Stocking-only versus additional eccentric compression after below-the-knee truncal vein sclerotherapy: A SOVAECS prospective randomized within-person trial.

OBJECTIVE: After foam sclerotherapy in the truncal saphenous vein, the clinical effects of additional eccentric compression has not yet been explored. METHODS: Between April 2020 and February 2021, we enrolled 42 patients (84 limbs) who underwent bilateral endovenous combined therapy for great saphenous vein (GSV) reflux. Each patient received the same type of endovenous ablation in both above-the-knee GSVs (laser, radiofrequency, cyanoacrylate glue), and combined foam sclerotherapy was performed on both below-the-knee GSVs. Subsequently, we conducted a prospective randomized, single-blind, within-person study in which each patient's bilateral truncal saphenous vein of the calves underwent two different compression therapies: wearing of a regular class II compression stocking on one side (RC group) and additional eccentric compression on the other side (AC group). The primary end point was the occlusion range (score, 0-10) of the below-the-knee truncal GSV after foam sclerotherapy. The secondary outcomes were the pain score (visual analog scale score range, 0-10) of the paired limb, the required number of additional foam sclerotherapy sessions, compliance with compression therapy, and procedure-related complications. RESULTS: For the above-the-knee GSV, endovenous laser treatment (n = 44), endovenous radiofrequency ablation (n = 14), and endovenous cyanoacrylate glue ablation (n = 26) were performed. The mean subcompression pressure of the medial calf in the supine and standing positions were 16.7 ± 2.34 mm Hg and 24.5 ± 6.6 mm Hg in the RC group and 38.5 ± 5.5 mm Hg and 45.3 ± 8.2 mm Hg in the AC group, respectively (P = .000). The secondary outcomes of pain score, number of additional foam sclerotherapy sessions, and pigmentation were not significantly different statistically between the two groups. The patient-reported satisfaction scores (range, 0-10) on compression at 24 hours postoperatively were 8.03 ± 1.9 for the AC group and 7.98 ± 1.9 for the RC group (P = .317; Wilcoxon signed ranks test). In both groups, the closure rate of the above-the-knee GSV at 1 month postoperatively was 100%. No procedure-related complications were identified within 1 month postoperatively, including no deep vein thrombosis, numbness, or skin necrosis requiring additional medical attention. CONCLUSIONS: The 24 hours of additional eccentric compression on the truncal GSV compared with the use of a conventional knee-level stocking only did not yield any clinical advantages in terms of the occlusion range, postoperative pain, need for additional sclerotherapy, or skin pigmentation after foam sclerotherapy. The decision on which type of compression therapy to perform after foam sclerotherapy in the truncal vein should be comprehensively determined.

Incidence and Clinical Impact of Endovenous Glue-Induced Hypersensitivity Among Patients Who Underwent Endovenous Cyanoacrylate Ablation Procedures: A Registry-Based Cohort Study.

BACKGROUND: The characteristics of endovenous glue-induced hypersensitivity (EGIH) remain unclear. OBJECTIVE: To assess the clinical impacts on patients with EGIH after endovenous cyanoacrylate-glue ablation (CA). MATERIALS AND METHODS: A prospectively designed endovenous CA-specific registry was created, and a total of 335 limbs from 173 patients who underwent endovenous CA were enrolled for a cohort study. RESULTS: Symptomatic EGIH was observed in 55 (31.8%) patients. Beyond the target vein area, systemic side effects were noted in 5.8% of the treated patients after CA. The median onset time was 13 postoperative days (range: 1-35 days). The median duration was 7 days, but about 10.9% of the affected patients experienced symptoms lasting longer than 4 weeks. In the EGIH and non-EGIH groups, significant improvements in venous clinical severity score and Chronic Venous Insufficiency Quality of Life Questionnaire-14 scores were observed 3 months postoperatively. The development of EGIH did not affect the postoperative patient-reported satisfaction scores ( p = .524). CONCLUSION: EGIH is observed in a substantial proportion of patients. The side effects do not affect the clinical outcomes and patient-reported outcome measures. Further studies are required on the detailed pathogenesis and definition of EGIH.

Symptom improvement after cyanoacrylate glue adhesion and endovenous laser ablation in low-grade CEAP clinical classes.

