Endovascular reconstruction of the inferior vena cava in a patient presenting with deep venous thrombosis with concomitant inferior vena cava hypoplasia and aneurysmal dilatation of the iliac veins.

INTRODUCTION: Congenital malformations of the inferior vena cava are rare and remain an under recognised cause of spontaneous deep venous thrombosis (DVT). The purpose of this case report is to highlight the rare occurrence of a concomitant iliac vein aneurysm and the feasibility of endovascular reconstruction in the presence of extensive iliocaval thrombus burden, especially in cases where other treatment modalities have been unsuccessful. REPORT: This is the report of a 25-year-old male who presented with acute onset left lower limb pain/swelling secondary to extensive iliocaval DVT. This was due to multiple abnormalities of the venous system including hypoplasia of the IVC with aneurysmal dilatation of the iliac veins. He failed an initial management strategy of anticoagulation and thrombolysis but subsequently underwent endovascular reconstruction of the iliocaval system via venoplasty and stenting. Complete symptom resolution and venous patency, including resolution of venous aneurysmal disease, were maintained at twelve-month follow-up. DISCUSSION: Reduction of the iliac vein diameter so early after successful reconstruction suggests that the iliac venous aneurysm was secondary to significant venous hypertension, and that if the obstruction causing it is treated, the vein can return to a normal vessel diameter.

Australian guideline on diagnosis and management of peripheral artery disease: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease.

BACKGROUND: Peripheral artery disease (PAD) is implicated in up to 50% of diabetes-related foot ulcers (DFU) and significantly contributes to morbidity and mortality in this population. An evidence-based guideline that is relevant to the national context including consideration of the unique geographical and health care system differences between Australia and other countries, and delivery of culturally safe care to First Nations people, is urgently required to improve outcomes for patients with PAD and DFU in Australia. We aimed to identify and adapt current international guidelines for diagnosis and management of patients with PAD and DFU to develop an updated Australian guideline. METHODS: Using a panel of national content experts and the National Health and Medical Research Council procedures, the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines were adapted to the Australian context. The guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were applied to the IWGDF guideline for PAD by the expert panel. Recommendations were then adopted, adapted or excluded, and specific considerations for implementation, population subgroups, monitoring and future research in Australia were developed with accompanying clinical pathways provided to support guideline implementation. RESULTS: Of the 17 recommendations from the IWGDF Guideline on diagnosis, prognosis and management of PAD in patients with diabetes with and without foot ulcers, 16 were adopted for the Australian guideline and one recommendation was adapted due to the original recommendation lacking feasibility in the Australian context. In Australia we recommend all people with diabetes and DFU undergo clinical assessment for PAD with accompanying bedside testing. Further vascular imaging and possible need for revascularisation should be considered for all patients with non-healing DFU irrespective of bedside results. All centres treating DFU should have expertise in, and/or rapid access to facilities necessary to diagnose and treat PAD, and should provide multidisciplinary care post-operatively, including implementation of intensive cardiovascular risk management. CONCLUSIONS: A guideline containing 17 recommendations for the diagnosis and management of PAD for Australian patients with DFU was developed with accompanying clinical pathways. As part of the adaptation of the IWGDF guideline to the Australian context, recommendations are supported by considerations for implementation, monitoring, and future research priorities, and in relation to specific subgroups including Aboriginal and Torres Strait Islander people, and geographically remote people. This manuscript has been published online in full with the authorisation of Diabetes Feet Australia and can be found on the Diabetes Feet Australia website: https://www.diabetesfeetaustralia.org/new-guidelines/ .

Quality of life after stenting for chronic iliocaval obstruction.

BACKGROUND: Iliocaval stenting is widely used for treatment of symptomatic iliocaval obstruction. The aim of our study was to compare quality of life before and after iliocaval stenting. METHOD: Prospectively collected data using CIVIQ20 questionnaire, Venous Clinical Severity Score (rVCSS) and Villalta-Prandoni score (VP) of patients following iliocaval stenting for non-thrombotic and post-thrombotic venous obstruction were analysed. RESULT: One hundred and one limbs (87 patients) were stented between May 2017 and May 2019. Baseline CIVIQ20 median value was 50 (34-66); 1 month after surgery CIVIQ20 value was 36 (26-58) and the scores then remained steady for the rest of the first year. Both rVCSS and VP scores decrease by 3.09 (95% CI: 2.39, 3.89; p < .001) and 5.21 (95% CI: 4.14, 6.48; p < .001) units, respectively, throughout the first year. CONCLUSION: Quality of life of patients with iliocaval obstruction significantly improves after successful percutaneous reconstruction. Severity of symptoms measured by rVCSS and VP scores decreases.

