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A 74-yr-old man with two prior coronary bypass surgeries experienced perforation of an occluded aortocoronary vein graft during a transluminal extraction catheter (TEC) procedure for unstable angina. The perforation was successfully closed using a Palmaz 154 stent covered with a short segment of autologous antecubital vein.
A 52-year-old man with a history of prior coronary bypass surgery suffered recurrent angina and underwent percutaneous placement of a stent within the midportion of the saphenous vein graft to the marginal branch of the left circumflex coronary artery, which was complicated by a significant perforation. The perforation was successfully closed using an NIR stent covered with a segment of autologous antecubital vein. Subsequent surgical exploration confirmed successful closure of the perforation. Cathet. Cardiovasc. Intervent. 48:382-386, 1999.
The most common cause of a neck mass that increases in size on the Valsalva maneuver is laryngocele. Jugular phlebectasia is a congenital dilation of the jugular vein, which is extremely rare in adults, may present similarly. Duplication of the internal jugular vein (IJV), which is usually encountered coincidentally, is another rare anatomic variation. Isolated cases or cases associated with IJV ectasia have been reported. We report on an adult patient with coexisting external jugular phlebectasia and internal jugular duplication on the same side.
The optimal dose of spironolactone to reduce portal vein pressure, alone or in combination with isosorbide-5-mononitrate (IsMn), has not been identified. We studied the effects of 8 days oral treatment with spironolactone, IsMn or both on portal pressure, plasma volume and renal sodium handling in rats with partial portal vein ligation. At daily doses of 0.33; 0.50; 1, and 1.50 mg/kg, spironolactone reduced portal pressure (all P < .05) as compared with placebo. Only the highest dose significantly lowered plasma volume (10.1 +/- 0.7 vs. 13.0 +/- 0.3 mL; P < .03) and enhanced urinary fractional sodium excretion (0.73 +/- 0.04 vs. 0.58 +/- 0.03%; P < .03) and the (Na+)/(K+) ratio in urine (0.43 +/- 0.04 vs. 0.30 +/- 0.03; P < .02). IsMn at doses of 0.25; 0.50, and 1 mg/kg decreased portal pressure (all P < .05) without a change in plasma volume but with a tendency (not significant) to lower fractional sodium excretion. IsMn impaired free water clearance at doses of 0.5 and 1 mg/kg (P < .05). Combinations of spironolactone 1 mg/kg with IsMn 0.5 or 1 mg/kg have no additive effect on portal pressure compared with spironolactone or IsMn alone. The higher the dose of IsMn in the combination, the more the natriuretic effect of spironolactone is opposed. Low doses of spironolactone are as effective as a higher dose to reduce portal pressure. This reduced portal pressure was independent of changes in plasma volume and diuretic effect, which suggests that spironolactone might have a direct vasoactive effect on the splanchnic circulation. To counteract sodium retention of nitrovasodilators, combination with high doses of spironolactone seems advantageous.
We considered performing living donor liver transplantation (LDLT) in a larger-size recipient. When the recipient was large-sized, or when the donor liver was severely steatotic or had a right-to-left volume discrepancy. We devised dual living donor liver transplantation (DLDLT) to make up for graft size insufficiency and to secure the donor's safety. However, portal vein thrombosis (PVT) presented a challenge for DLDLT because of the need for intact right and left portal veins for the implantation of both liver grafts. Our 52-year-old male patient with hepatitis B cirrhosis had suffered from repeated esophageal and gastric variceal bleeding and underwent 2 trials of a transjugular intrahepatic portosystemic shunt (TIPS). He developed TIPS occlusion and PVT involving the area just above the spleno-mesenteric confluence to the right and left PV. Also, the right PV orifice was destructed and difficult to isolate because of severe periportal inflammation and neointima growth in the TIPS mesh. The patient's two sons were inadequate for donation because of right-to-left volume discrepancy. Therefore, DLDLT using 2 left lobes was necessary to compensate for graft-size insufficiency and to secure donor safety, and we substituted an intact umbilical portion of recipient's left PV for the destroyed right PV. The patient recovered well, and liver function has been normal for more than a year. In conclusion, the umbilical portion of recipient's left PV can be a useful vascular substitute for the reconstruction of a thrombosed main portal branch in DLDLT.
