Schistocytosis and a thrombotic microangiopathy-like syndrome in hospitalized HIV-infected patients

Surgical repair of extremity venous injuries remains controversial. Literature supports both ligation and repair when analyzed for functional recovery. However, few studies review the natural history of venous repair for trauma. Twenty patients were prospectively enrolled in a protocol of immediate repair of major extremity veins. Simple venorraphy and complex reconstructions were performed at the discretion of the operative team. Patients were studied by contrast venogram on postoperative day 3 and 6 weeks after surgery. Patients with occluded repairs at 3 days received a 5-day course of intravenous anticoagulation and were discharged. Overall, patency at 3 days was 55 per cent and increased to 88 per cent at 6 weeks (P < 0.02). Lateral venorraphy and direct reapproximation had higher patency rates than complex repairs at 6 weeks (92% versus 50%; P < 0.05). All veins that were patent at 3 days remained patent (correlation coefficient 1.0). Repair of traumatized extremity veins carries minimal morbidity and has a high rate of early and eventual patency. Long-term anticoagulation in the face of early thrombosis is unnecessary.     

Thrombolytic and endovascular treatment of peripartum iliac vein thrombosis: a case report

This case report details the multidisciplinary treatment of peripartum left iliac vein thrombosis using percutaneous catheter-directed urokinase thrombolysis and balloon thromboplasty. Enhanced chances for long-term patency and the normalization of venous function make these minimally invasive procedures accepted options for the treatment of iliofemoral deep venous thrombosis in selected peripartum patients.     

Angiographic 20-year follow-up of 61 consecutive patients with internal thoracic artery grafts

OBJECTIVE: To assess the behavior of internal thoracic artery (ITA) grafts versus venous grafts in repeated angiograms up to 20 years. SUMMARY BACKGROUND DATA: Use of ITA grafts to bypass left anterior descending artery stenosis has been shown to be associated with improved survival in patients undergoing coronary artery bypass grafting. METHODS: Sixty-one consecutive patients who received one or two ITA grafts and who underwent surgery from Oct. 5, 1971, to Dec. 18, 1973, in Helsinki University Central Hospital, Finland, were included in this prospective follow-up series. Fifty-six of the patients (92%) also received at least one venous graft. The number of distal anastomoses was 157, of which 47.7% (75) were performed with ITA grafts. The median age of the patients was 47.7 years (range 30.0 to 63.1), and 85% (52) were men. RESULTS: After 20 years of follow-up, 18/20 (90%) of the survivors underwent angiography; the patency rate was 88.9% for ITA grafts and 47.8% for venous grafts. Cumulative graft patency at 20 years, using all the information obtained from repeated angiographic examinations and autopsies, was also calculated to eliminate selection bias. The cumulative 20-year patency rate was 81% for ITA-left anterior descending artery anastomoses, 53.8% for venous graft-right coronary artery anastomoses, and 48.5% for venous graft-left circumflex artery anastomoses. In paired comparisons between anastomoses, the patency time of the ITA-left anterior descending artery anastomoses was on average 2.8 years longer than the venous graft-left circumflex artery patency time and 2.6 years longer than the venous graft-right coronary artery. CONCLUSIONS: Internal thoracic artery grafts, especially in left anterior descending artery anastomoses, should be considered as a primary solution in coronary artery bypass grafting surgery in patients with >10 years of life expectancy; if venous grafting is preferred, further evidence is needed.     

