Balloon angioplasty: A promising adjunct to arteriovenous fistula creation compared with hydrostatic dilatation in small-caliber cephalic veins

Background To maintain the patency and longevity of arteriovenous fistula, the availability of a venous segment with adequate diameter is important. In Indian population, many chronic kidney disease patients have poor caliber veins. The study aimed to evaluate the efficacy of hydrostatic dilatation versus Primary balloon angioplasty of small caliber cephalic veins of (≤2.5 mm) preoperatively in terms of patency rate and maturation time of arteriovenous fistula. Methods Patients ( n = 80) with an end-stage renal disease requiring arteriovenous access surgery for hemodialysis with small caliber cephalic veins were randomized into two groups, i.e., hydrostatic dilatation and primary balloon angioplasty, each with 40 patients. All patients underwent a thorough clinical examination as well as duplex ultrasound vein mapping of both upper extremities. Patients were followed up for six months and primary patency, maturation time, and complications were noted. Results Immediate technical success with good palpable thrill was achieved in 97.5% of patients in the primary balloon angioplasty group and 87.5% in the hydrostatic dilatation group. The fistula maturation time in the primary balloon angioplasty group was 34.41 days and 46.18 days in the hydrostatic dilatation group. In the primary balloon angioplasty group, the primary patency of the fistula was 97.5% and 87.5% in the hydrostatic dilatation group, at six months. The arteriovenous fistula functioning rate was 77.5% in the hydrostatic dilatation group as compared to 92.5% in the primary balloon angioplasty group at six months. The incidence of surgical site infection was 5% in the primary balloon angioplasty group as compared to 10% in the hydrostatic dilatation group. Conclusion Primary balloon angioplasty of small caliber cephalic veins (≤2.5 mm) performed prior to arteriovenous fistula creation for hemodialysis is a beneficial procedure.

Predictive factors of venous recanalization in upper-extremity vein thrombosis

Background Upper extremity venous thrombosis (UEVT) represents about 10% of venous thrombo-embolic disease. This is mainly explained by the increasing use of central venous line, for oncologic or nutritional care. The factors associated with venous recanalization are not known. Objective The aim of this study was to investigate prognosis factor associated with venous recanalization after UEVT. Methods This study included patients with UEVT diagnosed with duplex ultra-sonography (DUS) from January 2015 to December 2017 with DUS evaluations during follow-up. A multivariate Cox proportional-hazards-model analysis was performed to identify predictive factors of UEVT complete recanalization. Results This study included 494 UEVT, 304 proximal UEVT and 190 distal UEVT. The median age was 58 years, 39.5% were women. Clinical context was: hematological malignancy (40.7%), solid cancer (14.2%), infectious or inflammatory context (49.9%) and presence of venous catheters or pacemaker leads in 86.4%. The rate of recanalization without sequelae of UEVT was 38%. For all UEVT, in multivariate analysis, factors associated with complete vein recanalization were: thrombosis associated with central venous catheter (CVC) (HR:2.40, [1.45;3.95], p<0.001), UEVT limited to a venous segment (HR:1.94, [1.26;3.00], p = 0.003), occlusive thrombosis (HR:0.48 [0.34;0.67], p<0.0001), the presence of a PICC Line (HR:2.29, [1.48;3.52], p<0.001), a thrombosis of deep and distal topography (HR:1.70, [1.10;2.63], p = 0.02) or superficial thrombosis of the forearm (HR:2.79, [1.52;5.12], p<0.001). For deep and proximal UEVT, non-occlusive UEVT (HR:2.23, [1.49;3.33], p<0.0001), thrombosis associated with CVC (HR:1.58, [1.01;2.47], p = 0.04) and infectious or inflammatory context (HR:1.63, [1.10;2.41], p = 0.01) were factors associated with complete vein recanalization. Conclusion In this study, factors associated with UEVT recanalization were UEVT limited to a venous segment, thrombosis associated with CVC, a thrombosis of deep and distal thrombosis topography and superficial thrombosis of the forearm. Occlusive thrombosis was associated with the absence of UEVT recanalization.

Minimal Incision Venectomy for Peripheral Septic Thrombophlebitis

Peripheral septic thrombophlebitis is an uncommon but potentially lethal condition fraught with systemic complications. Optimal treatment calls for surgical excision of the inflamed venous segment, followed by antimicrobial therapy. However, the extended skin incision and meticulous flap elevation of conventional venectomy leaves substantial residual scarring. Herein, we detail a minimal incision venectomy performed for peripheral septic thrombophlebitis in a 55-year-old man. The patient was initially admitted for conservative management of intracranial hemorrhage but subsequently developed high fever and hypotension. An abscessed intravenous catheter site of the left forearm was the apparent source. Following emergency drainage and serial irrigation, surgical venectomy was undertaken to radically remove the septic focus, excising a 10-cm segment of infected vein through a separate proximal incision. After the procedure, the patient’s recovery was complete and free of complications at postoperative 6-month visit. Under appropriate indications, minimal incision venectomy can be an effective therapeutic alternative with minimal scarring.

