondedicated venous stents in patients with acute DVT. In NIVL and PTS patients, stent patency was comparable at 1 year. There was inconsistency in the use of validated tools for the measurement of symptoms before and after intervention. When reported, venous claudication, improved in 83% of PTS patients and 90% of NIVL patients, and ulcer healing occurred in 80% of PTS patients and 32% of NIVL patients. CONCLUSIONS: The first generation of dedicated venous stents perform comparably in terms of patency and clinical outcomes to non-dedicated technologies at 1 year for the treatment of patients with NIVL and PTS. However, significant heterogeneity exists between studies and standardized criteria are urgently needed to report outcomes in patients undergoing deep venous stenting.

Endovenous Iliocaval Revascularization for Transplant Kidney Salvage.

PURPOSE: We report the case of a venous iliocaval recanalization to preserve a transplant kidney. CASE REPORT: A young patient with a nephrotic syndrome caused by focal segmental glomerulosclerosis (FSGS) underwent a robot-assisted living-donor kidney transplant. The postoperative course was uneventful; serum creatinine at discharge was 1.51 mg/dL (normal range = 0.72-1.17 mg/dL). In the course of the following months, the patient was readmitted repeatedly due to acute kidney failure not related to rejection, recurrent FSGS, or anastomotic stenosis. All episodes started after prolonged standing and renal function improved after bed rest. Several hospital admissions and investigations later, phlebography revealed an occlusion of the inferior vena cava (IVC) and both common iliac veins with large collateral vessels through the azygos system. An endovenous recanalization of the iliocaval tract was performed, with subsequent normalization of transplant kidney function. CONCLUSION: Vascular complications after renal transplantation are an important cause of graft loss. We present an endovenous treatment option for a chronic occlusion of the IVC and common iliac vein with intermittent venous congestion as a cause of transplant failure.

Paclitaxel coated balloon fibroplasty: A more effective treatment for chronic symptomatic lead/catheter related central venous obstruction?

Central venous occlusion is a common complication following transvenous lead or therapeutic catheter placement that can present either acutely or chronically.

Long-term incidence of upper extremity venous obstruction in implantable cardioverter defibrillator patients.

BACKGROUND: Very little is known about the long-term prevalence of severe venous obstruction and occlusion in patients with transvenous implantable cardioverter-defibrillator leads. The objective of the current investigation was to elucidate the incidence and prevalence and to identify predisposing conditions in an ICD cohort over a long follow-up period. METHODS: Based on a prospective database, we analyzed consecutive patients who received an ICD implantation in our hospital between 06/1988 and 2009 as well as all corresponding follow-up data until 02/2018. Cavographies were used for analysis, and all patients with at least one device replacement and one follow-up cavography were included. RESULTS: Over a mean follow-up period of 94 ± 50 months, severe venous obstruction was found in 147 (33%) of 448 patients. Kaplan-Meier analysis shows a severe obstruction or occlusion in 50% of patients after a period of 14.3 years. The total number of leads (p < .001, HR 2.01, CI 2.000-2.022), an advanced age (p = .004, HR 1.023 per year, CI 1.022-1.024) and the presence of dilated cardiomyopathy (p = .035, HR 1.49, CI 1.47-1.51) were predictive of venous obstruction whereas the presence of anticoagulation was not. CONCLUSION: Severe obstruction of the access veins after ICD implantation occurs frequently and its prevalence shows a nearly linear increase over long-time follow-up. Multiple leads, an advanced age and DCM as underlying disease are associated with an increased risk of venous obstruction while the role of anticoagulation to prevent venous obstruction in ICD patients is unclear.

Clinical Outcomes of Stenting Extending Below the Inguinal Ligament for Treatment of Chronic Iliofemoral Venous Obstruction.

BACKGROUND: Patients with chronic iliofemoral venous obstructive lesions that often require stenting extending below the inguinal ligament. However, the issue of stents crossing the inguinal ligament is currently controversial. Some guidelines suggest that it should be avoided, and some guidelines suggest that in order to ensure adequate flow, the inguinal ligament can be crossed if necessary. The aim of this study was to evaluate the technical aspects and examine patency rates of stent placement across the inguinal ligament for managing iliofemoral venous obstruction. METHODS: A retrospective analysis of 127 patients with chronic iliofemoral venous obstruction were treated with interventional surgery in a single institution from January 2012 to January 2018 was conducted. All patients underwent balloon dilatation and placement of at least 2 stents extending below inguinal ligament. Inflow condition, technical success, operation duration, stent patency rates, anticoagulant selection and duration, and complications were recorded after the interventions. RESULTS: The technical success rate was 100%. No major perioperative complications occurred. The mean number of stents was 2.14 ± 0.37. Follow up periods ranged from 12 to 60 months (28.79 ± 10.90 months). Overall cumulative primary, assisted primary, and secondary stent patency rates were 81.9%, 90.5%, and 92.9% at 12 months and 70.4%, 80.9%, and 86.0% at 24 months, and 64.2%, 72.3%, and 74.3% at 36months, respectively. Cumulative patency rates at 12 months, 24 months and 36 months were significantly greater in the patients with "good" inflow as compared to "fair" inflow. The symptoms of all patients improved. None of the stents were compressed, fractured or migrated. CONCLUSIONS: Stenting across the inguinal ligament for treatment of the patients with chronic iliofemoral venous obstruction was a feasible and safe treatment with good patency and clinical results in short and midterm follow up, and stents with good inflow have better patency.