Aneurysm of a subclavian-vertebral artery saphenous vein bypass graft: case report

OBJECTIVE AND IMPORTANCE: Although an autogenous saphenous vein is frequently used as a bypass graft, an aneurysm of a venous graft is a rare complication, especially in the case of cerebrovascular revascularization. We report a case of a successfully treated aneurysmal change in a venous graft after short vein bypass grafting. CLINICAL PRESENTATION: A 60-year-old man underwent a left subclavian-to-vertebral artery bypass operation with an interposed saphenous vein graft because of severe stenosis of the vertebral artery bilaterally. Angiograms of the left subclavian artery, obtained 4 months later, showed good patency of the graft without any dilation or stenosis. One year after the bypass surgery, the patient became aware of a pulsating mass in the left supraclavicular region, which was regarded as the grafted vein itself. A giant aneurysm of the vein graft, which developed at the nonanastomotic site, was shown in the angiogram 4 years later. INTERVENTION: The aneurysm was resected, and patch grafting of the orifice of the aneurysmal neck covered with an artificial vessel as a reinforcement was performed. CONCLUSION: The aneurysm seemed to have developed in a curved segment because of hemodynamic stress.     

Angiographic predictors of graft patency and disease progression after coronary artery bypass grafting with arterial and venous grafts

BACKGROUND: There are few data about angiographic determinants of functional graft patency and native artery disease progression after coronary artery bypass grafting operation with arterial grafts compared with venous grafts. METHODS: Baseline and follow-up coronary angiograms at a mean of 2 years after operation in 91 patients with 194 arterial and 204 venous graft anastomoses were analyzed. RESULTS: Ninety-two percent of the arterial and 87% of the venous graft anastomoses were patent at follow-up angiography (p = 0.05, odds ratio = 2.63). Unlike that of arterial grafts, the patency rate of venous graft anastomoses correlated negatively with decreasing severity of the bypassed lesion. In contrast to venous grafts, in which angiographic graft function was basically dichotomous (fully patent or occluded), compromised flow of the arterial graft anastomoses was registered in 12%. Progression of the disease was more common in segments bypassed with venous grafts than with arterial grafts (p = 0.001, odds ratio = 2.03). CONCLUSIONS: Angiographic determinants of functional graft patency and progression of occlusive changes in the bypassed artery segments are different for arterial and venous grafts.     

Pulse-spray treatment of subclavian and jugular venous thrombi with recombinant tissue plasminogen activator

PURPOSE: To evaluate the efficacy of recombinant tissue plasminogen activator (rtPA) injected by pulse-spray in lysing subclavian and jugular venous thrombi. MATERIALS AND METHODS: Twelve patients with symptomatic, venogram-confirmed, occlusive thrombi of the subclavian-axillary or jugular veins were treated with one or two daily 15-minute injections of rtPA delivered directly into the clots with pulse-spray catheters. Twenty-four hours after each treatment, repeated venograms were obtained to assess venous patency. Successful thrombolysis was defined as antegrade flow through the previously occluded segments with minimal collateral venous flow. Continued patency was assessed with repeated venograms obtained after 1 and 2 months of oral anticoagulation. RESULTS: The 15-minute rtPA injections successfully lysed thrombi in eight of the 12 patients. Hypofibrinogenemia developed in only one patient. The technique had a high success rate with thrombi less than 2 weeks old (seven of eight) regardless of the length of the clot, but had limited success with thrombi more than 2 weeks old (one of four). Continued patency over a 2-month interval was documented in four of the eight patients whose thrombi were successfully lysed. However, patency could be maintained in only one of the four patients who retained a venous access device in the treated vein. CONCLUSION: Pulse spray rtPA is an effective, safe, and practical alternative to continuous infusions of thrombolytic agents to treat upper extremity venous thrombi.     

Forearm free skin flap transplantation: a report of 56 cases. 1981

Primary arteriovenous fistulae remain the gold standard for hemodialysis access. The radiocephalic or Brescia-Cimino fistula is the autologous fistula of choice, with a primary success rate of nearly 93% and a 1-year patency rate of up to 82%. Alternative arteriovenous fistulae include the snuff box fistula and a brachiobasilic fistula with a 1-year patency rate of up to 90%. Complications include thrombosis, infection, arterial steal syndrome, venous hypertension, aneurysms, and congestive heart failure. Despite these complications, arteriovenous fistulae provide good long-term hemodialysis access.     