The purpose of this research was to study the efficacy and outcomes of transjugular intrahepatic shunt (TIPS) in end-stage liver disease (ESLD) patients with portal vein thrombosis (PVT) eligible for orthotopic liver transplant. Nine consecutive patients with PVT underwent TIPS as a nonemergent elective outpatient procedure. The primary indication for TIPS was to maintain portal vein patency for optimal surgical outcome. Eight patients underwent contrast enhanced computed tomography (CT) and 1 magnetic resonance imaging diagnosing PVT. Shunt creation was determined by available targets at the time of TIPS and by prior imaging. Patients were followed with portography, ultrasound, CT, or magnetic resonance imaging, and the luminal occlusion was estimated before and after TIPS. Primary endpoints were transplantation, removal from the transplant list, or death. Stabilization, improvement, or complete resolution of thrombosis was considered successful therapy. Failures included propagation of thrombosis or vessel occlusion, and poor surgical anatomy due to PVT. Of 9 patients with PVT, TIPS was successfully placed in all patients without complication or TIPS-related mortality. Eight of 9 patients (88.8%) had improvement at follow-up. One patient failed therapy and re-thrombosed. Two patients (22.2%) were transplanted without complication and had no PVT at the time of transplant. Eight of 9 patients were listed for transplant at the time of their TIPS. Eight of 9 PVTs were nonocclusive. Four of 9 patients (44%) had evidence of cavernous transformation. Two patients expired during follow-up 42 and 44 months after TIPS. Three patients remain on the transplant list. One patient has not been listed due to nonprogression of disease. One patient has been removed from the transplant list because of comorbid disease. In conclusion, TIPS is safe and effective in patients with PVT and ESLD requiring transplant. Patients can be successfully transplanted with optimal surgical anatomy.
An infant with severe congenital calcified thrombosis in the inferior vena cava, bilateral renal veins and left spermatic vein is presented. Five previously published cases and pertinent points concerning this rare occurence are discussed. The etiology of this calcified thrombosis remained unknown.
The amount and arrangement of smooth muscle in the intrahepatic vessels suggests that the guinea pig would be a good animal model for studying mechanisms controlling intrahepatic portal vein blood flow, while the raccoon would be good for studying hepatic vein mechanisms of control.
We describe a new approach for transvenous embolisation of cavernous sinus dural arteriovenous fistulae through the superior ophthalmic vein (SOV), i.e., via percutaneous cannulation of a frontal vein. Modern neurointerventional angiographic materials make it possible to reach the SOV in this way without puncturing it in the orbit or a surgical exposure. Orbital phlebography should still be in the repertoire of interventional neuroradiology units in large centres.
OBJECTIVES: The aim of this single, randomized study was to explore the efficacy of postoperative transarterial chemoembolization (TACE) and portal vein chemotherapy (PVC) for patients with hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombosis (PVTT) and to evaluate prognostic factors. METHODS: The study cohort consisted of 112 patients with HCC and PVTT randomly divided into three groups: Group A (37 patients), operation only; Group B (35 patients), operation plus TACE; Group C (40 patients), operation plus TACE and PVC. Disease-free survival rates and prognostic factors were analyzed. RESULTS: Most of the side effects and complications were related to the operation, catheters, and local chemotherapy and included liver decompensation (15.0%), catheter obstruction (11.6%), and nausea and loss of appetite (22.1%). The disease-free survival curve was significantly different among the three groups, as estimated by the Kaplan-Meier method (both P < 0.05). Group C showed a significantly higher disease-free survival rate than Group A (P < 0.05), but no statistical differences were found between group A and group B, and group B and group C (both P > 0.05). Tumor size, tumor number, PVTT location, and treatment modalities were independent prognostic factors (P < 0.05). CONCLUSION: Postoperative TACE combined with PVC may benefit the survival of patients with HCC complicated by PVTT in the short-term (less than 60 months), but long-term efficacy is not yet certain and needs to be confirmed by further studies.
