Surgical thrombectomy followed by intraoperative endovascular reconstruction for symptomatic ilio-femoral venous thrombosis.
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OBJECTIVES: To evaluate the efficacy of surgical thrombectomy combined with endovascular reconstruction for acute ilio-femoral/caval venous thrombosis. METHODS: Twenty consecutive patients with acute, symptomatic ilio-femoral/-caval thrombosis underwent valve-preserving thrombectomy with immediate endovascular repair between October 1996 and October 2003. Thrombectomy was classified by intraoperative venography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because endovascular repair was not performed. RESULTS: Left-sided venous thrombosis predominated (90%). Lesions were located in the common iliac vein (85%), the external iliac vein (10%), and the inferior vena cava (5%). Three TYPE II lesions and 17 TYPE III lesions (11 spurs, one hypoplasia, one fibrosis, one haematoma, and three others) were diagnosed. Catheter-directed recanalisation (thrombectomy/thrombolysis) resolved TYPE II lesions in three patients. Balloon angioplasty (one patient), iliac stenting (15 patients [two with thrombolysis]), and caval stenting (one patient) were employed in TYPE III stenoses. No serious complication or death occurred. Mean follow-up was 21 months. Of 20 patients clinical results were excellent in 18 patients who maintained patency of their reconstructed iliac veins. Primary and secondary patency rates were 80 and 90%, respectively. CONCLUSIONS: Ilio-caval venous obstructions detected intraoperatively can be reconstructed in a one-stage combined procedure. The specific endovascular approach depends on the type of residual venous obstruction. Excellent mid-term results indicate that the proposed thrombectomy classification (TYPE I-IV) and treatment algorithm optimises the results in selected patients with symptomatic venous thrombosis. (+info)
Independent predictors for primary non-function after liver transplantation.
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Primary non-function (PNF) after liver transplantation has been found to be the most common cause of early graft loss, which accounts for up to 36% of such failures. The cause of PNF is not known. The purpose of this study was to identify factors associated with and independently predictive of PNF after liver transplantation. Four hundreds twenty-four liver transplants performed at the Charles O. Strickler Transplant Center, University of Virginia were retrospectively reviewed. PNF was defined as the failure of an allograft after revascularization with no discernable cause, leading either to retransplantation or to patient death. Risk factors were analyzed using the Pearson chi-square test for univariate analysis and logistic regression for multivariate analysis. Factors found to be associated with PNF included: female recipient (6.4% vs. 2.6%, p=0.045), African-American donor (9.5% vs. 3.2%, p=0.043), inter-racial donor to recipient transplantation (9.5% vs. 2.8%, p=0.008), severe encephalopathy pretransplant (11.1% vs. 3.1%, p=0.034), pretransplant recipient PTT > 50 seconds (10.9% vs. 2.8%, p=0.004), portal vein reconstruction with conduit (15.0% vs. 3.5%, p=0.011), and downsizing of graft (22.9% vs. 3.8%, p=0.007). Logistic regression identified the use of donor iliac vein conduit for the portal vein reconstruction (p=0.003, odds ratio=3.15, 95% confidence interval: 1.49-6.64) and the racial difference between donor and recipient (p=0.012, odds ratio=2.31, 95% confidence interval: 1.20- 4.45) to be independent predictors of PNF. The exact cause of these findings, whether physiologic or immunologic, remains unknown. If confirmed in larger data sets, the attention to these factors may minimize the possibility of PNF in non-emergency situations. (+info)
Alternatives to the double vena cava method in partial liver transplantation.
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Minimizing graft congestion in partial liver transplantation is important, especially when the graft weight is marginal for the recipient metabolic demand. We prefer the double vena cava technique for reconstructing middle hepatic vein tributaries with thick, short hepatic veins because the technique can reduce the warm ischemic time of the graft and make a wide anastomosis. This technique requires a cryopreserved superior or inferior vena cava. We devised an alternative double vena cava method using iliac or femoral vein grafts and applied it to two right liver transplantation patients. There was no postoperative hepatic venous outflow block in either patient. In conclusion, application of this technique, even in the absence of a suitable vena cava, can help to minimize graft congestion. (+info)
Retrievable inferior vena cava filters: early clinical experience.
