Long-term clinical and functional outcome following treatment for Paget-Schroetter syndrome.

BACKGROUND: Effort-related thrombosis of the axillosubclavian vein (Paget-Schroetter syndrome, PSS) is uncommon. It tends to affect young, active individuals and yet consensus on management is lacking. The aim here was to analyse late outcomes in a series of patients treated for PSS using a standard protocol. METHODS: The medical records of patients treated for PSS over 16 years were analysed. Patients were divided into four groups according to their management. Clinical and functional outcomes were analysed regarding residual venous defects after treatment, and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores, respectively. RESULTS: Some 117 patients (52 men and 65 women, mean age 32 years) were included. Catheter-directed thrombolysis was successful in 42 of 56 treated patients. Thoracic outlet decompression surgery was performed in 95 patients. DASH scores improved significantly in patients treated surgically (P < 0.001 to P = 0·009); early surgery had a better outcome than delayed surgery (P = 0·040). Patients who were managed conservatively showed no improvement (P = 0·116). Where venoplasty was necessary, it was successful in 18 of 25 patients. A short duration of lysis (less than 24 h) increased the risk of rethrombosis (P = 0·020). The method of postoperative anticoagulation had no influence on the rate of rethrombosis. CONCLUSION: Patients treated surgically for PSS had better functional outcomes than those managed conservatively. Prompt thrombolysis and surgery was superior to delayed management with respect to rethrombosis and functional outcome.

Venous thoracic outlet compression and the Paget-Schroetter syndrome: a review and recommendations for management.

Paget Schroetter syndrome, or effort thrombosis of the axillosubclavian venous system, is distinct from other forms of upper limb deep vein thrombosis. It occurs in younger patients and often is secondary to competitive sport, music, or strenuous occupation. If untreated, there is a higher incidence of disabling venous hypertension than was previously appreciated. Anticoagulation alone or in combination with thrombolysis leads to a high rate of rethrombosis. We have established a multidisciplinary protocol over 15 years, based on careful patient selection and a combination of lysis, decompressive surgery, and postoperative percutaneous venoplasty. During the past 10 years, a total of 232 decompression procedures have been performed. This article reviews the literature and presents the Exeter Protocol along with practical recommendations for management.

Audit of the use of IVC filters in the UK: experience from three centres over 12 years.

AIM: To audit the use of inferior vena cava (IVC) filter insertions at three UK centres over 12 years to assess whether trends in filter use in the UK mirrored those seen elsewhere. MATERIALS AND METHODS: Radiology department databases were interrogated for IVC filter insertions and removals between 1994 and 2006. Reports for these interventions, along with prior and subsequent imaging reports, were analysed. Follow-up data were obtained when available. RESULTS: Five hundred and sixteen filters were placed with a significant year-on-year trend towards increasing use. Fifty-seven percent of filters placed were for absolute indications and 37% for relative indications. The filters were used for prophylaxis in 6% of patients in the absence of proven pulmonary embolism (PE) or deep vein thrombosis (DVT). A retrievable filter was used in 74% of cases with retrieval attempted in 40% of these and no evidence of an increasing rate of retrieval over time. A significant complication related to insertion or retrieval was encountered in 0.4 and 1% of procedures, respectively. Mean 24 h and 30 day mortalities were 1 and 8%, respectively. There was an absence of organized follow-up at all three centres. CONCLUSION: IVC filter use in the UK is increasing. The use of retrievable filters has not resulted in increased filter retrieval. Filter insertion and retrieval is associated with a low risk of significant complication, but lack of systematic follow-up limits conclusions regarding safety and efficacy.

Complex iliac and bilateral common femoral artery aneurysms: a novel hybrid procedure.

A 74-year-old man presented with a right common iliac artery aneurysm and bilateral common femoral artery aneurysms. These aneurysms were repaired by a hybrid procedure. A one-stage approach was chosen including an endovascular stent-graft and femoro-iliaco-femoral Y-bypass grafting. The authors describe a novel combined open and endovascular approach to repair these complex aneurysms.

Spatial learning in deer mice: sex differences and the effects of endogenous opioids and 60 Hz magnetic fields.

We examined the effects of brief exposure to weak 60 Hz extremely low frequency (ELF) magnetic fields and opioid systems on spatial behavior and learning in reproductive adult male and female deer mice, Peromyscus maniculatus. Sex differences were evident in spatial performance, with male deer mice displaying significantly better performance than female mice in the Morris water maze, whereby animals had to acquire and retain the location of a submerged hidden platform. Brief (maximum 5 min) exposure to weak (100 microT) 60 Hz magnetic fields during task acquisition significantly improved female performance, eliminating the sex differences in acquisition. The opiate antagonist, naltrexone, also improved female acquisition, though significantly less than the magnetic fields. These facilitatory effects involved alterations of "non-spatial" (task familiarization and reduction of related anxiety/aversive related behaviors) and possibly "spatial" aspects of the task. Enhancement of enkephalin activity with the enkephalinase inhibitor, SCH 34826, significantly reduced task performance by male deer mice. Both naltrexone and the 60 Hz magnetic fields attenuated the enkephalin mediated reductions of spatial performance. These findings indicate that brief exposure to 60 Hz magnetic fields can enhance water maze task acquisition by deer mice and suggest that these facilitatory effects on spatial performance involve alterations in opioid activity.

