Phlebologie最新文献

Leiomyosarcomas of the lower vena cava are tumours whose prognosis is bad. The best survival opportunities consist of the widest possible exeresis. You will find below two cases that lead us to proceed to a joint exeresis of the aortic and vena cava bifurcation.

A limited number of tomodensimetrical sections, MRI or echographical according to the fundamental, frontal, sagittal or horizontal plans makes possible the exploration of the sub-renal part of the lower vena cava. The comparison of pictures with the corresponding anatomical sections makes possible a detailed analysis of all the visualized structures, around the lower vena cava.

B mode real time echotomography associated with duplex and colour doppler makes possible a complete investigation of the lower vena cava. The ilio-cava fossa is difficult to explore because of gas and digestive superpositions. Diagramatically, it is possible to distinguish five levels of investigation. 1) Iliac veins and ilio-cava convergence. 2) Sub-renal LVC. 3) Inter-renal LVC and communications with renal veins. 4) Retro-hepatic LVC: communications with liver and supra-hepatic veins. 5) Thoracic LVC and termination in the right atrium. Sector-based probes provide a 60 to 110 degrees sector thanks to which it is possible to obtain a sufficient exploration field for a very limited acoustic fenestra. Duplex and colour doppler assess the venous flow and its variations during the respiratory cycle and during the operations of compression or Valsalva's experiment. Colour doppler detects more precisely slow, collateral or repermeation flows. The recent complete thrombosis leads no duplex and colour doppler signal but an increase of the vein diameter associated with a collateralitis syndrome. In case of partial thrombosis, the vein is partially compressible as colour doppler fits thrombus closely round and visualizes the remaining lumen. In the ilio-cava fossa, compressions (either tumorous, ganglial or aneurysmal) which are often associated are diagnosed in the meanwhile. It is important to know the change of diameter and the abnormalities of the LVC position when a cava blocking is advised. A LVC whose diameters exceed 28 mm (mega-cava) contra indicated filter because of the risk of migration. Colour doppler makes easier the supervision of the blocking.

We described in 1988 the case of a young patient with a right iliac vein and vena cava thrombosis who developed lubagoes and intermittent claudication of paralytic type. A digital venography by left femoral approach showed a derivation via the lumbar vein towards the spinal plexus. Later, the patient experienced a left external iliac vein thrombosis. Subsequently, collaterization went through the truncal veins and the clinical manifestations of the tight spinal canal disappeared. Since then, several cases of chronic thrombosis of the left primary iliac veins have been discovered. These also showed unexplained lumbagoes of the same duration. The idea of a relation of cause and effect was seldom accepted by the patients, which prevented us to proceed to many venous catherisms. Also, we performed only one operation until now: the cesarean of an ascending lumbar vein. In this very case, the tight spinal canal symptoms disappeared but appeared again after a few month-time for unknown reasons. Only one acute case has been found up to now: a woman who delivered by ligation suffered from lumbagoes and sciaticae. A dilatation of spinal veins and a lower vena cava thrombosis were showed by tomography. This woman had no leg symptom and lumbagoes disappeared with the partial recanalization of the cava.

Anticoagulation, by means of heparin and warfarin is, till now, the most common treatment in deep venous thrombosis. Although thrombolytic agents have been available for over 10 years, their use remains quite low, ranging from 15 to 20% of deep venous thromboses. This is due to the relatively high incidence of contraindications as well as to the fact that the potential advantages versus heparin are diminished by the increased bleeding risk and by the potential risk of pulmonary embolism (migration of partially lysed thrombi). Following the example of the "triple armed therapy" proposed by Rosenthal for the treatment of pulmonary embolism, we will evaluate if loco-regional thrombolysis, with the catheter wedged against the thrombus, associated with a temporary vena cava interruption by means of an intraluminal filter, can achieve a better lysis of the thrombus without pulmonary embolism. In our Unit 18 patients affected by proximal deep venous thrombosis were submitted to thrombolytic therapy, 6 to systemic treatment, 3 to local treatment and the last 9 to loco-regional thrombolysis, using recombinant tissue-type Plasminogen Activator. We obtained 10 complete lyses, 1 with systemic and 9 with loco-regional treatment. There were no major complications. Thus, we think that venous loco-regional thrombolysis with rt-PA at lower doses, associated with temporary caval interruption, can probably achieve a better lysis than systemic treatment without risk of pulmonary embolism and with a very low haemorrhagic risk, as in arterial loco-regional thrombolysis. Furthermore, loco-regional thrombolysis, by means of a faster thrombus dissolution, could better prevent post-phlebitic syndrome.

Superficial and deep veins have different evolutions, structures and functions. Phylogenetically, superficial veins of limbs appear before the deep ones. In mammals other than man, both anatomical and histological abnormalities of superficial and deep veins have been noticed. In phlebology, the date of the first appearance of these veins was examined, from the infantile age to the age of 60 in 2,259 patients. Incomplete truncal varicose veins or an excess of certain perforating veins were found in 13.9% cases among children of school age. In 71.0% cases, these defects had a hereditary origin.