[Clinical analysis of patients with lower extremity deep venous thrombosis complicated with inferior vena cava thrombus].

OBJECTIVE: To explore the clinical profiles of patients with lower extremity deep venous thrombosis (DVT) complicated with inferior vena cava (IVC) thrombus and summarize their clinical diagnostic and therapeutic experiences. METHODS: The clinical characteristics, diagnosis and treatment of 20 hospitalized patients with DVT complicated with inferior vena cava thrombus were analyzed retrospectively. RESULTS: All of them were of proximal DVT. There were phlegmasia cerulea dolens (n = 3), pulmonary embolism (n = 3) and completely occlusion of IVC (n = 5). Clinical manifestations were severe. Retrievable inferior vena cava filter (IVCF) was implanted for 17 cases. Catheter-directed thrombolysis (CDT) through ipsilateral popliteal vein was applied for 7 cases and systemic thrombolysis therapy for 8 cases. The effective rate of thrombolysis for fresh IVC thrombus was 100%. Among 5 cases with Cockett Syndrome, 3 cases underwent balloon dilatation angioplasty and endovascular stenting of iliac vein. And 17 IVCFs were retrieved successfully within 3 weeks. IVC thrombus disappeared completely in 15 cases. CONCLUSION: Systemic or local thrombolysis with protective IVCF is a safe and effective therapy for nonocclusive IVC thrombus in DVT. And CDT is recommended for symptomatic occlusive IVC thrombus.

[Clinical analysis of 20 pregnant women with venous thromboembolic disease].

OBJECTIVE: To evaluate the clinical features, diagnostic methods and treatment of venous thromboembolic disease (VTE) during pregnancy. METHODS: From June 2006 to June 2011, a total of 20 pregnant women were diagnosed VTE at the Department of Obstetrics and Gynaecology, Qilu Hospital of Shandong University. Clinical data of these patients were analyzed retrospectively. RESULTS: (1) Characteristics of patients:the symptoms of all the 20 patients commenced in pregnancy. Of these, 6(30%) happened in the first trimester, 7 (35%) in the second trimester, and 7 (35%) in the third trimester. Twelve (60%) patients went to hospital in one week after they had symptoms, while 8 (40%) went to hospital after one week. (2) Clinical manifestation: 18 patients were diagnosed deep venous thrombosis (DVT), one was diagnosed pulmonary embolism (PE). One patient was diagnosed DVT and PE simultaneously. Among the 19 DVT patients, 16 (16/19)were on the left side, 3(3/19)were on the other. They all came with sudden swelling and pain of the affected lower extremity. In 17 (17/19) patients, the circumference differences between two legs were beyond (4.0 ± 0.5) cm. In all the 20 patients, 12(60%) had elevated plasma level of D-dimmer. The diagnosis of DVT was made mainly by a Doppler ultrasound. Among the 19 DVT events, 7 (7/19) were proximal DVT, 2 (2/19) were distal, and 10(10/19) were mixed type. (3) Anticoagulant therapy: patients with VTE during pregnancy were treated with low molecular weight heparin (LMWH) (enoxaparin, once 1 mg/kg subcutaneous, twice a day). After delivery, patients were treated with subcutaneous LMWH and warfarin simultaneously for at least 5 days, until the prothrombin time-international normalized ratio (PT-INR) was > 2.0 for 24 hours. (4) Thrombolytic therapy: for most patients with VTE, we are against the routine use of thrombolytic therapy, especially before delivery. For patients with acute massive PE, urokinase of 600 000 units intravenously daily was recommended for 3 days. For those patients with DVT whose standard anticoagulation therapy was < 30 days, an inferior vena cava filter (IVCF) placement was recommended before delivery or abortion. If it was ≥ 30 days, IVCF was not recommended as a routine, and anticoagulant therapy was used 24 hours after delivery. If there was no recurrent DVT or PE, IVCF was retrieved routinely in 12 days. (5) OUTCOME: among patients treated with LMWH (95%, 19/20). Three received IVCF placement, which was retrieved successfully in 12 days, with no interventional complication. All patients recovered well after 2 weeks, and the circumference differences between two legs were within (2.0 ± 0.3) cm. Of the 18 patients maintained to the third trimester, 17 received anticoagulant therapy, and no abnormal findings were found during antenatal examination. Ten patients received cesarean section (50%, 10/20), while 8 had vaginal delivery (40%, 8/20). Neither neonatal asphyxia nor malformation was observed. The patients were followed-up for 1 - 24 months, no venous thrombus extension was found in 17 cases by Doppler ultrasound, thrombus disappeared in 2 cases of distal DVT after 4 weeks and 8 weeks respectively. By echocardiography, the pulmonary arterial pressure of the 2 patients with PE was found normal 3 months after hospital discharge. There was no maternal death during the study, no recurrent PE or bleeding occured. CONCLUSIONS: LMWH is safe and effective for VTE during pregnancy. Routine use of thrombolytic therapy is not recommended. VTE in pregnancy is not the absolute indication of termination of pregnancy. The indication of an IVCF placement should be stricter, and a retrievable suprarenal IVCF is recommended under certain circumstances.

