Adventitial Cystic Disease of the Femoral Vein: a Case Report with the CT Venography

Fewer than 20 cases of adventitial cystic disease of the vein have been reported in the worldwide literature. This small number of reported cases may be due not only to the disease's low incidence, but also to the difficulty in making the proper diagnosis. Many techniques have been used to investigate this disease, but venography has been the traditional diagnostic tool. In this report we present a case of adventitial cystic disease that was well demonstrated by CT venography.

Spontaneous Rupture of the Left Common Iliac Vein: Management with Surgical Repair and Endovascular Stent

We report here on a case of spontaneous rupture of the left common iliac vein that was diagnosed preoperatively with computed tomography (CT), and the patient was successfully treated with surgery and stent placement. A 60-year-old woman was referred to our emergency room because of sudden left lower abdominal pain and swelling of the left lower extremity. CT revealed a huge retroperitoneal hematoma and extrinsic compression of the left common iliac vein with acute thrombosis of the deep veins of the left lower extremity. Venous patch angioplasty was performed at the site of spontaneous rupture. After performing thrombectomy with using a Forgaty catheter, a stent was placed at the occluded segment of the left common iliac vein under C-arm fluoroscopic guidance. The follow-up CT scans taken at 10 days and 8 months after the initial examination demonstrated a venous stent with preserved luminal patency and the striking resolution of the deep vein thrombosis of the left lower extremity.

Role of CT Venography in the Diagnosis and Treatment of Benign Thoracic Central Venous Obstruction

OBJECTIVE: To evaluate the role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction. MATERIALS AND METHODS: Eighteen patients who had undergone both CT venography and digital subtraction venography were prospectively enrolled in this study. The following features were analyzed by two observers: the cause, degree, and extent of venous obstruction; associated thrombosis; and implications for the planning of treatment. CT venography and digital subtraction venography were compared in defined venous segments, and the degree of obstruction, and correlation was expressed using Spearman's rank correlation coefficient. RESULTS: In all patients, CT venography depicted the causes of obstruction, including extrinsic compression of the left brachiocephalic vein, and mediastinal inflammatory pseudotumor. Interobserver agreement regarding classification of the degree of obstruction was judged as good for CT venography (k=0.864), and in evaluating this, there was significant correlation between CT venography and digital subtraction venography (reader 1: Rs = 0.58, p < 0.01; reader 2: Rs = 0.56, p < 0.01). In evaluating the status of central veins proximal to long segmental obstruction, and associated thrombosis, CT venography was superior to digital subtraction venography. In half of all patients, the findings of CT venography led to changes in the treatment plan. CONCLUSION: The findings of CT venography correlated closely with those of digital subtraction venography, and the former accurately depicted the degree and extent of benign venous obstruction.

Venous Rupture Complicating Hemodialysis Access Angioplasty: Percutaneous Treatments and Outcomes

PURPOSE: To evaluate the usefulness of percutaneous management and prognosis in venous rupture during angioplasty of hemodialytic arteriovenous fistulas. MATERIALS AND METHODS: Among 814 patients who underwent angioplasty on account of inadequate hemodialysis, 63[39 women and 24 men aged 20-78 (mean, 55.8) years] were included in this study. All 63 had peripheral venous stenosis. Venous rupture was diagnosed when contrast leakage was seen at venography after percutaneous angioplasty (PTA). In order to manage venous rupture, the sites at which this occurred were compressed manually for 3-5 minutes or blood flow was blocked with a balloon catheter for the same period. In one case, a stent was inserted at the rupture site. Using the Kaplan-Meier method, we investigated the patency rate of arteriovenous fistula (AVF) in cases of successful PTA. We also compared PTA patency rates in cases with and without peripheral venous rupture. RESULTS: Venous rupture occurred in 38 cephalic, 16 brachial, and 9 basilic veins. In 63 patients, bleeding stopped and in 54 (85.7%) of these, PTA was successful. Among the nine failed cases, dilatation was incomplete in five, though bleeding had stopped. In patients with brachial and cephalic vein rupture, the venous tract at the rupture site was not located. Two patients underwent surgery: one of these experienced brachial venous rupture, with incontrollable bleeding, and the other had nerve compression symptoms due to hematoma. Among 54 patients in whom PTA was successful, the primary and secondary six-month rates for angioaccess were 47.9% and 81.2%, and the mean patency period was 6.1 and 15.8 months, respectively. In cases of non-venous rupture, the mean patency period was 9.6 months, significantly longer than in cases involving venous rupture (p=0.02). CONCLUSION: Venous rupture occurring during the PTA of hemodialytic AVF can be managed percutaneously.

