Enhanced Venous Thrombosis and Hypercoagulability in Murine and Human Metabolic Dysfunction-Associated Steatohepatitis.

BACKGROUND: Patients with metabolic dysfunction-associated steatohepatitis (MASH) are at an increased risk of developing venous thromboembolic events (VTE), including deep vein thrombosis (DVT). To date, the study of DVT in MASH has been hampered by the lack of reliable models that mimic the pathological aspects of human disease. OBJECTIVES: To evaluate DVT severity and hypercoagulability in murine and human MASH. METHODS: Transcriptional changes in the liver, plasma markers of coagulation, and DVT severity were evaluated in mice fed a chow diet or a high-fructose, high-fat, and high-cholesterol, MASH diet for 24 weeks. Plasma analyses of coagulations markers and thrombin generation assay were performed in a well-characterized cohort of patients with or without MASH. RESULTS: Mice fed the MASH diet developed steatohepatitis and fibrosis, mimicking human MASH. Liver RNA-sequencing revealed a significant upregulation of pathways related to inflammation and coagulation concomitant with increased plasma coagulation markers including increased prothrombin fragment 1+2, thrombin-antithrombin complex, plasminogen activator inhibitor-1 levels, and endothelin 1. MASH exacerbated DVT severity in mice, as evidenced by increased thrombus weight and higher thrombosis incidence (15/15 vs. 11/15 in controls, p=0.0317). Higher endothelin 1 release and increased apoptosis were found in endothelial cells stimulated with supernatants of palmitate-stimulated HepG2 cells. Patients with MASH exhibited increased plasma coagulation markers and delayed thrombin generation. CONCLUSION: We report enhanced DVT severity and hypercoagulability, both in murine and human MASH. Our model of MASH-DVT can facilitate a better understanding of the fundamental mechanisms leading to increased VTE in patients with MASH.

Internal jugular vein-femoral vein diversion during anterior mediastinal mass resection and superior vena cava replacement.

Surgery which involves anterior mediastinal mass resection with artificial replacement of the superior vena cava results in significant disruption to the circulatory system. In this case, a pathway was established to divert blood from the internal jugular to the femoral vein after clamping of the superior vena cava. Blood which would ordinarily return to the right atrium via the superior vena cava was now being returned via the inferior vena cava. The mean arterial pressure was maintained at least 50 mmHg higher than the central venous pressure during clamping of the superior vena cava to avoid cerebral hypoperfusion. The combined use of the above strategies aimed to provide satisfactory surgical conditions and cerebral protection.

Inferior and Superior Vena Cava Reconstruction.

Obstructions of the superior and inferior vena cava are prevalent etiologies of deep venous obstruction, presenting a spectrum of clinical manifestations ranging from life-threatening conditions to asymptomatic states. The etiological diversity inherent to these central venous obstructions necessitates a subtle approach to their diagnosis and management. This discrepancy in clinical presentations emphasizes the importance of a differentiated diagnostic and therapeutic strategy, tailored to the specific form of vena cava obstruction encountered. This article aims to delineate the various manifestations of vena cava obstruction and encourages specific diagnostic and treatment pathways.

Evaluation of the Predictive Character of the Expiratory Inferior Vena Cava/Abdominal Aorta (eIVC/Ao) Index for Minimum Blood Pressure Following Spinal Anesthesia With 0.5% Hyperbaric Bupivacaine.