OBJECTIVE: Low-grade primary superficial venous reflux (C0-C3 EpAsPr [Ep (primary), As (superficial), and Pr (reflux)]) is a common feature of chronic venous disease. However, the procedural efficacy focusing on symptom characteristics and improvement patterns in this population has not been fully explored. METHODS: From 2018 to 2019, 325 limbs from 279 patients with C0-C3 EpAsPr (including 66.1% with C0-C1) who had undergone cyanoacrylate ablation (CA) with ultrasound-guided foam sclerotherapy (UGFS) or endovenous laser ablation (EVLA) with UGFS were included in the present study. Venous symptoms were classified into five categories: leg heaviness, calf cramping, itching sensation, pain, and numbness. A retrospective propensity score-matched analysis of data collected using a prospectively designed case report form was performed to identify the improvement magnitude of each symptom. As secondary outcomes, the postoperative changes in symptom severity (0-5 points), venous reflux-originated severity score, venous clinical severity score (VCSS), and 14-item chronic venous insufficiency quality of life questionnaire (CIVIQ-14) were evaluated in a 3-month postoperative data analysis. RESULTS: After adjusting the data, 174 limbs (CA with UGFS, n = 87; EVLA with UGFS, n = 87) were matched. The symptoms with the greatest improvement after treatment were night cramping (94.7%) and itching (93.8%), followed by heaviness (85.2%), numbness (77.8%), and pain (60.9%). All symptom improvement scores after each endovenous procedure showed similar patterns in both groups. The advantages of CA with UGFS over EVLA with UGFS were a shorter procedure time (20.1 ± 10.6 minutes vs 28.4 ± 10.9 minutes; P = .001) and lower perioperative visual analog for pain scores (2.99 ± 2.34 vs 3.74 ± 2.49; P = .03). Compared with the preoperative values, the venous reflux originated severity score, VCSS, CIVIQ-14 score, and symptom severity score were significantly improved in both groups (P < .001 for all). Improvements in all five symptoms (P = .085 to P = 1.0), VCSS (P = .435), CIVIQ-14 score (P = .788), and satisfaction score (P = .392) at 3 months postoperatively were comparable between the two groups. In the CA group, 2 cases of endovenous glue-induced thrombosis and 24 cases (27.6%) of type IV hypersensitivity reactions occurred. CONCLUSIONS: Minimally invasive endovenous surgery with CA and EVLA provides significant symptom improvement for patients with low-grade CEAP classes.

Upper extremity revascularization with autologous femoral vein graft in an immunocompromised patient: 5-year computed tomographic findings.

Femoral veins have been used as a substitute graft for limb bypass in selected patients. The long-term efficacy of deep-vein grafts in neoaortoiliac system reconstruction has been shown to be excellent but the efficacy in extremity bypass is still unclear. Here, we report a case of subclavian-to-brachial artery bypass surgery using a femoral vein graft in a chronically immunocompromised patient with previous kidney transplantation. The patient remains symptom-free at 5 years with a patent bypass without any complications, such as aneurysmal dilatation, recurrent infection, stenosis or harvested limb oedema. The femoral vein would be a good option for extremity bypass in patients with high-risk immune problems when other veins are not available.

Cough, Aortobronchial Fistula, and Air Migration in the Remnant Aneurysm Sac: An Unforeseen Path?

The pressure gap between the aortic lumen and bronchial air spaces makes hemoptysis the most frequent feature of aortobronchial fistula (ABF). However, air migration can be a rare cause of ABF. The literature has demonstrated some "indirect routes" that would serve as a bridge between ABF and consecutive air migrations. However, evidence suggesting the presence of a "direct route" between them is lacking. We present an extremely rare case of newly onset cough-induced "perigraft space ABF" and ABF-related air migration in the remnant aneurysm sac occurring 3 years after an aortic surgery and a near-misdiagnosis of a delayed graft infection.

Achenbach Syndrome: A Benign Painful Blue Finger with Tip Sparing.

Vascular surgeons are often consulted for patients with spontaneous painful discoloration of fingers and toes. In most cases, no diagnosis can be ascertained after extensive investigations and the condition resolves spontaneously. Awareness of Achenbach syndrome among physicians may help mitigate anxiety in patients because it is relatively benign and has a good prognosis. This report presents a case of Achenbach syndrome in an Asian woman along with a literature review.

Activated clotting time test alone is inadequate to optimize therapeutic heparin dosage adjustment during post-cardiopulmonary resuscitational extracorporeal membrane oxygenation (e-CPR).

