Journal of vascular surgery. Venous and lymphatic disorders最新文献

Objectives: Chronic anticoagulation for atrial fibrillation, history of venous thromboembolism, and following heart valve replacement is often stopped or bridged for surgery. Our institutional practice is to continue anticoagulation through ambulatory phlebectomy (AP) procedures. As such, we aimed to compare post-procedure bleeding and major adverse events in patients on anticoagulation who received ambulatory phlebectomy compared to patients not on anticoagulation.

Methods: We included all patients who required AP from January 2016 to February 2023. Given the low frequency of chronic anticoagulation during the study period, as defined as patients on anticoagulation ≥30 days before index procedure and not held through the procedure, a propensity score match of 16 demographic parameters was performed to better match patients. Following propensity matching, we compared the frequency and quality of post-procedural bleeding (none, incisional, large volume), extent of post-procedural ecchymosis (none, minimal, moderate, significant), and pain (minimal, moderate, severe) on follow up examination with a provider. Thirty-day ED visits and major adverse cardiac events (MACE) were also recorded for each patient. Continuous variables were compared using independent t-tests or Mann-Whitney U tests while categorical variables were compared using a Chi-square or Fisher's Exact test.

Results: In total, 1,853 patients received AP from four outpatient offices during the study period, 101 (5.5%) of which were on chronic anticoagulation. Seventy patients for each group were propensity score matched in key demographics including age, gender, BMI, Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification, prior vein procedures, concomitant laser procedures, number of phlebectomies performed, and co-morbidities like history of deep vein thrombosis, pulmonary embolism, and peripheral arterial disease. There were no intra-operative major bleeding events. Patients on chronic anticoagulation were not more likely to have increased post-procedural bleeding (2.9% vs 0%, p=0.496), significant ecchymosis (4.5% vs 1.5%, p=0.671), severe pain on follow up (1.4% vs 0%, p=0.604), or increased likelihood of post-procedural cellulitis (1.4% vs 0%, p=1.000). There were no instances of 30-day ED visits, or MACE. Within patients on anticoagulation, use of rivaroxaban (8%) had higher incidence of bleeding than those on apixaban or warfarin (0%), however, these findings were not significant.

Conclusions: Ambulatory phlebectomy while continuing chronic anticoagulation did not result in an increased rate of bleeding, ED visits, or major adverse events. It is likely safe to continue anticoagulation throughout these outpatient procedures.

Purpose: The aim of the study was to assess the mechanical thrombectomy (MT) and the catheter directed thrombolysis (CDT) utilization in patients with deep vein thrombosis (DVT) in tertiary care.

Materials and methods: We conducted a single-center retrospective cohort study. Tertiary hospital database from January 2022 to December 2023 was analyzed. All the records of patients referred for DVT were extracted. The collected data included general patient's information, medical history, results of physical examination, duplex ultrasound, laboratory analysis, etc. We assessed indications and contraindications for MT and CDT considering possible benefits and risks. We have identified patients who could be eligible for this technique.

Results: A total of 2427 patients with DVT were referred to hospital from January 2022 to December 2023. Among them, 961 patients (39.6%) had no indications for hospital admission or refused it and were recommended to receive anticoagulation on an outpatient basis, while 1466 patients (60.4%) were admitted to hospital. Among the hospitalized patients, 1277 had proximal DVT and 189 had distal DVT. The number of patients with iliofemoral DVT was 451 (18.6%). We found only 82 (3.4%) cases that could be potentially eligible for endovascular thrombectomy considering all possible indications and contraindications. Two attempts and fourteen successful procedures were conducted during the period of the study.

Conclusions: The number of patients with DVT who could be eligible for MT and CDT in a tertiary hospital is low.

Background: Despite advances in wound care, the dressing and management of chronic ulcers on lower limbs (LL) remains unsatisfactory. The simplicity, cost-efficiency, and diverse application possibilities of ultrasound guided foam sclerotherapy make it an attractive and effective approach to treat patients with no access or contraindications to more invasive methods.

Objective: To evaluate the healing rate of chronic venous ulcers (CEAP C6) in patients treated with ultrasound guided foam sclerotherapy.