Vena cava duplex imaging before caval interruption

PURPOSE: Venacavograms are routinely obtained before vena cava filter placement to evaluate cava size, patency, and the presence of thrombus or venous anomalies. The objective of this study was to determine the ability of duplex ultrasonography to adequately evaluate the inferior vena cava (IVC) for size, patency, and the presence of thrombus before Greenfield filter (GF) insertion. METHODS: Duplex ultrasonographic scans were performed in 40 patients who had documented lower-extremity deep venous thrombosis diagnosed by duplex scan before GF placement. The infrarenal transverse and anteroposterior diameters of the IVC were measured, and the entire IVC was imaged for patency and the presence of thrombus or anomalies. Preoperative venacavograms were not obtained in any patients who had GFs placed in the operating room, but was performed during surgery during filter insertion. An additional 26 patients who had deep venous thrombosis and did not have caval interruption underwent IVC duplex to determine the patency and proximal extent of venous thrombosis. RESULTS: The indications for GF placement were contraindication to anticoagulation in 72.5% (29 patients); five filters were placed prophylactically; three for failure of anticoagulation; two after a complication of anticoagulation; and one before pulmonary embolectomy. The filters were placed in the operating room by surgeons in 82.5% of patients, with the remainder inserted in an angiography suite by an interventional radiologist. The ability of duplex to measure a transverse diameter of 26 mm or less had a sensitivity of 97.5%, positive predictive value of 100%, and overall accuracy of 97.5% using venacavography as the standard. Measurements of IVC diameter by duplex correlated with those based on venacavograms (r = 0.766; p < 0.001). Of the entire group of 66 IVC duplex examinations, one (1.5%) was incomplete because of technical limitations. IVC thrombus was noted by duplex in two patients who underwent GF insertion, which was confirmed with venacavography. No IVC anomalies were noted by duplex scans or venacavograms. CONCLUSION: Duplex ultrasonography is a useful and accurate method for assessment of the IVC before vena cava filter placement.     

Prevention of thrombosis in arterial and venous microanastomoses by using topical agents

A replantation model, using the rat's foot severed at the ankle and replanted on an extended vascular pedicle, was used to study the effect of topical vasodilators in preventing microvascular thrombosis. Magnesium sulfate, Xylocaine, and papaverine gave arterial patency rates of 89% or more, compared to 65% for saline alone. There was no appreciable effect on the venous patency rates. The possible mechanisms of action for the various drugs are discussed.     

Results of reconstruction in major pelvic and extremity venous injuries

PURPOSE: Outcome and venous patency after reconstruction in major pelvic and extremity venous injuries was studied. METHODS: We retrospectively reviewed 46 patients with 47 venous injuries. RESULTS: Injuries were caused by penetrating trauma in 37 extremities, blunt trauma in 6 patients, and were iatrogenic in 4 patients. Pelvic veins were injured in 4 patients, lower-extremity veins were injured in 39 limbs in 38 patients, and upper-extremity veins were injured in 4 patients. Concomitant arterial injuries occurred in 37 patients. Venous repairs were mostly of the complex type and included spiral or panel grafts in 15 (32%) reconstructions, interposition grafts or patch venoplasty in 19 (40%) reconstructions, end-to-end and lateral repair in 11 patients, and ligation in 2 patients. Two patients underwent early amputation. Early transient limb edema occurred in 2 patients, and postoperative venous occlusions were documented in 4 patients. Full function was regained in 39 (81%) extremities. No variable, including 4 retrospectively applied extremity injury scores (mangled extremity severity score [MESS], limb salvage index [LSI], mangled extremity syndrome index [MESI], predictive salvage index [PSI]), correlated with outcome. High values on all 4 scores were significantly associated with reexplorations (P <.02), which were done in 8 patients for debridement (5), arrest of bleeding (2), and repair of a missed arterial injury (1). Follow-up of 28 +/- 6 months on 27 patients (57%; duplex scan in 18, continuous-wave Doppler and plethysmography in 9, and venography in 3) showed 1 occlusion 6 weeks after the injury and patency of all other venous reconstructions. CONCLUSION: Reconstructions of major venous injuries with a high rate of complex repairs result in a large proportion of fully functional limbs and a high patency rate. A high extremity injury score predicts the need for reexploration of the extremity. Mostocclusions occur within weeks of injury, and the subsequent delayed occlusion rate is very low.     