Spinal anesthesia has many side effects, one of them being a drop in blood pressure (BP). Identifying predictive factors for this drop is a clear matter of concern. In this regard, the expiratory inferior vena cava/abdominal aorta (eIVC/Ao) index has already been spotted as such for doses of 0.5% hyperbaric bupivacaine greater than 12mg. Departing from the demonstrated correlation between this index and hypotension post-spinal anesthesia, our study aimed to (1) evaluate whether an eIVC/Ao index greater than 0.7, thus defining non-hypovolemic patients, can also predict minimal BP for doses inferior to 12mg and (2) identify other predictive factors for minimal BP post-spinal anesthesia. Lastly, we verified whether preoperative fasting induces hypovolemia.  This single-center prospective observational pilot study included 20 patients. The baseline measurements of BP, eIVC/Ao index, and fasting time were recorded at time T0'. Then spinal anesthesia was administered with 0.5% hyperbaric bupivacaine in doses inferior to 12 mg. The patients' systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and metameric levels were each recorded at times T5', T10', T15', and T20'.  The results indicated that baseline DBP was predictive of low DBP and minimum MAP, which reflect myocardial perfusion and systemic pressures, respectively. Therefore, it should trigger prophylaxis (spinal-lateralized, continuous, or lower dose) in patients with a low DBP baseline. Additionally, baseline SBP was predictive of minimum SBP, an independent risk factor for post-anesthetic hypotension if its baseline is less than 120 mmHg. Although female gender was linked to minimum SBP, other confounding factors (size, dose administered, and type of surgery related to gender) must also be considered. Moreover, a correlation was established between height and MAP in parturients. Hypotension was not recorded at local anesthetic (LA) doses between 8 and 12 mg and the doses administered were sufficient to achieve the metameric levels required for surgery (ether tests). Since 8 mg of 0.5% hyperbaric bupivacaine achieved the same level as 12 mg, lower doses of LA might prevent a significant drop in BP and its deleterious effects. Therefore, in the current cohort, the eIVC/Ao index was not predictive of minimum BP during spinal anesthesia with doses less than 12 mg of 0.5% hyperbaric bupivacaine. However, predictive factors for minimum BP included gender and baseline SBP (for minimum SBP), height and baseline DBP (for minimum MAP), and baseline DBP (for minimum DBP). Lastly, preoperative fasting did not cause hypovolemia.

Superior Vena Cava Syndrome Masquerading as Angioedema: A Chemotherapy Port Complication.

Superior vena cava (SVC) syndrome is a constellation of symptoms that occur secondary to external compression of the SVC, most commonly by a mediastinal malignancy. With the increased use of implanted cardiac devices and indwelling central venous catheters, SVC syndrome from a benign cause has become quite common. This report follows a 62-year-old female who was initially admitted to the critical care unit for treatment of angioedema without a history of malignancy but was found to have a surgically placed port used to treat her rheumatoid arthritis. Despite treatment of what was presumed to be angioedema, her symptoms failed to resolve. Imaging of the thorax revealed a venous thrombosis in the previously placed port. The port was subsequently removed, and the patient's symptoms hastily resolved. This case report underscores the importance of obtaining a thorough history, maintaining a broad differential diagnosis, and revising the differential when the patient's symptoms fail to improve.

Management of Persistent Left Superior Vena Cava: Overcoming Lead and Vascular Complications With Transcatheter Pacing System Implantation.

Isolated persistent left superior vena cava (PLSVC) is a rare congenital anomaly typically found incidentally due to its asymptomatic nature. However, it can present technical challenges for device implanters. We report a case involving a patient with PLSVC, for whom the implantation of a transcatheter pacing system proved to be the most effective long-term solution. Although this venous anomaly initially provided a safe pacing route, it eventually led to early complications. The patient, a 78-year-old Puerto Rican man with hypertension, diabetes mellitus, and complete atrioventricular block, experienced multiple complications with pacing devices. After a failed left-sided pacemaker implant, a right-sided single-chamber ventricular device was placed, but it led to right ventricular lead fractures and was eventually abandoned. A new pacing system implanted in the left chest lasted only a year. Venography revealed a patent PLSVC with a previously implanted device now obstructed by an occluded left brachiocephalic vein. After laser-assisted extraction, a dual-chamber device was successfully implanted through the PLSVC. Despite unremarkable physical and lab results, the patient later showed syncope and high lead impedances with fractures in both leads and total PLSVC occlusion. A transcatheter pacing system was chosen to address the complex anatomical issues and abandoned hardware. Atrial synchronized pacing was confirmed the morning after implantation, and the patient was safely discharged. Ensuring a stable ventricular rhythm is crucial for patients with complete heart block. When hemodynamic stability is compromised by recurrent lead fractures and rare anatomical variants, implanters must consider alternative solutions. In this case, a transcatheter system was selected to avoid further lead and pocket-related complications and mitigate the risks of additional laser-assisted extractions. At the end of the device's lifespan, a new device can be implanted without significant anatomical issues, and the epicardial route remains a viable option if necessary.