Objective assessment of skin microcirculation using a smartphone camera.

BACKGROUND: Existing techniques for assessment of microcirculation are limited by their large size and high costs and are often not so easy to use. Advances in mobile technology have enabled great improvements in smartphone sensor technology. In this study, we used SkinSight, an app for iPhone and iPad, to measure changes in skin microcirculation during physiological provocations. The system estimates changes in the concentration of hemoglobin in the skin by analyzing the reflected light emitted from the built-in light-emitting diode and detected by the camera of the smartphone. METHODS: A relative hemoglobin (Hb) index was measured during a 5-min arterial occlusion, post-occlusive reactive hyperemia, and a 5-min venous occlusion in 10 healthy subjects, on two separate days. The index was calculated in an area of the skin from the color information in the images acquired by the phone camera. Polarized light spectroscopy imaging was used to measure changes in red blood cell concentration for comparison. RESULTS: During arterial occlusion, relative Hb index was unchanged compared to baseline (P = .40). After release of the cuff, a sudden 60%-75% increase in Hb index was observed (P < .001) followed by a gradual return to baseline. During venous occlusion, Hb index increased by 80% (P < .001) followed by a gradual decrease to baseline after reperfusion. Day-to-day reproducibility of the relative Hb index was excellent (ICC: 0.92, r = 0.94), although relative Hb index was consistently higher during the second day, possibly as a result of changed lighting conditions or calibration issues. CONCLUSION: Microvascular responses to physiological provocations in the skin can be accurately and reproducibly measured using a smartphone application. Although the system offers a handheld, easy to use and flexible technique for skin microvascular assessment, the effects of lighting on the measured values and need for calibration need to be further investigated.

An unusual pediatric case of tuberculosis-associated mediastinal fibrosis with concomitant pulmonary arterial and venous occlusion.

We present a case of a 4-year-old boy with tuberculosis-associated mediastinal fibrosis with concomitant pulmonary arterial and venous occlusion, highlighting the role computed tomography angiography in identification of the disease process, coexistent vascular abnormalities and associated complications.

A retrospective cohort study comparing high and low balloon inflation pressure on technical success and patency for treating central venous lesions in patients on chronic hemodialysis.

BACKGROUND: We aimed to analyze the success rates and the access patency rates at 12 months between patients on chronic hemodialysis with symptomatic central venous stenosis (CVS) or occlusion (CVO), receiving high or low balloon inflation pressure for treatment. METHODS: We performed a retrospective study in which angioplasty balloons were inflated using a low-pressure or a high-pressure for the management of hemodialysis patients with CVS/CVO. The outcomes of this study were the success rate and the access patency rates at 12 months after balloon angioplasty, and the differences between groups were compared. RESULTS: We included a total of 74 patients on hemodialysis and assigned them to the low-pressure or the high-pressure groups. Success rates in patients of the high-pressure group (94.12%) were higher than those in patients of the low-pressure group (67.50%) (p = 0.005). With a total of 59 patients with technical success, at 6 and 12 months after angioplasty, the rates of access patency in the low-pressure group were 68 and 48%, respectively; on the other hand, the primary patency rates in the high-pressure group were 86.67% (6-months) and 76.67% (12-months). The 6 and 12 months post-interventional patency rates were higher in patients of the high-pressure group than those in patients of the low-pressure group (p = 0.10 at 6 months and p = 0.03 at 12 months). CONCLUSIONS: Compared to balloon angioplasty using a low inflation pressure, hemodialysis patients with CVS/CVO receiving angioplasty using a high inflation pressure have significantly higher technical success and 12-month patency rates.

The Venous Occlusion Image Score: A Novel Quantitative Scoring Instrument for Cerebral Venous Sinus Thrombosis.

PURPOSE: This study aims to test the validity of a new quantitative scoring instrument-the Venous Occlusion Image Score (VOIS), and assess the diagnostic and prognostic value of VOIS for cerebral venous sinus thrombosis (CVST). METHODS: The VOIS divided the major cerebral venous sinuses and internal jugular veins into nine parts of interest. CT venography and DSA source images and reconstruction were extracted from the database, then interpreted and scored independently according to VOIS by a panel of three reviewers. Inter-observer and intra-observer reliability were determined using the intraclass correlation coefficient (ICC) and the kappa coefficient (κ). The primary outcome was the 3-month functional outcome and evaluated by modified Rankin Scale (mRS). The sensitivity and specificity of VOIS for the primary outcomes were computed. Logistic regression was applied to evaluate the association between the score on VOIS and the primary outcomes. RESULTS: Fifty-six patients with CVST were included in the study. For 16 patients underwent cerebral CTV and DSA, excellent interobserver agreement was observed for DSA (ICC=0.90, 95%CI = 0.87 - 0.92, P < 0.001), and CTV (ICC = 0.92, 95%CI = 0.84 - 0.93, P < 0.001). The κ coefficient of agreement for the two radiology measures was 0.88 (95%CI = 0.79-0.92), indicating good inter-method agreement. For 56 patients followed up by CTV, baseline VOIS value correlated inversely with the severity of stroke on the National Institutes of Health Stroke Scale (r = -0·53, P < 0·001), and modified Rankin Scale (r = -0·59, P < 0·001). Baseline CTV-VOIS value predicted functional outcome (P < 0·05). CONCLUSION: VOIS may serve as a convenient and reliable method in the treatment guidance and outcome prediction of patients with CVST.

