Impact of anticoagulation status on recanalization and outcome of cerebral venous thrombosis.

Effective anticoagulation status may determine the recanalization and outcome of cerebral venous thrombosis (CVT). We report impact of anticoagulation status on recanalization and outcome of CVT. This is a retrospective study on 126 patients with CVT diagnosed on magnetic resonance venography (MRV). Their clinical features and risk factors were noted. The data were retrieved from a prospectively maintained registry, and international normalized ratio (INR) was noted after discharge till 3 months. All the patients were on acenocoumarol. Based on INR value, patients were categorized as Group A (effective anticoagulation INR within the therapeutic range or above) and Group B (ineffective anticoagulation INR > 50% below the therapeutic range). A repeat MRV at 3 months was done for recanalization. Outcome at 3 months was evaluated using modified Rankin Scale (mRS), and categorized as good (mRS ≤ 2) and poor (mRS 2 or more) 101(80.2%) patients were in group A and 25(19.8%) in group B. Their demographic, risk factors, magnetic resonance imaging (MRI) and MRV findings were comparable. On repeat MRV, recanalization occurred in 22/24(91.7%); 15(88%) in group A and 7(100%) in group B. Recanalization was independent of coagulation status. Seven (5.6%) patients died and 107(84.9%) had good outcome; 85(84.2%) in group A and 22(88%) in group B. Kaplan Meier analysis also did not reveal survival or good outcome benefits between the groups. In CVT, outcome and recanalization at 3 months are not dependent on coagulation status. Further prospective studies are needed regarding duration of anticoagulant and its impact on recanalization and outcome.

Patient-Level, Institutional, and Temporal Variations in Use of Imaging Modalities to Confirm Pulmonary Embolism.

BACKGROUND: The choice of the imaging modality for diagnosis of pulmonary embolism (PE) could be influenced by provider, patient or hospital characteristics, or over time. However, little is known about the choice of the diagnostic modalities in practice. The aim of this study was to evaluate the variations in the use of imaging modalities for patients with acute PE. METHODS: Using the data from Registro Informatizado Enfermedad TromboEmbolica (RIETE), a prospective international registry of patients with venous thromboembolism (March 2001-January 2019), we explored the imaging modalities used in patients with acute PE. The imaging modalities included computed tomography pulmonary angiography, ventilation/perfusion scanning, pulmonary angiography, a combination of these tests, or PE signs and symptoms plus imaging-confirmed proximal deep vein thrombosis but no chest imaging. RESULTS: Among 38 025 patients with confirmed PE (53.1% female, age: 67.3±17 years), computed tomography pulmonary angiography was the dominant modality of diagnosis in all RIETE enrollees (78.2% [99% CI, 77.6-78.7]); including pregnant patients (58.9% [99% CI, 47.7%-69.4%]) and patients with severe renal insufficiency (62.5% [99% CI, 59.9-65.0]). A greater proportion of patients underwent ventilation/perfusion scanning in larger hospitals compared with smaller hospitals (13.1% versus 7.3%, P<0.001). The use of computed tomography pulmonary angiography varied between 13.3% and 98.3% across the countries, and its use increased over time (46.5% in 2002 to 91.7% in 2018, P<0.001). CONCLUSIONS: In a large multinational PE registry, variations were observed in the use of imaging modalities according to patient or institutional factors and over time. However, computed tomography pulmonary angiography was the dominant modality of diagnosis, even in pregnancy and severe renal insufficiency. The safety, costs, and downstream effects of these tests on PE-related and non-PE-related outcomes warrant further investigation.

Depressed Skull Fractures Overlying Dural Venous Sinuses: Management Modalities and Review of Literature.