Results of venous resections in cancer of the pancreatic head.

e16785 Background: Studies have shown that pancreaticoduodenal resection (PDR) with resection and reconstruction of the venous segment does not interfere with surgical treatment for ductal pancreatic adenocarcinoma with suspected venous invasion. Venous resection improves survival compared to palliative interventions. However, the advantages and disadvantages of marginal resection, segmental resection with direct anastomosis, and venous segment prosthetics are not reflected. Methods: The study included 52 patients (23 women, 29 men) undergoing PDR with venous resection and reconstruction for cancer of the pancreatic head in 2015-2019. The average tumor size was 3.8 cm. Results: Superior mesenteric vein reconstruction (PTFE grafts) was performed in 17 patients (32.7%), sleeve resection with direct anastomosis - 24 (46.2%), marginal resection - 11 (21.1%). Venous reconstruction was planned in 78.8% of patients before the surgery. In the early postoperative period, thrombosis of the reconstructed zone was developed in two patients (3.8%), bleeding from the pancreatic bed - in one case (1.9%). Postoperative mortality was 5.8% (3 patients). After the final pathological examination, macroscopically incomplete resection was diagnosed only in the group with marginal resection and amounted to 3.8%. Microscopically incomplete resection was diagnosed in 9.6% of the studied preparations (in marginal resection of the vein wall - 3.8%, with direct anastomosis - 1.9%, SMV prosthetics - 3.8%). Most often, R1 resection was detected in the retroperitoneal resection margin (80%). The lowest 1-year survival was observed in the group with marginal resection (36.4%). No significant differences in survival rates were found in patients with direct venous anastomosis (62.5%) and venous prosthetics (64.7%) (RR 1.69; 95% CI 0.69-4.12, p > 0.05). Microscopically complete resection R0 improved the survival (RR 2.7; 95% CI 1.45-5.04, p < 0.05). Planning the venous resection was an additional risk factor affecting the completeness of resection (RR 4.6; CI 95% 1.5-14.5, p > 0.05). Conclusions: Expanding the surgery volume in PDR due to venous resection and reconstruction shows acceptable rates of postoperative morbidity and mortality. Planning the venous resection enhances the results of radical surgery.

Management of Nonthrombotic May-Thurner Syndrome

Venous outflow pathology of the lower extremity may be categorized into thrombotic or nonthrombotic etiology. This chapter focuses on the nonthrombotic etiology that results from the compression of the left iliac vein or May-Thurner syndrome (MTS). MTS is an anatomic variant condition associated with venous outflow stenosis due to extrinsic compression of the iliocaval venous segment. The most common cause of the partial obstruction is left iliac vein compression by the overlying right common iliac artery, although other anatomic varieties of MTS do exist. Partial or complete impedance to the venous outflow in the iliocaval venous segment may lead to extensive deep vein thrombosis of the ipsilateral extremity. Clinical presentations may include, but are not limited to, pain, extensive lower-extremity swelling, venous stasis ulcers, and skin discolorations. Treatment is based entirely on the clinical presentation; normally for nonthrombotic MTS, angioplasty and stenting of the diseased iliac vein segment are usually sufficient after defining the location and extent of stenosis. In this review, we (1) describe and define MTS, (2) highlight variable presentations of MTS, and (3) outline the possible management strategies within the current Society for Vascular Surgery updated consensus guidelines. This review contains 3 Figures, 2 Videos, 3 Tables and 66 references Key Words: angioplasty, artery compression, deep venous thrombosis, iliac vein, iliofemoral stenosis, May-Thurner syndrome, spur, stent, venogram, venous hypertension

Management of Nonthrombotic May-Thurner Syndrome

Venous outflow pathology of the lower extremity may be categorized into thrombotic or nonthrombotic etiology. This chapter focuses on the nonthrombotic etiology that results from the compression of the left iliac vein or May-Thurner syndrome (MTS). MTS is an anatomic variant condition associated with venous outflow stenosis due to extrinsic compression of the iliocaval venous segment. The most common cause of the partial obstruction is left iliac vein compression by the overlying right common iliac artery, although other anatomic varieties of MTS do exist. Partial or complete impedance to the venous outflow in the iliocaval venous segment may lead to extensive deep vein thrombosis of the ipsilateral extremity. Clinical presentations may include, but are not limited to, pain, extensive lower-extremity swelling, venous stasis ulcers, and skin discolorations. Treatment is based entirely on the clinical presentation; normally for nonthrombotic MTS, angioplasty and stenting of the diseased iliac vein segment are usually sufficient after defining the location and extent of stenosis. In this review, we (1) describe and define MTS, (2) highlight variable presentations of MTS, and (3) outline the possible management strategies within the current Society for Vascular Surgery updated consensus guidelines. This review contains 3 Figures, 2 Videos, 3 Tables and 66 references Key Words: angioplasty, artery compression, deep venous thrombosis, iliac vein, iliofemoral stenosis, May-Thurner syndrome, spur, stent, venogram, venous hypertension

Endovascular Thrombectomy of Septic Thrombophlebitis of the Inferior Vena Cava: Case Report and Review of the Literature

We describe the cases of 2 patients who had septic thrombophlebitis and were successfully managed with endovascular thrombectomy. Patient A developed septic thrombophlebitis of the inferior vena cava after several retroperitoneal resections for metastatic renal cell carcinoma. The thrombus was successfully removed via endovascular mechanical balloon thrombectomy. Patient B was a patient with pancreatic adenocarcinoma involving the portal vein who developed a septic inferior vena cava thrombus extending from the level and beyond the renal veins, for which she underwent endovascular thrombectomy. We argue that this approach is safe and feasible. It should be considered as a supplemental treatment modality for select decompensating patients who require lifesaving interventions and have contraindications to traditional management of surgical thrombectomy or excision of the involved venous segment.