Combined approach of high-power and very high-power, short-duration ablation in superior vena cava isolation.

INTRODUCTION: The effectiveness and safety of 50 W, high-power, short-duration (HPSD) ablation in superior vena cava isolation (SVCI) for patients with atrial fibrillation (AF) have been reported. However, the acute outcomes of SVCI combined with 90 W/4 s, very high-power, short-duration (vHPSD) ablation remain unknown. In this study, we aimed to investigate a novel approach that combines 50 W-HPSD and 90 W/4 s-vHPSD ablation in SVCI and to elucidate the characteristics, outcomes, and safety of this approach by comparing SVCI with conventional ablation index (AI)-guided middle-power, middle-duration (MPMD) ablation. METHODS: Overall, 126 patients who underwent AF ablation with SVCI using the QDOT MICROTM catheter were retrospectively reviewed; one group underwent SVCI with a combined approach of HPSD and vHPSD ablation (50 W/90 W group, n = 73) and another group underwent AI-guided MPMD ablation (30-40 W group, n = 53). This study compared the procedural details, radiofrequency (RF) ablation profiles, and complications. The RF settings used in the 50 W/90 W group were 50 W/7 s for the lateral segment close to the phrenic nerve and 90 W/4 s for the nonlateral segment. RESULTS: The 50 W/90 W group required a significantly shorter procedural time (3.2 vs. 5.9 min, p < .001), shorter RF duration (42.0 vs. 162.0 s, p < .001), and lower RF energy (2834 vs. 5480 J, p < .001) than the 30-40 W group. Procedural success, first-pass SVCI, number of RF applications, and SVC reconnection after isoproterenol loading were comparable between the groups. The maximum tip-electrode temperature of the multi-thermocouple system was significantly higher in the 50 W/90 W group than in the 30-40 W group (50.0°C vs. 47.0°C, p < .001). No complications, such as phrenic nerve injury or bleeding requiring transfusion, were observed in either group. CONCLUSIONS: The combined approach of 50 W/7 s-HPSD and 90 W/4 s-vHPSD ablation resulted in successful and safe SVCI with shorter procedural time, shorter RF duration, and lower RF energy.

Guidelines on deep vein thrombosis of the Brazilian Society of Angiology and Vascular Surgery.

Deep vein thrombosis is one of the main causes of inpatient and outpatient morbidity, both in medical and surgical patients, significantly impacting mortality statistics and requiring prompt diagnosis so that treatment can be initiated immediately. This document was prepared and reviewed by 11 specialists certified by the Brazilian Society of Angiology and Vascular Surgery, who searched the main databases for the best evidence on the diagnostic (physical examination, imaging) and therapeutic approaches (heparin, coumarins, direct oral anticoagulants, fibrinolytics) to the disease.

Conservative management of inferior vena cava thrombus during nephrectomy for renal cell carcinoma.

