Managing iliofemoral deep venous thrombosis of pregnancy with a strategy of thrombus removal is safe and avoids post-thrombotic morbidity.

BACKGROUND: Extensive deep venous thrombosis (DVT) during pregnancy is usually treated with anticoagulation alone, risking significant post-thrombotic syndrome (PTS) in young patients. Catheter-directed thrombolysis (CDT) and operative venous thrombectomy have been safely and effectively used in nonpregnant patients, demonstrating significant reduction in post-thrombotic morbidity. This report reviews short- and long-term outcomes of 13 patients with extensive DVT of pregnancy treated with a strategy of thrombus removal. METHODS: From 1999 to 2013, 13 patients with iliofemoral DVT during pregnancy were offered CDT, pharmacomechanical thrombolysis (PMT), and/or venous thrombectomy. Gestational age ranged from 8 to 34 weeks. Fetal monitoring was performed throughout hospitalization. Radiation exposure was minimized with pelvic lead shields, focal fluoroscopy, and limited angiographic runs. Follow-up included objective vein evaluation using venous duplex and PTS assessment using the Villalta scale. RESULTS: CDT and/or PMT were used in 11 patients. Two patients underwent venous thrombectomy alone, and one patient had operative thrombectomy as an adjunct to CDT and PMT. Each patient had complete or near-complete thrombus resolution and rapid improvement in clinical symptoms. Eight of 11 having CDT or PMT underwent venoplasty and stenting of the involved iliac veins. Twelve of the 13 delivered healthy infants at term. One patient opted for termination of her pregnancy. Mean patient and gestational ages were 26 years and 26 weeks, respectively. Mean follow-up was 1.3 years, with only one recurrence. Duplex ultrasonography demonstrated patent veins in all but one patient and normal valve function in 10 patients. Eleven patients had Villalta scores <5 (considered normal), with a mean score of 0.7. CONCLUSIONS: Extensive DVT of pregnancy can be effectively and safely treated with a strategy of thrombus removal, resulting in a patent venous system, normal valve function in many, prevention of PTS, and reduction in recurrence.

Postthrombotic morbidity correlates with residual thrombus following catheter-directed thrombolysis for iliofemoral deep vein thrombosis.

BACKGROUND: Iliofemoral deep vein thrombosis (DVT) is associated with severe postthrombotic morbidity when treated with anticoagulation alone. Catheter-directed thrombolysis (CDT), with or without the addition of mechanical techniques, is increasingly recommended for patients with iliofemoral DVT, although its effect on postthrombotic syndrome is not established. This study examined the correlation of residual thrombus with postthrombotic syndrome after catheter-based attempts at thrombus removal in patients with iliofemoral DVT. METHODS: Seventy-one consecutive patients with iliofemoral DVT were treated with CDT. Pretreatment and posttreatment phlebograms were evaluated for quantity of residual thrombus by physicians blinded to clinical patient outcomes. Postthrombotic syndrome was assessed using CEAP and Villalta scores by examiners blinded to phlebographic results. Patients were grouped by the amount of residual thrombus in treated vein segments (group 1, ≤50%; group 2, >50%). Clinical score and postthrombotic outcomes were plotted vs residual thrombus. RESULTS: Sixty-three of 71 patients completed CEAP and Villalta analyses. Groups 1 and 2 had median CEAP scores of 1 and 4 (P = .025) and mean Villalta scores of 2.21 and 7.13, respectively (P = .011). There was a direct and significant correlation of clinical class of CEAP with residual thrombus (R(2) = .74; P = .004) and a direct linear correlation of Villalta score with residual thrombus (R(2) = .61; P = .0014). CONCLUSIONS: In patients with iliofemoral DVT treated with catheter-based techniques of thrombus removal, postthrombotic morbidity is related to residual thrombus. When thrombus clearance was complete, the postthrombotic syndrome was avoided. Residual thrombus is associated with an increasing risk of postthrombotic syndrome.

Stab wound of the neck with contralateral hemo-pneumothorax.

A rare case of stab wound of the neck with contralateral hemo-pneumothorax with a mediastinal shift is presented. After tube thoracostomy and computed tomography, the patient had angiographic coil embolotherapy of transected internal mammary artery (IMA). Subsequently, neck exploration with the repair of sternocleidomastoid was done. The patient underwent decortication on the 11(th) post-operative day for persistent residual hemothorax. IMA transection most often occurs from ipsilateral parasternal stab wounds and rarely from iatrogenic trauma. It is important to recognize the presentation of this rare entity as appropriate aggressive diagnostic and therapeutic interventions may be warranted.

The quantitative benefit of isolated, segmental, pharmacomechanical thrombolysis (ISPMT) for iliofemoral venous thrombosis.