A 43-year-old non-cirrhotic woman suffered from encephalopathy caused by an extrahepatic portosystemic shunt between the ileal vein and inferior vena cava via the right gonadal vein. Percutaneous transcatheter embolization with stainless steel coils was performed by the retrograde systemic venous approach. Encephalopathy improved dramatically.
PURPOSE: Central vein occlusions (CVO) with an avascular area of more than 10 optic-disc areas are classified as ischemic by the Central Vein Occlusion Study Group (CVOSG). For patients without neovascularizations (NV) clinical controls every 4 weeks during the first 6 months are recommended instead of prophylactic pancoagulation (PC). In this study we examined the practicability of this recommendation. PATIENTS AND METHODS: We analysed the records of 15 patients with ischemic CVO and no clinical signs of NV and no prophylactic PC retrospectively. All these patients developed a neovascular glaucoma (NVG) despite using the criteria of the CVOSG and were then treated with cyclophotocoagulation (CPC). RESULTS: The time between first presentation and CPC was 4.4+/-2.9 months. Of these patients 7 developed a NVG within 4 weeks after initial presentation. CONCLUSIONS: This study shows that NV and NVG may develop much faster than 4 weeks and can already be irreversible. Therefore it seems advisable to follow-up patients with increased risk factors even more frequently especially during the initial phase after CVO.
INTRODUCTION: Pulmonary vein (PV) stenosis is an important complication of the AF ablation and could be underestimated if their assessment is not systematically done. Selective Segmental Ostial Ablation (SSOA) and Circunferential Pulmonary Veins Ablation (CPVA) have demonstrated efficacy in atrial fibrillation (AF) treatment. In this study the real incidence of PV stenosis in patients (pts) submitted to both SSOA and CPVA was compared. METHODS: Those pts with focal activity and normal left atrial size were submitted to SSOA, remaining pts were submitted to CPVA to treat refractory, symptomatic AF. Contrast enhanced magnetic resonance angiography (MRA) was routinely performed in all patients 4 months after the procedure. RESULTS: A series of 73 consecutive patients (mean age of 51 +/- 11 years; 75% male) were included. SSOA was performed in 32 patients, and the remaining 41 patients underwent to CPVA, obtaining similar efficacy rates (72% vs 76% arrythmia free probability at 12 months; log rank test p = NS). Six patients had a significant PV stenosis, all in SSOA group none in CPVA group (18.8% vs 0%; p = 0.005). All patients were asymptomatic and the stenosis was detected in routine MRA. No predictors of stenosis has been identified analysing patient procedure characteristics. CONCLUSION: PV stenosis is a potential complication of SSOA not seen in CPVA. The study confirms than MRA is useful for identifying patients with asymptomatic PV stenosis.
Prior work has suggested that cryopreserved venous allografts may serve as an effective arterial substitute. To determine the relative thrombogenicity of this material, platelet uptake of cryopreserved canine jugular veins (CJV) before and after deendothelialization was compared to fresh CJV before and after deendothelialization, and to PTFE. CJV were frozen in Medium 199 (M199) with 10% dimethylsulfoxide to -70 degrees C. CJV were deendothelialized with collagenase (165 u/mg Worthington type II in phosphate-buffered saline) for 15 min at 37 degrees C. Canine platelets were harvested, labeled with indium-III-oxine, and suspended in 1 liter of M199. Labeled platelets were used to perfuse each graft in a nonpulsatile flow loop for 120 min. Deendothelialization led to a significant increase in platelet uptake (P less than 0.05). Frozen deendothelialized CJV showed the highest affinity for platelets. PTFE, cryopreserved, and fresh CJV showed similar affinity for platelets. Cryopreservation alone did not seem to inhibit the ability of endothelial cells to act as a nonthrombogenic surface and did not alter the histologic structure of the veins.