Iliofemoral venous stenoses: effectiveness of treatment with metallic endovascular stents

PURPOSE: To assess effectiveness of metallic endovascular stents in treatment of venous stenoses and occlusions. MATERIALS AND METHODS: Stents were placed intravenously in 56 patients (59 stenoses or occlusions) over a 6-year period. Stent sites included the inferior vena cava (n = 10) and common iliac (n = 31), external iliac (n = 46), common femoral (n = 27), and superficial femoral veins (n = 4). Indications for stent placement included stenoses from pelvic malignancy and its treatment; trauma, surgery, or pregnancy; and idiopathic stenoses. Patients underwent anticoagulation therapy for 3-6 months after stent placement. Follow-up was performed with duplex ultrasound. RESULTS: With use of life-table analysis, overall primary and secondary 1-year patency rates were 50% and 81%, respectively. Primary and secondary 4-year patency rates were and 50% and 75%, respectively. Five patients died of primary disease progression within 6 months after stent placement. Major complications occurred in 6.8% of cases. One-year secondary patency rates were statistically significantly lower (P = .05) for patients with malignant disease, although primary patency rates were comparable. Overall sustained decrease in symptoms (P < .0001) was observed 1 year later. CONCLUSION: Endovascular stent placement is a nonsurgical alternative for reestablishment of venous flow and sustained relief of symptoms in patients with malignant or benign pelvic venous disease.     

Venous rupture complicating hemodialysis access angioplasty: percutaneous treatment and outcomes in seven patients

OBJECTIVE: To evaluate percutaneous treatment options for preserving hemodialysis access after angioplasty-related venous rupture, we retrospectively reviewed the charts for all dialysis access angioplasties performed over a 33-month period. Seven cases of venous rupture after venous angioplasty were identified (four men and three women; mean age, 63.5 years). Treatment included observation only (n = 1), a second prolonged balloon inflation at the rupture site (n = 2), stent insertion (n = 5), and manual graft occlusion (n = 1). Treatment was successful in eliminating contrast extravasation in all patients while maintaining immediate graft function in six out of seven patients. None of the patients required emergent surgical intervention. The mean primary and secondary patency rates of the salvaged grafts after intervention were 2.3 and 9.3 months, respectively. Five of seven access sites were still patent at the most recent follow-up. CONCLUSION: Prolonged balloon inflation or placement of a stent may salvage hemodialysis access in most patients after angioplasty-related venous rupture. Primary and secondary patency have proven to be satisfactory.     

Percutaneous translumbar central venous catheter in infants and small children

Vascular occlusion is a common clinical problem in children dependent on prolonged vascular access. As an alternative to conventional central venous catheter placement we report our experience of four children receiving translumbar inferior vena cava catheter on 12 different occasions. All catheter placements were successful. No procedure-related complications occurred. The median catheter patency was 4.8 months (range 1-10 months). The translumbar route for central venous access is safe and reliable and should be considered when prolonged use is anticipated in infants and small children.     

Urinary excretion of proteolyzed alpha1-antitrypsin: specificity, quantitation, and relation to therapy response in patients with acute myeloid leukemia

The purpose of this study was to characterize the long-term safety and efficacy of the stainless-steel Greenfield filter. All patients who underwent Greenfield filter placement at three institutions during tenure of the senior author (L.J.G.) were entered prospectively into a filter registry and followed on an annual basis. Follow-up consisted of clinical examination to evaluate the status of venous disease or recurrence of pulmonary embolism, abdominal radiographs to determine the stability of the filter and an evaluation of the patency of the inferior vena cava and lower extremities. This report summarizes the 20-year experience. The rate of recurrent pulmonary embolism was 4% and the caval patency rate was 96%. Some filter movement of no clinical significance was seen in 8% of cases. There was no procedural mortality and morbidity was minimal. Greenfield filter insertion provides long-term protection from pulmonary embolism while preserving caval patency.     