Method: From January 2018 to December 2020, 279 patients (336 legs) classified at the first consultation as stage 6 for CEAP (clinical, etiological, anatomical, pathophysiological classification) were followed during treatment of axial venous reflux in saphenous and tributary veins with Polidocanol (Aethosxysklerol^R) foam and evaluated at 52 weeks for complete healing rates or ≥ 50% ulcer size reduction, using Kaplan-Meier statistics and Cox regression to study the influence of covariates.

Results: Average age of the 279 patients was 55 years. Of these, 156 (56%) showed complete healing in 52 weeks and 89 (32%) had a wound area reduction above 50%. Ulcer size severity, lymphedema and reduced dorsiflexion of the ankle were significantly associated with healing difficulty. Time of ulcer progression up to beginning of treatment (p < 0.01), ulcer size (p = 0.01), lymphedema (p = 0.006), reduced dorsiflexion of the ankle (p = 0.01) and age equal to or greater than 65 years (p = 0.003) were significantly associated with difficulty in healing. Patients with a mean Venous Clinical Severity Score (VCSS) of 18.7 had a better prognosis (18.7 vs 22.5; p<0.001).

Conclusion: Most patients with chronic venous ulcers (CEAP 6) treated with foam sclerotherapy achieved healing or significant improvement within 52 weeks. Healing was highly influenced by time until treatment, ulcer size, reduced dorsiflexion of the ankle and/or lymphedema presence and use of compression therapy.

Background: This study aimed to examine the early clinical outcomes of AngioJet rheolytic thrombectomy (RT) in patients with acute bilateral iliofemoral deep vein thrombosis (IFDVT), with a specific focus on the incidence of post-thrombotic syndrome (PTS).

Methods: From March 2021 to August 2023, sixteen consecutive patients with acute bilateral IFDVT treated with AngioJet RT at our center were evaluated. Primary outcomes include patency of the target veins, development of PTS, recurrent DVT, and procedure related death. Secondary outcomes included minor or major bleeding, acute kidney injury (AKI), documented haemoglobinuria, cardiac event, pulmonary embolism, limb loss, and death.

Results: The mean age of the patients was 69 ± 12 years (range, 53-87 years). Malignancy and recent major surgery were the most prevalent risk factors, each observed in 25% of patients (n=4). Technical success, complete clot removal, and alleviation of symptoms were achieved in all patients (n=16; 100%). In a quarter of the patients (n=4), transient hemoglobinuria was observed following the procedure. This complication resolved spontaneously after adequate fluid replenishment. Minor bleeding occurred in three patients (19%), while no patients had major bleeding complication. There was one postoperative AKI and transient bradycardia (6%). Three patients died after the procedures (19%). One patient (6%) developed postoperative massive PE. The mean follow-up was 11±6 months (range, 5-19 months). The primary patency rate was 92% and 91%, respectively, six and twelve months after procedures. One patient had reocclusion during the follow-up.

Conclusions: AngioJet RT applied to patients with bilateral IFDVT provides a promising picture, providing a patent vein lumen with high procedural success and achieving convincing early symptomatic improvement in severely symptomatic patients with impaired quality of life. In this early case series, the feasibility of the AngioJet device in elderly cases appears to be a significant problem. Therefore, patient selection is essential.

Objective: This study sought to investigate the changes in plasma D-dimer levels during catheter-directed thrombolysis (CDT) in patients with acute lower extremity deep venous thrombosis (DVT), analyze imaging results, and assess their clinical implications.

Methods: We retrospectively analyzed 62 patients diagnosed with acute lower extremity DVT who underwent CDT between March 2019 and December 2022. Plasma D-dimer levels were measured before CDT, at regular intervals after CDT, and at the end of CDT. Lower limb venography was performed every two days during CDT to assess the thrombus clearance rate and level of thrombus dissolution. Statistical analysis was conducted to observe the D-dimer concentration changes and analyze the correlation between D-dimer concentration and thrombus clearance rate. Additionally, a receiver operating characteristic (ROC) curve was constructed to determine the diagnostic performance of D-dimer in assessing the efficacy of thrombolysis, including the calculation of the area under the curve (AUC), sensitivity, specificity, and optimal cut-off value.

Results: During CDT for acute lower extremity DVT, plasma D-dimer levels rapidly increased, peaking on CDT day 1, and then gradually decreased, followed by a rapid decline but remained slightly elevated compared to normal levels. There was a positive correlation between D-dimer levels and thrombolysis efficacy (r = 0.809, P = 0.00). The linear regression equation for this correlation was Y = 0.161 + 0.028X. The AUC of D-dimer was 0.95, with a cut-off value of 9.935 mg/L (sensitivity 93.2% and specificity 95.4%).

