Valvar bypass surgery to ameliorate persistent lower limb edema caused by post-thrombotic syndrome: a case report and literature review.

Obstruction and/or reflux compromise during venous emptying can facilitate different pathophysiologies in chronic venous insufficiency (CVI). We present a patient with persistent lower limb CVI edema caused by post-thrombotic syndrome (PTS), who responded well to femoral vein valve therapy via axillary vein bypass after unsuccessful valvuloplasty, and led a normal life. During a 12 month observation period, bridging vessels completely restored original anatomical structures. In a literature study, no similar surgeries were reported, but we show that this operation may be feasible in selected patients.

Anatomical variation of femoral vessels and ultrasound-guided femoral vein puncture for catheter ablation of arrhythmias.

OBJECTIVE: This study aims to investigate the anatomical variations in femoral vasculature and evaluate the clinical value of ultrasound-guided femoral vein puncture in catheter ablation procedures. METHODS: In this retrospective analysis conducted from January 2023 to March 2023, we examined data from patients who underwent catheter ablation with ultrasound-guided femoral venipuncture. We evaluated the anatomy of the femoral vasculature at both high and low inguinal levels. Based on the relationship between the femoral vein and artery, we classified the anatomy into four types: Type I (vein parallel to artery without overlap), Type II (vein medial to artery with lumen overlap ≤50%), Type III (vein posterior to artery with lumen overlap > 50%), and Type IV (vein lateral to artery). Additionally, we assessed procedure-related vascular complications that required interventions or prolonged hospital stays. RESULTS: A total of 254 patients were included in this study. At the upper inguinal level, most cases (92.5%) exhibited Type II, followed by Type I (6.5%), while Type III (0.6%) and IV (0.4%) were less common. At the lower inguinal level, Type II accounted for 70.7%, there was a significantly higher proportion of Type III (23.4%) and Type IV (5.9%). The overall complication rate was 0.4%, no pseudoaneurysm or hematoma was observed in our study. CONCLUSION: Our study revealed significant anatomical variations in the relationship between the femoral vein and femoral artery. Ultrasound-guided femoral venipuncture significantly reduced vascular complication rate, making it a valuable tool for guiding puncture procedures.

CHIVA for dummies.

BACKGROUND: Sparing the Great Saphenous Vein capital for possible arterial substitution and recurrence decrease may be an alternative to current ablation options for Varicose Veins treatment. Conservative surgery of varicose veins (CHIVA) was suggested in 1988 by Franceschi, by limited veins interruptions in strategic points. However, the method did not diffuse due to the need for high Duplex expertise to determine the procedure in every single patient. METHOD: Evaluation of the literature regarding saphenous sparing, with special reference to CHIVA. RESULT: It has been realized that basic Ultrasound expertise is sufficient for performing GSV conservation. Most of the time, only a few parameters are needed: a junction competence assessment and a re-entry perforator position. CONCLUSION: For achieving the goal of saphenous conservative treatment, a limited phlebectomy and possible Junction interruption (crossotomy) may be a simplified solution.

Variations and inconsistencies in venous ablation coverage policies between single-state and multistate carriers in the United States.

BACKGROUND: Vein ablation is a common and effective treatment for patients with chronic venous insufficiency. The overuse of vein ablation despite the existence of evidence-based guidelines has resulted in insurance companies developing restrictive policies for coverage that create barriers to appropriate care. This study compares the insurance coverage by single-state carriers (SSCs) and multistate carriers (MSCs), highlighting the variations and inconsistencies in the various policies. METHODS: The American Venous Forum Venous Policy Navigator was reviewed for the various policies available in the United States. The policies were divided into SSCs and MSCs. The characteristics of the policies, including the anatomic and hemodynamic criteria for specific veins, duration of conservative treatment, disease severity, symptoms, and types of procedures covered, were compared between the two groups. SAS, version 9.4 (SAS Institute Inc) was used for statistical analysis. RESULTS: A total of 122 policies were analyzed and divided between SSCs (n = 85; 69.7%) and MSCs (n = 37; 30.3%). A significant variation was found in the size requirement for great saphenous vein ablation. Although 48% of the policies did not specify a size criterion, the remaining policies indicated a minimal size, ranging from 3 to 5.5 mm. However, no significant differences were found between SSCs and MSCs. Similar findings were encountered for the small and anterior accessory saphenous veins. MSCs were more likely to define a saphenous reflux time >500 ms compared with SSCs (81.1% vs 58.8%; P = .04). A significant difference was found between the SSCs and MSCs in the criteria for perforator ablation in terms of size and reflux time. MSCs were significantly more likely to provide coverage for mechanochemical ablation than were SSCs (24.3% vs 8.2%; P = .03). SSCs were more likely to require ≥12 weeks of compression stocking therapy than were MSCs (76.5% vs 48.7%; P = .01). No significant differences were found in the clinical indications between the two groups; however, MSCs were more likely to mention major hemorrhage than were SSCs. CONCLUSIONS: The results of this study highlight the variations in policies for venous ablation, in particular, the striking inconsistencies in size criteria. MSCs were more likely to cover mechanochemical ablation and require a shorter duration of conservative therapy before intervention compared with SSCs. Evidence-based guidance is needed to develop more coherent policies for venous ablation coverage.

