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.

Timing of iliac vein stenting for Cockett syndrome complicating acute lower extremity deep venous thrombosis / 中华普通外科杂志

Objective To evaluate treatment outcomes in patients with Cockett syndrome complicating acute lower extremity deep vein thrombosis (DVT) either by direct stenting after taking angioplasty followed by catheter-directed thrombolysis or staged stenting after taking angioplasty and catheterdirected thrombolysis with urokinase.Methods From Jun 2015 to Jun 2017,35 Cockett syndrome patients with DVT were divided into group A (direct stenting after taking angioplasty followed by catheterdirected thrombolysis,n =15) and group B (staged stenting after taking angioplasty and catheter-directed thrombolysis with urokinase,n =20).The total urokinase dosage,the time of thrombolysis,and the score of thrombolysis rate were evaluated.After six months of follow-up,the difference between two groups of limb circumference,patency rate and PTS rate were compared.Results The technical success rate in both group was 100％.There was no fatal pulmonary embolism and massive bleeding during the perioperative period.During treatment,both groups showed significant improvement in limb swelling compared with that before operation.The differences in the total used dosages of urokinase and thrombolysis time were not statistically significant (P =0.47,P =0.51 respectively).Thrombolysis rates above grade Ⅱ in group A and group B were 93.33％ and 90％ (P =0.64),but stent placement was not satisfactory in 2 cases in group A.After six months of follow-up,there was no significant difference between two groups of limb circumference and PTS rate,but patency rate of the two groups was 85.2％ ± 2.4％ and 87.6％ ± 1.8％ respectively (P =0.02).Conclusions For the treatment of Cockett syndrome with DVT,the timing of stent implantation does not affect thrombolytic treatment process.However,the complete removal of the iliac vein thrombosis is beneficial to precise release of the stent and the stent implantation can better maintain iliac vein lumen patency.

Clinical outcome of one-stop treatment of Cockett syndrome combined with varicose veins / 中国介入影像与治疗学

Objective: To evaluate the safety and efficacy of one-stop treatment (iliac vein stenting and varicose vein surgery) for Cockett syndrome combined with varicose veins of lower limbs. Methods: There were 58 cases diagnosed as Cockett syndrome combined with varicose veins of lower limbs underwent one-stop treatment. The postoperative complications and with or without varicose veins recurrence were observed, venous clinical severity score (VCSS), Aberdeen varicose vein questionnaire (AVVQ) score and iliac vein stent patency rate of preoperative and postoperative followed up 1, 3, 6 and 12 months were recorded. Results: All the 58 patients underwent one-stop treatment successfully, and the technical success rate was 100%; 3 patients with active ulcer healed completely within 1 month after operation; there were no severe complications such as deep vein thrombosis and pulmonary embolism occurred. The VCSS and AVVQ scores at 1, 3, 6 and 12 months after operation were significantly lower than those of before surgery (all P<0.001). At 12 months follow-up, the patency rate of iliac vein stent was 100%, and there were no recurrence of varicose veins in lower limbs. Conclusion: The one-stop treatment for Cockett syndrome combined with varicose veins of lower limbs has good safety and effectiveness, and the short-term iliac vein stent patency rate is satisfactory, which has a certain promotion significance.

Concurrent hybrid AngioJet and stenting in the treatment of acute deep vein thrombosis of the lower extremity caused by Cockett syndrome / 中华普通外科杂志

Objective To study the short term results for Cockett syndrome resulting in acute deep vein thrombosis (DVT) of the lower extremity treated by AngioJet.Methods 32 Cockett syndrome resulting in acute DVT cases treated by hybrid AngioJet thrombolysis and stenting or catheter-directed thrombolysis (CDT) from Feb 2014 to Jan 2017 were retrospectively reviewed.There were 16 patients treated by AngioJet thrombolysis and stent (group A).The other 16 cases were treated by CDT (group B).All the 32 patients received warfarin at least 6 month after operation.Results The mean time of hospital stay was shorter in group A than B [(6.8 ± 2.1) d vs.(10.8 ± 3.2) d,P ＜ 0.05].The amount of urokinase was less in grpup A than in B [(101.8 ± 45.2) U vs.(312.8 ± 85.1) U,P ＜ 0.05].29 patients were followed up.The score of vein patency between the two groups had no significant difference (P ＞ 0.05).Conclusion Compared with CDT group,AngioJet thrombolysis and stent group has a less total dosage of urokinase,shorter hospital stay.