Chronic occlusion mimicking agenesis of the inferior vena cava in patients with iliofemoral deep vein thrombosis.

Agenesis of the inferior vena cava (IVC) has been described as a risk factor for proximal deep vein thrombosis (DVT). We have described the cases of two patients with iliofemoral DVT who had developed post-thrombotic syndrome (PTS). Both cases were misdiagnosed as IVC agenesis on routine imaging; however, an IVC lumen was successfully identified and recanalized during venography with significant improvement in the patients' PTS symptoms. Patients with iliocaval segment DVT with a misdiagnosis of IVC agenesis might have chronic occlusion imitating agenesis. It is worthwhile to attempt percutaneous recanalization of the IVC lumen in these patients and restoring normal venous flow to prevent the development of PTS.

Venous Adventitial Cyst Mimicking a Persistent Femoral Deep Venous Thrombosis.

OBJECTIVE: We describe the case of lower limb unilateral swelling due to a cystic mass (adventitial cystic disease) compressing on the common femoral vein. This was misdiagnosed as a deep vein thrombosis on both computed tomography venography and Doppler ultrasound. METHOD: We describe the diagnostic pathways and surgical excision of this venous adventitial cyst of the femoral vein. CONCLUSION: Venous adventitial cysts are a rare occurrence and diagnosis remains difficult. It often presents clinically as a Deep Vein Thrombosis (DVT). Suspicions should be raised should symptoms persist despite appropriate DVT management. Surgical management include endovascular, minimally invasive procedures, and complete evacuation of the mucoid cyst with excision of the cystic wall.

Symptomatic abdominal aortic aneurysm (AAA) presenting as unilateral lower limb swelling: A case report.

INTRODUCTION: The abdominal aorta is the most common site of true arterial aneurysm, predominantly affecting the segment below the renal arteries [1]. Typically, they are now diagnosed as asymptomatic incidental findings on abdominal imaging for unrelated pathology/symptoms. Symptomatic aneurysms typically present with pain localised to the abdomen, back, or flank [2]. An extremely uncommon scenario is presentation due to the sequelae of compression of the Inferior Vena Cava (IVC). Previously, open surgical repair has been the treatment modality of choice in such cases [3]. PRESENTATION OF CASE: We describe the case of a symptomatic infra-renal AAA presenting with lower limb oedema and shortness of breath due to compression of the IVC which resulted in caval thrombosis and associated embolic disease in the form of a pulmonary embolus (PE). Novel endovascular techniques allowed for management via minimally invasive surgery in the form of endovascular aneurysm repair (EVAR) which avoided the high morbidity and mortality of the previous standard of care, open surgery. DISCUSSION: This resulted in a short duration of admission with resolution of clinical symptoms by follow-up at six-weeks post intervention. CONCLUSION: This case highlights that the endovascular management of symptomatic AAA's resulting in caval thrombosis may offer a viable alternative to open repair with decompression.

Multicentre Covariate Adjustment Analysis of Short-Term and 5-Year Outcomes after Endovascular Repair according to Sex.

BACKGROUND: Several studies have reported worse outcomes in women compared to men after endovascular aneurysm repair (EVAR). This study aimed to evaluate sex-specific short-term and 5-year outcomes after EVAR. METHODS: A total of 409 consecutive patients underwent elective EVAR from 2004 to 2017 at two tertiary hospitals in Western Australia. Baseline, intraoperative, and postoperative variables were examined retrospectively according to sex. The primary outcome was 30-day mortality (death within 30 days after EVAR). Secondary outcomes were 30-day composite endpoint, length of stay after EVAR, 5-year survival, freedom from reintervention, residual aneurysm size after EVAR, and major adverse event rate at 5-year follow-up. RESULTS: A cohort of 409 patients, comprising 57 women (14%) and 352 men (86%), was analysed. Female patients were older (median age, 76.8 versus 73.5 years, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%, p=0.017). Male patients were more likely to be past smokers (40.9% versus 22.8%. CONCLUSION: This study found no significant differences in 30-day and 5-year outcomes between female and male patients treated with EVAR, implying that EVAR remains a safe treatment choice for female patients.

One-Year Results of Iliocaval Stenting.