Pharmacomechanical thrombectomy of iliofemoral deep vein thrombosis is associated with a low incidence of post-thrombotic syndrome and perioperative complications.

BACKGROUND: Iliofemoral deep venous thrombosis (IFDVT) is associated with an incidence of post-thrombotic syndrome (PTS) of up to 50%. PTS is associated with high morbidity, impaired quality of life and a significant economic burden. The aim of the current study was to assess the impact of a single session pharmacomechanical thrombectomy (PMT), dedicated venous stents and a risk mitigation protocol on the rate of PTS. METHODS: Between 2015 and 2022, patients presenting with acute or subacute IFDVT treated with the same protocol of single session PMT, dedicated venous stents, and risk-mitigation measures were included. Procedural success rate, complications, stent patency and incidence of PTS were determined. RESULTS: Of 60 patients (58 ± 19 years; 65% male), the procedural success rate was 93%, with 7% of patients experiencing complications but no long-term sequelae or mortality. Most (n = 52; 87%) patients were stented, including 46% across the inguinal ligament. At 3 months post-procedure, primary, assisted primary and secondary stent patency rates were 89%, 93% and 98%, respectively, with no loss of patency or re-interventions after that. At latest follow-up of a median 48 months (n = 32), stent patency rate was 97%, with only three patients (9%) experiencing symptoms of PTS. CONCLUSION: Single session PMT, dedicated venous stents and a risk-mitigation protocol results in high success rate, excellent long-term stent patency and low incidence of PTS without compromising safety. These results support early intervention for iliofemoral DVT.

Quality of Life after Venous Stenting for Post-thrombotic Syndrome and the Effect of Inflow Disease.

OBJECTIVE: Patients with PTS experience an impaired quality of life (QoL). We aimed to study QoL in patients stented for post thrombotic syndrome (PTS) and analyze the influence of different parameters. METHODS: Patients stented for PTS after iliofemoral deep vein thrombosis were asked to complete the Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20) and the Short Form Health Survey (SF-36) in this cross-sectional study. All other data were collected retrospectively. Primary endpoints were median CIVIQ-20 and physical (PCS) and mental (MCS) component summary SF-36 scores. The influence of age, sex, and years between the procedure and completion of questionnaire were investigated using a multivariate linear regression model. Wilcoxon signed rank test compared the PCS and MCS with the normative. Effects of inflow from the deep femoral vein (DFV) and/or the femoral vein (FV) on QoL was analyzed in patients with patent stents. RESULTS: The response rate was 70.3% (n = 45/64). Time period (median) from stenting to questionnaire completion was 6.6 years (IQR: 8.0). Most stents were placed unilateral left-sided (73.3%). For patients with patent stents (n = 42) median CIVIQ-20 was 35.5 (IQR: 17.3), higher than the minimum of 20.0 (P < .001). Median PCS of 44.7 (IQR: 14.2) was lower (P < .001), and MCS of 55.9 (IQR: 7.1) higher (P = .001) than the normative (50.0). Time since stenting and sex were not associated with QoL. Age was a significant predictor [standardized coefficient ß = .36, P = .04] for QoL using the CIVIQ-20, but not for the SF-36. Inflow disease did not impact QoL, but patients with occluded stents (n = 3) had poor functioning levels. CONCLUSION: Quality of life is impaired after venous stenting for PTS, particularly physical functioning, among patients with an open stent, but was similar between patients with good and impaired inflow. Patients with a permanent stent occlusion had the lowest QoL.