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AIM: Multiple-trauma patients often have injuries that prevent the use of anticoagulant or sequential compression device prophylaxis. Temporary inferior vena cava filters (IVCFs) offer protection against pulmonary embolism (PE) during the early, highest-risk perioperative and immediate injury period, while avoiding potential long-term sequelae of a permanent IVCF. The objective of this study was to evaluate the efficacy of prophylactic, temporary IVCF placement at the intensive care unit (ICU) bedside under real-time intravascular ultrasound (IVUS) guidance in multiple-trauma patients. METHODS: One hundred and three multiple-trauma patients between July 1, 2002, and July 1, 2004, under-went placement of Gunther-Tulip (n=38), Recovery (n=30) or OptEase (n=35) retrievable IVCFs under real-time IVUS guidance. The mean+/-SD injury severity score of the patients was 27.7 (+/-2.2). All patients had abdominal X-rays to verify filter location. Before IVCF retrieval, all patients underwent femoral vein color-flow ultrasonography to rule out deep vein thrombosis (DVT) and pre and postprocedure vena-cavography for possible IVCF thrombus entrapment and postretrieval IVC injury. RESULTS: Twenty-four patients died of their injuries; no deaths were related to IVCF placement. One PE occurred during follow-up after filter retrieval, and 2 insertion site femoral vein DVT occurred. As verified by abdominal X-rays, 97.1% (100/103) of IVCFs were placed without complications at the L2-3 level. Filter-related complications included 3 groin hematomas (2.9%) and 3 IVCFs misplaced in the right iliac vein early in our experience; these filters were uneventfully retrieved and replaced in the IVC within 24 h. Forty-four patients underwent uneventful retrieval of IVCFs after DVT or PE anticoagulation prophylaxis was initiated. Thirty-five filters were not removed, including 32 because severity of injury prevented DVT or PE prophylaxis and 3 because of thrombus trapped with the filter. CONCLUSIONS: Prophylactic, temporary IVCFs placed at the ICU bedside under IVUS guidance in multiple-trauma patients serves as an effective bridge to anticoagulation until venous thromboembolism prophylaxis can be initiated. Further investigation of this bedside technique and the role of temporary IVCFs in these patients is warranted. (+info)
Leg oedema due to a rheumatoid cyst in the pelvis.
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We describe a case in which chronic oedema of a leg was due to pressure on the external iliac vein from an intrapelvic rheumatoid cyst. Ultrasound and CT scanning gave the clues to diagnosis. (+info)
Unusual case of pulmonary hypertension.
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Truly reversible pulmonary hypertension is rare. Acquired systemic arteriovenous (A-V) fistulas following spinal surgery (laminectomy) are a less recognized cause of secondary pulmonary hypertension. We describe a patient who presented with symptoms and clinical evidence of pulmonary hypertension and underwent endovascular correction of an acquired A-V fistula, which led to improvement according to clinical and noninvasive hemodynamic criteria. (+info)
Intravascular synovial sarcoma of the external iliac vein and reconstruction with the superficial femoral vein.
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Intravascular synovial sarcoma is a rare neoplasm that arises in large veins of the junctional zone between the proximal leg and lower trunk in adult women. Herein we report the first case of an intravascular synovial sarcoma of the external iliac vein. It was successfully treated with neoadjuvant radiotherapy, radical excisional surgery, and combined arterial and venous reconstruction. Intravascular synovial sarcoma should be considered in the differential diagnosis of any adult woman with deep venous thrombosis and a mass of the femoral or iliac venous system. (+info)
Fatality due to acute alpha-methyltryptamine intoxication.
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In February 2003, the Miami-Dade County Medical Examiner Department reported the first known death in the country related to alpha-methyltryptamine (AMT). AMT is an indole analogue of amphetamine investigated in the 1960s as an antidepressant, stimulant, and monoamine oxidase inhibitor. Today, AMT is recognized as a powerful psychedelic drug among high school and college-aged men and women. Its popularity is partly due to the multitude of anecdotal websites discussing AMT as well as its legality and availability for purchase via the Internet prior to April 2003. Emergency designation of AMT as a Schedule 1 controlled substance by the Drug Enforcement Administration occurred shortly after the death in Miami-Dade County. The case in Miami involved a young college student who, prior to death, advised his roommate that he was "taking hallucinating drugs" and as a result had "discovered the secret of the universe". Approximately 12 h later, the roommate discovered the deceased lying in bed unresponsive. An empty 1-g vial of AMT was recovered from the scene and sent to the toxicology laboratory. Initial screening of urine by enzyme-multiplied immunoassay technique was positive for amphetamines, and the basic drug blood screen detected a small peak later identified by mass spectrometry as AMT. For quantitation, AMT was isolated using solid-phase extraction, derivatized with pentafluoropropionic anhydride, and analyzed using gas chromatography-mass spectrometry. Quantitative analysis was based upon m/z 276, 303, and 466 for AMT and m/z 306, 333, and 496 for the internal standard, 5-methoxy-alpha-methyltryptamine. A linear calibration curve from 50 to 500 ng/mL was used to calculate the concentration of AMT in the samples and controls. Blood, tissue, and gastric specimens were diluted to bring the observed concentration within the limits of the standard curve. Matrix matched controls were extracted and analyzed with each run. Postmortem iliac vein blood revealed 2.0 mg/L, gastric contents (48 g collected at autopsy) contained 9.6 mg total of AMT, liver contained 24.7 mg/kg, and the brain contained 7.8 mg/kg. An additional Medical Examiner case from another jurisdiction revealed 1.5 mg/L in antemortem serum. (+info)