Association between the degree of iliac venous outflow obstruction by intravascular ultrasound and lower limb venous reflux.

OBJECTIVE: The present study aims to evaluate the association between the degree of iliac venous outflow obstruction (IVOO) identified by intravascular ultrasound (IVUS) and venous reflux presentation in the lower limbs on duplex ultrasound (DU). METHODS: Patients with bilateral chronic venous insufficiency, CEAP (clinical-etiology-anatomy-pathophysiology) C3 to C6, and a visual analog scale score for pain >5 underwent DU for reflux evaluation of the deep venous system (reflux ≥1 second); superficial system, great saphenous vein, and small saphenous vein (reflux ≥0.5 second); and perforator system (reflux ≥0.35 second). All patients underwent IVUS in the iliac venous territory. The area of the impaired venous segments was categorized as obstruction <50% (category 1), 50% to 79% (category 2), and ≥80% (category 3). The venous clinical severity score and reflux multisegment score (RMS) were assessed. RESULTS: A total of 51 patients (n = 102 limbs; age, 50.53 ± 14.5 years; 6 men) were included. The predominant clinical severity CEAP class was C3 in 54 of 102 limbs (52.9%). The mean VCSS was 14.3 ± 6.7. A severe RMS (≥3) was registered in 63.4% of the limbs. Of the 102 limbs, 51 (50%) presented with category 1, 27 (26.5%) with category 2, and 24 (23.5%) with category 3. Previous deep vein thrombosis (DVT) was associated with critical obstruction (odds ratio [OR], 3.65; 95% confidence interval [CI], 1.29-10.38; P = .015). The superficial and perforator venous systems had no association with the degree of IVOO. Deep venous reflux (DVR) had a significant association with significant IVOO (obstruction ≥50%; OR, 6.44; 95% CI, 2.19-18.93; P = .001) and critical IVOO (obstruction ≥80%; OR, 4.57; 95% CI, 1.70-12.27; P = .003) and a significant linear association with the IVOO degree and reflux in the femoral veins (P < .001) and popliteal vein (P = .008). Significant lesions were significantly more likely to develop in the left limb (OR, 5.76; 95% CI, 2.46-13.50; P < .001). After multivariate analysis, DVR remained a predictor for significant and critical obstruction (P < .003 and P < .012, respectively). Left limb and previous DVT remained as predictors for IVOO of ≥50% and ≥80% (P < .001 and P = .043, respectively). CONCLUSIONS: We found a significant linear association between the degree of IVOO and reflux in the deep venous system on DU. Limbs with DVR, a severe RMS, loss of respiratory variation on DU, and previous DVT were more likely to be affected by IVOO of ≥50%, especially with left leg involvement.

Association between the degree of iliac venous outflow obstruction by intravascular ultrasound and lower limbs venous reflux

OBJECTIVE: This study aims to evaluate the association between the degree of iliac venous outflow obstruction (IVOO) identified by Intravascular Ultrasound (IVUS) and venous reflux presentation in lower limbs on Duplex Ultrasound (DU). METHODS: Patients with bilateral chronic venous insufficiency, CEAP C3-6 (Clinical-Etiology-Anatomy-Pathophysiology classification), and with Visual Analogic Scale score for pain > 5, underwent DU for reflux evaluation: deep venous system (reflux ≥ 1 s); superficial system, great saphenous vein (GSV) and small saphenous vein (SSV) (reflux ≥ 0.5 s); perforator system (reflux ≥ 0.35s). All patients underwent IVUS in the iliac venous territory. The area of the impaired venous segments was categorized as obstructions< 50% (Cat. 1); 50-79% (Cat. 2), and ≥ 80% (Cat. 3). Venous clinical severity scale (VCSS) and reflux multisegment score (RMS) were assessed. RESULTS: 51 patients (n=102 limbs; 50.53 ± 14.5 years, 6 men) were included. The predominant clinical severity CEAP class was C3 in 54/102 (52.9%) limbs. VCSS mean was 14.3 ± 6.7. Severe RMS (≥ 3) was registered in 63,4% of the limbs. In 51/102 limbs (50%) presented cat. 1, 27/102 (26.5%) cat. 2, and 24/102 (23.5%) cat. 3. Previous DVT was associated with critical obstruction (OR 3.65; 95% CI: 1.29-10.38; p=0.015). Superficial and perforator venous systems had no association with the degree of iliac obstruction. Deep venous reflux (DVR) had a significant association with significative IVOO (obstruction ≥ 50%) (OR 6.44; 95% CI: 2.19-18.93; p=0.001) and critical IVOO (obstruction ≥ 80%) (OR 4.57; 95% CI: 1.70-12.27; p=0.003), and significant linear association with IVOO degree and reflux in femoral veins (p<0.001) and popliteal vein (p=0.008). Significant lesions had 5.76 (95% CI: 2.46-13.50; p<0.001) more odds of happening in the left limb. After a multivariate analysis, DVR remained as predictor for significant and critical obstruction (p<0.003, p< 0.012; respectively). Left limb and previous DVT remained as predictors for IVOO ≥50% and IVOO≥ 80% (p<0.001, p=0.043; respectively) CONCLUSIONS: There is a significant linear association between the degree of iliac venous outflow obstruction and reflux in the deep venous system on DU. Limbs with DVR, severe RMS, loss of respiratory variation on DU, and previous DVT, were more likely to be affected by IVOO ≥ 50%, especially with the left leg involvement.