AIM: To characterize the sociodemographic, clinical and radiological findings of patients with depressed skull fractures overlying cranial dural sinuses that we have faced in our institute. In addition, to explore the indications and choices for the surgical and nonsurgical management of such cases, and assess outcomes in these two treatment groups. MATERIAL AND METHODS: We prospectively followed up a cohort of 34 patients with fractures over dural venous sinuses from January 2013 to December 2017. Twelve (35.1%) were simple depressed fractures (SDFs) and 22 (64.7%) were compound depressed fractures (CDFs). Eighteen patients (52.9%) were treated surgically, and 16 (47.1%) were treated conservatively. RESULTS: The mean age was 20.8 years. Thirty-two of the patients were males (94.12%). The mean time from trauma until hospital arrival was 3.8 hours, and the mean admission Glasgow Coma Score (GCS) was 13.7. Direct trauma was the most common mode of injury. Funduscopy was performed in 16 patients (47.1%), and magnetic resonance venography (MRV) in four patients (11.8%). Twenty-four patients (70.59%) had the fracture overlying the superior sagittal sinus (SSS). The mean length of hospital stay was five days, and the mean follow-up duration was 6.8 months. Twenty-eight patients (82.35%) had a good recovery. CONCLUSION: The majority of SDFs and some CDFs overlying dural sinuses can be managed safely without major surgical intervention. Conservation should be favored when the sinus is patent, dura intact, and bone displacement is insignificant in neurologically intact patients with an apparently clean wound. Otherwise, surgery should be considered. We also propose including a funduscopic examination and venogram as parts of the initial trauma work-up for these patients.

Role of imaging techniques in liver veno-occlusive disease diagnosis: recent advances and literature review.

INTRODUCTION: Veno-occlusive-disease (VOD), known also as sinusoidal-obstruction-syndrome (SOS), is one of the main complications of haematopoietic stem cell transplantation and is related to the treatment with pyrrolizidine alkaloids or other toxic agents (chemotherapy for liver-metastasis). Clinical diagnosis using the recent criteria from the European Society for Blood and Marrow Transplantation, is the reference for VOD/SOS diagnosis. However, increasing evidence suggests the emerging role of several imaging methods that could help the clinician in VOD/SOS assessment. Areas covered: This review evaluates the current literature on the various imaging techniques used in VOD/SOS diagnosis in several clinical scenarios. Literature searches were performed using several keywords on MEDLINE/Ovid/In-Process/Cochrane Library/EMBASE and PubMed up to July 2018. Expert commentary: Hepatic-gradient-measurement (HVPG) and contextual transjugular-liver-biopsy are invasive and should always be considered in unclear cases. The main studies revolve around ultrasound with Doppler evaluation, identifying numerous findings suggestive of VOD/SOS. However, their accuracy and validation are still suboptimal and controversial. CT-Scan and MRI have shown encouraging data in other contexts in which VOD/SOS can develop, but studies on the post-HSCT patient are lacking. Elastography techniques measuring liver stiffness (LSM) represent the most recent and promising approach for an accurate and early diagnosis of VOD/SOS. In our view, a multidisciplinary approach to the VOD/SOS diagnosis should be highly encouraged.

Anatomy of the deep venous system in vein of Galen malformation and its changes after endovascular treatment depicted by magnetic resonance venography.

BACKGROUND AND PURPOSE: It is classically thought that the internal cerebral veins (ICV) do not communicate with the venous pouch of vein of Galen malformations (VGM). We report on the anatomy of the deep venous system in VGM with special emphasis on the drainage of the ICV and possible changes after endovascular treatment. MATERIALS AND METHODS: We retrospectively analyzed DSA and 2D time-of-flight MR venograms of 55 children with VGM. We evaluated all pre- and post-operative images for the presence of the ICVs and determined their route of venous drainage. RESULTS: Of 55 children, pre-operative 2D MRV detected the ICVs in 19 cases (35%) compared with one case (2%) for pre-embolization DSA (2%) (P<0.0001). Of the cases in which the ICVs were seen preoperatively, in 15 cases (78.9%) the ICV drained directly into the VGM while in the other four cases, the ICV used alternative venous drainage routes. On post-operative MRV, the ICVs were seen in 17 cases (31%) on MRV and 10 cases (18.2%) on DSA with drainage into an adult-like vein of Galen in 13 cases (76%), respectively (P=0.08). In four cases normal ICV drainage into the vein of Galen was seen even when the venous sac was closed. In two cases there was a change in ICV drainage from the vein of Galen to the lateral mesencephalic vein. CONCLUSION: The communication of the ICV with the VGM is a common phenomenon. Different changes of venous drainage routes do occur after treatment and are best seen on MRV.

Endovascular Iliocaval Stent Reconstruction for Iliocaval Thrombosis: A Multi-Institutional International Practice Pattern Survey.

