Long-term integrity of 53 iliac vein stents after catheter-directed thrombolysis.

BACKGROUND: Long-term surveillance data on venous stent integrity is sparse. There is limited knowledge on whether duplex ultrasound (DUS) can detect potential stent deformities such as kinking, straightening, and fracture, which may impact long-term patency of the stented veins. PURPOSE: To assess venous stent integrity after at least five years of follow-up and to establish the efficacy of DUS as surveillance in patients with venous stent. MATERIAL AND METHODS: A total of 45 patients with acute iliac-femoral deep vein thrombosis (DVT) treated with catheter directed thrombolysis (CDT) and stenting >5 years before follow-up. Stents were evaluated with 3D volume low dose non-contrast computed tomography (CT) and DUS for kinking, straightening, stent fracture, and patency. Results from CT scans and DUS were compared to assess the overall agreement between the methods. RESULTS: Median follow-up was 13.2 years (mean = 11.2 years; range = 5.2-15.8 years). 3D CT reconstructions showed normal stent configuration in 47 stents (89%). All intact stents were identified by DUS. In the remaining six stents, 3D CT reconstructions showed compression, tapering, kinking, and minor fracture. DUS recognized all stent complications except the minor fracture. Overall agreement between CT and DUS was 98% (kappa = 0.90). Two cases of stent occlusion were found. CONCLUSION: The long-term physical resilience of iliac vein stents evaluated with 3D CT in patients treated with CDT for iliofemoral DVT was high. Stent deformities were mostly compression, whereas fracture was rarely seen. DUS seems to be sufficient to evaluate venous stent integrity.

Characterization of Mast Cells from Healthy and Varicose Human Saphenous Vein.

Mast cells (MCs) are distributed in tissues throughout the body and are highly involved in many physiological and pathophysiological processes. The potential and involvement of different MC phenotypes are still not well understood. MCs are present in blood vessel walls, but their specific phenotypic features are unknown. We aimed at characterizing MCs from human saphenous veins for localization, mediator content, and receptor expression. This was done in MCs from both healthy and varicose human saphenous veins (hSV and vSV, respectively). For both vSV and hSV, we found that vein MCs are mainly present in the tunica adventitia (99% MCs in adventitia) and that the population consists of both MCT and MCTC phenotypes (vSV: 55% MCT, hSV: 64% MCT). The vein MCs contained high levels of histamine (vSV: 27 pg/MC, hSV: 55 pg/MC) and tryptase (vSV: 98 pg/MC, hSV: 111 pg/MC), indicating a strong potential for regulatory effects on blood vessels. The receptor expression of FcεRI, MRGPRX2, PTAFR, C3aR, and C5aR was found, even though the percentage of positive cells differed between vSV and hSV MCs. We conclude that vein MCs from the blood vessel wall have a high potential to affect the tissue around them.

Endovenous ablation.

Varicose vein surgery is among the most commonly performed surgical interventions. The standard treatment 'high ligation and stripping' has in many countries been replaced by endovenous techniques. However, there are many different techniques available. All have a different way of action and sometimes need different skills. The purpose of this review article is to give an update in those different endovenous ablation techniques. We describe the indications, technique, mechanisms of action, and results. We conclude that all different techniques can be used safely and are effective. Even on long term there seems to be no difference in outcome, even compared to high ligation and stripping.

Evaluation of Peak Reflux Velocities with Vector Flow Imaging and Spectral Doppler Ultrasound in Varicose Veins.

Purpose Spectral Doppler ultrasound (SDUS) is used for quantifying reflux in lower extremity varicose veins. The technique is angle-dependent opposed to the new angle-independent Vector Flow Imaging (VFI) method. The aim of this study was to compare peak reflux velocities obtained with VFI and SDUS in patients with chronic venous disease, i. e., pathological retrograde blood flow caused by incompetent venous valves. Materials and Methods 64 patients with chronic venous disease were scanned with VFI and SDUS in the great or the small saphenous vein, and reflux velocities were compared to three assessment tools for chronic venous disease. A flow rig was used to assess the accuracy and precision of the two methods. Results The mean peak reflux velocities differed significantly (VFI: 47.4 cm/s vs. SDUS: 62.0 cm/s, p<0.001). No difference in absolute precision (p=0.18) nor relative precision (p=0.79) was found. No correlation to disease severity, according to assessment tools, was found for peak reflux velocities obtained with either method. In vitro, VFI was more accurate but equally precise when compared to SDUS. Conclusion Both VFI and SDUS detected the pathologic retrograde flow in varicose veins but measured different reflux velocities with equal precision. VFI may play a role in evaluating venous disease in the future.

Respiratory variability of peak velocities in the common femoral vein estimated with vector flow imaging and Doppler ultrasound.