Uterine artery embolization with highly compressible calibrated microspheres for the treatment of uterine fibroids.

Objective: To evaluate the safety and efficacy of using highly compressible calibrated microspheres in uterine artery embolization (UAE) for the treatment of uterine fibroids. Materials and Methods: This was a prospective multicenter study. Thirty-two women with symptomatic uterine fibroids were selected for UAE between January 2019 and March 2020. The participants completed the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire, underwent contrast-enhanced pelvic magnetic resonance imaging (MRI), and were submitted to anti-Müllerian hormone measurement, subsequently undergoing UAE with Embosoft microspheres. After six months, the patients again completed the UFS-QOL questionnaire and underwent pelvic MRI. Results: The most common symptoms were abnormal uterine bleeding (in 81.3% of the cases), pelvic pain (in 81.3%), and compression (in 46.9%). Of the 32 patients evaluated, 12 (37.5%) had anemia due to abnormal uterine bleeding. Thirty patients completed the study. Among those patients, we observed median reductions of 21.4% in uterine volume and 15.9% in dominant fibroid volume. We identified no adverse events that could be attributed to the material itself, although there were events attributed to the UAE procedure in general. Conclusion: For the treatment of uterine fibroids, UAE using Embosoft microspheres shows satisfactory results, providing reductions in uterine and dominant fibroid volumes, with a low rate of adverse events, and improving patient quality of life, as well as demonstrating safety and efficacy.

Objetivo: Avaliar a eficácia e segurança da embolização da artéria uterina (EAU) com microesferas calibradas de alta compressibilidade no tratamento de miomas uterinos. Materiais e Métodos: Este foi um estudo prospectivo e multicêntrico. Foram selecionadas 32 mulheres com miomas uterinos sintomáticos para EAU de janeiro de 2019 a março de 2020. As participantes preencheram o questionário Uterine Fibroid Symptom and Quality of Life (UFS-QOL), realizaram ressonância magnética (RM) pélvica com contraste e teste para medição dos hormônios antimüllerianos, seguido de embolização de miomas com microesferas Embosoft. Após seis meses, as pacientes novamente preencheram o UFS-QOL e realizaram RM pélvica. Resultados: Os sintomas mais relatados foram sangramento uterino anormal (81,3%), dor pélvica (81,3%) e compressão (46,9%). Doze pacientes (37,5%) apresentaram anemia consequente a sangramento uterino anormal. Nas 30 pacientes que completaram o estudo, observou-se redução mediana de 21,4% no volume uterino e 15,9% no volume do mioma dominante. Não foram identificados eventos adversos possivelmente relacionados ao material utilizado, apenas em relação ao procedimento de EAU. Conclusão: EAU com microesferas Embrosoft mostrou resultados satisfatórios no tratamento de miomas uterinos, com redução dos volumes uterino e do mioma dominante, baixa taxa de eventos adversos e melhora na qualidade de vida, demonstrando segurança e eficácia.

Uterine artery embolization with highly compressible calibrated microspheres for the treatment of uterine fibroids / Embolização de miomas uterinos com microesferas calibradas de alta compressibilidade

OBJECTIVE: To evaluate the safety and efficacy of using highly compressible calibrated microspheres in uterine artery embolization (UAE) for the treatment of uterine fibroids. MATERIALS AND METHODS: This was a prospective multicenter study. Thirty-two women with symptomatic uterine fibroids were selected for UAE between January 2019 and March 2020. The participants completed the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire, underwent contrast-enhanced pelvic magnetic resonance imaging (MRI), and were submitted to anti-Müllerian hormone measurement, subsequently undergoing UAE with Embosoft microspheres. After six months, the patients again completed the UFS-QOL questionnaire and underwent pelvic MRI. RESULTS: The most common symptoms were abnormal uterine bleeding (in 81.3% of the cases), pelvic pain (in 81.3%), and compression (in 46.9%). Of the 32 patients evaluated, 12 (37.5%) had anemia due to abnormal uterine bleeding. Thirty patients completed the study. Among those patients, we observed median reductions of 21.4% in uterine volume and 15.9% in dominant fibroid volume. We identified no adverse events that could be attributed to the material itself, although there were events attributed to the UAE procedure in general. CONCLUSION: For the treatment of uterine fibroids, UAE using Embosoft microspheres shows satisfactory results, providing reductions in uterine and dominant fibroid volumes, with a low rate of adverse events, and improving patient quality of life, as well as demonstrating safety and efficacy.