BACKGROUND: The aim of the study was to assess results of interventions for iliocaval obstruction or compression in patient with acute and chronic venous disease. METHODS: Patients with chronic venous insufficiency (CVI) C3-C6 (Clinical, Etiology, Anatomy, Pathology - classification of venous insufficiency) and acute deep venous thrombosis were assessed by ultrasound scan, computed tomography, venography, and/or intravascular ultrasound, and if an obstruction in their iliocaval or iliofemoral segments were confirmed, they underwent venoplasty and stenting. Acute deep venous thrombosis cases were treated with pharmacomechanical and/or catheter-directed thrombolysis and residual obstruction was then stented. RESULTS: One hundred eighteen consecutive limbs were treated between October 2011 and December 2017. Thirty-two limbs had an active ulcer (27%), 27 limbs had healed ulcer or advanced skin changes (23%), 39 limbs had swelling with or without other symptoms of CVI (33%), 15 limbs had acute symptomatic deep venous thrombosis (13%), and the residual 5 iliac vein cases were causing pelvic congestion syndrome (4%). Patency rates of the stents in acute cases were 84.6%, 76.9%, 76.9%, and in chronic cases (combined thrombotic and nonthrombotic) 93.1%, 91%, and 89.9% in 3, 6, and 12 months, respectively. A relief of symptoms was achieved in 81.5 % of limbs at some stage during the first 12 months (most of them within the first 3 months), although at the end of this period only 59.3% remained free of symptoms. There was no limb loss and no mortality within 30 days from the intervention. CONCLUSIONS: Iliocaval and iliofemoral venoplasty and stenting in both acute and chronic obstruction cases can be performed safely with good patency rates and reasonable improvement of symptoms of CVI.

Management challenges of late presentation Dacron patch infection after carotid endarterectomy.

An 83-year-old man presented 4 years after right carotid endarterectomy (CEA) with an infection of his prosthetic Dacron patch. Initial scans (CT angiogram and whole body labelled white cell scan) were clear with no infection or collection noted. Systemically, the patient presented well with no recorded fevers. With an occluded left internal carotid artery and severely stenosed vertebral arteries, surgery presented a high risk of major stroke due to the lack collateral supply and this was discussed extensively. The patient subsequently declined surgical management, and he was monitored closely on an outpatient basis. He presented again a year later with ongoing haemoserous ooze from the CEA site. Subsequently a two-stage procedure was performed, where initially a stent was inserted, followed by patch excision and debridement. A muscle flap was then mobilised over the opening. This new approach to carotid patch infections should gain traction over time as a safer alternative for high-risk patients.

Hypothenar hammer syndrome in an office worker.

Hypothenar hammer syndrome (HHS) is an uncommon cause of unilateral Raynaud's phenomenon, splinter haemorrhages and hypothenar weakness. The typical patient is a male blue-collar worker who uses their hypothenar eminence to hammer objects as part of their work. The distal ulnar artery beyond Guyon's canal is superficial and vulnerable to blunt trauma. CTA and MRA are common initial investigations and can suggest the diagnosis. DSA is the gold standard imaging modality and offers therapeutic opportunities. Management is controversial, but unless there is critical digital ischaemia, conservative treatment is first line.

Major Lower Limb Amputation: Outcomes are Improving.

BACKGROUND: Outcomes following major lower limb amputation (MLLA) between 2000 and 2002 from the Department of Vascular Surgery at Royal Perth Hospital have been published; mean postoperative length of stay 20 days, inpatient complication rate 54%, and 30-day mortality 10%. The last decade has seen increasing endovascular revascularization techniques, increased focus on MLLA patients, and general improvements in the model of care. The aim of this study is to compare outcomes between 2000-2002 and 2010-2012. METHODS: Data on all patients undergoing MLLA, transtibial or proximal, in the 2 time periods were extracted from the department of vascular surgery database. Medical records, government registries, and phone calls to primary care providers were used to clarify mortality. RESULTS: Limb ischemia remains the most common indication for MLLA with smoking, hypertension, and diabetes being the main comorbid diseases. The rates of wound infections have fallen from 26.4% to 12.4% (P = 0.023), rate of admission to ICU has fallen from 48.3% to 17.5% (P = 0.001), and revision amputation to a higher level has fallen from 11.5% to 7.2% (P = 0.043). Acute hospital, postoperative length of stay has trended down from 15.74 to 20.29 days (P = 0.075). Mortality overall has fallen from 60.92% to 46.39% (P = 0.049). Thirty-day mortality fallen from 10.34% to 5.15% (P = 0.185), 6-month 28.76% to 16.5% (P = 0.046), and 1-year 40.22% to 21.65% (P = 0.006). CONCLUSIONS: Patients undergoing MLLA still carry a high burden of comorbid disease. With changes in revascularization technique, consultant supervision, and multidisciplinary model of care, we have seen the rate of complications fall, length of stay trend down, and overall mortality reduce. Despite improvements, outcomes remain sobering and more can be done.

Serum homocysteine is associated with the severity of primary chronic venous disease.