Arteriovenous fistulae complicating central venous catheterization: value of endovascular treatment based on a series of seven cases

OBJECTIVES: To point out the usefulness and effication of endovascular treatment of arteriovenous fistulae complicating the insertion of central venous catheter. MATERIAL AND METHOD: Retrospective study of 7 cases treated between 1983 and 1993. The central venous catheterization had involved the right internal jugular vein in 5 cases and the right subclavian vein in 2 cases. RESULTS: Isolated endovascular therapy was performed in 5 cases. Surgery was necessary in 1 case to remove an hematoma. In another case, occlusion of a large AVF was performed during intraoperative endovascular temporary occlusion of the AVF. The choice of the occluding agent was primarily dictated by the hemodynamic and anatomical conditions (releasable balloons, coils). Vertebro-vertebral fistulae (3 cases) could be treated with patency of this vessel. No complications were encountered. CONCLUSION: Endovascular approach is a reliable and safe method to perform occlusion of post catheter AVF.     

Reconstruction of large veins for nonmalignant venous occlusive disease

To evaluate the effectiveness of venous grafting, we reviewed the management and clinical course of 28 patients (21 males and seven females) who underwent 29 reconstructions of large veins for benign disease. There were 12 patients with superior vena cava (SVC) syndrome, two with subclavian vein thrombosis, and 15 with occlusion of the inferior vena cava (IVC) or iliac veins. One of these patients underwent both IVC and SVC reconstructions. Reconstruction of the SVC was performed with spiral saphenous vein graft (SSVG) in nine patients and expanded polytetrafluoroethylene (ePTFE) in three. All seven straight SSVGs had documented patency at a median of 7 months (2 weeks to 5 years) after reconstruction. Six patients had complete relief of symptoms. Two patients with bifurcated SSVG had early occlusion of one graft limb. Two of the three ePTFE grafts needed early thrombectomy. One graft reoccluded at 6 months and two were patent at 2 and 5 years. The two subclavian vein reconstructions with axillary-jugular ePTFE grafts with an arteriovenous fistula had documented early patency. Both patients had rapid resolution of symptoms. The IVC or iliac vein was reconstructed with ePTFE graft in 11 patients, SSVG in three, and Dacron in one. A femorofemoral arteriovenous fistula was added in eight patients with ePTFE grafts. Seven of the 11 ePTFE grafts had documented patency at the last follow-up (median 9 months; range 2 weeks to 5 years). None of the three SSVGs had documented long-term patency. The one Dacron cavoatrial graft occluded at 3 years. A straight SSVG continues to be our first choice for SVC replacement. Short, large-diameter ePTFE grafts perform the best in the abdomen. Femorocaval or long iliocaval grafts need an arteriovenous fistula to maintain patency. Long-term patency after closure of the fistula is still unknown. Femorocaval grafts with poor venous inflow have limited chance of success. Failed or failing grafts may be salvaged by early thrombectomy. Venous reconstruction to treat selected patients with symptoms with large vein occlusion continues to be a viable option.     

Duplex ultrasonography: a noninvasive technique in monitoring of Le Veen shunt

Monitoring of peritoneovenous Le Veen shunt by duplex ultrasonography was first performed in 1993 in 10 patients. The duplex signal was picked up selectively in the venous tube and the peak velocity was measured at forced inspiration. Thirty-two examinations were performed. Of these, 13 had follow-up examinations by other modalities (radionuclide imaging, shuntography, or surgical exploration), all of which confirmed the findings of duplex ultrasonography. Shuntography was avoided in all instances with a patent shunt. Duplex ultrasonography allows noninvasive assessment of Le Veen shunt patency and appears reliable for determining the need for invasive diagnostic modalities or surgical shunt correction.     

