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

Objective: Acute iliofemoral deep vein thrombosis (IFDVT) in young adults and adolescents is a cause of lower extremity pain and edema that may lead to chronic debilitating symptoms. Treatment options include pharmaco-mechanical thrombectomy, stent placement, and anticoagulation. The lack of long-term data in young patients after venous stenting leads to variability in treatment and reluctance to employ stents in this population. The purpose of this study is to review the etiology and incidence of post-thrombotic syndrome (PTS) along with the role of intervention in young patients after IFDVT.

Methods: Patients presenting with acute IFDVT were identified retrospectively through Peripheral Vascular Lab databases. IFDVT was defined as any thrombus believed to be <1 month old involving the common femoral or more proximal veins. Charts were reviewed to identify demographics, risk factors for venous thrombosis, relevant laboratory data, treatment provided for the DVT, and patient outcomes.

Results: Forty-nine patients under age 25 were identified with acute IFDVT and no other acute illness or trauma precipitating thrombosis. Forty patients (81%) were female. Thirty-three patients (58.1%) identified as White, 10 (28%) as Black and five (9.3%) as Hispanic. Hypercoagulable states were identified in 25 patients (51%) with Factor V deficiency (9 patients) and antiphospholipid antibodies (6 patients) being the most common. Intervention was performed in 36 patients (73.5%), which consisted of pharmaco-mechanical thrombectomy with balloon angioplasty in 22 patients and with stent placement in 14. One year after IFDVT, 19 patients (43.2%) reported no PTS symptoms, 10 (22.7%) reported mild symptoms, and 15 (34.1%) reported moderate or severe symptoms. Recurrent IFDVT occurred in 18% of patients at 1 year and 26.2% at 3 years after IFDVT.

Conclusions: Acute IFDVT in young patients occurs typically in females, the majority of whom are found to have a hypercoagulable state. Most of this cohort were treated without venous stenting. However, significant PTS and recurrent IFDVT occurred frequently after the initial event, suggesting that aggressive treatment is warranted. This is an understudied patient population in whom the role of intervention and stenting is unclear, suggesting that focused study in larger cohorts is required to improve treatment recommendations.

Objectives: Chronic anticoagulation for atrial fibrillation, a history of venous thromboembolism, and after 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 postprocedure bleeding and major adverse events in patients on anticoagulation who received AP compared with 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. After propensity matching, we compared the frequency and quality of postprocedural bleeding (none, incisional, large volume), extent of postprocedural ecchymosis (none, minimal, moderate, significant), and pain (minimal, moderate, severe) on follow-up examination with a provider. Thirty-day emergency department (ED) visits and major adverse cardiac events were also recorded for each patient. Continuous variables were compared using independent t tests or Mann-Whitney U tests, and categorical variables were compared using a χ² or Fisher's exact test.

Results: In total, 1853 patients received AP from four outpatient offices during the study period, 101 (5.5%) of whom were on chronic anticoagulation. Seventy patients for each group were propensity score matched in key demographics including age, gender, body mass index, Clinical-Etiology-Anatomy-Pathophysiology classification, prior vein procedures, concomitant laser procedures, number of phlebectomies performed, and comorbidities like history of deep vein thrombosis, pulmonary embolism, and peripheral arterial disease. There were no intraoperative major bleeding events. Patients on chronic anticoagulation were not more likely to have increased postprocedural bleeding (2.9% vs 0%; P = .496), significant ecchymosis (4.5% vs 1.5%; P = .671), severe pain on follow-up (1.4% vs 0%; P = .604), or increased likelihood of postprocedural cellulitis (1.4% vs 0%; P = 1.000). There were no instances of 30-day ED visits or major adverse cardiac events. 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: AP 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.

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

Methods: We conducted a single-center retrospective cohort study. A tertiary hospital database from January 2022 to December 2023 was analyzed. All records of patients referred for DVT were extracted. The collected data included general patient information, medical history, results of physical examination, duplex ultrasound, and laboratory analyses. 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, and 1466 patients (60.4%) were admitted to the hospital. Among the hospitalized patients, 1277 had a proximal DVT and 189 had a distal DVT. The number of patients with iliofemoral DVT was 451 (18.6%). We found only 82 cases (3.4%) that could be potentially eligible for endovascular thrombectomy considering all possible indications and contraindications. Two attempts and 14 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 remains unsatisfactory. The simplicity, cost effectiveness, and diverse application possibilities of ultrasound-guided foam sclerotherapy make it an attractive and effective approach to treat patients with no access to or contraindications to more invasive methods. We sought to evaluate the healing rate of chronic venous ulcers (Clinical, Etiological, Anatomical, Pathophysiological [CEAP] C6) in patients treated with ultrasound guided foam sclerotherapy.

Methods: From January 2018 to December 2020, 279 patients (336 legs) classified at the first consultation as stage 6 for CEAP disease were followed during treatment of axial venous reflux in saphenous and tributary veins with polidocanol (Aethosxysklerol) 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: The average age of the 279 patients was 55 years. Of these, 156 (56%) showed complete healing in 52 weeks and 89 (32%) achieved a wound area reduction of >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 < .01), ulcer size (P = .01), lymphedema (P = .006), reduced dorsiflexion of the ankle (P = .01), and age ≥65 years (P = .003) were significantly associated with difficulty in healing. Patients with a mean Venous Clinical Severity Score of 18.7 had a better prognosis (18.7 vs 22.5; P < .001).

Conclusions: 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 the use of compression therapy.

Objective: 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.

Methods: From March 2021 to August 2023, 16 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 post-thrombotic syndrome, recurrent DVT, and procedure-related death. Secondary outcomes included minor or major bleeding, acute kidney injury, documented hemoglobinuria, 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 one-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%), whereas no patients had major bleeding complication. There was one postoperative acute kidney injury and transient bradycardia (6%). Three patients died after the procedures (19%). One patient (6%) developed postoperative massive pulmonary embolism. The mean follow-up was 11 ± 6 months (range, 5-19 months). The primary patency rate was 92% and 91%, respectively, 6 and 12 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 2 days during CDT to assess the thrombus clearance rate and level of thrombus dissolution. Statistical analyses were 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 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, 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 with normal levels. There was a positive correlation between D-dimer levels and thrombolysis efficacy (r = 0.809; P = .00). The linear regression equation for this correlation was Y = 0.161 + 0.028X. The area under the curve of D-dimer was 0.95, with a cut-off value of 9.935 mg/L (sensitivity, 93.2%; specificity, 95.4%).

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