OBJECTIVES: To assess the impact on survival outcomes of positive vascular margins (PVM) after nephrectomy, open thrombectomy and renal vein ostium resection without inferior vena cava (IVC) segmental resection for nonmetastatic clear cell renal cell carcinoma (ccRCC). MATERIALS AND METHODS: Medical records of patients undergoing nephrectomy and open thrombectomy for ccRCC in 1 center were retrospectively reviewed. Baseline characteristics, pathological features and surgery parameters were collected. A Cox uni- and multivariate regression model was used to evaluate the association between common prognosis factors including PVM and survival outcomes. RESULTS: Thirty-nine patients were included. Median age was 65 (55-74) years, mean tumor size was 101±35.7mm, 35/39 (89%) had an infra-diaphragmatic IVC thrombus, and on pathological examination 19 (49%) and 17 (44%) patients had a Fuhrman/ISUP grade 3 and grade 4 ccRCC, respectively, and 23 (59%) had PVM. The median overall survival (OS), cancer specific survival (CSS) and disease-free survival (DFS) were 66, 116 and 28 months, respectively. In the univariate analysis, OS was significantly shorter in case of PVM (HR 4.21, P = 0.01), but there was no significative impact on CSS, local recurrence and DFS. In the multivariate analysis, PVM had no impact on OSS, CSS, local recurrence and DFS, but metastatic lymph nodes were associated with a higher risk of death (HR 4.37, P = 0.015), local recurrence (HR 9.98, P = 0.004) and disease progression (HR 6.09, P = 0.002) and a supra-diaphragmatic thrombus was associated with a higher risk of local recurrence (HR 13.83, P = 0.007) and disease progression (HR 7.77, P = 0.003). CONCLUSION: In a population with a high rate of positive vascular margins, inferior vena cava wall invasion had a minimal impact on survival outcomes. This must be considered regarding the invasiveness of the surgery used for these patients.

Epithelioid angiomyolipoma with vascular invasion: An aggressive presentation of an unusual AML variant.

Renal angiomyolipoma (AML) is a typically benign renal tumor that is divided into 2 classes, the classical variant and the more aggressive epithelioid variant. It is extremely rare for an AML to exhibit aggressive features such as vascular invasion. We present the case of a 36-year-old female who presented with right lower quadrant pain for 9 months and was found to have an AML with tumor extension into the renal vein and the IVC. Diagnosis was confirmed with histopathology and the patient was treated with a total nephrectomy. The epithelioid subtype of AML is a rare variant that should be considered in the differential of a renal mass with vascular invasion.

Effect of Respirophasic Displacement of the Inferior Vena Cava on Size Measurement in 2-D Ultrasound Imaging.

OBJECTIVE: Volume status assessment of a patient by ultrasound (US) imaging of the inferior vena cava (IVC) is important for the diagnosis and prognosis of various clinical conditions. In order to improve the clinical investigation of IVC, which is mainly based on unidirectional US (in M-mode), automated processing of 2-D US scans (in B-mode) has enabled tissue movement tracking on the visualized plane and can average this in various directions. However, IVC geometry outside of the visualized plane is not under control and could result in errors that have not yet been evaluated. METHODS: We used a method that integrates information from long- and short-axis IVC views (simultaneously acquired in the X-plane) to assess challenges in IVC diameter estimations using 2-D US scans in eight healthy subjects. RESULTS: Relative movements between the US probe and IVC induced the following problems when assessing IVC diameter via 2-D view: a median error (i.e., absolute difference with respect to diameter measured in the X-plane) of 17% using 2-D US scans in the long-axis view of the IVC affected by medio-lateral displacements (median: 4 mm); and a median error of 7% and 9% when measuring the IVC diameter from a short-axis view in the presence of pitch angle (median: 0.12 radians) and cranio-caudal movement (median: 15 mm), respectively. CONCLUSION: Relative movements in the IVC that are out of view of B-mode scans cannot be detected, which results in challenges in IVC diameter estimation.

Agreement between manual and automatic ultrasound measurement of the velocity-time integral in the left ventricular outflow tract in intensive care patients: evaluation of the AUTO-VTI® tool.