Central Venous Obstruction in Hemodialysis Patients: The Usefulness of Percutaneous Treatment

PURPOSE: To analyse the effectiveness of percutaneous treatment of central venous obstruction in patients undergoing hemodialysis. MATERIALS AND METHODS: In 100 patients, 107 central venous strictures [56 subclavian (occlusion:21, stenosis:35) and 51 innominate (occlusion:23, stenosis:28)] were assessed, and 170 percutaneous angioplasty procedures were performed. Balloon dilation of the venous lumen was the preferred mode, but if dilation was incomplete we inserted a stent at the site of the stricture. Technical success, procedural complications and the long-term patency rate were evaluated, and the patency difference according to location and degree of stricture, the existence of DM, and any history of central catheter insertion were also determined. RESULTS: We inserted 52 stents in 170 procedures, in 157 (92.4%) of which initial technical success was achieved. Stent migration occurred in two cases and balloon rupture in three. The 6- and 12-month primary patency rates were 46.2% and 24.1%, respectively, and the mean patency rate was 8.5 months. The 1-, 2- and 3-year accumulative patency rates were 59.8%, 47.5% and 35.7%, respectively, and the mean patency rate was 23.5 months. Other than in the history of central catheter insertion, there were no statistically significant differences in patency rates (p=0.0128). CONCLUSION: In hemodialysis patients with a central venous stricture, percutaneous angioplasty is a safe and useful procedure, but to maintain long-term central venous patency, repeated interventions are required.

The Usefulness of Wire-Loop Technique for Percutaneous Angioplasty of Insufficient Hemodialysis Fistula

PURPOSE: To evaluate the usefulness of the Wire-Loop technique, used to perform percutaneous transluminal angioplasty (PTA) in occluded arteriovenous fistula when standard methods fail to pass the balloon catheter. MATERIALS AND METHODS: In 30 patients [M:F=14:16; aged 27 -77 (mean, 51.3) years], the Wire-Loop technique was used to perform percutaneous transluminal angioplasty of insufficiently hemodialysed arteriovenous fistula where a balloon catheter had failed to pass through the stenotic lesion after a guide wire had successfully passed. Native and Goretex fistula were used in 22 and eight cases, respectively. Sixteen stenoses were located in the central vein, and fourteen in the peripheral. The punture sites used in order to perform the technique were the femoral vein in all cases of central stenosis; three basilic, four cephalic, and five femoral veins in cases of peripheral stenosis and one femoral and one radial artery in cases of anastomotic stenosis. The guide wire was passed through the stenotic lesion, pulled out using the snare technique, and then stretched in order to tighten it. The balloon catheter was then passed through the lesion and traditional balloon angioplasty was performed. The technical success rate and complications of the technique, and the patency rate of recanalized arteriovenous fistula, were evaluated. RESULTS: In 26 of the thirty patients, (86.7%), the procedure was technically successful. In the remaining four cases, failure was due to venous dissection (n=1), marked residual stenosis (n=2), or cardiac arrest (n=1) during the procedure. The average procedure time was 105 (range, 40 -210) minutes, and in three cases rupture of the vein occurred. The patency rate of PTA was 80% (24/30) at four months, 63% (19/30) at six months, and 30% (9/30) at twelve months. The expected technical success rate of traditional PTA, without the Wire-Loop technique, would have been 79.3%, but using the technique, the rate increased to 86.7%. CONCLUSION: The Wire-Loop technique appears to be a safe and valuable procedure in patients with insufficiently hemodialysed arteriovenous fistula, and is therefore useful in cases in which traditional PTA fails.

Deep Venous Thrombosis in the Lower Extremity: Catheter-Directed Thrombolysis

PURPOSE: To evaluate the efficacy of catheter-directed thrombolysis in treating symptomatic deep venous thrombosis (DVT) in lower limbs. MATERIALS AND METHODS: Twenty-six consecutive patients (16 male and 10 female; mean age, 55 years) with lower extremity DVT underwent thrombolytic therapy. The duration of symptoms was 1 -90 (mean, 17) days: 20 days or less in 16 cases (acute DVT) and less than 20 days in ten (chronic DVT). Catheter-directed infusions of urokinase were administered via ipsilateral popliteal veins, and angioplasty or stent placement was performed after the thrombolytic procedure. Oral medication of warfarin continued for six months, and for the evaluation of venous patency, follow-up ultrasonography was performed. The total dose of infused urokinase was 1,750,000 -10,000,000 (mean 4, 84,000) IU, and the total procedural time was 25 -115 (mean, 64) hours. RESULTS: Lysis was complete in 16 cases (62%, all acute DVT), partial in five (19%, chronic DVT), and failed in five (19%, chronic DVT). Eight patients with venous stenosis and two with occlusion were treated by means of angioplasty (n=4) or Wallstent placement (n=6). Minor bleeding occurred in six cases and major complications in two (one of pulmonary embolism, and one of multiorgan failure). CONCLUSION: Catheter-directed thrombolysis with urokinase is effective for the treatment of DVT in lower limbs.