Significance of electron-beam tomography in the evaluation of the patency of aortocoronary bypasses

PURPOSE: Electron beam tomography (EBT) permits acquisition of images with high spatial and temporal resolution. The value of EBT and other imaging modalities for the depiction of patent coronary artery bypass grafts (ACVB, IMA) are compared to coronary angiography and an overview of current results is given. MATERIAL AND METHODS: Graft patency can be evaluated with indirect methods stress, such as echocardiography, radionuclide ventriculography, myocardial scintigraphy, positron-emission tomography (PET) and direct imaging modalities, such as Doppler/2D echocardiography, EBT, spiral computed tomography (SCT) and magnetic resonance angiography (MRA). RESULTS: With indirect methods graft patency can be evaluated with sensitivity of 64-100% and specificity of 73-100%. EBT and SCT are equivalent in sensitivity (= 94%) in the assessment of open venous grafts and specificity is up to 100%, but EBT is superior in the diagnosis of patent IMA grafts (sensitivity 100% vs 89%). Visualization of high-grade venous bypass stenosis seems possible with EBT. MRA with gradient echo technique is highly accurate in the assessment of patent venous grafts (sensitivity 77-93%) but has limited value in the evaluation of IMAs (sensitivity = 53%). Promising are ultrafast 3D-MRA methods which permit high accuracy (sensitivity = 94-96%) in assessing venous and arterial grafts. DISCUSSION: Indirect imaging methods cannot differentiate between an occluded bypass, progression of coronary artery disease and myocardial infarction. EBT and SCT are equivalent in the diagnosis of open and occluded venous grafts, but EBT is superior in the assessment of patent IMA grafts. Visualization of high-grade venous bypass stenosis seems possible with EBT. MRA techniques, especially ultrafast 3D-MR methods, are highly accurate in the assessment of patent venous and arterial grafts but are still limited to scientific research.     

Therapy of venous stenosis using wall stents

OBJECTIVE: To evaluate the patency of Wallstents implanted for the treatment of venous stenoses in patients with benign or malignant disease. PATIENTS AND METHODS: 22 Wallstents (20 central venous; two peripheral) were implanted during a period of two years in 12 patients (nine men, three women; mean age 57.8 [26-76] years) with malignant venous stenoses (n = 9) or stenosed dialysis shunts (n = 3). Stent diameter ranged from 8-16 mm, length from 32-91 mm. Introduction of the stents were by percutaneous transfemoral catheterisation, in six patients with simultaneous wire placement from a cubital to the femoral vein. The superior vena cava was the involved vessel in six patients (in two each also the subclavian or brachiocephalic veins), in three only the subclavian vein, twice only the inferior vena cava and once the cephalic vein. RESULTS: The patency of the stents was checked after 4.7 +/- 3.6 (1-14) months, in seven patients clinically, by digital subtraction phlebography in three, by computed tomography in two. In nine patients there was no evidence of obstruction to flow or flow was normal. Stent occlusion had occurred in three patients, 4, 9 and 14 months after placement. There were no complications. Five patients died after a mean period of 4.8 +/- 3.6 (1-6.5) months from the underlying disease, without symptoms of obstruction to flow. CONCLUSION: Stent placement should be considered early, as it is a well-tolerated and effective palliative procedure for central venous stenoses associated with malignant disease or stenosis of dialysis shunts.     

Diagnosis, intensive therapy and surgery of peritonitis and enterocolic occlusions of thromboembolic origin

The authors present a series of 14 cases of intestinal or colonic obstruction due to arterial ischema (7 cases) or mesenteric vein thrombosis (7 cases), for which they provide an analysis of pathogenesis, clinical aspects, surgical strategy, and intensive care. Mortality was 87.5% in cases of arterial origin and 42.8% in those of venous origin. The authors stress the need for diagnosing intestinal infarction right from the start, relying on clinical intuition and with the help of only a few clinical symptoms and objective signs. Surgically speaking, the best chance of survival is afforded by restoration of arterial or venous patency associated with whatever resection of the ileum or colon the anatomical situation may require.