OBJETIVO: Avaliar a eficácia e segurança da embolização da artéria uterina (EAU) com microesferas calibradas de alta compressibilidade no tratamento de miomas uterinos. MATERIAIS E MÉTODOS: Este foi um estudo prospectivo e multicêntrico. Foram selecionadas 32 mulheres com miomas uterinos sintomáticos para EAU de janeiro de 2019 a março de 2020. As participantes preencheram o questionário Uterine Fibroid Symptom and Quality of Life (UFS-QOL), realizaram ressonância magnética (RM) pélvica com contraste e teste para medição dos hormônios antimüllerianos, seguido de embolização de miomas com microesferas Embosoft. Após seis meses, as pacientes novamente preencheram o UFS-QOL e realizaram RM pélvica. RESULTADOS: Os sintomas mais relatados foram sangramento uterino anormal (81,3%), dor pélvica (81,3%) e compressão (46,9%). Doze pacientes (37,5%) apresentaram anemia consequente a sangramento uterino anormal. Nas 30 pacientes que completaram o estudo, observou-se redução mediana de 21,4% no volume uterino e 15,9% no volume do mioma dominante. Não foram identificados eventos adversos possivelmente relacionados ao material utilizado, apenas em relação ao procedimento de EAU. CONCLUSÃO: EAU com microesferas Embrosoft mostrou resultados satisfatórios no tratamento de miomas uterinos, com redução dos volumes uterino e do mioma dominante, baixa taxa de eventos adversos e melhora na qualidade de vida, demonstrando segurança e eficácia.

Uterine artery embolization with highly compressible calibrated microspheres for the treatment of uterine fibroids / Embolização de miomas uterinos com microesferas calibradas de alta compressibilidade

Abstract Objective: To evaluate the safety and efficacy of using highly compressible calibrated microspheres in uterine artery embolization (UAE) for the treatment of uterine fibroids. Materials and Methods: This was a prospective multicenter study. Thirty-two women with symptomatic uterine fibroids were selected for UAE between January 2019 and March 2020. The participants completed the Uterine Fibroid Symptom and Quality of Life (UFS-QOL) questionnaire, underwent contrast-enhanced pelvic magnetic resonance imaging (MRI), and were submitted to anti-Müllerian hormone measurement, subsequently undergoing UAE with Embosoft microspheres. After six months, the patients again completed the UFS-QOL questionnaire and underwent pelvic MRI. Results: The most common symptoms were abnormal uterine bleeding (in 81.3% of the cases), pelvic pain (in 81.3%), and compression (in 46.9%). Of the 32 patients evaluated, 12 (37.5%) had anemia due to abnormal uterine bleeding. Thirty patients completed the study. Among those patients, we observed median reductions of 21.4% in uterine volume and 15.9% in dominant fibroid volume. We identified no adverse events that could be attributed to the material itself, although there were events attributed to the UAE procedure in general. Conclusion: For the treatment of uterine fibroids, UAE using Embosoft microspheres shows satisfactory results, providing reductions in uterine and dominant fibroid volumes, with a low rate of adverse events, and improving patient quality of life, as well as demonstrating safety and efficacy.

Resumo Objetivo: Avaliar a eficácia e segurança da embolização da artéria uterina (EAU) com microesferas calibradas de alta compressibilidade no tratamento de miomas uterinos. Materiais e Métodos: Este foi um estudo prospectivo e multicêntrico. Foram selecionadas 32 mulheres com miomas uterinos sintomáticos para EAU de janeiro de 2019 a março de 2020. As participantes preencheram o questionário Uterine Fibroid Symptom and Quality of Life (UFS-QOL), realizaram ressonância magnética (RM) pélvica com contraste e teste para medição dos hormônios antimüllerianos, seguido de embolização de miomas com microesferas Embosoft. Após seis meses, as pacientes novamente preencheram o UFS-QOL e realizaram RM pélvica. Resultados: Os sintomas mais relatados foram sangramento uterino anormal (81,3%), dor pélvica (81,3%) e compressão (46,9%). Doze pacientes (37,5%) apresentaram anemia consequente a sangramento uterino anormal. Nas 30 pacientes que completaram o estudo, observou-se redução mediana de 21,4% no volume uterino e 15,9% no volume do mioma dominante. Não foram identificados eventos adversos possivelmente relacionados ao material utilizado, apenas em relação ao procedimento de EAU. Conclusão: EAU com microesferas Embrosoft mostrou resultados satisfatórios no tratamento de miomas uterinos, com redução dos volumes uterino e do mioma dominante, baixa taxa de eventos adversos e melhora na qualidade de vida, demonstrando segurança e eficácia.

Real life outcomes of infrapopliteal endovascular and surgical bypass intervention for chronic limb threatening ischaemia in GLASS stages II and III

OBJETIVE: Great efforts have been made to determine when choosing between bypass surgery or angioplasty as first-time revascularization in chronic limb-threatening ischemia (CLTI). Endovascular therapy predominates despite limited evidence for their advantage. The purpose of this observational cohort study, was to investigate outcomes after open and endovascular infrapopliteal revascularization in extensive infrainguinal arterial disease. METHODS: The medical records of 1427 patients who underwent infrainguinal revascularization exclusively for CLTI in the period of January 2014 to February 2019 were reviewed. After detailed analysis, only infrapopliteal revascularizations classified as GLASS stage II or III were considered, resulting in 326 procedures. There were 127 patients who underwent endovascular therapy and 199 patients who underwent bypass graft surgery (BGS). The primary endpoints included amputation-free survival (AFS) and overall survival (OS). Secondary endpoints included the analyses of multiple factors related to long-term AFS. RESULTS: Regarding the primary endpoint, AFS were 75.2% and 65.2% at 1 and 3 years, respectively. Overall survival at 1 and 3 years were 91.2% and 83.1%, respectively. In the univariate analysis, the hazard of the combined endpoint of major amputation or death was higher following bypass surgery than after endovascular therapy (HR 1.80; 95% CI, 1.13-2.89; P= .013). After either revascularization method, TASCII femoropopliteal D was associated with a higher risk of amputation or death (HR 1.69; 95% CI, 1.10-2.58; P= .015). Multivariate Cox regression analysis revealed no association between the variables analysed for AFS. CONCLUSIONS: CLTI patients submitted to infrapopliteal revascularization and classified as GLASS II and III had satisfactory AFS and OS rates after indivualized team conference decision. Furthermore, the revascularization modality (endo or open) did not influence the results of AFS.