Conclusion: Plasma D-dimer concentration can serve as an indicator for evaluating the efficacy of thrombolysis during CDT in acute lower extremity DVT.

Objective: To assess changes in noncontrast magnetic resonance imaging (MRI)-based biomarkers after upper extremity lymphedema surgery.

Methods: We retrospectively identified secondary upper extremity lymphedema patients who underwent vascularized lymph node transplant (VLNT), debulking lipectomy, or VLNT with a prior debulking (performed separately). All patients with both preoperative and postoperative MRIs were compared. An MRI-based edema scoring system was used: 0 (no edema), 1 (<50% fluid from myofascial to dermis), and 2 (≥50% fluid from myofascial to dermis). Edema scores and subcutaneous thickness (ST) were obtained along four quadrants across the upper and lower third of the arm and forearm each-for a total of 16 anatomical locations-and compared before and after surgery. Net changes in edema scores and ST were then correlated with Lymphoedema Quality-of-Life Questionnaire scores, L-Dex (bioimpedance), and limb volume difference by perometry.

Results: Patients who underwent lymphatic surgeries between January 2017 and December 2022 and successfully completed preoperative and postoperative MRI were included, resulting in a total of 33 unilateral secondary upper extremity lymphedema patients m(mean age, 63 ± 14 years; 32 female). The median postoperative follow-up times were 12.5 months (range, 6-19 months) for VLNT, 13.5 months (range, 12-40 months) for debulking, and 12.0 months (range, 12-24 months) for patients who underwent VLNT after debulking surgery. There was a decrease in mean ST in 15 of 16 anatomical segments of the upper extremity after debulking (P < .001), and the edema score increased in 7 of 16 segments (P ≤ .001-.020). Edema stage did not change in patients who underwent VLNT only or VLNT after debulking. ST decreased only along the radial forearm in patients who underwent VLNT after debulking despite an improvement in the Lymphoedema Quality-of-Life Questionnaire score in the former group. There was correlation between a decrease in ST with a decrease in volume within the debulking group (r = 0.79; P < .001). A decrease in ST also correlated with improved lymphedema quality of life questionnaires in the debulking group (r = 0.49; P = .04).

Conclusions: A decrease in ST was demonstrated in most anatomical segments after liposuction debulking, whereas edema stage was increased. Fewer changes were seen with VLNT, possibly a reflection of more gradual changes within this short follow-up period, with the radial forearm potentially revealing the earliest response.

Objective: Hand arteriovenous malformations (AVMs) are extremely difficult to manage for their functional importance and cosmetic disfiguration. A single-center retrospective study was conducted to identify long-term outcomes of multidisciplinary team management of hand AVMs.

Methods: Institutional review board approved this retrospective study. Multidisciplinary vascular anomalies center data was reviewed from 1995 to 2023. Patient demographics, Schobinger's AVM stage, sclerotherapy details, surgical history, and adverse events after sclerotherapy were reviewed.

Results: A total of 150 patients with hand AVMs visited our hospital from 1995 to 2023, with a mean age of 33 years (range, 1-75 years), and 91 were females. Forty-four patients were Schobinger stage II, and 106 were stage III. Sclerotherapy was performed on 101 patients (67%) with 320 sessions. Angiographic devascularization rates after sclerotherapy were: 16 with 100%, 30 with over 90%, 34 with 50% to 90%, 15 with 0% to 50%, and six showed aggravation. Sclerotherapy-related adverse events occurred in 123 of 320 sessions (39%), with 112 minor and 11 major events. Fifteen patients (15%) eventually underwent amputation surgery a mean of 1618 days after sclerotherapy for necrosis (n = 3) and delayed complications (n = 12). Thirteen patients (9%) underwent primary surgical amputation for ulcers or bleeding (all Schobinger stage III). Thirty-six patients (24%) were followed without any procedure.

Conclusions: Multidisciplinary management of hand AVMs shows varied long-term outcomes. Although sclerotherapy is effective for many patients, it carries a significant risk of adverse events. The necessity for amputation in some cases highlights the severity of advanced AVMs and the need for individualized treatment approaches.