BACKGROUND: Early thrombus removal in patients with iliofemoral deep venous thrombosis (IFDVT) reduces postthrombotic morbidity. Preserving valve function and relieving venous obstruction prevents deterioration of quality of life and loss of economic potential. The preferred method for treating IFDVT is catheter-directed thrombolysis (CDT). Recently, isolated segmental pharmacomechanical thrombolysis (ISPMT) has emerged as a treatment option for patients with extensive IFDVT. The purpose of our study is to determine whether there are advantages to using ISPMT as the primary treatment for patients with iliofemoral IFDVT and, if so, to quantify those advantages relative to CDT. METHODS: Forty-three patients with IFDVT were treated with percutaneous CDT between May 2003 and June 2007. Twenty-one patients (27 limbs) were treated with CDT and 22 patients (25 limbs) were treated with ISPMT +/- CDT. Demographics, extent of thrombus, procedural details, and thrombus resolution were recorded. RESULTS: Treatment time (55.4 vs 23.4 hours; P < .0001) and dose of rt-PA (59.3 vs 33.4 mg; P = .0009) were decreased and overall lytic success (60% vs 80%; P = .0016) increased with ISPMT. Adjunctive venoplasty and stenting, complications, hospital length-of-stay (LOS), and intensive care unit LOS were similar between groups. CONCLUSION: ISPMT offers more effective thrombus removal in less time and with a reduced dose of thrombolytic agent. However, decreased treatment time did not translate into decreased hospital or ICU stay. Longer-term follow-up is required to determine whether improved thrombus resolution translates to better functional outcome and reduced postthrombotic morbidity.

Endoluminal embolization and revascularization for complicated mesenteric pseudoaneurysms: a report of two cases and a literature review.

Mesenteric artery pseudoaneurysms are a rare and complex complication after abdominal trauma, surgery, or inflammatory disease. These lesions can be associated with compression or erosion into adjacent structures and may result in life-threatening hemorrhage. Traditional management has been open surgical ligation, aneurysm resection with interposition grafts, or resection or partial resection of the end organ involved. We present two cases of endovascular repair of complex mesenteric pseudoaneurysms. One patient presented with a recurrent pseudoaneurysm of the superior mesenteric artery and the second presented as recurrent gastrointestinal bleeding secondary to a traumatic celiac artery pseudoaneurysm-to-pancreatic duct fistula. A systematic review of the literature on endovascular management of mesenteric vascular disease and mesenteric pseudoaneurysms is included in this report to allow these cases to be put into proper perspective.

Bell-bottom aortoiliac endografts: an alternative that preserves pelvic blood flow.

OBJECTIVE: Dilated common iliac arteries that complicate aortic aneurysm stent grafting usually have been managed with endograft extension across the iliac artery bifurcation with internal iliac artery (IIA) occlusion. We studied 25 patients with significant common iliac artery (CIA) dilation treated with two methods: endograft extension across the iliac bifurcation or a new approach with a flared cuff within the CIA that preserves the IIA. METHODS: Of 86 patients with abdominal aortic aneurysm (AAA) who underwent bifurcated endovascular stent grafting (ESG), 25 (29.1%) had at least one dilated CIA. Two treatment groups had different methods of management of iliac artery dilation. Group 1 underwent ESG with straight extension across the iliac bifurcation and IIA coil embolization before the ESG procedure (n = 2) or simultaneously with ESG (n = 8). Group 2 underwent ESG with flared distal cuff (AneuRx, Medtronic AVE, Santa Rosa, Calif) contained within the CIA, the so-called "bell-bottom" procedure, thus preserving the IIA (n = 15). Iliac artery dimensions, operating room time, fluoroscopy time, and postoperative complications were prospectively gathered. RESULTS: Two women and 23 men had mean diameters of AAA of 56.6 mm (range, 38 to 98 mm) and of CIA of 21.4 mm (range, 15 to 48 mm). The diameters of CIA treated with device extension into external iliac artery after IIA coil embolization in group 1 and with the bell-bottom procedure in group 2 were not different (mean CIA diameter, 19.9 mm; range, 15 to 26 mm; and mean, 19.1 mm; range, 15 to 24 mm; respectively). However, significantly lower operating room and catheter procedure times were found in group 2 compared with group 1 (137 versus 192 minutes; 58 versus 106 minutes; P =.02 and.02, respectively). No periprocedural type I endoleaks were found in either group. Nine patients in group 2 also had a second contralateral CIA aneurysm, and five patients (mean CIA diameter, 33.0 mm; range, 22 to 48 mm) underwent treatment with extension across the iliac artery bifurcation and IIA occlusion. Use of the bell-bottom procedure on the other side allowed preservation of one IIA. Four cases (mean diameter, 19.3 mm) also underwent contralateral bell-bottom procedure. Two of these group 2 patients had complications, with severe buttock claudication in one and distal embolism necessitating limb salvage bypass after preoperative coil embolization of the IIA in another. CONCLUSION: Significant CIA ectasia or small aneurysm is often associated with AAA. In such cases, the bell-bottom procedure that preserves IIA circulation is a new alternative to the common practice of placement of endograft extensions across the iliac artery bifurcation in patients with at least one CIA diameter of less than 26 mm. Additional benefits include reduced total procedure time. Early technical success appears to justify continued use. However, long-term evaluation is necessary to determine durability because the risk of rupture as the result of potential expansion of the excluded iliac artery or late failure is unknown.