Endovascular interventional therapy for Cockett syndrome associated with deep vein thrombosis of left lower extremity / 介入放射学杂志

Objective To evaluate the clinical effect of endovascular interventional therapy in treating Cockett syndrome associated with deep vein thrombosis (DVT) of left lower extremity.Methods The clinical data of a total of 256 patients with Cockett syndrome complicated by DVT of left lower extremity,who were admitted to authors' hospital during the period from January 2011 to January 2015,were retrospectively analyzed.The patients were treated with catheter-directed thrombolysis,balloon dilatation of the occluded or narrowed venous segment,and/or stent implantation.The circumference differences of the affected limbs before and after treatment and the long-term patency rates were compared.Results Of the 256 patients with Cockett syndrome complicated by DVT of left lower extremity,complete dissolution of thrombus was achieved in 232 (90.6％) and partial dissolution of thrombus in 24 (9.4％).The circumference difference of thigh and calf was (7.12±2.15) and (4.57±2.81) cm respectively before and after treatment.Iliac vein reconstruction was carried out in 206 patients,among them simple balloon dilatation was employed in 46 and balloon dilatation together with stent implantation was adopted in 160.The patients were followed up for 9-24 months with a mean of 15 months.In simple balloon dilatation group,3 patients lost touch with the authors during the following-up period,26 patients (60.5％) developed iliac vein occlusion and post-embolization syndrome occurred in 21 patients (48.8％).In balloon dilatation plus stent implantation group,11 patients lost touch with the authors during the following-up period,stenosis or occlusion of the stent was seen in 13 patients (8.7％),post-embolization syndrome was observed in 15 patients (10.1％).The differences in vascular stenosis or occlusion and in the occurrence of post-embolization syndrome between the two groups were statistically significant (P＜0.001).Conclusion For the treatment of Cockett syndrome complicated by DVT of left lower extremity,catheter-directed thrombolysis and balloon dilatation combined with stent implantation carry definite clinical curative effect.

Clinical effect of TAPAS intravascular closed catheter-directed thrombolysis combined with endovascular intervention treatment for Cockett syndrome complicated with deep venous thrombosis of lower limbs / 中国医师进修杂志

Objective To evaluate the clinical effect of TAPAS intravascular closed catheter-directed thrombolysis combined with endovascular intervention treatment for Cockett syndrome complicated with deep venous thrombous of lower limbs. Methods The clinical data of 31 patients of Cockett syndrome complicated with deep venous thrombosis of lower limbs were retrospectively analyzed, and the patients were treated with TAPAS intravascular closed catheter-directed thrombolysis combined with endovascular intervention.Results Thirty patients were placed self-expandable stent,and 1 patient was treated by balloon dilation.The pain disappeared and the swelling decreased postoperatively.Twenty-two cases was cured (70.97%, 22/31), 7 cases showed excellence (22.58%, 7/31), and 2 cases showed effective (6.45%, 2/31), and there were no invalid patients. There was no pulmonary embolism and bleeding event during treatment. Conclusions The TAPAS intravascular closed catheter-directed thrombolysis combined with endovascular intervention treatment for Cockett syndrome complicated with deep venous thrombous of lower limbs is an effective and safe technique with satisfactory short term result.However,the long term clinical effect need to be further researched.

Síndrome de May-Thurner como diagnóstico diferencial en trombosis a repetición / May-Thurner syndrome as a differential diagnosis in recurrent thrombosis