BACKGROUND: We conducted an observational study to evaluate the relationship between activated clotting time (ACT) and activated partial thromboplastin time (aPTT) tests, anticipating the possibility that the ACT will become a substitute test for the aPTT in post-CPR extracorporeal membrane oxygenation (e-CPR). PATIENTS AND METHODS: Three hundred and fifteen paired ACT and aPTT samples were derived from 60 in-hospital e-CPR patients and were divided into three groups according to the observed ACT value: low level (ACT < 170 s, Group A), intended target level (ACT 170-210 s Group B) and high level (ACT > 210 s, Group C). The relationship of aPTT in each group was analyzed. RESULTS: The mean ACT and aPTT values were 189.39 ± 48.27 s (IQR, 163-202) and 71.85 ± 45.32 s (IQR, 44.5-81.8), respectively. Although the observed mean ACT value of 189.39 s was similar to the intended mean target value of 190 s (p = 0.823), the observed mean aPTT value (71.85 s) was significantly lower than the predicted mean target value (77.5 s, p = 0.027). Despite the mean ACT values being significantly different in each group (p < 0.0001), the mean aPTT values were not statistically different between Groups A and B (p = 0.317). Of the Group B samples (n = 139), only 31 samples (22.3%) met the optimal therapeutic aPTT range. Pearson's correlation coefficient for Group B showed only a weak correlation between ACT and aPTT (r = 0.177; p = 0.037). CONCLUSIONS: Our study demonstrates that the ACT test alone does not seem to be enough to optimize therapeutic heparin dosage adjustment during e-CPR.

Phlegmasia cerulea dolens after coronary artery bypass surgery: what should we know.

Phlegmasia cerulea dolens (PCD) is one of the most critical disorders of acute deep vein thrombosis in that it can cause permanent disability secondary to the compartment syndrome. Although several etiological factors have been proposed, PCD after coronary artery bypass surgery is extremely rare and its definitive pathophysiology is still under debate. We herein present a case of PCD that resulted in the compartment syndrome after coronary artery bypass surgery. Early recognition and decompression of PCD are crucial for saving the affected limbs.

Extracorporeal membrane oxygenation for extremely complicated scrub typhus.

Scrub typhus is a mite-borne disease caused by Orientia tsutsugamushi. Although early diagnosis and appropriate antibiotic therapy improve the prognosis for the majority of patients, life-threatening complications are not uncommon. Here, we present a case of successfully performed veno-veno type extracorporeal membrane oxygenation for scrub typhus-induced complications, including acute respiratory distress syndrome, sudden cardiac arrest, and multiorgan dysfunction. To our knowledge, this is the first case report of successful extracorporeal membrane oxygenation in complicated scrub typhus.

Juvenile first rib fracture caused by morning stretching.

BACKGROUND: First rib fractures are very rare, being primarily associated with external blunt trauma. Related conditions, such as sudden contraction of the neck muscle, stress fractures, and fatigue fractures, have been reported sporadically. These fractures are mostly related to repetitive or explosive physical training. However, anatomical relationships and related injury mechanisms may cause first rib fractures without repetitive sports activity. OBJECTIVE: To present a case of juvenile first rib fracture caused by morning stretching without sports activity. CASE  REPORT: We present a rare case report of juvenile atraumatic first rib fracture. CONCLUSION: Physicians should be aware that even morning stretching with yawning can cause a first rib fracture in children. Awareness is important for early recognition, and proper management is critical for a pain-free return to normal life. An understanding of the mechanism of atraumatic first rib fracture is important.

Papillary fibroelastoma of the aortic valve with atypical chest pain: late presentation with acute myocardial infarction and cardiac arrest.

We report a case of a 54-year-old female with papillary fibroelastoma of the aortic valve who presented with ST-elevation myocardial infarction and cardiac arrest. Though her initial symptom was only atypical chest pain, life-threatening complications such as acute myocardial infarction and cardiac arrest developed. After cardiopulmonary resuscitation, we promptly resected the fibroelastoma on cardiopulmonary bypass, and the patient was discharged without any other complications.

Peripheral vascular reconstruction using deep vein graft for critically ill patients.