Endovascular Thrombectomy for Acute Iliofemoral Deep Venous Thrombosis Through a Jugular Approach with a Rotational Device.

PURPOSE: To report the effectiveness of pharmacomechanical catheter-directed thrombolysis (PCDT) in the management of acute iliofemoral deep venous thrombosis (DVT) via the jugular vein using a slow rotation and large-tip device (SRD) in a large cohort of patients. MATERIAL AND METHODS: From 2011 to 2021, 277 patients (mean age 45 years, 59.2% women) were treated in 6 centres with PCDT for ilio-fémoral DVT. PCDT was performed via the jugular vein and consisted of one session of fragmentation-fibrinolysis, aspiration and, if needed, angioplasty with stenting. The aim of PCDT was to achieve complete clearance of the venous thrombosis and to restore iliofemoral patency. Residual thrombotic load was assessed by angiography, venous patency by duplex ultrasound and clinical effectiveness by the rate of post-thrombotic syndrome (Villalta score > 4). RESULTS: All patients were treated via the jugular vein using an SRD, and all but one were treated with fibrinolysis. Angioplasty with stenting was performed in 84.1% of patients. After the procedure, the residual thrombotic load at the ilio-fémoral region was < 10% in 96.1% of patients. The rate of major complications was 1.8% (n = 5), the rate of minor complications was 4% (n = 11), and one patient died from pulmonary embolism (0.4%) At a median follow-up of 24 months, primary and secondary iliofemoral patency was 89.6% and 95.8%, respectively. The rate of PTS was 13.8% at 12 months. CONCLUSION: PCDT via the jugular vein using an SRD is an efficient treatment for acute iliofemoral DVT and results in high long-term venous patency and low PTS rates. Level of evidence Level 4, Case series.

Right Common Femoral Vein Invasion: A Unique Case of Inguinal Ectopic Breast Cancer.

OBJECTIVES: Ectopic breast cancer may present anywhere in the milk line, from the axilla to the groin which is extremely rare in the inguinal region. Despite morphologic differences, ectopic breast tissue presents characteristics related to orthotopic breast tissue in terms of function and pathologic degeneration. The case report describes the treatment of a unique ectopic breast carcinoma which was located in the inguinal region with a common femoral vein invasion. METHODS: We present a unique case of an ectopic breast carcinoma presenting in an unusual anatomic location along the milk line. The study was approved by the local Ethics Committee (protocol no: 12.01.2023-2023/02) Informed consent was obtained from the patient. RESULTS: The patient is surgically treated and supplemented with neoadjuvant chemotherapy,radiotherapy and endocrine therapy. Histopathological examination revealed the diagnosis of invasive ductal carcinoma. The right common femoral vein was reconstructed with bovine pericardial patch after totally removal of the mass. CONCLUSIONS: This report alerts the reader to be cognizant of the unusual location of an ectopic breast cancer which was detected in the inguinal region with a common femoral vein invasion and discusses the treatment, suggesting novel therapeutic advice that could bring considerable clinical advantages. A multidisciplinary approach should be warranted in such cases to confirm a complete remission.

Central Venous Catheter as a Novel Approach to Postoperative Thrombolysis in Patients with Acute Iliofemoral Deep Venous Thrombosis.

