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

Objective: Thrombolytic therapy has been a mainstay of treatment for massive or submassive pulmonary embolism (PE), a common and highly morbid pathology. New percutaneous mechanical thrombectomy (PMT) devices have recently become widely available and have been used increasingly for the treatment of acute PE, but evidence demonstrating its efficacy over standard catheter-directed lytic protocol remains limited.

Methods: Using TriNetX Data Network, a global federated database of >250 million patients, we conducted a retrospective cohort study of patients from January 2017 to August 2023 with a diagnosis of PE, treated with either PMT or catheter-directed thrombolysis (CDT). Eligible patients were 1:1 propensity score-matched for preoperative covariates including demographics and comorbidities. We calculated and compared the 30-day outcomes of all-cause mortality, bleeding complications (blood transfusion, gastrointestinal bleed, and intracranial hemorrhage), diagnosis of acute respiratory failure (RF), myocardial infarction (MI), and pulmonary hypertension (PH) using odds ratios (OR) with 95% confidence intervals (CIs). Also, the 5-year outcomes of all-cause mortality, a composite outcome of chronic PH (chronic PE, chronic cor pulmonale, chronic thromboembolic PH), right heart failure (RHF), RF, and emergency department visits, were compared using hazard ratios (HRs) with 95% CIs.

Results: We identified 2978 patients treated with PMT and 1137 patients treated with CDT. After matching, we compared 1102 patients in each cohort. For 30-day outcomes, all-cause mortality, acute RF, and blood transfusion were similar between the two groups. However, compared with CDT, PMT was associated with a better safety profile, including lower bleeding risk for both ICH (OR, 0.46; 95% CI, 0.24-0.890) and gastrointestinal bleed (OR, 0.42; 95% CI, 0.28-0.63). PMT also demonstrated better immediate functional outcomes, with less PH (OR, 0.53; 95% CI, 0.41-0.68) and MI (OR, 0.54; 95% CI, 0.41-0.76). At 5 years, the all-cause mortality and RF for both procedures were similar, but PMT was associated with lower rates of chronic PH (HR, 0.70; 95% CI, 0.55-0.90), RHF (HR 0.49; 95% CI, 0.37-0.65), and emergency department visits (348 for PMT vs 426 for CDT; P < .01).

Conclusions: In patients undergoing catheter-based therapy for PE, PMT has an improved procedural safety profile vs CDT and results in significantly fewer 30-day postoperative complications, with fewer bleeding events, and is also associated with fewer periprocedural MIs and less acute PH. Perhaps, more important, PMT also demonstrated improved long-term outcomes with significantly fewer chronic PH and RHF diagnoses with fewer emergency department visits.

Objective: Venous thoracic outlet syndrome (vTOS) is caused by compression of the subclavian vein at the costoclavicular space, which may lead to vein thrombosis. Current treatment includes thoracic outlet decompression with or without venolysis. However, given its relatively low prevalence, the existing literature is limited. Here, we report our single-institution experience in the treatment of vTOS.

Methods: We performed a retrospective review of all patients who underwent rib resection for vTOS at our institution from 2007 to 2022. Demographic, procedural details, and perioperative and long-term outcomes were reviewed.

Results: A total of 76 patients were identified. The mean age was 36 years. Swelling was the most common symptom (93%), followed by pain (6.6%). Ninety percent of patients had associated deep vein thrombosis, with 99% of these patients starting anticoagulation preoperatively. A total of 91% of patients underwent rib resection via the infraclavicular approach, 2% via the paraclavicular approach (due to a neurogenic component), and 7% via the transaxillary approach. Eighty-three percent of patients had endovascular intervention before or at the time of the rib resection, with catheter-directed thrombolysis (87%), followed by angioplasty (71%) and rheolytic thrombectomy (57%) being the most common interventions. The median time from endovascular intervention to rib resection was 14 days, with 25% at the same admission. The median postoperative stay was 3 days (2-5 days). There was no perioperative mortality or nerve injury. Fourteen percent of patients had postoperative complications, with bleeding complications (12%) being the most common. Waiting more than 30 days between initial endovascular intervention and rib resection was not associated with decreased risk of bleeding complications. Patients were seen postoperatively at 1-month (physical examination) and 6-month (duplex) intervals or for any new or recurrent symptoms. Twenty-two percent of our overall patient population underwent reintervention, most commonly angioplasty (21%). At last follow-up, 97% of subclavian veins were patent, and 93% of patients were symptom free.