Transthoracic echocardiography is widely used in intensive care unit (ICU) to manage patients with acute circulatory failure. Recently, automated ultrasound (US) measurement applications have been developed but their clinical performance has not been evaluated yet. The aim of this study was to assess the agreement between automated and manual measurements of the velocity-time integral in the left ventricular outflow tract (VTI-LVOT) using the auto-VTI® tool. This prospective, single-center, interventional study included ICU patients with acute circulatory failure. The examination involved two successive manual measurements of VTI-LVOT (mean of 3 consecutive heartbeats in regular sinus rhythm, and 5 heartbeats in irregular rhythm), followed by a measurement using auto-VTI® software. In patients receiving a fluid challenge, trending ability in detecting fluid responsiveness was also evaluated. Seventy patients were included between January 19, 2020, and September 24, 2020, at the Nîmes University Hospital. The feasibility of the auto-VTI® was 94%. The mean difference between the two methods was 11% with limits of agreement from - 19% to 42%. The proportion of agreement at the 15% difference threshold was 68% [58%; 80%]. The precision and least significant change measured for the manual measurement of VTI were 7.4 and 10.5%, respectively, and by inference for the automated method 28% and 40%. The new auto-VTI® tool, despite interesting feasibility, demonstrated an insufficient agreement with a systematic bias and an insufficient precision limiting its implementation in critically ill patients.Clinical trial registration: ClinicalTrials.gov identifier: NCT04360304.

Surgical Treatment of Superior Vena Cava Syndrome in a Preterm Neonate.

Superior vena cava syndrome is rare and challenging clinical entity in neonates. Medical treatment options are usually effective. However, when failed, surgery is warranted. Herein, we present a preterm neonate with SVC syndrome and associated chylothorax. When 2 weeks old, he underwent successful open thrombectomy and SVC reconstruction under cardiopulmonary bypass. Immediately after the operation findings of SVC syndrome and chylotorax were completely resolved. To our knowledge, this patient is the smallest baby underwent open SVC reconstruction with cardiopulmonary bypass.

Unveiling absent inferor vena cava in young patients: Case reports and clinical insights.

INTRODUCTION: Inferior vena cava agenesis (IVCA), a rare congenital anomaly, contributes to approximately 5 % of deep venous thrombosis (DVT) cases lacking other risk factors. It can lead to chronic venous insufficiency and DVT when collateral circulation is insufficient, presenting diagnostic challenges due to its rarity. CASE PRESENTATION: We present two cases of Absent IVC (AIVC) in young males. Case 1: a 22-year-old developed bilateral lower limb DVT post-appendectomy. Imaging revealed AIVC with azygos continuation. Treatment included Heparin and Rivaroxaban, achieving symptom resolution. Case 2: a 41-year-old with recurrent DVT and chronic venous insufficiency was diagnosed with AIVC via venography. Managed with warfarin and compression therapy, his symptoms stabilized. CLINICAL DISCUSSION: These cases underscore the importance of recognizing AIVC in young patients presenting with unexplained DVT. Diagnosis often requires advanced imaging techniques like CT venography. Management typically involves long-term anticoagulation and compression therapy to mitigate the risk of recurrence and chronic venous complications. CONCLUSION: Early identification of AIVC in young adults presenting with recurrent DVT is essential for appropriate management and prevention of long-term complications.

Three Cases of Intracardiac Leiomyomatosis with Very Long-term Follow-up.

Uterine intravascular leiomyomatosis (IVL) with extension into the right heart is uncommon, with no more than 400 cases reported in the literature since 1907. The present study aims to report three patients with intracardiac IVL surgically treated in our institution, with long-term follow-up. Three female patients in their third to fifth decades of life, with a history of difficult hysterectomy due to extensive myomatosis, presented with symptoms of right-sided heart failure. Echocardiography and computed tomography were performed, where IVL extending from the pelvis into the right heart was observed. All three patients underwent a one-stage operation under extracorporeal circulation through a right auriculotomy and inferior vena cavotomy, accessed via a sterno-laparotomy. The tumors were extirpated without complications, with ligation of the vena cava or iliac vein. The patients at 10-, 13-, and 37-year follow-up were well and alive with mild lower extremities symptoms.