Real Life Outcomes of Infrapopliteal Endovascular and Surgical Bypass Intervention for Chronic Limb Threatening Ischaemia in GLASS Stages II and III.

OBJECTIVE: Great efforts have been made to choose between bypass surgery and angioplasty as the first choice for revascularisation in chronic limb threatening ischaemia (CLTI). Endovascular therapy predominates despite limited evidence for its advantages. The purpose of this observational cohort study was to investigate outcomes after open and endovascular infrapopliteal revascularisation in extensive infrainguinal arterial disease. METHODS: The medical records of 1 427 patients who underwent infrainguinal revascularisation exclusively for CLTI in the period January 2014 to February 2019 were reviewed. After detailed analysis, only infrapopliteal revascularisations classified as GLASS stage II or III were considered, resulting in 326 procedures. In total, 127 patients underwent endovascular therapy and 199 patients underwent bypass graft surgery (BGS). The primary endpoints included amputation free survival (AFS) and overall survival (OS). Secondary endpoints included the analyses of multiple factors related to long term AFS. RESULTS: Regarding the primary endpoint, AFS was 75.2% and 65.2% at one and three years, respectively. OS at one and three years was 91.2% and 83.1%, respectively. In the univariable analysis, the hazard of the combined endpoint of major amputation or death was higher after bypass surgery than after endovascular therapy (hazard ratio [HR] 1.80, 95% confidence interval [CI] 1.13 - 2.89; p = .013). After either revascularisation method, TASC II femoropopliteal D was associated with a higher risk of amputation or death (HR 1.69, 95% CI 1.10 - 2.58; p = .015). Multivariable Cox regression analysis revealed no association between the variables analysed for AFS. CONCLUSION: Patients with CLTI submitted to infrapopliteal revascularisation and classified as GLASS II and III had satisfactory AFS and OS rates after an individualised team conference decision. Furthermore, the revascularisation modality (endovascular or open) did not influence the AFS results.

Tratamento percutâneo/vascular para coartação da aorta associada à aneurismas / Percutaneous/vascular treatment for aortic coarctation associated with aneurysms

INTRODUÇÃO: As coartações da aorta (CoAo) associadas a aneurismas representam um grande desafio terapêutico, especialmente nos casos que ambas lesões envolvem os vasos supra-aórticos. OBJETIVOS: Apresentar uma série de casos em que o tratamento da coartação da aorta e dos aneurismas foi realizado com técnicas associadas de cirurgia vascular, endovascular e percutânea. MÉTODOS: Realizado estudo retrospectivo descritivo incluindo os pacientes submetidos ao tratamento da coartação da aorta com aneurismas associados que necessitaram do uso combinado de intervenções vasculares entre 2012 e 2020. A partir do prontuário médico foram obtidos dados demográficos e dados clínicos basais, manometrias, dados angiográficos, dispositivos, técnicas cirúrgicas e percutâneas empregadas e complicações imediatas. RESULTADOS: No período estudado, 5 pacientes (4 mulheres) com mediana de idade de 29 anos (16-68) e de peso de 60 kg (54-89) foram submetidos a aortoplastia combinada ao uso de técnicas vasculares para o tratamento de aneurisma relacionado à CoAo. Três deles receberam tratamento com endoprótese e os outros dois foram submetidos a derivações cirúrgicas carotídeo-subclávias prévias à aortoplastia. As endopróteses utilizadas foram VALIANT® ou GORE-TAG®. Em 2 pacientes foram implantados stents convencionais no local coartado no interior da endoprótese para aumentar a força radial e ampliar efetivamente o vaso. Os pacientes que realizaram a derivação carotídeo-subclávia apresentavam aneurismas próximos à emergência da artéria subclávia esquerda (ASCE). Um deles tinha histórico de três abordagens prévias na região da CoAo, a última delas com implante de stent convencional evoluindo com dois aneurismas associados ao stent. O implante do stent coberto (CP COVERED®) foi realizado 2 dias após a cirurgia. No outro caso, tratava-se de CoAo nativa com aneurisma e hipoplasia do arco aórtico. Foi optado pela derivação carotídeo-ASCE com PTFE nº6 e aortoplastia com stent coberto cinco dias após a cirurgia vascular. Os tratamentos foram bem-sucedidos em todos os cinco casos sem complicações imediatas relacionadas ao procedimento. CONCLUSÃO: O manejo da coartação da aorta com aneurismas próximos aos vasos supra-aórticos é desafiador e requer uma análise criteriosa, individualizada e detalhada. O envolvimento de múltiplas equipes e técnicas aumenta o arsenal terapêutico e consequentemente a chance de sucesso no tratamento. A combinação entre intervenções percutâneas e vasculares é um exemplo de interdisciplinaridade que possibilita a abordagem minimamente invasiva para casos complexos. Os principais candidatos são aqueles com recoartação e aneurismas de grandes dimensões ou com comprometimento da ASCE. Em casos bem selecionados, esta combinação parece ser segura e eficaz.