El síndrome de May-Thurner es una anomalía anatómica que genera insuficiencia venosa y episodios trombóticos recurrentes de los miembros inferiores. Se presenta el caso de una paciente de 29 años, con cuadro de trombosis venosas profundas en miembros inferiores a repetición desde los 20 años, sin factores de riesgo identificados, en quien se realizan estudios de extensión para neoplasia y trombofilia con resultados negativos, además de estudios para patología reumatológica con anticuerpos antinucleares (ANAS) positivo a títulos bajos como único hallazgo, con lo que se hace diagnóstico de enfermedad del tejido conectivo no diferenciado y se instaura manejo con anticoagulación plena; sin embargo, ante la persistencia de eventos trombóticos se realiza angio-TAC, la cual reporta obstrucción de la vena ilíaca izquierda, por lo cual se realiza una venografía más cavografía documentándose obstrucción de la vena ilíaca externa izquierda y la común estableciéndose el diagnóstico de síndrome de May-Thurner, el cual debe considerarse dentro de los diagnósticos diferenciales de los episodios trombóticos recurrentes.(Acta Med Colomb 2016; 41: 67-70).

The May-Thurner syndrome is an anatomic abnormality generating venous insufficiency and recurrent thrombotic episodes of lower limbs. The case of a 29 years old patient with clinical picture of recurrent deep venous thrombosis in lower limbs since the age of 20 years is presented. No risk factors were identified; extension studies for neoplasia and thrombophilia were performed with negative results, as well as studies for rheumatic disease with positive anti-nuclear antibodies (ANAs) at low titers as unique finding, being diagnosed as undifferentiated connective tissue disease and management with full anticoagulation is established. However, at the persistence of thrombotic events, an angio-CT which reports obstruction of the left iliac vein and the common vein is performed whereby a venography and cavography are done establishing the diagnosis of May Thurner syndrome, which should be considered within the differential diagnosis of recurrent thrombotic events. (Acta Med Colomb 2016; 41: 67-70).

Lower Limb Varicose Vein or Swelling Secondary to Cockett Syndrome / 中国微创外科杂志

Objective To explore the treatment method and curative effect for lower limb varicose vein or swelling secondary to Cockett syndrome. Methods From March 2014 to March 2015,a total of 25 cases of lower limb varicose vein (22 cases)or swelling (3 cases)secondary to Cockett syndrome were treated with percutaneous transluminal angiography (PTA).Stents were placed in the veins in 19 cases,and 22 patients with varicose veins were treated with the great saphenous vein high ligation and point type stripping at secondary stage. Results The operations were successful.The iliac vein PTA was performed in all the 25 patients.The iliac vein stent implantation was performed in 17 cases of varicose veins and 2 cases of lower limb swelling.The saphenous vein high ligation and point type stripping was performed in 22 cases of varicose veins of lower extremity at 1 month after the interventional treatment.Postoperatively,no complications such as lower limb swelling,infection,or deep vein thrombosis occurred.Follow-up at the first postoperative month showed 20 cases of cured and 5 cases of alleviated.Follow-up for 3 -15 months (mean,12.4 months)in the 25 cases showed no lower limb swelling,recurrence of varicose vein,or deep vein thrombosis. Conclusions Cockett syndrome patients can be treated with iliac vein PTA.Whether or not a stent placement is required is determined according to the extent of vein stenosis.Postoperatively,lower limb swelling can be significantly alleviated.For patients with secondary varicose vein of lower extremity,saphenous vein ligation and point type stripping is recommended after 1 month.

Comparison of surgical thrombectomy and catheter-directed thrombolysis for acute deep vein thrombosis of the low extremity caused by Cockett syndrome / 中华普通外科杂志

Objective To study the short-and long-term results for Cockett syndrome caused acute deep vein thrombosis (DVT) of the lower extremity by surgical thrombectomy or catheter-directed thrombolysis.Methods One hundred and two Cockett syndrome caused acute DVT cases were treated by surgical thrombectomy or catheter-directed thrombolysis (CDT) from Jan 2006 to Dec 2011.There were 52 patients treated by CDT (group A),and 50 cases by surgical thrombectomy (group B).All patients received warfarin treatment after operation.Results There were no significant differences in general clinical characteristics between the two groups.The limb edema reduction rates between the two groups were of no significant difference(83％ ± 6％ vs.82％ ± 8％ P ＞ 0.05).The venous patency were basically the same (64.6％ ± 6.7％ vs.65.3％ ± 7.2％,P ＞ 0.05).The mean time required was shorter in group A than in group B[(30.5 ±6.7) min vs.(97.5 ±23.6) min,P ＜0.01].The average hospital stay was shorter [(9.8±5.4) d vs.(17.7 ±8.2) d,P＜0.01],and morbidity was less[13.4％ vs.42％,P＜0.01].Eighty six patients were followed up.The circunference difference of thigh,the score of vein patency between the two groups were of no significant difference (P ＞ 0.05).Conclusions Compared with surgical group,patients in CDT group have shorter hospital stay,less complication and similar long and shortterm results.