Respiratory variability of peak velocities (RVPV) in the common femoral vein measured with ultrasound can reveal venous outflow obstruction. Pulse wave (PW) Doppler is the gold standard for venous velocity estimation of the lower extremities. PW Doppler measurements are angle dependent, whereas vector flow imaging (VFI) can yield angle-independent measures. The hypothesis of the present study was that VFI can provide RVPV estimations without the angle dependency of PW Doppler for an improved venous disease assessment. Sixty-seven patients with symptomatic chronic venous disease were included in the study. On average, VFI measured a lower RVPV than PW Doppler (VFI: 14.11 cm/s; PW: 17.32 cm/s, p = 0.002) with a non-significant improved precision compared with PW Doppler (VFI: 21.09%; PW: 26.49%, p = 0.08). In a flow phantom, VFI had improved accuracy (p < 0.01) and equal precision compared with PW Doppler. The study indicated that VFI can characterize the hemodynamic fluctuations in the common femoral vein.

Patients and physicians agree only partially in symptoms and clinical findings before and after treatment for varicose veins.

Objective Quality improvement in surgery has mainly been based on clinical database outcomes. This study compared variables from the patient-reported Aberdeen Varicose Vein Questionnaire with the Danish Clinical Vein Database, in order to reveal agreements and differences in symptoms and clinical findings. Methods In the period January-March 2011, 379 legs in 287 patients treated for varicose veins were registered in the Danish Clinical Vein Database and compared to the Aberdeen Varicose Vein Questionnaire. Results Patients and physicians agreed in reduction of symptoms after intervention with one or more complaints still present in 128 (93%) patients according to Aberdeen Varicose Vein Questionnaire compared to the Danish Clinical Vein Database with only 64 (47%) patients. Patients reported cosmetic complaints and teleangiectasies both before and after treatment (p < 0.001) more often than doctors. Conclusion The Aberdeen Varicose Vein Questionnaire has added valuable information to the dialogue between the doctor and patient on which symptoms expecting to improve and which not.

Endothelial Regulator of Calcineurin 1 Promotes Barrier Integrity and Modulates Histamine-Induced Barrier Dysfunction in Anaphylaxis.

Anaphylaxis, the most serious and life-threatening allergic reaction, produces the release of inflammatory mediators by mast cells and basophils. Regulator of calcineurin 1 (Rcan1) is a negative regulator of mast-cell degranulation. The action of mediators leads to vasodilation and an increase in vascular permeability, causing great loss of intravascular volume in a short time. Nevertheless, the molecular basis remains unexplored on the vascular level. We investigated Rcan1 expression induced by histamine, platelet-activating factor (PAF), and epinephrine in primary human vein (HV)-/artery (HA)-derived endothelial cells (ECs) and human dermal microvascular ECs (HMVEC-D). Vascular permeability was analyzed in vitro in human ECs with forced Rcan1 expression using Transwell migration assays and in vivo using Rcan1 knockout mice. Histamine, but neither PAF nor epinephrine, induced Rcan1-4 mRNA and protein expression in primary HV-ECs, HA-ECs, and HMVEC-D through histamine receptor 1 (H1R). These effects were prevented by pharmacological inhibition of calcineurin with cyclosporine A. Moreover, intravenous histamine administration increased Rcan1 expression in lung tissues of mice undergoing experimental anaphylaxis. Functional in vitro assays showed that overexpression of Rcan1 promotes barrier integrity, suggesting a role played by this molecule in vascular permeability. Consistent with these findings, in vivo models of subcutaneous and intravenous histamine-mediated fluid extravasation showed increased response in skin, aorta, and lungs of Rcan1-deficient mice compared with wild-type animals. These findings reveal that endothelial Rcan1 is synthesized in response to histamine through a calcineurin-sensitive pathway and may reduce barrier breakdown, thus contributing to the strengthening of the endothelium and resistance to anaphylaxis. These new insights underscore its potential role as a regulator of sensitivity to anaphylaxis in humans.

Should catheter-directed thrombolysis be monitored?

Catheter-directed thrombolysis for deep venous thrombosis is considered the basic treatment modality for intrathrombus removal. This method is preferably used in patients with iliofemoral deep venous thrombosis due to poor spontaneous recanalization in this segment, especially on the left side. The method was published almost 25 years ago and has gained ground in the treatment because of poor results from systemic thrombolysis and because of the possibility of stenting any underlying iliac obstruction during the procedure. However, the publications of catheter-directed thrombolysis reveal a great heterogeneity concerning catheter-directed thrombolysis technique and the lack of high quality evidence about monitoring as a tool to minimize the risk of bleeding and pulmonary embolism. Strict inclusion and exclusion criteria, correct composition and infusion of thrombolysis agent, imaging thrombus clearance during catheter-directed thrombolysis, ensuring flow enhancement during the bedridden situation, careful evaluation of indication for stenting based on imaging, and sufficient conversion to anticoagulation treatment following catheter-directed thrombolysis are essential. The aim of this paper is to discuss different treatment aspects of catheter-directed thrombolysis for iliofemoral thrombosis and to suggest a monitoring model for future treatment.

Excellent long-term results with iliac stenting in local anesthesia for post-thrombotic syndrome.