Mid- to long-term clinical and echocardiographic outcomes after transcatheter aortic valve replacement with a new-generation, self-expandable system.

OBJECTIVES: The aim of the study was to evaluate mid- to late clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) with Acurate neo™ (Boston Scientific, Boston, MA). BACKGROUND: TAVR is an established treatment for aortic stenosis (AS). Few data exist on mid- to long-term outcomes and durability after new-generation valves. METHODS: All consecutive patients (n = 104) who underwent Acurate neo™ implantation from 2012 to 2018 were included. Follow-up was systematically performed at 1, 6, 12, and 24 months and yearly thereafter. Outcomes were reported according to VARC-2, and structural valve deterioration (SVD) or bioprosthetic valve failure defined accordingly to new definitions. RESULTS: Mean age was 82 ± 5.4 years, 56.7% were female and the Society of Thoracic Surgeons score for mortality was 5.9 ± 4%. Patients were followed for a median of 3 years (1,092 days; IQR 1.5-4 years), and the maximum follow-up was 7 years. All-cause mortality values at 1 and 5 years were 8.5% and 40.5%, respectively. No relevant changes in mean gradient and orifice area occurred (7.9 ± 3.8 mmHg and 1.9 ± 0.3 cm2 at 1 year; 6.6 ± 2.1 mmHg and 1.8 ± 0.3 cm2 at 5 years), and there was a significant rate of paravalvular leaks resolution at 1, 2, and 3 years (p = .004; p < .001; p < .001, respectively). None of the patients had leaflet thrombosis or endocarditis. One patient developed SVD at 84 months. CONCLUSIONS: Acurate neo™ was associated with sustained echocardiographic results. Reassuring mid- to long-term outcomes was observed in this cohort of elderly patients with severe AS.

Mid- to long-term clinical and echocardiographic outcomes after transcatheter aortic valve replacement with a newgeneration, self-expandable system / Desfechos clínicos e ecocardiográficos de médio a longo prazo após a substituição da válvula aórtica transcateter com uma nova geração, sistema auto-expansível

Abstract Objectives: The aim of the study was to evaluate mid- to late clinical and echocardiographic outcomes after transcatheter aortic valve replacement (TAVR) with A curate neo™ (Boston Scientific, Boston, MA). Background: TAVR is an established treatment for aortic stenosis (AS). Few data exist on mid- to long-term outcomes and durability after new-generation valves. Methods: All consecutive patients (n = 104) who underwent A curate neo™ implantation from 2012 to 2018 were included. Follow-up was systematically performed at 1, 6, 12, and 24 months and yearly thereafter. Outcomes were reported according to VARC-2, and structural valve deterioration (SVD) or bioprosthetic valve failure defined accordingly to new definitions. Results: Mean age was 82 ± 5.4 years, 56.7% were female and the Society of Thoracic Surgeons score for mortality was 5.9 ± 4%. Patients were followed for a median of 3 years (1,092 days; IQR 1.5­4 years), and the maximum follow-up was 7 years. All-cause mortality values at 1 and 5 years were 8.5% and 40.5%, respectively. No relevant changes in mean gradient and orifice area occurred (7.9 ± 3.8 mmHg and 1.9 ± 0.3 cm2 at 1 year; 6.6 ± 2.1 mmHg and 1.8 ± 0.3 cm2 at 5 years), and there was a significant rate of paravalvular leaks resolution at 1, 2, and 3 years (p = .004; p < .001; p < .001, respectively). None of the patients had leaflet thrombosis or endocarditis. One patient developed SVD at 84 months. Conclusions: A curate neo™ was associated with sustained echocardiographic results. Reassuring mid- to long-term outcomes was observed in this cohort of elderly patients with severe AS.

Comparison of computed tomography venography and intravascular ultrasound in screening and classification of iliac vein obstruction in patients with chronic venous disease.

OBJECTIVE: To investigate power of computed tomography venography (CTV) to identify and characterize iliac vein obstruction (IVO) compared with intravascular ultrasound (IVUS) examination in highly symptomatic patients with chronic venous disease (CVD). METHODS: CVD CEAP C3-6 limbs with visual analog scale for pain score of greater than 3 and/or Venous Clinical Severity Scale of greater than 8 were prospectively investigated with CTV and IVUS examination. The segment of maximum IVO was verified and categorically classified: group I, 0% to 49%; group II, 50% to 79%; and group III, 80% or greater. The CTV's screening power to detect the point and degree of maximum IVO was compared with IVUS. RESULTS: The CTV point of maximum IVO was 80% in the left limb, 10% in the right limb, 10% bilaterally; 2% in the inferior vena cava; 91% in the common iliac vein (CIV) confluence (41.6% below the CIV confluence, 34.5 at the CIV confluence, and 23.9% above the CIV confluence); 7% at the external iliac vein (kappa index 0.841; P < .001, when compared with IVUS). The distal venous segment considered free of obstruction was above inguinal ligament: 68% (CIV, 47%; external iliac vein, 21%) 32% below the inguinal ligament (common femoral vein, 26%; deep femoral vein, 6%) (kappa index 0.671; P = .023, when compared with IVUS). The power of CTV to detect an IVO of 50% or greater (groups II and III) when compared with IVUS achieved a sensitivity and specificity ratio of 94.0% and 79.2%, respectively. The positive predictive value was 94%, the negative predictive value was 79.1%, accuracy was 86.7% (kappa, 0.733), and interobserver agreement was 92.1% (95% confidence interval, 87.1-97.7; kappa, 0.899). CONCLUSIONS: CTV is a powerful screening method in determining the precise point of compression and classifying IVO in limbs with symptomatic CVD when compared with IVUS. The prevalence of an obstruction above the iliac vein confluence is significant and should be considered in iliac vein stenting treatment strategy. The tomographic classification system proposed here may help to define the optimum technique of treatment, prognosis, and comparison of outcome results.

