Current treatment strategies for primary upper extremity deep venous thrombosis; a retrospective observational multicenter case series.

Introduction: Current treatment strategies for primary upper extremity deep venous thrombosis (pUEDVT) range from conservative treatment with anticoagulation therapy to invasive treatment with thoracic outlet decompression surgery (TOD), frequently combined with catheter directed thrombolysis, percutaneous transluminal angioplasty, or stenting. Due to a lack of large prospective series with uniform data collection or a randomized trial, the optimal treatment strategy is still under debate. We conducted a multicenter observational study to assess the efficacy and safety of both the conservative and invasive treatment strategies for patients with pUEDVT. Methods: We retrospectively collected data from patients treated in five vascular referral and teaching hospitals in the Netherlands between 2008 and 2019. Patients were divided into a conservative (Group 1), an invasive treatment group (Group 2) and a cross-over group (Group 3) of patients who received surgical treatment after initial conservative therapy. Follow-up consisted of outpatient clinic visits and an electronic survey. Primary outcome was symptom free survival defined as absence of any symptom of the affected arm reported at last follow-up regardless of severity, or extent of functional disability. Secondary outcomes were incidence of bleeding complications, recurrent venous thromboembolism, surgical complications, and reinterventions. Results: A total of 115 patients were included (group 1 (N = 45), group 2 (N = 53) or group 3 (N = 27). The symptom free survival was 35.6%, 54.7% and 48.1% after a median follow-up of 36, 26 and 22 months in groups 1, 2 and 3 respectively. Incidence of bleeding complications was 8.6%, 3.8% and 18.5% and recurrent thrombosis occurred in 15.6%, 13.2% and 14.8% in groups 1-3 respectively. Conclusion: In this multicenter retrospective observational cohort analysis the conservative and direct invasive treatments for pUEDVT were deemed safe with low percentages of bleeding complications. Symptom free survival was highest in the direct surgical treatment group but still modest in all subgroups. Perioperative complications were infrequent with no related long term morbidity. Of relevance, pUEDVT patients with confirmed VTOS and recurrent symptoms after conservative treatment may still benefit from TOD surgery. However, symptom free survival of this delayed TOD seems lower than direct surgical treatment and bleeding complications seem to occur more frequently.

A temporary hemostatic valve in the short limb of a bifurcated stent-graft to facilitate endovascular repair of ruptured aortic aneurysm: experimental findings.

PURPOSE: To evaluate a homemade tricuspid valve placed in the short limb of a bifurcated aortic stent-graft to facilitate endovascular treatment of ruptured abdominal aortic aneurysms (AAA). METHODS: A valve consisting of 3 polytetrafluoroethylene cusps was constructed in the short limb of a bifurcated stent-graft. The endoprosthesis was placed into an in vitro circulation model with pulsatile flow. Angiography was performed before and after insertion of the second graft limb. RESULTS: Angiographically, there was complete occlusion of the short limb before and normal patency after deployment of the second graft limb. Cannulation of the short limb with a guidewire was performed without technical difficulty. CONCLUSIONS: Addition of a temporary hemostatic valve in the short limb of a bifurcated stent-graft can potentially reduce blood loss during endovascular treatment of ruptured AAAs.

Endovascular grafting of complex aortic aneurysms with a modular side branch stent-graft system in a porcine model.

OBJECTIVES: To evaluate and refine a stent-graft system with side branches for treatment of aneurysms with essential branch arteries. METHODS: In a porcine model (n=4) supra- and juxta-renal aortic aneurysms were created by suturing an artificial patch onto an anterior aortotomy. Angiography was performed to determine the exact location of the renal arteries. Accordingly, fenestrations were created in an appropriately sized aortic stent-graft. Initial deployment of the aortic graft is partial, whereby the top stent is secured in a cap and distal stents are being restrained, thus ensuring longitudinal and rotational manoeuvrability during alignment of the branch arteries. Separate branch grafts with silicone flanges for connection with the main stent-graft are subsequently placed in the renal arteries followed by full deployment of the main stent-graft. Outcome was evaluated by postoperative angiography and autopsy results and by measuring operating time, blood loss and use of contrast agent. RESULTS: Branched grafts were placed successfully in all trials. The median endovascular procedure time was 126 min (90-160), with 575 ml (400-800) blood loss and 65 ml (50-80) contrast agent use. Angiographically, all aneurysms were excluded without signs of endoleak and all renal arteries were patent. At autopsy, the main stent-graft and all side branches were adequately placed with intact connections between main stent-graft and branch grafts. CONCLUSIONS: In this model, endovascular repair of complex aneurysms using a modular branch graft system is feasible in a reliable, predictable and timely fashion.

False lumen thrombectomy of the superior mesenteric artery followed by iliomesenteric bypass after Stanford type B aortic dissection.

A 55-year-old man with an acute Stanford type B aortic dissection presented with clinical signs of mesenteric ischemia. Computed tomography (CT) revealed a thrombosed false lumen in the superior mesenteric artery. At laparotomy, the dissection was found to be extending into the jejunal branches and medial colic artery. Thrombus was removed from the false lumen, and perfusion was restored with an iliomesenteric bypass, with the dissected layers tacked together in the suture line. A postoperative CT scan showed a stable diameter of the thoracoabdominal aorta and a patent iliomesenteric bypass.

Aortic aneurysm pulsatile wall motion imaged by cine MRI: a tool to evaluate efficacy of endovascular aneurysm repair?

OBJECTIVES: to evaluate cine MRI as a means of determining the two-dimensional pulsatile wall motion (2D-PWM) of abdominal aortic aneurysm (AAA). DESIGN: prospective study of 21 patients with AAA. 2D-PWM was defined as change in cross-sectional area. RESULTS: the median diastolic area was 28 cm(2) (intraquartile range, IQR, 22-31 cm(2)) and the median (IQR) 2D-PWM was 0.25 (0.10-0.40) cm(2). Assuming that the AAA is circular in cross-section this represents a median (IQR) diameter increase of 0.3 (0.1-0.4) mm. However, local wall displacements up to 2 mm were present in varying directions, without significant change in surface area. CONCLUSION: AAA PWM is negligible and may not therefore be a potential tool to assess efficacy of endovascular aneurysm exclusion.