Conclusions: Over the last decade, we have transitioned to an infraclavicular approach for isolated vTOS, with low perioperative morbidity and good patency rates. These results support the adoption of the infraclavicular approach with adjunct endovascular techniques as a safe and efficacious treatment of vTOS.

Objective: Inferior vena cava (IVC) filter placement is associated with important long-term complications. Predictive models for filter-related complications may help guide clinical decision-making but remain limited. We developed machine learning (ML) algorithms that predict 1-year IVC filter complications using preoperative data.

Methods: The Vascular Quality Initiative database was used to identify patients who underwent IVC filter placement between 2013 and 2024. We identified 77 preoperative demographic and clinical features from the index hospitalization when the filter was placed. The primary outcome was 1-year filter-related complications (composite of filter thrombosis, migration, angulation, fracture, and embolization or fragmentation, vein perforation, new caval or iliac vein thrombosis, new pulmonary embolism, access site thrombosis, or failed retrieval). The data were divided into training (70%) and test (30%) sets. Six ML models were trained using preoperative features with 10-fold cross-validation (Extreme Gradient Boosting, random forest, Naïve Bayes classifier, support vector machine, artificial neural network, and logistic regression). The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). Model robustness was assessed using calibration plot and Brier score. Performance was evaluated across subgroups based on age, sex, race, ethnicity, rurality, median Area Deprivation Index, planned duration of filter, landing site of filter, and presence of prior IVC filter placement.

Results: Overall, 14,476 patients underwent IVC filter placement and 584 (4.0%) experienced 1-year filter-related complications. Patients with a primary outcome were younger (59.3 ± 16.7 years vs 63.8 ± 16.0 years; P < .001) and more likely to have thrombotic risk factors including thrombophilia, prior venous thromboembolism (VTE), and family history of VTE. The best prediction model was Extreme Gradient Boosting, achieving an AUROC of 0.93 (95% confidence interval, 0.92-0.94). In comparison, logistic regression had an AUROC of 0.63 (95% confidence interval, 0.61-0.65). Calibration plot showed good agreement between predicted/observed event probabilities with a Brier score of 0.07. The top 10 predictors of 1-year filter-related complications were (1) thrombophilia, (2) prior VTE, (3) antiphospholipid antibodies, (4) factor V Leiden mutation, (5) family history of VTE, (6) planned duration of IVC filter (temporary), (7) unable to maintain therapeutic anticoagulation, (8) malignancy, (9) recent or active bleeding, and (10) age. Model performance remained robust across all subgroups.

Conclusions: We developed ML models that can accurately predict 1-year IVC filter complications, performing better than logistic regression. These algorithms have potential to guide patient selection for filter placement, counselling, perioperative ma

Background: Concomitant iatrogenic proximal venous stenosis increases venous pressure and can be a risk factor for unfavorable outcomes of lymphaticovenular anastomosis (LVA) in extremities with secondary lymphedema. This study investigated the frequency and relevant factors of venous stenosis in patients diagnosed with secondary lymphedema who underwent LVA.

Methods: Patients who underwent preoperative computed tomographic venography (CTV) and LVA for secondary lymphedema of the extremities from October 2018 to March 2022 were included. The incidence of proximal venous stenosis in the affected limb on preoperative CTV and the rate of endovascular intervention were compared between upper and lower extremities. Factors affecting proximal venous stenosis were identified through multivariable analysis using independent variables, including patient age, body mass index, comorbidities, smoking history, radiation therapy, duration of lymphedema, and location of lymphedema.