Comparison of computed tomography venography and intravascular ultrasound in screening and classification of iliac vein obstruction in patients with chronic venous disease

Objective: To investigate power of computed tomography venography (CTV) to identify and characterize iliac vein obstruction (IVO) compared with intravascular ultrasound (IVUS) examination in highly symptomatic patients with chronic venous disease (CVD). Methods: CVD CEAP C3-6 limbs with visual analog scale for pain score of greater than 3 and/or Venous Clinical Severity Scale of greater than 8 were prospectively investigated with CTV and IVUS examination. The segment of maximum IVO was verified and categorically classified: group I, 0% to 49%; group II, 50% to 79%; and group III, 80% or greater. The CTV's screening power to detect the point and degree of maximum IVO was compared with IVUS. Results: The CTV point of maximum IVO was 80% in the left limb, 10% in the right limb, 10% bilaterally; 2% in the inferior vena cava; 91% in the common iliac vein (CIV) confluence (41.6% below the CIV confluence, 34.5 at the CIV confluence, and 23.9% above the CIV confluence); 7% at the external iliac vein (kappa index 0.841; P < .001, when compared with IVUS). The distal venous segment considered free of obstruction was above inguinal ligament: 68% (CIV, 47%; external iliac vein, 21%) 32% below the inguinal ligament (common femoral vein, 26%; deep femoral vein, 6%) (kappa index 0.671; P » .023, when compared with IVUS). The power of CTV to detect an IVO of 50% or greater (groups II and III) when compared with IVUS achieved a sensitivity and specificity ratio of 94.0% and 79.2%, respectively. The positive predictive value was 94%, the negative predictive value was 79.1%, accuracy was 86.7% (kappa, 0.733), and interobserver agreement was 92.1% (95% confidence interval, 87.1-97.7; kappa, 0.899). Conclusions: CTV is a powerful screening method in determining the precise point of compression and classifying IVO in limbs with symptomatic CVD when compared with IVUS. The prevalence of an obstruction above the iliac vein confluence is significant and should be considered in iliac vein stenting treatment strategy. The tomographic classification system proposed here may help to define the optimum technique of treatment, prognosis, and comparison of outcome results. (J Vasc Surg: Venous and Lym Dis 2019;-:1-10.) Keywords: Iliac vein obstruction; Computed tomography Venography; Intravascular ultrasound; May-Thuner syndrome; Cockett syndrome; Classification

Best practices in diagnosis and treatment of chronic iliac vein obstruction.

Iliac vein obstruction occurs in 20-30% of the general population. In patients with severe chronic venous insufficiency, this prevalence can be even higher, reaching 50-90% when the obstruction is investigated using intravascular ultrasound. Less invasive methods, such as venous Duplex Scanning, and even invasive ones such as venography may fail to diagnose the condition. Endovascular treatment of these obstructions is effective, safe, and associated with excellent clinical outcomes and stent patency rates, provided that fundamental anatomical and technical principles are considered and applied.

O caminho das pedras no diagnóstico e tratamento da síndrome obstrutiva ilíaca venosa crônica / Best practices in diagnosis and treatment of chronic iliac vein obstruction

Resumo A obstrução venosa ilíaca ocorre em 20% a 30% da população. Nos portadores de insuficiência venosa crônica grave, essa prevalência é ainda maior, podendo chegar a 50% a 90% dos pacientes, situação em que essa obstrução é investigada pelo ultrassom intravascular. Métodos diagnósticos menos invasivos, como o Doppler vascular, ou mesmo invasivos, como a flebografia, podem falhar em seu diagnóstico. O tratamento endovascular dessas obstruções tem se demonstrado eficaz, seguro e associado a excelente resultado clínico e de perviedade, desde que princípios anatômicos e técnicos fundamentais sejam considerados e aplicados.

Abstract Iliac vein obstruction occurs in 20-30% of the general population. In patients with severe chronic venous insufficiency, this prevalence can be even higher, reaching 50-90% when the obstruction is investigated using intravascular ultrasound. Less invasive methods, such as venous Duplex Scanning, and even invasive ones such as venography may fail to diagnose the condition. Endovascular treatment of these obstructions is effective, safe, and associated with excellent clinical outcomes and stent patency rates, provided that fundamental anatomical and technical principles are considered and applied.

