A unique case of acute bilateral internal iliac deep vein thrombosis leading to right iliofemoral venous outflow obstruction.

Venous thromboembolism has been associated with high morbidity and mortality, with a cost burden for the U.S. health care system owing to secondary complications such as pulmonary embolism and post-thrombotic syndrome. The current standard of therapy for acute deep vein thrombosis (DVT) is anticoagulation. For patients with venous outflow obstruction of the iliac vein system, several minimally invasive recanalization techniques are now available. In the present report, we have described a case of bilateral internal iliac DVT that had progressed to right-sided iliofemoral DVT in a young athletic adult, in the absence of anatomic abnormalities, that was treated with thrombolysis-free mechanical thrombectomy.

Outcomes of Stented vs Nonstented Femoropopliteal Lesions Treated With Drug-Coated Balloon Angioplasty.

PURPOSE: Drug-coated balloon (DCB) angioplasty has been increasingly used for the treatment of lower limb peripheral artery disease (PAD). However, bail-out stenting may be necessary in cases of suboptimal angioplasty. This study investigated the outcomes of femoropopliteal disease treated with DCB with/without bail-out stenting. MATERIALS AND METHODS: This was a single-center retrospective study enrolling 166 consecutive patients (DCB+stent: n=81 vs DCB: n=85) with 253 femoropopliteal lesions (DCB+stent: n=99 vs DCB: n=154) treated with DCB with/without stenting. Bail-out stenting was performed at the operator discretion for postangioplasty dissections or otherwise suboptimal angiographic result (>30% residual stenosis). Cox regression analysis was performed to examine the outcomes of DCB with/without stenting during 2-year follow-up. RESULTS: The baseline clinical characteristics were similar between the 2 groups. About half of the patients presented with critical limb ischemia, with most of the lesions located at the superficial femoral artery. The overall mean lesion length was 147±67 mm. The most frequent bail-out stent types were bare metal stents (BMS) (53.5%) followed by drug-eluting stents (DES) (41.4%). Lesions requiring bail-out stenting were on average longer (177±67 mm vs 127±59 mm; p<0.01) and on average had higher prevalence of flow-limiting postangioplasty dissections. The overall procedural success rate was 94% without any differences between the 2 groups. Both the stented and nonstented treatment modalities were effective and safe, demonstrating similar rates of 2-year freedom from major adverse limb event (stented: 71.3% vs nonstented: 64.4%) and 2-year freedom from target lesion revascularization (stented: 77.1% vs nonstented: 72.3%) during following up. The use of DES as bail-out therapy was associated with a lower risk of 2-year death compared with the use of BMS (DES: 97.2% vs BMS: 75.8%; p=0.01). CONCLUSION: Drug-coated balloon with bail-out stenting is a viable treatment option for cases of suboptimal DCB results, promising similar efficacy with DCB-alone procedures. However, as the patency of stents at the femoropopliteal segment may be a challenge due to the biomechanical stress of the artery, the efficacy of DCB+bail-out stenting should be further evaluated. In addition, future studies are needed to determine which grades of post-DCB dissections should be treated and optimize current bail-out strategies.

Assessing the suitability of the carotid bifurcation for stenting: Anatomic and morphologic considerations.

OBJECTIVE: Over the years where stents have been used to treat carotid lesions, a great deal has been learned about which anatomic characteristics lead to adverse outcomes. This review summarizes the anatomic and morphologic characteristics of the carotid vasculature that can help guide patient selection and clinical decision-making. METHODS: Each of the carotid artery anatomy and lesion characteristics that are relevant to carotid stenting is described in detail. These are accompanied with evidence-based outcomes and results. RESULTS: Data on the prevalence of carotid artery lesions that are unsuitable for stenting are summarized and the implications of these data for practice are discussed, especially as they pertain to transcarotid artery revascularization. CONCLUSIONS: Carotid artery stenting can be a viable option for carotid revascularization, but the lesion must be acceptable and safe for stent placement. There should be thorough assessment to rule out the presence of severe tortuosity, long-segment disease, severe calcification (circumferential or exophytic), mobile plaque, swollen internal carotid artery sign, and carotid diameters outside the acceptable range. In carefully chosen lesions with the absence of the unfavorable characteristics described, transcarotid artery revascularization may offer improved periprocedural success and carotid artery stenting may attain better long-term durability.

Investigation of venous ulcers.

The evaluation of patients with venous ulceration primarily includes noninvasive methods to elucidate the distribution and extent of pathology. Duplex ultrasound is the first line of investigation, as it provides assessment of both reflux and obstruction conditions. In patients with iliofemoral pathology, axial imaging with computed tomography scan or magnetic resonance imaging should be performed. If the treatment of iliofemoral vein obstruction is warranted, then invasive assessment using venography and/or intravascular ultrasound should be used to guide the interventional procedure. Venous valve reflux can be identified and accurately characterized by duplex ultrasound, whereas the ultrasound assessment of functional abnormality associated with obstruction is less reliable. In patients with ulceration, the evaluation for and treatment of proximal venous obstruction has resulted in improved ulcer healing.

Inflow stenosis as a contributing factor in the etiology of AV access-induced ischemic steal.