When the lead extractor becomes the assistant for new lead implant.

With the increasing number of cardiovascular implantable electronic device upgrade and vein obstruction caused by previous leads, it is important to have alternative techniques to upgrade the device with the maintenance of functioning leads. We report an 83-year old male with 13-year old one-lead dual-chamber pacemaker, ischemic cardiac disease and pre-dialytic chronic kidney disease submitted to an upgrade to cardiac resynchronization therapy. A sub-occlusion in the transition of left brachiocephalic vein and the superior vena cava was documented. Re-permeabilization was only achieved with a TightRail™ rotating dilator sheath over a guidewire with successful left ventricle lead implant.

Impacts of arterial ischemia or venous occlusion on vascularized groin lymph nodes in a rat model.

BACKGROUND: Reported ischemia time of vascularized lymph nodes was 5 hours. This study investigated the effects of arterial ischemia and venous occlusion on vascularized lymph node function in rats. METHODS: Bilateral pedicled groin lymph node flaps were raised in 27 Lewis rats. Femoral artery and vein were separated and clamped for 1, 3, 4, or 5 hour(s). Lymph node flap perfusion and drainage were assessed by laser Doppler flowmetry and indocyanine green lymphography. Histologic changes were assessed using hematoxylin and eosin stain, terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL), and glutathione assays. RESULTS: Perfusion units of 2.84 ± 1.41, 2.46 ± 0.64, 2.42 ± 0.37, and 2.01 ± 0.90 were measured in arterial ischemia groups, and 1.71 ± 0.45, 2.20 ± 0.98, 1.49 ± 0.35, and 0.81 ± 0.20 in venous occlusion groups after 1, 3, 4, and 5 hours of clamping, respectively. Lymphatic drainage showed mean latency periods of 5.33 ± 0.88, 9.00 ± 3.21, 10.00 ± 2.08, and 24.50 ± 11.50 seconds in arterial clamping groups, and 25.00 ± 3.61, 26.00 ± 3.06, 23.33 ± 4.41, and 152.00 ± 0 seconds in venous clamping groups, respectively. Severe medullary and cortical congestion and hemorrhage on histology and cell damage by glutathione levels and TUNEL assay were found after 4 hours of venous clamping. CONCLUSIONS: Arterial ischemia and venous occlusion impact the function and viability of vascularized lymph node flaps differently. The critical venous occlusion time was 4 hours.

Assessment of Upper Extremity Venous Compliance in Patients With Abdominal Aortic Aneurysms.

OBJECTIVE: Abdominal aortic aneurysm (AAA) is associated with morphological and functional changes in both aneurysmal and non-aneurysmal arteries. However, it remains uncertain whether similar changes also exist in the venous vasculature. The aim of this study was to evaluate global venous function in patients with AAA and controls. METHODS: This experimental study comprised 31 men with AAA (mean ± standard deviation age 70.0 ± 2.8 years) and 29 male controls (aged 70.6 ± 3.4 years). Venous occlusion plethysmography (VOP) was used to evaluate arm venous compliance at venous pressures between 10 and 60 mmHg in steps of 5 mmHg. Compensatory mobilisation of venous capacitance blood (capacitance response) was measured with a volumetric technique during experimental hypovolaemia induced by lower body negative pressure (LBNP). RESULTS: The VOP induced pressure-volume curve was significantly less steep in patients with AAA (interaction, p < .001), indicating lower venous compliance. Accordingly, the corresponding pressure-compliance curves displayed reduced venous compliance at lower venous pressures in patients with AAA vs. controls (interaction, p < .001; AAA vs. control, p = .018). After adjusting for arterial hypertension, diabetes mellitus, hyperlipidaemia, chronic obstructive pulmonary disease, and smoking, VOP detected differences in venous compliance remained significant at low venous pressures, that is, at 10 mmHg (p = .008), 15 mmHg (p = .013), and 20 mmHg (p = .026). Mean venous compliance was negatively correlated with aortic diameter (r = -.332, p = .010). Mobilisation of venous capacitance response during LBNP was reduced by approximately 25% in patients with AAA (p = .030), and the redistribution of venous blood during LBNP was negatively correlated with aortic diameter (r = -.417, p = .007). CONCLUSION: Men with AAA demonstrated reduced venous compliance and, as a result, a lesser capacity to mobilise peripheral venous blood to the central circulation during hypovolaemic stress. These findings imply that the AAA disease may be accompanied by functional changes in the venous vascular wall.