Correlation between venous pressure gradients and intravascular ultrasound in the diagnosis of iliac vein compression syndrome

Objective: The objective of this study was to evaluate the correlation between venous pressure gradients (VPGs) and intravascular ultrasound (IVUS) for the diagnosis of caval-iliac venous obstructions in patients with advanced chronic venous insufficiency. Methods: Fifty patients with advanced chronic venous insufficiency symptoms (Clinical, Etiology, Anatomy, and Pathophysiology class 3 to 6) were prospectively submitted to multiplanar venography (MV) with intravenous pressure measurements and IVUS. The patients' lower limbs were divided accordingly: group I, limbs with <50% obstruction on IVUS (n » 49); and group II, limbs with $50% obstruction on IVUS (n » 51). Receiver operating characteristic curves compared the diagnostic performance of the VPGs. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy assessed the performance of VPGs in categories to determine the presence of significant obstruction. Logistic regression assessed the capacity of the VPGs to identify significant obstruction. Results: The most frequent point of venous compression according to IVUS was the proximal left common iliac vein (70%; P < .05). Group II showed a greater prevalence of transpelvic (group I, 8.2%; group II, 74.5%; P < .001) and paravertebral collaterals (group I, 4.1%; group II, 45.1%; P < .001) on n MV. The femoral vein pressures at rest and after reactive hyperemia as well as the femorocaval gradient after reactive hyperemia (FCG-rh) and the femoral gradient after reactive hyperemia were significantly higher in group II (P » .001, P < .001, P » .002, and P » .006). The FCG-rh and the femoral gradient after reactive hyperemia presented the best diagnostic performance among the VPGs (P » .004 and P » .007) in n the receiver operating characteristic curve analysis, although no significant differences between them were found. All the gradients presented low values of sensitivity (<40%). negative predictive value (<60%). and accuracy (<30%). Logistic regression showed that FCG-rh was significantly independent of MV (OR, 8.1; P » .011) in identifying significant obstructions. Conclusions: There is correlation between the VPGs and significant obstructions with IVUS. However, this correlation does not translate to a good diagnostic performance of these VPGs. Only the FCG-rh added significant information to MV in identifying significant caval-iliac vein obstructions.

Correlation between venous pressure gradients and intravascular ultrasound in the diagnosis of iliac vein compression syndrome.

OBJECTIVE: The objective of this study was to evaluate the correlation between venous pressure gradients (VPGs) and intravascular ultrasound (IVUS) for the diagnosis of caval-iliac venous obstructions in patients with advanced chronic venous insufficiency. METHODS: Fifty patients with advanced chronic venous insufficiency symptoms (Clinical, Etiology, Anatomy, and Pathophysiology class 3 to 6) were prospectively submitted to multiplanar venography (MV) with intravenous pressure measurements and IVUS. The patients' lower limbs were divided accordingly: group I, limbs with <50% obstruction on IVUS (n = 49); and group II, limbs with ≥50% obstruction on IVUS (n = 51). Receiver operating characteristic curves compared the diagnostic performance of the VPGs. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy assessed the performance of VPGs in categories to determine the presence of significant obstruction. Logistic regression assessed the capacity of the VPGs to identify significant obstruction. RESULTS: The most frequent point of venous compression according to IVUS was the proximal left common iliac vein (70%; P < .05). Group II showed a greater prevalence of transpelvic (group I, 8.2%; group II, 74.5%; P < .001) and paravertebral collaterals (group I, 4.1%; group II, 45.1%; P < .001) on MV. The femoral vein pressures at rest and after reactive hyperemia as well as the femorocaval gradient after reactive hyperemia (FCG-rh) and the femoral gradient after reactive hyperemia were significantly higher in group II (P = .001, P < .001, P = .002, and P = .006). The FCG-rh and the femoral gradient after reactive hyperemia presented the best diagnostic performance among the VPGs (P = .004 and P = .007) in the receiver operating characteristic curve analysis, although no significant differences between them were found. All the gradients presented low values of sensitivity (<40%), negative predictive value (<60%), and accuracy (<30%). Logistic regression showed that FCG-rh was significantly independent of MV (OR, 8.1; P = .011) in identifying significant obstructions. CONCLUSIONS: There is correlation between the VPGs and significant obstructions with IVUS. However, this correlation does not translate to a good diagnostic performance of these VPGs. Only the FCG-rh added significant information to MV in identifying significant caval-iliac vein obstructions.

Randomized double-blinded study comparing medical treatment versus iliac vein stenting in chronic venous disease.

OBJECTIVE: Iliac vein stenting has emerged as the procedure of choice in the treatment of iliac vein obstruction (IVO). However, clinical outcomes have never been studied by a randomized clinical trial. Our purpose was to compare medical and endovascular treatment results in symptomatic chronic venous disease (CVD) patients with significant IVO documented by intravascular ultrasound (IVUS). METHODS: Patients with Clinical, Etiology, Anatomy, and Pathophysiology clinical class C3 to C6 and a visual analog scale for pain (VAS pain) score >3 were considered eligible. We randomly assigned limbs with ≥50% IVO on IVUS to undergo medical treatment alone or medical treatment plus iliac vein stenting. The patient and clinical physician were blinded. Primary outcomes included change from baseline in VAS pain score, Venous Clinical Severity Score, and 36-Item Short Form Health Survey quality of life questionnaire. Secondary outcomes included stent integrity, migration, and patency rates at 6 months. RESULTS: Of 207 CVD patients, 58 (28%) were eligible and eight (14%) were excluded; 51 of 85 class C3 to C6 limbs (60%) had ≥50% IVO by IVUS. Iliac vein stenting, in randomized patients, was 100% technically successful. At 6 months' follow-up, the mean VAS pain score declined from a median of 8 to 2.5 in patients receiving stents and from 8 to 7 in patients receiving only medical treatment (P < .001). The Venous Clinical Severity Score dropped from a median of 18.5 to 11 after stenting and from 15 to 14 with medical treatment (P < .001). The 36-Item Short Form Health Survey (0-100) improved from a total median score of 53.9 to 85.0 with stenting and 48.3 to 59.8 after medical treatment (P < .001). There was no stent fracture or migration, and the primary, assisted primary, and secondary patency rates were 92%, 96%, and 100%, respectively (median, 11.8; range, 6-18 months). CONCLUSIONS: Endovascular treatment of IVO with stenting is safe and promotes effective relief of symptoms and improvement in quality of life compared with medical treatment alone in symptomatic CVD patients. Our results echo those achieved in numerous previously published nonrandomized clinical series.