BACKGROUND: Limited guidelines for the treatment and management of acute and chronic iliocaval thrombosis are published in the literature. The purpose of this report is to present global iliocaval stent reconstruction practices by interventionalists. METHODS: A 45-question survey focusing on iliocaval stent reconstruction evaluation was distributed through the Open Forum and Venous Disease Service Line of the Society of Interventional Radiology Connect website from June 20, 2017 until September 7, 2017 and the Cardiovascular and Interventional Radiological Society of Europe electronic newsletter on August 11, 2017. RESULTS: One hundred seven complete responses were received from interventional radiologists in the United States, 2 from South America, and 2 from Central America. 92.5% performed iliocaval reconstruction, and 79.8% performed the procedure for both acute and chronic iliocaval thrombosis. 82.8% completed a standardized physician assessment tool, and 91.9% obtained computed tomography (CT) venography before the procedure. 64.6% used intravascular ultrasound to guide reconstruction. 41.4% found blunt recanalization successful for >75% of patients. 63.6% used sharp recanalization for <25% of patients. 97.0% and 90.9% used uncovered and self-expanding stents, respectively. Wallstents were used most commonly. Most common stent diameters were 24-mm in the inferior vena cava, 14-mm in the common iliac vein, and 12-mm in the external iliac vein. 48.5% and 21.2% prescribed 2 and 3 anticoagulants after stent placement, respectively. 62.6% found iliocaval reconstruction provided symptomatic clinical improvement for iliocaval thrombosis in >75% of patients. 72.7% estimated their 1-year primary stent patency to be >75%. CONCLUSIONS: Iliocaval reconstruction is performed by many interventionalists; however, there are global inconsistencies in practices, suggesting a need for further research and guideline development.

Obstrucción del drenaje venoso hepático tras trasplante: resultados del tratamiento con endoprótesis autoexpandibles / Hepatic venous outflow obstruction after transplantation: outcomes for treatment with self-expanding stents

Objetivos. Evaluar la seguridad y permeabilidad del tratamiento de la obstrucción del drenaje venoso hepático tras trasplante ortotópico con endoprótesis autoexpandibles. Valorar las diferencias en la respuesta en pacientes con obstrucción precoz y tardía. Material y métodos. Análisis retrospectivo de 16 pacientes trasplantados con obstrucción del drenaje venoso hepático tratados con endoprótesis (1996-2011). El seguimiento se realizó mediante venografía/manometría, ecografía, TC y pruebas de laboratorio. Se realizó análisis estadístico descriptivo de supervivencia de pacientes e injertos, éxito técnico y clínico, recurrencia y complicaciones del total de la muestra, así como inferencial para comparar las diferencias entre pacientes con obstrucción precoz y tardía. Resultados. La media de seguimiento fue de 3,34 años (21-5.331 días). La tasa de éxito técnico fue del 93,7%, y la de éxito clínico, del 81,2%. La tasa de complicaciones fue del 25%. La tasa de supervivencia para pacientes fue de 87,5%, y para injertos, de 92,5%. La tasa de recurrencia fue del 12,5%. La tasa de permeabilidad primaria a los 3, 6, 12 y 60 meses fue de 0,96 (IC 95% 0,91-1), 0,96 (IC 95% 0,91-1), 0,87 (IC 95% 0,73-1) y 0,87 (IC 95% 0,73-1), respectivamente. No hubo diferencias significativas entre los pacientes con obstrucción precoz o tardía, aunque las tasas de permeabilidad primaria mostraron tendencia a ser significativamente superiores en el grupo precoz (p = 0,091). Conclusiones. El tratamiento con endoprótesis autoexpandibles en obstrucciones del drenaje venoso hepático tras trasplante ortotópico es efectivo, duradero y seguro. No hay diferencias significativas entre pacientes con obstrucción precoz y tardía (AU)