OBJECTIVE: To determine how frequent inflow stenosis is a contributing factor in the etiology of arteriovenous access-induced steal (AVAIS). METHODS: A retrospective review of hemodialysis patients who underwent interventions from October 1998 to December 2011 for AVAIS was conducted at Mount Sinai Hospital. Patients with grade 3 AVAIS and complete arch and upper extremity vascular imaging were included. Demographics, access history, time to AVAIS, preoperative angiographic imaging and interventions performed were analyzed. RESULTS: A total of 52 patients were diagnosed with grade 3 (severe) AVAIS requiring intervention over the study period. Forty-seven percent of the patients were male, average age was 62 years, 47% were of African American race and 88% were diabetic. Seventeen consecutive patients, with imaging, were included in this study. The average time to presentation of steal symptoms was 147±228 days. All of the accesses were proximal, and 65.7% were autogenous. Imaging studies consisted of angiography (14) and computed tomography angiography (3). Five patients had imaging evidence of >50% luminal inflow stenosis (29.4%). The location of stenosis was the subclavian (3 cases) and brachial (2 cases) arteries. Patients underwent distal revascularization and interval ligation (3), ligation (1) and angioplasty/stenting (1). CONCLUSION: In our population, nearly one-third of the patients with severe AVAIS had a significant subclavian or brachial artery stenosis. The implications of this finding suggest the importance of complete preoperative imaging. The treatment of the inflow stenosis by itself may not be curative, but the correction may serve as an adjunct and contribute to the success of other therapeutic procedures.

Experience of HeRO dialysis graft placement in a challenging population.

OBJECTIVE: To assess the outcomes of the hemodialysis reliable outflow (HeRO) device in a subset of hemodialysis access-challenged patients with central venous obstruction. METHODS: Retrospective analysis of a series of patients in 2 centers who underwent placement of the HeRO device between September 2009 and November 2010. Patients' demographics, access history, HeRO patency, and number of reinterventions were analyzed. RESULTS: Eleven patients underwent 12 HeRO implantations. The average duration of dialysis prior to HeRO placement was 5.55 ± 3.64 years. Primary and secondary patencies at 6 months and 1 year were 36.4% and 54.5% and 9.1% and 45.5%, respectively. CONCLUSIONS: In the end-stage renal disease population with central venous occlusive disease, the HeRO device offers the best long-term dialysis option when an arteriovenous fistula or graft is not possible. Close follow-up and subsequent aggressive interventions can prolong the use of the HeRO and avoid the last resort of dialysis catheters.

Current endovascular treatment of infrarenal abdominal aortic aneurysms and future directions.

The paradigm in elective surgical management of infrarenal abdominal aortic aneurysms (AAAs) has quickly shifted from major open surgical repairs to less invasive, endovascular procedures. In the last few years, there have been numerous advancements to commercially available devices making the endovascular approach more attractive and efficacious. This review serves to detail the similarities, differences, advantages, and disadvantages of currently available endovascular stent-grafts as well as preview future and emerging technologies in endovascular aortic therapies.

The distribution and significance of varicosities in the saphenous trunks.

OBJECTIVE: The purpose of this study was to determine the prevalence, distribution, and extent of varicosities and focal dilatations in the saphenous trunks, their association with the sites of reflux, and their correlation with CEAP classes. METHODS: This prospective study included patients belonging to different CEAP classes (2-6) and a control group of age- and gender-matched healthy volunteers (group C). Color-flow duplex scan imaging was used to evaluate the entire venous system from groin to ankle for reflux and obstruction. Varicose segments and focal dilatations of the great and small saphenous veins (GSV and SSV) were recorded, and the diameters throughout the length of the saphenous trunks were measured. The presence of varicosities in the tributaries and accessory veins were documented. RESULTS: From the 739 consecutive patients, 239 were excluded due to superficial venous thrombosis (SVT), deep venous thrombosis (DVT), both SVT and DVT, previous interventions, or C3-C6 presentation with no chronic venous disease (CVD). The included 500 patients (681 limbs) were divided into two groups based on CEAP class: group A (C2 + C3) and group B (C4-6). Group A had significantly more women than group B and a younger mean age (48 vs 56 years). Overall, GSV reflux (86%) was more prevalent than SSV reflux (17%), P < .0001. Saphenous trunk diameters, saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) involvement were greater in group B, (P < .01). Group C had smaller saphenous diameters compared to group A in all locations (P < .05) but the malleoli. The prevalence of the saphenous varicose segments in both groups was small with the GSV in group B being the highest (4.3%) and the SSV in group A being the smallest (1.2%). Focal dilatations were significantly more prevalent than varicosities in the saphenous trunks (P < .0001). Varicosities of tributaries and accessory veins were more prevalent than those of saphenous trunks (P < .0001). The mean length of varicose segments in the saphenous trunks was short (3.8 cm, range, 2.1-6.4 for group A vs 4.1 cm, range, 2.3-8.3 for group B, P = .09). CONCLUSION: A novel definition for varicosities in the saphenous trunks was established. Using this definition, it was determined that focal dilatations are far more common than varicosities. Because both of these entities are more prevalent in the accessory saphenous veins and tributaries, and CEAP class correlates positively with the extent of reflux and saphenous trunk diameter, studies on earlier interventions are warranted to prevent CVD progression.

Pediatric nontraumatic myositis ossificans of the neck.

Nontraumatic myositis ossificans circumscripta (MOC) is a rarely reported benign heterotopic ossification characterized by the aberrant formation of bone in extraskeletal soft tissues. Although a history of trauma can be elicited in 75% of MOC patients, the etiology is unclear in patients without inciting injury. MOC is associated with young male athletes, and is most often localized to the muscle groups of the extremities. Rare cases have been reported in children and adolescents of nontraumatic MOC in the neck. We present a 15-year-old adolescent with a rapidly growing, painful neck mass without traumatic stimulus.