BACKGROUND: Only 20% of iliac veins will recanalize on anticoagulation (AC) treatment alone and may, therefore, develop venous obstruction after iliofemoral deep venous thrombosis (DVT). A considerable number of these patients will suffer from post-thrombotic syndrome (PTS) leading to impaired quality of life in more than 50%. Endovascular treatment for iliac vein obstruction using stents is known to alleviate PTS symptoms in selected patients. PURPOSE: To report the Danish long-term results of endovascular treatment with iliac stenting. MATERIAL AND METHODS: From 2000 to 2013 consecutive patients were evaluated and 19 patients with severe venous claudication were identified and subsequently underwent angioplasty and stenting. AC treatment was prescribed for 6 months, and knee-high class II compression stocking recommended for 1 year. Scheduled follow-up was done in the outpatient clinic at 6 weeks, 3 months, and annually thereafter. RESULTS: Nineteen patients, all women, all with left-sided iliac vein obstruction, and all with severe PTS symptoms were included. The median follow-up time was 81 months (range, 1-146 months; mean, 69 months). Primary patency rate of the inserted iliac stent was 89% (17/19) and 16 patients (84 %) had almost or total symptom relief at follow-up. CONCLUSION: Endovascular stenting of iliac obstruction in local anesthesia is minimally invasive and shows excellent long-term outcomes for patients suffering from PTS.

[Twisted arteriae et venae iliaca externa after total hip arthroplasty].

Vascular injuries associated with total hip arthroplasty are rare, but often lead to serious complications even in the hand of a very skilled surgeon. Fast diagnosis of vascular complication is of crucial importance for the prognosis.

Treatment of chronic upper limb ischaemia is safe and results are good.

INTRODUCTION: Chronic ischaemia of the upper extremity is rare, and only a few small studies are published on results after revascularisation. We found it of interest to present this larger population-based registry-study of patients treated for chronic ischaemia of the upper limb by open or endovascular procedures. MATERIAL AND METHODS: A total of 101,725 primary arterial vascular procedures in the Danish National Vascular Registry (Karbase) were recorded from 1.1.1993 to 31.12.2011. Of these, a total of 453 (0.4%) procedures were performed for chronic stenotic disease of the proximal arteries of the upper limb, 233 endovascularly and 220 by open surgery. RESULTS: Open reconstructions: Two patients died within 30 days, which is equivalent to a mortality rate of 0.9%. Six (2.7%) reconstructions occluded before discharge. Complications were observed in 41 patients (19%); the complications were predominantly related to surgical wound. At follow-up, 74 (70%) had no symptoms. Endovascular reconstructions: There were six deaths within the first 30 days, which is equivalent to an early mortality rate of 2.6%. Four (2%) reconstructions occluded before discharge. Complications were observed for 23 (10%) patients; the complications were predominantly of neurovascular origin. At follow-up, 90 (74%) had no symptoms. The one-year survival was 95% with no difference between the two groups. CONCLUSION: Chronic ischaemia of the upper limb can be treated both with open surgery and endovascularly with acceptable results. There was an excellent one-year patency rate for the patients who showed up for follow-up; the patency rate was comparable to that reported in the literature. FUNDING: not relevant. TRIAL REGISTRATION: not relevant.

[Modern treatment of type B dissections]. / Moderne behandling af type B-aortadissektion.

Rapid classification is essential in the management of aortic dissections, as Type A dissections require surgery, while the optimal treatment of Type B dissections is controversial. Medical treatment with antihypertensive medication and analgesics has so far been the main treatment of uncomplicated Type B dissections, while surgery has been reserved for complications and persistent pain in spite of medical treatment. Endovascular techniques are less invasive than open repair and show promising early results.

[Treatment of recurrent varices in the region of the long saphenous vein. A follow-up study]. / Behandling af recidivvaricer i saphena magna-gebetet. Et followupstudie.

INTRODUCTION: The recurrence rate for varicosities is up to 40%, which leads to reoperation for many patients. The purpose of this study was to evaluate the results after stripping the long saphenous vein in addition to the reoperation in the groin. The study was designed as a retrospective follow-up study and was set at the department of vascular surgery, Amtssygehuset i Gentofte. MATERIAL AND METHODS: The operations were performed from January 1st to the end of December 2000 and consisted of reoperation in the groin and stripping of the long saphenous vein from groin to knee in 39 patients with 44 legs which had been operated. No patients had had their saphenous vein stripped earlier. The follow-up consisted of duplex scanning and the mean follow-up time was 18 months. RESULTS: Thirty legs (68%) were cured, twelve (27%) had reflux in the thigh--eight from a Hunterperforant and four in a long saphenous vein duplication. Two (5%) had remaining reflux in the groin. DISCUSSION: The recurrence rate in the groin (5%) is acceptable. Stripping of the long saphenous vein in addition to reoperation in the groin reduces the recurrence rate. The recurrence rate at the thigh is not acceptable and a possible explanation for this is the potential role of some kind of long saphenous vein duplications. Half of the patients with recurrence are offered a new operation. We believe that the operating surgeon should focus more on duplication of the vein at the pre-operative duplex scanning in order to reduce the recurrence rate further. New varicosities can arise from an insufficient Hunterperforant even when the whole superficial system is stripped.