Drenaje venoso anómalo. Vena cava superior izquierda persistente que drena en la aurícula derecha y vena cava superior derecha que drena en la aurícula izquierda: reporte de un caso / Anomalous Venous Drainage. Persistent Left Superior Vena Cava Draining into the Right Atrium and Right Superior Vena Cava Draining into the Left Atrium: Case Report

Introducción: Entre 0,3-0,5% de niños nacidos presentan una vena cava superior izquierda persistente, lo que lo hace una de las malformaciones congénitas más frecuentes del drenaje venoso. El drenaje de esta en la aurícula derecha, además del drenaje de la vena cava superior derecha en la aurícula izquierda, es extremadamente infrecuente. Caso Clínico: Se presenta el caso de un infante de 8 meses asintomático que es llevado a consulta por presentar desaturaciones. El examen físico es normal. El ecocardiograma de contraste con solución salina muestra una vena cava superior izquierda persistente que drena en la aurícula derecha y un retorno anómalo de la vena cava superior derecha. Se realiza una corrección quirúrgica y evoluciona de forma favorable. Conclusión: La presentación en simultáneo de una vena cava superior izquierda persistente que drena en la aurícula derecha y una vena cava derecha que drena en la aurícula izquierda es extremadamente rara. La mayoría de los casos registrados se diagnosticaron de manera incidental en personas adultas al no presentar síntomas.

Introduction: Between 0.3-0.5% of children born have a persistent left superior vena cava, which makes it one of the most frequent congenital malformations of venous drainage. Drainage of this vein into the right atrium, in addition to drainage of the right superior vena cava into the left atrium, is extremely rare. Clinical case: We present a case of an asymptomatic 8-month-old infant who was taken to the clinic for desaturations. Physical examination was normal. The contrast echocardiogram with saline solution showed a persistent left superior vena cava draining into the right atrium and an anomalous return of the right superior vena cava. Surgical correction was performed and the patient evolved favorably. Conclusion: The simultaneous presentation of a persistent left superior vena cava draining into the right atrium and a right superior vena cava draining into the left atrium is extremely rare. Most of the reported cases were diagnosed incidentally in adults in the absence of symptoms.

Superior and inferior vena cava syndrome caused by a rare lung cancer: A case report.

Superior vena cava syndrome (SVCS) is commonly caused by mediastinal malignancies. Early identification through clinical signs and imaging is critical to avoid complications including cerebral and laryngeal edema, and cardiogenic shock. We present a case of large cell neuroendocrine carcinoma causing superior and inferior vena cava compression that responded well to radiotherapy and chemotherapy.

Intravenous lipomas of head and neck: an exceptional entity and its clinical implications.

Intravenous lipomas (IVLs) of the head and neck are uncommon benign tumors that develop within the venous walls, often detected incidentally during imaging for unrelated issues. While usually asymptomatic, these IVLs can cause congestive venous symptoms like swelling, paresthesia or pain in the head and neck and upper limbs, or even venous thromboembolism. The precise diagnosis of IVLs is predominantly achieved through computed tomography (CT) and magnetic resonance imaging (MRI), with CT being the most frequently used method. Symptomatic patients generally undergo open surgery with excision of the IVL followed by venous reconstruction, which has shown safe and effective outcomes. However, the management of asymptomatic IVLs remains controversial due to the limited number of reported cases. Despite this, there is a notable trend toward recommending surgical removal of IVLs to prevent complications and rule out malignancy, driven by the challenges of differentiating IVLs from malignant tumors using imaging alone. This review highlights the key differential imaging characteristics of IVLs and the main surgical techniques to remove the tumor and repair the vascular defect. Further research is necessary to establish a robust, evidence-based approach for treating asymptomatic IVLs, balancing the risks of surgery against the potential for future complications.