Objectives. To evaluate the safety and patency of self-expanding stents to treat hepatic venous outflow obstruction after orthotopic liver transplantation. To evaluate differences in the response between patients with early obstruction and patients with late obstruction. Material and methods. This is a retrospective analysis of 16 patients with hepatic venous outflow obstruction after liver transplantation treated with stents (1996-2011). Follow-up included venography/manometry, ultrasonography, CT, and laboratory tests. We did a descriptive statistical analysis of the survival of patients and stents, technical and clinical success of the procedure, recurrence of obstruction, and complications of the procedure. We also did an inferential statistical analysis of the differences between patients with early and late obstruction. Results. The mean follow-up period was 3.34 years (21-5,331 days). The technical success rate was 93.7%, and the clinical success rate was 81.2%. The rate of complications was 25%. The survival rates were 87.5% for patients and 92.5% for stents. The rate of recurrence was 12.5%. The rate of primary patency was 0.96 (95% CI 0.91-1) at 3 months, 0.96 (95% CI 0.91-1) at 6 months, 0.87 (95% CI 0.73-1) at 12 months, and 0.87 (95% CI 0.73-1) at 60 months. There were no significant differences between patients with early and late obstruction, although there was a trend toward higher rates of primary patency in patients with early obstruction (P = .091). Conclusions. Treating hepatic venous outflow obstruction after orthotopic transplantation with self-expanding stents is effective, durable, and effective. There are no significant differences between patients with early obstruction and those with late obstruction (AU)

Tratamiento de la trombosis venosa de esfuerzo en el miembro superior / Treatment of effort-induced venous thrombosis of the upper limb

IntroducciónEl correcto tratamiento de la trombosis venosa profunda (TVP) subclavia puede disminuir la secuela a largo plazo.ObjetivoAnalizar el resultado clínico a largo plazo de los pacientes tratados en nuestro servicio de trombosis venosa de esfuerzo en el miembro superior.Material y métodosEstudio retrospectivo (1986-2009). Veintinueve pacientes diagnosticados de TVP subclavia sin antecedente de marcapasos, neoplasia, accesos venosos o de hemodiálisis. Once mujeres y 18 hombres, edad media 38 años. Más de la mitad con trabajos o deportes con sobreesfuerzo de la cintura escapular. Diagnóstico: flebografía y/o ecodoppler. Tratamiento: anticoagulación: 5, fibrinólisis y anticoagulación: 9, cirugía y anticoagulación: 2, fibrinólisis, cirugía y anticoagulación: 13. La fibrinólisis (urokinasa) fue total o parcialmente efectiva en el 77% de los casos (17 de los 22 tratados con urokinasa), en 2 de ellos trombectomía adicional. Cirugía descompresiva en 15 casos: el 59% de los tratados con fibrinólisis; 4 abordajes vía transaxilar, 2 supraclavicular y 9 suprainfraclavicular. En todos los pacientes salvo en uno, resección de primera costilla asociando escalenectomía en todos. Evaluamos la secuela mediante test de calidad de vida QuickDASH y permeabilidad de la vena mediante ecodoppler.ResultadosComplicaciones precoces: una reintervención por sangrado. No complicaciones tardías. Seguimiento medio 126 meses. Siete pacientes perdidos en el seguimiento. A largo plazo, el 68% asintomáticos, de estos, el 73% sometidos a cirugía descompresiva.ConclusionesEn nuestra serie, los pacientes con TVP de esfuerzo sometidos a cirugía descompresiva, presentan un mejor resultado clínico a largo plazo que los no intervenidos(AU)

IntroductionApplying appropriate treatment for subclavian deep vein thrombosis may reduce long-term sequels.ObjectiveTo analyse the long-term clinical results of those patients treated in for upper body stress thrombosis in our Department.Materials and methodsA retrospective study (period 1986-2009) was conducted on 29 patients diagnosed with Venous Thoracic Outlet Syndrome (TOS) without pacemaker, neoplasia, previous vein access, or history of haemodialysis. The subjects included 11 women and 18 men, with a mean age of 38 years. More than half of the study subjects had jobs or took part in a sport activity involving acute stress of pectoral girdle. The diagnosis was made using Duplex Ultrasound With Venography. Treatment consisted of: anti-coagulation: 5; fibrinolysis: 9; surgery: 2; fibrinolysis+surgery: 13. Fibrinolysis was total or partially successful in 77% of cases (17 out of the 22 treated with Urokinase), two of them needing a further thrombectomy. Decompression surgery was used in 15 cases; 59% of the patients who had been treated with fibrinolysis, 4 via transaxillary approach, 2 supraclavicular and 9 supra- and infraclavicular combined. All patients but one had first rib resection, half of them had scalenectomy.ResultsEarly complications: one patient required post-intervention because of bleeding. There were no late complications. Seven patients were lost during follow up (126 months on average). In the long-term, 68% of interviewed patients remained asymptomatic, 73% of of them were subjected to decompression surgery.ConclusionsIn our series, patients who had a venous TOC decompression surgery after extrinsic compression, showed better long-term clinical results than those not operated on(AU)