BACKGROUND AND AIMS: Percutaneous mechanical thrombectomy (PMT) along with postoperative thrombolysis (POT) has been the standard treatment for acute iliofemoral deep venous thrombosis (IFDVT). However, commonly used catheter directed thrombolysis (CDT) approaches for POT carry certain disadvantages, including the need for a sheath, inferior comfortability, and catheter-related complications. Therefore, we propose a new simplified method of POT using a central venous catheter (CVC). METHODS: The retrospective study analyzed patients with IFDVT who underwent POT using CVC from January 2020 to August 2021. The treatment modalities included filter placement, thrombus removal, iliac vein obstruction release, postoperative CVC thrombolysis, filter retrieval, and adequate full course anticoagulation. RESULTS: A total of 39 patients were included in this retrospective study. All patients underwent PMT surgery with a procedure success rate of 100%. In the post-PMT CVC thrombolysis, the puncture sites were located in the below-knee vein, including 58.97% in the peroneal vein. The mean duration of CVC-directed thrombolysis was 3.69 ± 1.08 days, and the total urokinase dose was 2.27 ± 0.71 MIU. A total of 37 patients (94.87%) had successful thrombolysis with a length of hospital stay of 5.82 ± 2.21 days. During CVC-directed thrombolysis, only four minor bleeding complications occurred, two of which were indwelling catheter-related. During the 12-month follow-up period, the patency rate and post-thrombotic syndrome incidences were 97.44% and 2.56%, respectively. CONCLUSION: Thrombolysis through a CVC is a feasible, safe, and effective POT method, and could be an alternative to the conventional CDT approach for patients with IFDVT.

Cystic Adventitial Disease of the Common Femoral Vein Presenting with Lower Limb Swelling: A Case Report.

Cystic adventitial disease (CAD) is a rare vascular disorder predominantly seen in adults without cardiovascular risk factors. We report a case of CAD involving the common femoral vein in a 38-year-old female presented with right lower extremity swelling that was initially misdiagnosed as deep vein thrombosis (DVT). A computed tomography revealed a cystic structure that compressed the right common femoral vein with resultant severe stenosis of the vascular lumen. Complete evacuation of the cyst with excision of the cyst wall was performed, and the patient remained symptom-free at 3 year follow-up. This case highlighted that the rare venous CAD should be incorporated in the differential diagnosis of unilateral lower extremity swelling suspicious for a DVT. Complete evacuation and surgical excision of the cyst often conferred favorable clinical outcome.

Two-Year Results of a First-In-Human Study in Patients Surgically Implanted With a Bioprosthetic Venous Valve, the VenoValve in Patients With Severe Chronic Venous Insufficiency.

OBJECTIVE: Two-year follow-up results from a first-in-human study of patients implanted with the VenoValve are evaluated for supporting the long-term clinical safety and performance of the device. BACKGROUND: Chronic Venous Insufficiency (CVI) involves improper functioning of lower limb vein valves and inability of these valves to move blood back towards the heart. CVI symptoms include swelling, varicose veins, pain, and leg ulcers. Currently, there is no cure for this condition and treatment options are limited. This study provides 2-year outcomes for 8 patients who were implanted with the bioprosthetic VenoValve for treating severe CVI with deep venous reflux measured at the mid-popliteal vein. The 6-month and 1-year results were previously published. METHODS: Eleven patients with C5 & C6 CVI were implanted with VenoValve into the midthigh femoral vein and followed for 2 years. Assessed clinical outcomes include device-related adverse events, reflux time, disease severity, and pain scores. RESULTS: All 11 implant procedures were successful. Two-year follow-up data was obtained for 8 subjects: 1 patient died of non-device related causes, 1 was lost to follow-up, and 1 refused to follow-up due to the COVID-19 pandemic. No device-related adverse events occurred between the first and second years of follow-up. Reported 2-year clinical performance outcomes included significant decreases in mean reflux times of the mid-popliteal vein (61%), and significant improvements in mean scores for disease severity rVCSS (56%) and VAS pain (87%). CONCLUSIONS: Results from this study support long-term safety and effectiveness of the VenoValve for improving CVI severity by reducing reflux and thereby venous pressures in the lower extremities. With limited treatments for valvular incompetence involved in severe, deep venous CVI, the device may be considered as a novel therapy. A pivotal trial in the United States is currently being conducted to assess the device in a larger number of patients.

The efficacy of stenting in the iliofemoral vein of patients with venous obstruction and secondary lymphedema from malignancy.

