Review of the literature supporting international clinical practice guidelines on iliac venous stenting and their applicability to Australia and New Zealand practice.

BACKGROUND: The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO). METHODS: A group of vascular surgeons from Australia and New Zealand with specific interest, training, and experience in the management of VOO were surveyed to assess current local practices. The results were analyzed and areas of disagreement identified. After this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely, the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. A selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. The final recommendations were further reviewed and endorsed by another group of venous experts. RESULTS: The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with clinically relevant VOO, a Clinical-Etiologic-Anatomic-Physiologic score of ≥3 or a Venous Clinical Severity Score for pain of ≥2, or both, including venous claudication, with evidence of >50% stenosis should be considered for venous stenting (Level of Recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should also be considered for venous stenting (Level of Recommendation Ic). Asymptomatic patients should not be offered venous stenting (Level of Recommendation IIIc). Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion of >50% has been uncovered, should be considered for venous stenting (Level of Recommendation Ib). CONCLUSIONS: Patients with VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. International guidelines aimed at developing standards of care to avoid undertreating and overtreating patients are applicable to Australia and New Zealand practice and will serve as an educational platform for future developments.

RETRACTED: Australian and New Zealand Society for Vascular Surgery clinical practice guidelines on venous outflow Obstruction of the femoral-iliocaval veins.

BACKGROUND: The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO) in Australia and New Zealand. METHODS: A group of vascular surgeons from the Australian and New Zealand Society for Vascular Surgery with specific interest, training, and experience in the management of VOO were surveyed to assess current local practice. The results were analyzed and areas of disagreement identified. Following this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. Finally, a selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. RESULTS: The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with a CEAP (Clinical-Etiologic-Anatomic-Physiologic) score of ≥3 or a venous clinical severity score for pain of ≥2, or both, and evidence of >50% stenosis on venography, computed tomography venography, magnetic resonance venography, and/or intravascular ultrasound should be considered for venous stenting (level of recommendation Ib) Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion has been uncovered, should be considered for venous stenting (level of recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should be considered for venous stenting (level of recommendation Ic). Asymptomatic patients should not be offered venous stenting (level of recommendation IIIc). CONCLUSIONS: Patients with deep VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. The advent of simpler and safer treatment options has revolutionized its management, but, unfortunately, formal training for venous disease has not grown at the same rate. Simplifying the technology and training required can result in inconsistent outcomes. These guidelines are aimed at developing standards of care and will serve as an educational platform for future developments.

A rare case of penetrating atherosclerotic ulcer of the aorta.

We are reporting a case of 66 year-old man who presented to a regional hospital with sudden onset of inter-scapular pain, radiating to anterior chest. Initial assessment was unremarkable except for high blood pressure and computed tomography (CT) of chest showing an intramural haematoma in the thoracic descending aorta. He was transferred to our institution for the medical management of his blood pressure and intramural haematoma of the aorta. A transoesophageal echocardiography confirmed the diagnosis but in addition demonstrated a penetrating atherosclerotic ulcer (PAU). Subsequently CT aortogram revealed a slow leak from the PAU. Endovascular repair with stent-grafting was urgently performed. He improved clinically and remained well on discharge. This case demonstrated that PAU, although rare and often under-recognised, is potentially life-threatening and should be considered in the evaluation of chest pain. Multi-modality imaging techniques can aid the diagnosis and guide appropriate and timely management.

Breast cancer and pregnancy: a diagnostic and management dilemma.

BACKGROUND: The purpose of the present paper was to review the current knowledge of pregnancy concurrent with a diagnosis of breast cancer, and how best to manage this group of women and those breast cancer survivors who may subsequently conceive. RESULTS: Pregnancy-associated breast cancer or gestational breast cancer is defined as breast cancer diagnosed during pregnancy or in the 12 months post-partum. A review of the current literature on breast cancer-related pregnancy suggests an incidence of between 0.7 and 3.9%. The prognosis is thought not to be significantly different from non-pregnancy-associated breast cancer, except in cases where a delay in diagnosis is associated with more advanced disease. The treatment is similar to non-pregnant cases, with the exception of radiotherapy, which is contraindicated throughout pregnancy; and chemotherapy, which is contraindicated during the first trimester. Few breast cancer survivors go on to conceive, but those who do have no worse breast cancer or pregnancy outcomes. CONCLUSION: Most of the research in this field has come from small, specialized institutions and may not reflect what occurs in the wider community. Further population-based research in this area is needed, and is currently being undertaken in Western Australia.