Imaging of pulmonary veins during catheter ablation for atrial fibrillation: the role of multi-slice computed tomography.

Detailed anatomic imaging of the left atrium and related structures prior to ablation of atrial fibrillation (AF) is important for planning the procedure, enabling the use of advanced mapping techniques, and avoiding complications. Multidetector computed tomography (MDCT) allows visualization of the entire left atrium and each pulmonary vein (PV). This method provides precise delineation of anatomical features and dimensions by several types of reconstructed images. Additionally, the MDCT images are used with the electroanatomical mapping system to help guide the safe and effective catheter ablation of AF. MDCT also has been used for the assessment of serial changes in ablated PVs to detect and evaluate PV stenosis. The use of MDCT greatly aids the planning and complication-free execution of AF ablation.

Síndrome de May-Thurner y cirugía de escoliosis / May-Thurner syndrome and surgery for scoliosis

El síndrome de May-Thurner (M-T) consiste en la compresión de la vena iliaca izquierda por la arteria iliaca derecha. Presentamos el caso de una niña de 13 años con escoliosis severa y síndrome de M-T, que se evidenció tras una complicación durante la cirugía correctora de la escoliosis. El tratamiento inicial consistió en un abordaje posterior e instrumentación de Isola, pero fue concluido de manera prematura por la presencia de enormes venas perimedulares dilatadas y hemorragia. Se realizó una angiografía y flebografía diagnosticándose un síndrome de May-Thurner. Dada la edad de la paciente no se realizó tratamiento endovascular con stent. La paciente se encuentra a la espera de tratamiento definitivo. No existen casos en la literatura de dilatación varicosa de las venas perimedulares en el canal espinal que interfieran el tratamiento quirúrgico de la escoliosis. Este caso subraya la dificultad potencial de la técnica quirúrgica en presencia de una miríada de venas perimedulares dilatadas. El síndrome de May-Thurner debería sospecharse en pacientes escolióticos con venas perimedulares dilatadas (AU)

May-Thurner syndrome consists of the compression of the left iliac vein by the right iliac artery. We present the case of a 13-year-old girl with severe scoliosis and May-Thurner syndrome that became evident during surgery to correct the scoliosis. An initial attempt to treat the scoliosis employed a posterior approach using Isola instrumentation; however, the procedure was aborted due to the presence of enormous dilated perimedullary veins and hemorrhage. Angiography and venography confirmed the diagnosis of May-Thurner syndrome. Given the patient's age, the condition was not treated with an endovascular stent. She is currently awaiting definitive treatment. This is the first case in the literature in which varicose dilatation of the perimedullary veins in the spinal canal interfered with the surgical treatment of scoliosis. This case underlines the potential difficulties of surgery in the presence of myriad dilated perimedullary veins. May-Thurner syndrome should be suspected in scoliotic patients with dilated perimedullary veins (AU)

Imaging of the intracranial venous system.

BACKGROUND: Evaluation of the intracranial venous system has historically been performed with conventional catheter-based digital subtraction angiography (DSA). The continued importance of DSA can not be overstated in light of its inherent option of endovascular intervention and thrombolysis for cerebral venous thrombosis. DSA is, however, an invasive procedure with associated risks, including radiation exposure, and adverse effects of iodinated contrast medium. DSA also suffers from the limitations of 2-dimensional planar imaging. For these reasons, noninvasive imaging techniques are playing a greater role in evaluation of the intracranial venous system. REVIEW SUMMARY: This review provides an overview of the current noninvasive methods and their applications and limitations, with examples of their use in a variety of disease processes. Computed tomography venography (CTV) is discussed as well as the various types of cerebral magnetic resonance venography (MRV). CONCLUSION: When available, MR supplemented with the technique of triggered gadolinium-enhanced MRV is the method of choice for the diagnosis of dural sinus thrombosis as well as most other pathologic entities affecting the intracranial venous system.