OBJECTIVE: To investigate the safety and effectiveness of venous stenting in patients with chronic iliofemoral venous obstruction and secondary lymphedema from malignancy. METHODS: From July 2012 to December 2020, patients with iliofemoral venous obstruction and secondary lymphedema who underwent venous stenting in our institution were reviewed retrospectively. Clinical characteristics, surgical complications, and symptom relief were assessed. Stent patency was evaluated with duplex ultrasound or computed tomographic venography. Twelve-month outcomes were reported. RESULTS: Fifty-three patients with concurrent secondary lymphedema who had stents placed for iliofemoral venous obstruction were included. There were 42 females, and the mean age was 56.9 years. Nonthrombotic iliac vein lesions were identified in 16 patients (30.1%). Immediate technical success was 100%, with an average of two stents implanted. The median Villalta score, and Chronic Venous Disease Quality of Life quality of life questionnaire scores decreased from 12 (IQR, 10-15) and 58 (IQR, 50-66) at baseline, respectively, to 5 (interquartile range [IQR], 4-6) and 28 (IQR, 22-45) at 12 months after the procedure (P < .05), showing significant improvement in the quality of life. At the end of a median follow-up of 12 months (range, 3-25 months), the cumulative primary, assisted primary, and secondary patency rates were 70.8%, 76.9%, and 90.1%, respectively. CONCLUSIONS: In patients with secondary lymphedema from malignancy, venous stent placement is safe and effective for iliofemoral venous obstruction.

Emergency approach to the femoral artery.

PURPOSE: The purpose of this study was to evaluate the applicability and potentially associated harms of emergency access to the femoral artery and vein in a sample of physicians working together in the emergency department of a level I trauma center. In addition, to investigate whether there are differences between participants in terms of different levels of training. METHODS: A sample of 36 orthopedic trauma and anesthesiology assistant doctors, specialists, and senior physician was recruited from the emergency room management at a level I trauma center in Graz, Austria. Emergency approach to the femoral vessels was performed on 33 fresh cadavers. Attention was paid to time, successful clamping of the vessels, self-assessment and learning curve. RESULTS: The approach was performed correctly in 97.2% (35/36) of all cases. 97.2% of all participants (35/36) were confident to perform the emergency access. They were proven right, since especially the resident and senior subgroups achieved satisfactory results concerning the correct performance of the approach to the femoral vessels as well as correct identification of the femoral artery and vein. CONCLUSION: In conclusion, we evaluated the emergency access to the femoral artery (FA) and femoral vein (FV) as an easily teachable procedure including high success rates (correct performance in 97.2%).

Internal Spermatic Vein to Superficial Epigastric Vein Microsurgical Bypass in Varicocele Treatment.

INTRODUCTION: Identification and preservation of testicular artery and lymphatic vessels during microsurgical varicocelectomy can be tedious if adhered encompassing venous network is encountered. A venous bypass from internal spermatic to saphenous or inferior epigastric vein, that have been described for varicocele treatment, may be used in such situations. This paper describes a simplified modification of the venous bypass technique that reroutes the testicular blood to the superficial epigastric vein, which can easily be found in the incisional wound. Surgical technique and anastomotic patency test are described, and indications and results are discussed. MATERIALS AND METHODS: During 2020 and 2021, 32 adolescent patients underwent microsurgical varicocelectomy. In eight patients additional microsurgical testicular vein-superficial epigastric vein microvascular bypass was done. The indication for bypass was difficult identification of testicular artery and/or lymphatic vessels due to adhered venous plexus. RESULTS: Varicocele resolution was noted in all eight patients with clinical and/or semen analysis improvement. There were no complications or recurrences. Average length of procedure was 65 minutes. All patients were discharged within 24 hours and no antiplatelet or anticoagulant therapy was used. CONCLUSION: Testicular vein to superficial epigastric vein anastomosis is a useful and simplified venous bypass technique that reroutes the blood from the pampiniform plexus to the femoral vein. It can be done as an adjunct to microsurgical varicocelectomy in selected patients through a standard incision.

Cystic Adventitial Disease of the Popliteal Vein: A Case Report.

Venous cystic adventitial disease (VCAD) is a rare vascular anomaly located in the common femoral vein in most cases. We describe the case of a 59-year-old female patient with right leg edema who was misdiagnosed with deep vein thrombosis of the lower extremity at another hospital. Magnetic resonance angiography revealed a round mass in the popliteal vein, with a narrow lumen. Considering the location of the lesion, absence of a history of deep venous thrombosis and trauma, and clinical manifestations, the diagnosis is likely a popliteal vein adventitial cyst. Segmental popliteal vein resection and reconstruction were performed using a cylindrical great saphenous vein graft. No joint connection was found during the operation, and the postoperative pathology confirmed VCAD.

Great saphenous vein aneurysm mimicking inguinal hernia: a case report.