[Early and mid-term results of endovascular aneurysm repair for infrarenal abdominal aortic aneurysm].

OBJECTIVE: Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) has become a viable alternative to open surgical repair in the last decade. We report here our experience on the mid-term results of EVAR and analysis of the outcomes associated with endograft AAA repair. METHODS: Between Nov 2002 and Mar 2007, 26 patients with AAA were enrolled in a single institution. Indications for EVAR included unfavorable condition of body (eg. Heart, lung, or renal dysfunction, etc) for open surgery and maximum diameter of AAA > 5.0 cm. Customized stent-grafts were Talent TM, Zenith and some of products made in China. All of the patients were followed up with ultrasonography or computed tomography angiography every 3 months first year after EVAR and every year after. RESULTS: The mean (SD) follow-up was 38.8 ± 12.7 months (median, 35.0 months; range, 24 to 64 months), and no patients were lost to follow-up. All cause mortality was 15.4% (4/26), with all deaths occurring within the first 2 postoperative year; 30-day mortality was 4.1%. No patient died during the operation. Completion angiography demonstrated successful sealing in 25 of 26 patients. There was no stent occlusion of renal artery. The mid term complication were observed including 2 type I endoleak after 3 months of the operation, 2 sustained type II endoleak caused by lumber artery, 1 aneurysm of left femoral artery after 16 months of operation, 1 proximal neck dilation after 12 month of operation. The aneurysm sac size didn't increase significantly during follow time, except one of the type I endoleak. CONCLUSIONS: The mid-term results of EVAR support the continued use in patients with contraindications for traditional open surgery of AAA. Close surveillance is mandatory for endoleak, especially for type I endoleak. Some proximal neck dilation can be caused by the stent-graft expansion, injury, and aortic pathological changes. Endoleak of type II can not lead to enlargement of aneurysm sac probably.

Lateral subfascial endoscopic perforating vein surgery as treatment for lateral perforating vein incompetence and venous ulceration.

BACKGROUND: The aim of this study was to evaluate the clinical results of lateral subfascial endoscopic perforating vein surgery (SEPS). METHODS: Our study was conducted from February 2002 to January 2007. Sixty-three patients with lateral incompetent perforating veins (IPVs) and venous ulceration were allocated to two groups. Group 1 comprised 31 patients (33 limbs) who underwent only routine surgery (saphenofemoral or saphenopopliteal ligation, stripping, phlebectomies, endovascular laser treatment [EVLT], medial SEPS, and skin grafting). Group 2 comprised 32 patients (35 limbs) who underwent our routine surgery with the addition of lateral SEPS. Bidirectional ultrasonography was performed before the operation, and 6 weeks, 6 months, and 1 year after surgery. Clinical score and disability score were collected at the same time. RESULTS: Twenty-nine (87.9%) of 33 limbs with active ulcers in group 1 healed, with recurrence in four (12.1%) limbs at follow-up at 25.9 +/- 10.0 months. All 35 limbs in group 2 healed, with recurrence in 0 (0.0%) limbs at follow-up at 25.4 +/- 10.1 months. Lateral SEPS could reduce the rate of recurrence of ulcers (Kaplan-Meier analysis). Patients in group 2 also showed improvement in clinical and disability scores, although they were not statistically significant differences (t test, p > 0.05). A significantly higher proportion of patients in group 1 had IPVs on the lateral aspect of the lower leg on ultrosonography imaging. CONCLUSIONS: Lateral SEPS could contribute to ulcer healing and reduce ulcer recurrence. The addition of lateral SEPS to routine surgery did reduce the number of IPVs. Lateral SEPS may be safe and effective for lateral perforating vein incompetence and venous ulceration.