OBJECTIVE: This study was conducted to assess whether serum homocysteine concentration was associated with the severity of primary chronic venous disease. DESIGN: Cross-sectional study. METHODS: A total of 282 primary chronic venous disease patients were enrolled from outpatient vascular services. The severity of venous disease was graded using the Clinical Etiology Anatomy Pathophysiology classification system. The association of serum homocysteine concentration with advanced primary chronic venous disease (C4-6) was assessed using the Mann Whitney U test and logistic regression analysis. RESULTS: Median (interquartile range) serum homocysteine concentrations were 9.10 µM (7.55-10.75) and 10.40 µM (8.85-13.10) in patients with primary chronic venous disease classified by C1-3 (n = 209) and C4-6 (n = 73) grades, respectively, p < 0.001. Serum homocysteine concentration was positively associated with clinical grade 4-6 after adjusting for other risk factors including age, diabetes, male sex, hypertension, recurrent varicose veins and stroke. Patients with serum homocysteine in the third (odds ratio, 2.76, 95% confidence interval, 1.01-7.54) and fourth (odds ratio 3.29, 95% confidence interval 1.15-9.43) quartiles were more likely to have grade C4-6 chronic venous disease than subjects with serum homocysteine in the first quartile. CONCLUSIONS: Serum homocysteine is positively associated with the severity of primary chronic venous disease and therefore could play a role in promoting chronic venous disease complications.

Factors associated with patency following angioplasty of hemodialysis fistulae.

PURPOSE: Patency after percutaneous transluminal angioplasty of native hemodialysis arteriovenous fistulae (AVFs) is highly variable. This study aimed to identify predictors of patency following angioplasty in native AVFs. MATERIALS AND METHODS: All endovascular procedures performed in native AVFs between 2005 and 2013 at two institutions were retrospectively reviewed. Clinical, anatomic, biochemical, and medication variables were subjected to univariate and multivariate Cox regression analysis to identify predictors of postintervention primary and secondary patency. RESULTS: During the study period, 207 patients underwent first angioplasty of their AVF. Follow-up ranged from 14 days to 8 years, during which another 247 endovascular interventions were performed to maintain patency. Postintervention primary patency rates at 6, 12, and 24 months were 66%, 49%, and 29%, respectively. Postintervention secondary patency rates at 6, 12, and 24 months were 94%, 84%, and 79%, respectively. On multivariate adjusted Cox regression analysis, upper-arm AVFs (P = .00072), AVFs less than 6 months of age (P = .0014), presence of multiple stenoses (P = .019), and degree of initial stenosis (P = .016) were significantly associated with shorter postintervention primary patency. A previously failed AVF was the only significant predictor of postintervention secondary patency loss (P = .0053). CONCLUSIONS: Anatomic factors related to the AVF location, AVF age, and the extent of the lesion are important predictors of restenosis after balloon angioplasty. Traditional cardiovascular risk factors, metabolic and inflammatory markers, and medications were not associated with postintervention patency.

Abdominal aortic aneurysm calcification and thrombus volume are not associated with outcome following endovascular abdominal aortic aneurysm repair.

OBJECTIVES: Aortic calcification and thrombus have been postulated to worsen outcome following endovascular abdominal aortic aneurysm repair (EVAR). The purpose of this study was to assess the association of abdominal aortic aneurysm (AAA) calcification and thrombus volume with outcome following EVAR using a reproducible, quantifiable computed tomography (CT) assessment protocol. METHODS: Patients with elective EVAR performed between January 2002 and 2012 at the Townsville Hospital, Mater Private Hospital (Townsville) and Royal Brisbane and Women's Hospital (RBWH) were included if preoperative CTAs were available for analysis. AAA calcification and thrombus volume were measured using a semiautomated workstation protocol. Outcomes were assessed in terms of clinical failure, endoleak (type I, type II) and reintervention. Univariate and multivariate analyses were performed. Median follow-up was 1.7 years and the interquartile range 1.0-3.8 years. RESULTS: One hundred thirty-four patients undergoing elective EVAR were included in the study. Rates of primary clinical success and freedom from reintervention were 82.8% and 88.9% at the 24-month follow-up. AAA calcification and thrombus volume were not associated with clinical failure, type I endoleak, type II endoleak or reintervention. CONCLUSIONS: AAA calcification and thrombus volume were not associated with poorer outcome after EVAR in this study. KEY POINTS: • The association of calcification and thrombus volumes with EVAR outcome is unclear • Quantifiable methods for assessing calcification and thrombus were not used previously • This study used reproducible methods for assessing AAA calcification and thrombus volumes.