Male preference for the odors of estrous female mice is reduced by the neurosteroid pregnenolone sulfate.

The effects of the neurosteroid, pregnenolone sulfate (PS), on the responses of male mice to the odors of estrous female mice were examined in an odor preference test. Control untreated mice displayed a significant preference for the odors of an estrous female, spending more time in a Y-maze in the vicinity of the odors of an estrous than a non-estrous female. Administration of PS decreased male preference for the odors of estrous females, causing a significant dose-related (0.01-10 mg/kg) decrease in the amount of time spent in the proximity of the odors of the estrous female, while having significantly less of an effect on the responses to the non-estrous female odors. Neither pregnenolone nor sodium sulfate had any significant effects on the olfactory responses. The effects of PS were significantly reduced by peripheral administrations of the non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist, MK-801, but were not significantly affected by either the GABAA antagonists, bicuculline and picrotoxin, or the benzodiazepine antagonist, Ro 15-1788. These results suggest that pregnenolone sulfate has inhibitory effects on olfactory mediated male sexual interest, preference, or 'motivation' that, in part, involve interactions with NMDA receptor mediated mechanisms.

Preoperative assessment of the pedal arch using pulse generated runoff and subsequent femorodistal outcome.

Calf vessel continuity with an intact pedal arch is an important factor in femorodistal (FD) bypass for critical ischaemia. Pulse generated runoff (PGR) was used in combination with the pedal arch patency test of Roedersheimer to determine preoperatively calf vessel and pedal arch patency. Three pedal arch groups were identified; complete (two calf vessels in continuity), incomplete (one vessel) and occluded (no vessels). One hundred non-reversed FD grafts were performed for critical ischaemia (63 men and 37 women), median age 72 (range 43-89 years). Sixteen grafts were to the above knee popliteal artery, 36 to the distal popliteal, three to the tibioperoneal trunk and 45 to a single calf vessel. There were 25 complete, 64 incomplete and 11 occluded pedal arches. The overall primary patency rate was 73%, nine grafts were successfully revised giving a secondary patency rate of 83.5%. The secondary graft patency rates for the above knee popliteal, below knee popliteal, tibioperoneal and single calf vessel grafts were 100, 92, 66 and 66% respectively. The 1 year graft patency rates for grafts to a complete, incomplete and occluded pedal arch were 88, 75 and 9% respectively (Lee-Desu p < 0.01). Similar results were obtained for limb salvage; 100, 84 and 24% respectively (p < 0.01). These results confirm the value of PGR in the preoperative assessment of patients with critical ischaemia. In reconstructions to the popliteal artery, PGR derived pedal arch status does not appear to influence the outcome. By contrast PGR derived pedal arch status in an excellent predictor of success following reconstructions to a single calf vessel.(ABSTRACT TRUNCATED AT 250 WORDS)

Fat-suppression magnetic resonance imaging in the preoperative localization of parathyroid adenomas.

Prospective localization of parathyroid adenomas was attempted in 16 patients with hyperparathyroidism prior to surgery. All patients had magnetic resonance imaging (MRI) using T1-weighted spin-echo (SE) sequences and a fat-suppression sequence, the short-tau inversion recovery (STIR) sequence. Correlation with the results of surgery yielded an overall sensitivity of 71% and a specificity of 94%. Performance was good in patients with previous surgery and with ectopic tumours. We believe that fat-suppression MRI is a valuable technique in the preoperative localization of parathyroid adenomas in patients with hyperparathyroidism.

The radiological imaging of bronchial atresia.

The clinical and radiological findings in three cases of bronchial atresia are presented. Bronchial atresia has a characteristic plain radiographic appearance in the majority of cases. Computed tomography may be required to confirm the diagnosis. The condition often presents to the radiologist as an incidental finding on the chest radiograph in a patient undergoing investigation for an unrelated problem.

The role of magnetic resonance imaging in cystic fibrosis.

Magnetic resonance imaging (MRI) of the chest was performed on eight patients with known cystic fibrosis. Comparison was made with the findings on plain chest radiographs. MRI shows a greater extent of disease than that predicted by the chest films alone and clearly demonstrates peribronchial thickening and mucoid impacted bronchi. It also distinguishes between hilar lymphadenopathy and enlarged proximal pulmonary vessels as the cause of prominent hilar shadows without the need for contrast injection.