Prospective, double-blind, randomized controlled trial comparing electrocoagulation and radiofrequency in the treatment of patients with great saphenous vein insufficiency and lower limb varicose veins.

OBJECTIVE: Thermoablation has been replacing conventional surgery in the surgical treatment of great saphenous vein (GSV) reflux in patients with lower limb varicose veins; however, thermoablation is expensive. Intravenous electrocoagulation (EC) may, selectively and safely, cause necrosis of the GSV wall, but the clinical results have never been studied. The objective of this study was to compare EC and radiofrequency ablation (RFA) in the treatment of GSV insufficiency, considering efficacy, complications, and effect on quality of life. METHODS: This was a prospective, double-blind, randomized clinical trial. Patients with lower limb varicose veins and GSV reflux confirmed by duplex ultrasound were randomized into two treatment groups: EC and RFA. Patients were followed up at 1 week, 3 months, and 6 months after the procedure. Occlusion of the GSV confirmed by duplex ultrasound was considered the primary outcome, and the rate of complications and improvement in quality of life, using the Aberdeen Varicose Vein Questionnaire score, were the secondary outcomes. RESULTS: Fifty-seven patients were included, with a total of 85 treated GSVs; 43 were treated with RFA and 42 with EC. There was no statistically significant difference between the groups regarding age (P = .264), sex (P = .612), Aberdeen Varicose Vein Questionnaire score (P = .054), and diameter (P = .880) and depth (P = .763) of the treated GSV. In the intraoperative period, immediately after thermoablation, all GSVs treated with EC presented no flow and incompressibility in the treated segment, whereas 12 limbs still had flow in the treated GSV (P < .001) and 9 veins showed compressibility (P < .001) when treated with RFA. The main postoperative complication was paresthesia; however, there was no statistical significance between the groups (P = .320) regarding its presence. Time to return to routine activities was lower in the EC group than in the RFA group (P = .026). There was no difference between the groups at the 3-month (P = .157) and 6-month (P = .157) follow-up in occlusion of the GSV and improvement of the quality of life score (P = .786 and P = .401, respectively). CONCLUSIONS: EC has been shown to be an effective method for ablation of the GSV, with venous occlusion rate, occurrence of complications, and effect on quality of life similar to those with RFA.

Prospective, double-blind, randomized controlled trial comparing electrocoagulation and radiofrequency in the treatment of patients with great saphenous vein insufficiency and lower limb varicose veins

OBJECTIVE: Thermoablation has been replacing conventional surgery in the surgical treatment of great saphenous vein (GSV) reflux in patients with lower limb varicose veins; however, thermoablation is expensive. Intravenous electrocoagulation (EC) may, selectively and safely, cause necrosis of the GSV wall, but the clinical results have never been studied. The objective of this study was to compare EC and radiofrequency ablation (RFA) in the treatment of GSV insufficiency, considering efficacy, complications, and effect on quality of life.METHODS:This was a prospective, double-blind, randomized clinical trial. Patients with lower limb varicose veins and GSV reflux confirmed by duplex ultrasound were randomized into two treatment groups: EC and RFA. Patients were followed up at 1 week, 3 months, and 6 months after the procedure. Occlusion of the GSV confirmed by duplex ultrasound was considered the primary outcome, and the rate of complications and improvement in quality of life, using the Aberdeen Varicose Vein Questionnaire score, were the secondary outcomes...

Randomized double-blinded study comparing medical treatment versus iliac vein stenting in chronic venous disease

OBJECTIVE:Iliac vein stenting has emerged as the procedure of choice in the treatment of iliac vein obstruction (IVO). However, clinical outcomes have never been studied by a randomized clinical trial. Our purpose was to compare medical and endovascular treatment results in symptomatic chronic venous disease (CVD) patients with significant IVO documented by intravascular ultrasound (IVUS).METHODS:Patients with Clinical, Etiology, Anatomy, and Pathophysiology clinical class C3 to C6 and a visual analog scale for pain (VAS pain) score >3 were considered eligible. We randomly assigned limbs with ≥50% IVO on IVUS to undergo medical treatment alone or medical treatment plus iliac vein stenting. The patient and clinical physician were blinded. Primary outcomes included change from baseline in VAS pain score, Venous Clinical Severity Score, and 36-Item Short Form Health Survey quality of life questionnaire. Secondary outcomes included stent integrity, migration, and patency rates at 6 months.