Hemodialysis Shunts-related Subclavian Vein Stenosis: Treatment with Self-expandable Metallic Stent

PURPOSE: To evaluate the usefulness of placement of self-expandable stents in hemodialytic shunt-relatedsubclavian vein stenosis. MATERIALS AND METHODS: Self-expandable metallic stent was placed in nine patients withhemodialytic shunt-related subclavian vein stenosis. In seven cases, angioplasty was attempted before stentplacement; in five, stents were placed immediately after failed angioplasty; and in two, due to restenosis afterangioplasty. Procedures involved a 10mm diameter, 7-10cm length Wallstent in eight cases, and a 10mm diameter, 8cm length Hanaro stent in one. In all cases, clinical follow-up, which included physical examination and themeasurement of venous resistance pressure during hemodialysis, was performed. The follow-up period was between 5months and 1 year 7 months. Repeated intervention was performed if restenosis was detected. RESULTS: The stenoticsites were in eight cases the site of a previous subclavian venous line, and in one, the site of anatomicnarrowing at the thoracic inlet of the subclavian vein. The technical success rate was 100%; a resultingcomplication was stent migration into the right atrium in one case in which a Hanaro stent had been used; this wasremoved by snaring. During follow-up of the eight patients in whon stent placement was successful, restenosisdeveloped in three cases. This occurred during the 7th, 8th, and 15th month, respectively. Two such cases weretreated by balloon dilatation. CONCLUSION: In hemodialytic shunt-related subclavian vein stenosis, treatmentinvolving the use of a self-expandable metallic stent is useful, especially for treating a lesion which has notresponded to angioplasty with a high patency rate.

Percutaneous Transluminal Angioplasty and Stent Insertion in Central Venous Steno-occlusion

PURPOSE: To evaluate the efficacy of percutaneous transluminal angioplasty (PTA) and stent insertion incentral venous steno-occlusion. MATERIALS AND METHODS: Between August 1992 and January 1998, 11 patients with symptomatic central venous steno-occlusion(six stenoses and five occlusions) underwent pereutaneous treatment. Eleven PTAs were performed and stents were introduced in two patients because of incomplete PTA. During follow-up, a total of eight revisions were performed in five patients with recurrence(six stenoses and two occlusions). Success and long term patency rates were evaluated. The length and degree of the lesion and degree of residualstenosis, as well as pressure gradient through the lesion and decrease of the gradient after PTA, were correlated with patency rates. Complications during the procedures and follow-up period were evaluated. RESULT: The overall success rate was 89.5%; those of primary and revision intervention were 90.9% and 87.5%, respectively. Primary and revision patency rates were 72.7% and 50%, respectively, at 6 months, and 40% and 25% at 12 months. In five patients who underwent revision, primary and secondary patency rates were 80% and 100% at 6 months, 40% and 80% at 12 months, and 0% and 60% at 18 months. Only reduction of the pressure gradient after PTA correlated significantly with patency rates. No significant complications observed during the procedures follow-up period. CONCLUSION: PTA and stent insertion is effective for the treatment of central venous steno-occlusion.

Spiral CT Venography in Central Venous Obstruction

PURPOSE: To determine the clinical usefulness of spiral computed tomographic (CT) venography for theevaluation of central venous obstruction. MATERIALS AND METHODS: The authors prospectively performed a total of29 spiral CT venography procedures in 25 consecutive patients with suspected central venous obstruction. Dilutedcontrast media were directly injected into the peripheral veins of the hand or the foot. Scan parameters were 3 mmX-ray beam collimation, table speed of 4-6 cm/sec, scan time of 32-40 sec, and injection delay of 20 sec. Axialimages were reconstructed at 2-mm intervals, and using shaded surface display (SSD), maximum intensity projection(MIP), and multiplanar reformation (MPR), 3-D reconstruction was performed. In all cases, ascending venograp-hy(n=13) and/or direct catheter venography (n=21) was performed within 2 days of CT venography. With regard to site,extent, extent, severity, and cause of obstruction and collateral circulation, we compared the results of CT andcontrast venography. RESULTS: In 24 patients, a total of 56 sites of central venous obstruction or stenosis(>50%) were demonstrated. The causes of obstruction were venous thrombosis (n=6), malignant tumors (n=4),arteriovenous fistula for hemodialysis (n=5), extrinsic compression (n=2), coincidence of extrinsic compressionand arteriovenous fistula (n=1), pacemaker (n=1), mediastinal inflammatory pseudotumor (n=1), spinal tuberculosis(n=1), membranous obstruction of the hepatic inferior vena cava (n=1), Behcet's disease (n=1), or unknown cause(n=1). When compared with ascending venography (n=13), CT venography was superior for evaluation of the extent andcause of obstruction and collateral circulation in two, four and one case(s), respectively. For the evaluation ofsite and severity of obstruction, CT venography was equal to ascending venography. In two cases, direct cathetervenography (n=21) was superior to CT venography for evaluating the obstruction site, but in three, five and onecase(s) respectively, CT venography was superior to direct catheter venograp-hy for evaluating the extent andcause of obstruction and collateral circulation. For the evaluation of severity of obstruction, CT and directcatheter venography were equal. CONCLUSION: In patients with suspected central venous obstruction, spiral CTvenography can be an alternative to replace not only conventional CT but also direct contrast venography.