Aneurisma de la vena poplítea: tratamiento quirúrgico / The surgical treatment of popliteal vein aneurysms

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Sonography for deep venous thrombosis: current and future applications.

Deep venous thrombosis (DVT) is a one of the most common problems facing the clinician in medicine today. It is often asymptomatic and goes undiagnosed with potentially fatal consequences. Ultrasound has become the "gold standard" in the diagnosis of deep venous thrombosis and with proper attention to technique sensitivity of this test is approximately 97%. An understanding of anatomy, pathophysiology, and risk factors is important. Thrombus formation usually begins beneath a valve leaflet below the knee. Approximately 40% will resolve spontaneously, 40% will become organized, and 20% will propagate. Whether or not a calf vein thrombus is identified, a repeat examination in 7 to 10 days is recommended in patients with risk factors or when deep venous thrombosis is suspected. The three main risk factors for thrombus formation are age greater than 75 years, previous history of deep venous thrombosis, and underlying malignancy. Other diagnostic studies include the contrast venogram, CT or MRI venogram, Tc99m Apcitide study, and the laboratory test D-Dimer. The D-Dimer study is being used more frequently as a screening test with 99% sensitivity in detecting thrombus, whether deep venous thrombosis or pulmonary embolism. However, specificity is only approximately 50% with many conditions leading to false-positive exams. Therefore, a negative examination is useful in avoiding other diagnostic studies, but a positive one may be misleading. Conditions that can lead to a false-positive examination include, but are not limited to diabetes, pregnancy, liver disease, heart conditions, recent surgery, and some gastrointestinal diseases. Like the sonogram, two negative D-Dimer studies a week apart exclude the diagnosis of deep venous thrombosis. Compression sonography with color Doppler remains the best overall test for deep venous thrombosis. It is easy to perform, less expensive than most "high tech" studies, can be performed as a portable examination, and is highly reliable when done properly.

1994 update on phlebography and varicography.

BACKGROUND: Appropriate management of venous disease requires definitive diagnosis. The place of phlebography and varicography in acute and chronic venous disease is to complement other less invasive and less expensive tests of venous function. OBJECTIVE: This paper will address the present indications for phlebography and present the techniques of ascending and descending phlebography and of varicography practiced in our environment. METHODS: The technique of each type of phlebography are outlined. These include ascending phlebography at the foot, popliteal and femoral levels, varicography, and descending phlebography. Complications are discussed briefly. RESULTS: The advantages and complications of each method are discussed with the description of the procedures. CONCLUSION: The most frequent uses of phlebography in acute venous thrombosis are to define deep vein thrombosis isolated to the calf or to the iliac veins, or to clarify findings from duplex scan examinations. In chronic venous disease, phlebography is used to clarify problem cases of superficial venous disease and to study patients with advanced deep vein disease who are potential candidates for deep vein reconstruction.

[The external saphenous vein, its past, its future]. / La saphène externe, son passé, son avenir.

1) An unknown or underestimated vein. During the 3 first quarters of the century, except some outstanding but confidential anatomical studies, the SSV has been reduced to a diagram that assimilates it to a Long but shortened SV Surgeons contented with this representation, often to their cost. Moreover the SSV has not retained the clinician's attention due to ignorance or diagnostic negligence. 2) A feared or disliked vein. Awareness appeared twenty years ago (Soc. Fr. de Phlébologie 1972-1973, etc.). The stress was put on the prevalence of the pathology of the short Saphenous vein, on the shortage of the therapeutics: unforeseen events, casualties and failures. 3) An investigation. New methods of vascular investigation are asserting themselves. The non-invasive ones are more open to everyone although less accurate than phlebography. They contribute towards a larger field of exploration of the SS network and create infatuation for the vein. False varices of SSV are detected, perforating and anastomotic veins are taken into account. 4) A spokesman of deep venous circulation? The SSV pathology is closely linked with the functioning of the femoropopliteal trunk and also with the gastrocnemial and solear muscular veins. The study of deep and superficial interferences initiates into a new pathology, that of the muscular veins.