Results: A total of 211 patients were analyzed, including 83 patients with upper extremity and 128 patients with lower extremity lymphedema. The incidence of proximal venous stenosis in the preoperative CTV was 32.5% and 7.8% in upper extremity, and lower extremity lymphedema, respectively (P < .001). The incidence of venous stenosis requiring endovascular intervention was significantly higher in the upper extremity compared with the lower extremity (16.9% vs 6.3%; P = .014). In multivariable analysis, risk factors affecting incidence of venous stenosis requiring endovascular intervention was the patient age (P = .007) and upper extremity (P = .009).

Conclusions: Preoperative evaluation and treatment of venous stenosis in extremities with secondary lymphedema are necessary before LVA surgery, particularly in upper extremity lymphedema.

Objective: This study aimed to evaluate the effectiveness and safety of coils plus glue (CPG) in slope embankment technology vs coils plus sclerosant (CPS) in treating reflux-type pelvic venous disorders.

Methods: The analysis included patients diagnosed with reflux-type pelvic venous disorders who were treated with CPG or CPS from 2019 to 2021. The inclusion criteria were noncyclic pain lasting more than 6 months, atypical varicose, and transvaginal Doppler ultrasound (TVDUS) and computed tomographic venography confirming the diagnosis and excluding compression factors and other diseases. Propensity score matching was performed at a 1:1.1 ratio based on the following covariates: age, pregnancy, body mass index, pretreatment visual analog scale (VAS), dysmenorrhea, dyspareunia, urinary urgency, tenesmus, low back pain, vulvar varicosities, vaginal varicosities, and lower limb varices. The pain was relieved by embolizing the target lesions with different embolic materials. The efficacy and safety of the different embolization materials were compared by VAS and TVDUS examinations at 1, 3, 6, 12, 24, and 36 months.

Results: From a total of 495 patients, 88 patients were selected from the CPG group and 77 patients from the CPS group by propensity score matching. The patients were followed up for 36 months. The preoperative VAS score of the CPG group was 8 (range, 6-8), and the CPS score was 8 (range, 7-8; P = .64). The postembolization VAS score of the CPG group was 2.05 ± 0.37, and the CPS score was 2.14 ± 0.35 (P = .55). A total of 28 cases (16.9%) showed complications, most of which were transient pain after embolization. No serious complications such as coil embolization to the lungs occurred. In addition, the CPG group used fewer coils than the CPS group by using the slope embankment technique. The mean coil length of the CPG group was 77.18 ± 33.82 cm, and the CPS group was 105.29 ± 71 cm (P = .001). The CPG group had an average operative time of 44.49 ± 5.72 minutes, whereas the CPS group took 43.45 ± 4.18 minutes on average (P = .19). The radiation dose in the CPG group was 398.40 ± 76.16 mGy, and the radiation dose in the CPS group was 388 ± 44.23 mGy (P = .30). The median recurrence-free survival in the CPG group was 34.23 months (95% confidence interval, 33.2-35.2), and the median recurrence-free survival in the CPS group was 30.39 months (95% confidence interval, 28.2-32.6; log rank P = .018).

Conclusions: Embolization therapy for refluxing PeVD was safe and effective, and proficient use of slope embankment technique with CPG increased efficacy and reduced complications.

Objective: To determine the sex prevalence of lower limb varicose networks fed by reflux of the great saphenous vein (GSV), anterior accessory saphenous vein (AASV), and small saphenous vein singularly or in combination.

Methods: We scanned by the means of the same color Doppler ultrasound protocol 3000 lower limbs in 1500 consecutive patients, affected by symptomatic chronic venous insufficiency from 2013 to 2023. Limbs with normal venous function, incomplete scans, or that were affected by post-thrombotic syndrome, pelvic reflux, isolated perforator reflux, venous malformation, phlebolymphedema and Clinical, Etiological, Anatomical, Pathophysiological clinical class C5 and C6 were excluded from the final analysis.