The great saphenous veins are gaining wide popularity as acceptable native vascular grafts, but in terms of flow capacity, their small caliber may be unsuitable for immediate replacement of arterial flow. Ten peripheral vascular or central venous reconstructions were performed using superficial femoral vein free grafts for re-establishment of immediate high-flow patency. Seven of the patients were men with a mean age of 61.5 ± 17.9 years (range, 21-81 years). The majority of the patients were of preoperative or intraoperative critically ill statuses in that they had extensive infection (n = 5), bleeding (n = 4), renal failure (n = 3) or hepatic failure (n = 1). The mean preoperative physiology score of the vascular POSSUM was 24.1 ± 8.8 (range, 15-37), and the mean operative severity score was 18.4 ± 4.9 (range, 10-26). All patients survived and recovered from systemic infection or critical hemodynamic instability. During the mean 28.9 months of follow-up, complications such as aneurysmal dilation, recurrent infection, graft stenosis/occlusion, lower limb edema and other clinical problems that required attention were not observed. In conclusion, we determined that deep veins can be applied as ideal graft conduits for reconstructing the major peripheral vessels under complicated conditions in select patients.

Off-pump total left anterior descending area re-vascularisation using left internal thoracic artery auto Y graft; angiographic early and 3-year follow-up results.

BACKGROUND: We evaluated the efficacy of a well-prepared left internal thoracic artery (LITA) auto Y graft for simultaneous left anterior descending artery (LAD) and diagonal artery (DA) re-vascularisation in selected patients for the reduction of the number of required grafts and improved graft patency, while limiting technical problems. METHODS: Twenty well-controlled diabetic patients, mean age 62.8+/-8.3, 17 males and three females, underwent isolated elective off-pump coronary artery bypass grafting using the LITA auto Y graft from July 2003 to August 2004. RESULTS: In-hospital data and angiographic results at 6 months after the surgery showed that there was no early mortality, early graft failure and major morbidity except for two cases of superficial wound infection. The 3-year follow-up results including angiographic findings (mean of 37+/-3.3-month follow-up) demonstrated that all patients are alive and have excellent graft patency in both the LAD and DA. Only two cases required right coronary artery (RCA) stenting during the follow-up period. Compared with our previous routine LITA composite Y graft technique, it is assumed that LITA auto Y graft technique may reduce the number of mobilised conduits or avoided sequential anastomosis. CONCLUSIONS: This small study showed that our technique is technically feasible and may be safely performed to the selective patients. The LITA auto Y graft might be an additional surgical option, in terms of not only preserving the other grafts and maintaining patency in the LAD area bypass, but also preventing the need for sequential anastomoses.

Angiographic results of the radial artery graft patency according to the degree of native coronary stenosis.

OBJECTIVE: Radial arteries are gaining widespread acceptance as complementary arterial conduits for surgical myocardial revascularization, but there are limited reports about its angiographic patency compared with that of the internal thoracic artery or saphenous vein according to the degree of native coronary stenosis. Therefore, we tried to evaluate the mid-term angiographic results of the radial artery graft patency focusing on the native coronary stenotic status in a prospective manner. METHODS: From March 2000 to September 2006, a total of 488 patients underwent coronary artery bypass grafting using radial artery graft at our institution. From this group, 123 patients (mean age of 59.02+/-8.9 years (range 34-73 years)) were enrolled in the present study, and underwent a postoperative angiography after surgery (mean 32 months). The angiograms were assessed visually and quantitatively. RESULTS: A total of 382 distal anastomoses were performed and 352 anastomosis remained patent (92.1%). Left internal thoracic artery showed the most excellent patency in all of the conduits (128/129, 99.2%). Overall the radial artery graft patency was 92% (160/174). In the univariate analysis, patency was significantly worse for targets of the right coronary system (left coronary system 129/135, 94.4% vs right coronary system 31/39, 79.4%. p<0.05) and the radial artery graft showed a higher patency rate in the case of a severe stenotic lesion that preoperatively revealed more than 90% stenosis (defined as critical stenotic lesion) than in the case of a less severe lesion (50%

Bidirectional cavopulmonary shunt as a rescue procedure for right ventricular endomyocardial fibrosis.

The surgical treatment for patients with endomyocardial fibrosis consists of resection of endocardial fibrotic tissue and replacement or repair of atrioventricular valve. Even after endocardiectomy and valvular remodeling, some patients exhibit very poor hemodynamic profile because of myocardial failure due to long-standing restriction of ventricle or ventricles. Here, we report a case of endomyocardial fibrosis in right ventricle who underwent endocardiectomy and valvular replacement followed by bi-directional cavopulmonary shunt to compensate weaning failure from cardiopulmonary bypass. The long-term outcome and the indication of bi-directional cavopulmonary shunt has not been confirmed, although it was effective for saving the life of patients with low cardiac output and acute right ventricular failure.