Interventional treatment and imaging diagnosis of Cockett's syndrome / 介入放射学杂志

Objective To evaluate the imaging diagnosis and select rational interventional treatment for Cockett's syndrome. Methods Clinical analyses and retrospective studies were carried out for 14 cases with Cockett's syndrome in the past five years. Results Three cases of simple Cockett's syndrome and 2 cases of varicose veins showed obvious curable efficacy. In 2 cases of synthetically interventional treatment, 1 case showed no relapse after long-term follow-up of 24 months, another developed acute thrombosis again two weeks later but with a further recurrence after a successful thrombolysis; and then the patient was undergone vascular graft bypass and temporary arteriovenous shunt. Conclusions Through proper and prompt evaluation of stenotic and hemadynamic changes of the iliac and femoral veins giving a complete picture of the pathophysiology, whould lead to a successful treatment for cocketts syndrome especialy before the venous thombosis, and in turn would greatly reduce the late stage complications.

Interventional treatment of iliac vein compression syndrome / 中华放射学杂志

Objective To explore the clinical significance of interventional treatment of iliac vein compression syndrome(IVCS). Methods Percutaneous transluminal angioplasty(PTA) was performed in 40 cases. Thirty three cases underwent endovascular stent implantation and 27 cases underwent second stage left saphenous vein ligation and stripping and the valves of left femoral veins narrowing. Thirty one cases were followed up postoperatively and the duration was 6～66 months (mean 28 months). Results The dilation of iliac veins was successful in 36 cases and there were good efficacy in all patients when they discharged from hospital. Followed up during post operation, all the limbs ulcers were cured and varicose veins disappeared. The skin pigmentation disappeared in 17 of 19 cases and markedly relieved in 2 cases. Left lower limb swelling disappeared in 15 of 17 cases and relieved in 2cases. Conclusion There is good efficacy in the interventional treatment of left iliac vein lesions, but second stage procedures should be performed in secondary lesions of saphenous veins and valves of femoral veins.

Treatment of acute deep venous thrombosis of left lower extremity accompanied with Cockett syndrome / 中国普通外科杂志

Objective To explore the effective treatment of acute deep venous thrombosis(DVT) of left lower extremity accompanied with Cockett syndrome.Methods The data of 16 patients with acute DVT of left lower extremity accompanied with Cockett syndrome,who were admitted to our hospital from August,2004 to January,2008,were analyzed retrospectively.Inferior vena caval filters were inserted and thrombectomy was done to all of the 16 patients;PTA and stent insertion were done in 13 patients and PTA only in the other 3 patients.Anticoagulation,thrombolysis and antiplatelet therapy were given postoperatively to all the patients.Results There was no death or pulmonary embolism in all 16 patients;Forteen patieats had good outcome,2 had acute DVT of left lower extremity one day after surgery,and limbs swelling subsided after anticoagulation,thrombolysis and antiplatelet treatment before their discharge.Forteen patients were followed up from 1 month to 25 months(average 11 months),and 2 patients had post-DVT syndrome,but the others had no swelling or varicose veins of the lower extremity.Conclusions Most patients with acute DVT of left lower extremity accompanied with Cockett syndrome could get satisfactory outcome with thrombectomy,PTA and stent insertion.

Deep venous thrombosis of lower extremity and Cockett′s syndrome in aged patients / 中国普通外科杂志

60 years)group and younger(≤60)group. Analysis of the pathogenesis of DVT in the 2 groups was made and the relationship of DVT and CS (between) the 2 groups was compared. There were 43 patients in elder group and 46 in younger group. All (patients) were treated by thrombectomy. Results There were 25 (58.1%) patients with concomitant CS in elder group and 37 (80.4%) in younger group. There was a significant difference between the two groups (?~2=5.2274, P