Results: Overall, 1072 patients-252 (23.5%) males and 820 (76.5%) females (P < .0001) matched for age (P = .692)-were included in the study for a total of 1956 limbs affected by primary chronic venous insufficiency, clinical class C2 to C4. The main finding was the significant prevalence of varicose networks fed by reflux of the AASV alone (odds ratio [OR], 1.96; 95% confidence interval [CI], 1.26-3.06; P = .001) or combined with GSV (OR, 1.84; 95% CI, 1.34-2.52; P = .0002) in females. In contrast, GSV insufficiency alone was significantly prevalent in males (OR, 0.54; 95% CI, 0.43-0.68; P < .0001). No significant sex differences regarding SSV reflux were detected. Moreover, we considered the presence of competent terminal valve (TV+) at the level of the saphenofemoral junction, which resulted more significantly present in female (OR, 1.57; 95% CI, 1.12-2.19; P = .0083); to the contrary incompetent terminal valve (TV-) was more common in males (OR, 0.64; 95% CI, 0.46-0.89; P = .0083). Finally, considering reflux in the AASV territory in the presence of a TV+, a strong prevalence in females was detected (OR, 2.28; 95% CI, 1.48-3.52; P = .0002), whereas males developed reflux along the GSV when a concomitant TV- was present (OR, 0.62; 95% CI, 0.41-0.94; P = .0244).

Conclusions: The analysis of the lower limb varicose networks highlights that reflux along the AASV alone, in presence of a TV+ at the junction or coupled with GSV insufficiency, is more prevalent in females. In contrast, GSV resulted the main trunk feeding varicose veins in males, in particular when a TV- was detected. Our findings suggest that females could be more prone to developing varicose veins with an ascending mechanism, whereas in males the descending one seems to be more common.

Objective: The most severe form of chronic venous insufficiency includes venous leg ulcers in the CEAP-6 stage. The aim of this study is to evaluate the relationship between incompetent perforator veins occluding with cyanoacrylate and closure of perforator veins and healing of venous leg ulcers in patients at the CEAP-6 stage.

Methods: A total of 187 patients who underwent cyanoacrylate application to incompetent perforator veins due to venous leg ulcers from 2018 to 2021 were retrospectively reviewed. Twelve months after the procedure, patients were evaluated for perforator vein closure, ulcer diameter, and Venous Clinical Severity Scale. Receiver operating characteristic analysis was used to estimate the probability of postoperative nonocclusion of the perforating vein based on the preoperative ulcers' diameters and the perforating veins' mean diameters. Univariate and multivariate binary logistic regression analyses were conducted to identify the risk factors associated with incomplete closure of the perforating vein.

Results: At the 12 months, 87.1% of patients experienced incompetent perforator veins closure, leading to complete healing of venous leg ulcers. Preoperative ulcer diameter significantly decreased from 7.20 ± 3.48 cm² to 0.28 ± 0.77 cm² after the procedure (P < .001). On average, 3.5 ± 1.01 perforating veins were treated, with a diameter of 4.09 ± 0.41 mm. No postoperative paresthesia or deep vein thrombosis occurred. Preoperative Venous Clinical Severity Scale scores decreased significantly from 17.85 ± 3.06 to 8.03 ± 3.53 postoperatively (P < .001). Patients with nonoccluded perforating veins had larger preoperative ulcer diameters (13.77 ± 1.78 cm²) than those with occluded perforating veins (6.24 ± 2.47 cm²; P < .001). The mean perforating vein diameter was also larger in nonoccluded perforating veins patients (4.45 ± 0.41 mm) than in occluded perforating veins patients (4.04 ± 0.38 mm; P < .001). The sensitivity, specificity, and accuracy of the preoperative ulcer diameter cutoff point of 11.25 cm² for the possibility of postoperative nonocclusion of perforating veins were 100% each. In contrast, those for the preoperative mean perforating vein diameter cutoff point of 4.15 mm were determined as 66.7%, 79.1%, and 77.5%, respectively. The presence of diabetes mellitus increased the likelihood of incompetent perforator veins, remaining open by 3.4 times (95% confidence interval: 1.11-10.44; P = .032), whereas a 1 mm larger mean perforating vein diameter increased this likelihood by 9.36 times (95% confidence interval: 3.47-25.29; P < .001).

Conclusions: This study demonstrates that occlusion of incompetent perforator veins with cyanoacrylate is effective, safe, and associated with low complication rates in CEAP-6 patients. The findings support that cyanoacrylate occlusion of perforato