BACKGROUND: Diagnosis of venous aneurysm may be difficult and can be misjudged as mass-like lesions, including hernias. Here we present the case of a patient with a great saphenous vein aneurysm misdiagnosed and operated as an inguinal hernia. CASE PRESENTATION: A 39-year-old Middle Eastern/Persian male presented with left inguinal bulging 15 years ago, which was misdiagnosed and operated on with a diagnosis of inguinal hernia. He was referred to our clinic, in which color Doppler sonography revealed left-sided saphenofemoral junction incompetence with severe flow reversal during the Valsalva maneuver, in favor of a great saphenous vein aneurysm. Ligation of left saphenofemoral junction and stripping of saphenous vein, and stab avulsion phlebotomy of left lower extremity varicose veins, were done. He was discharged the next day after the operation with an uneventful postoperative course or complication on follow-up. CONCLUSION: Venous aneurysms can be misdiagnosed as other, more common, mass-like lesions, such as inguinal hernias. Therefore, our report emphasizes the consideration of thorough assessment and utilization of color duplex sonography to prevent further misdiagnosis and unnecessary intervention and operations.

Safety and Efficacy of Endovascular Treatment on Pregnancy-Related Iliofemoral Deep Vein Thrombosis.

Objective: This study investigates the safety and efficacy of endovascular treatments on pregnancy-related iliofemoral deep vein thrombosis (DVT). Methods: We retrospectively reviewed data of 46 patients who had symptomatic pregnancy-related iliofemoral DVT and underwent endovascular treatment. The patients treated with catheter-directed thrombolysis (CDT) were classified as the CDT group. In contrast, those treated with CDT combined with pharmacomechanical thrombectomy (PMT) or angioplasty/stenting were classified as the pharmacomechanical catheter-directed thrombolysis (PCDT) group. Results: Based on the immediate post-operative clot burden reduction rate analysis of 46 patients: 22 cases were completely dissolved (lysis grades III), 12 were partially dissolved (lysis grades II), and 12 failed (lysis grades I). There was a statistically significant difference in the rate of clot burden reduction between the CDT group (n = 19) and the PCDT group (n = 27) (p = 0.001). There was no statistically significant difference in the number of bleeding events between the two groups (p = 0.989). At 24 months, cumulative venous patency in the CDT group was 50.0%, compared to 78.2% in the PCDT group. Furthermore, there was a statistically significant difference in Villalta score (p = 0.001) and venous severity scoring (VCSS score) (p = 0.005) between the two groups. Conclusions: CDT treatment combined with PMT or angioplasty/stenting is comparatively safe and effective for pregnant-related DVT patients. PCDT outperforms CDT in terms of immediate efficacy and reduces the incidence of post-thrombotic syndrome with better midterm outcomes.

Successful endovascular treatment with a stent graft for chronic deep vein thrombosis with multiple arteriovenous fistulas: a case report.

BACKGROUND: Deep vein thrombosis with arteriovenous fistulas is rare, with few therapeutic options available for chronic-phase deep vein thrombosis. Moreover, the effectiveness of endovascular treatment for chronic-phase deep vein thrombosis with arteriovenous fistulas has not been established. We describe herein a case of successful endovascular treatment for chronic deep vein thrombosis with multiple arteriovenous fistulas. CASE PRESENTATION: We describe the case of a 72-year-old Asian woman who had begun experiencing left leg swelling and intermittent claudication 2 years prior. Enhanced computed tomography revealed left common iliac vein occlusion with vein-to-vein collateral formation and several arteriovenous fistulas. Angiography and ultrasound showed the arteriovenous fistulas to run from the common and internal iliac arteries to the external iliac and superficial femoral veins. We opted against surgical repair for the arteriovenous fistulas due to their complex nature and complicated morphology. Since her condition was progressive, endovascular treatment with a stent graft was performed for the deep vein thrombosis, after which her symptoms gradually improved. Four months following the procedure, enhanced computed tomography confirmed remarkable reduction of the vein-to-vein collaterals and arteriovenous fistulas. CONCLUSIONS: In the present case, enhanced computed tomography with a stent graft was effective in improving symptoms. This strategy may therefore be a treatment option for intractable chronic deep vein thrombosis with arteriovenous fistulas.