The technique of lengthening of the pedicles of the rectus abdominus and latissimus dorsi free flaps are described in five patients. Lengthening of these pedicles allowed scalp reconstruction using the external carotid artery and internal jugular vein as the recipient vessels without the need for interpositional vein grafts or arterio-venous loops. Post-operative recovery was uneventful in all cases.
PURPOSE: To define the association between venous volume as measured with air-plethysmography and the duplex ultrasound measured diameter of incompetent perforator of the lower limb. PATIENTS AND METHODS: Thirty-six patients with chronic venous disease were investigated with air-plethysmography and duplex ultrasound. Venous volume and venous filling time was measured. Venous filling index was calculated. The findings were correlated with the diameter of the largest incompetent perforator vein of the lower limb. RESULTS: Twenty-six patients with venous volume in the normal range (80-170 ml) had a median perforator diameter of 3.5 mm (IQR 3.2-4.3). Ten patients with venous volume above 170 ml had median perforator diameter of 5.5 mm (IQR 4.6-7.7). (p=0.001, Mann-Whitney). There was a correlation between the venous volume and diameter of the largest incompetent perforator vein. (Pearson correlation factor 0.69, p=0.01). CONCLUSION: Limb volume correlates to the diameter of the largest incompetent perforator of the calf. Increase in venous limb volume could be partly responsible for an increase in the size of calf perforators thereby promoting incompetence.
OBJECTIVES: Duplex ultrasonography assessment of superficial forearm veins is frequently used before a hemodialysis arteriovenous fistula (AVF) is created. There is, however, no standardized preoperative duplex ultrasonography protocol. This study assessed B-mode image analysis reproducibility and reproducibility of repeated forearm superficial venous diameter measurements on different days at different venous congestion pressures (VCPs). METHODS: Diameters were determined using B-mode ultrasonography in 10 healthy male volunteers on days 1 and 14 at incremental VCP values (10 to 80 mm Hg). Intra- and interobserver agreement was assessed for B-mode image analysis by calculating interclass correlation coefficients (ICC). Reproducibility of repeated diameter measurements (maximum and minimum diameter at days 1 and 14), cross-sectional area size increase, and shape change due to incremental VCPs were determined by calculating ICC values. RESULTS: Analysis of intraobserver agreement of B-mode image interpretation yielded ICC values of 0.97 (95% confidence interval [CI], 0.94 to 0.99) and 0.97 (95% CI, 0.96 to 0.99) for determination of maximum and minimum diameters, respectively. Interobserver agreement analysis yielded ICC values of 0.95 (95% CI, 0.92 to 0.97) and 0.96 (95% CI, 0.96 to 0.99) for determination of maximum and minimum diameters, respectively. Reproducibility of repeated diameter measurements on days 1 and 14 improved substantially at incremental VCP values, with best reproducibility at VCPs >40 mm Hg. Repeated determination of cross-sectional area size increase and shape change due to VCP increase from 10 to 80 mm Hg yielded ICC values of 0.49 (95% CI, 0.19 to 1.00) and 0.09 (95% CI, 0.00 to 0.92), respectively. Maximum and minimum diameters as well as cross-sectional area size increased significantly (P < .01) due to VCP increase during both sessions. Cross-sectional area shape changed significantly (P < .01) due to VCP increase during both sessions. CONCLUSIONS: Diameter measurements on B-mode images are largely observer independent. Superficial venous cross-sectional area shape is noncircular, and cross-sectional area size depends on VCP. Both maximum and minimum venous diameters should be determined at VCPs >40 mm Hg to attain the best reproducibility. Further studies are needed to determine whether a standardized preoperative vein mapping protocol can reduce AVF nonmaturation rates.
Cystic adventitial disease of veins is a rare condition. We report the case of a 28-year-old man who presented with a swollen leg secondary to obstruction of the common femoral vein as a result of this disease. He underwent excision of the cyst and made a full recovery. The presentation, investigation, treatment and pathology of this condition is discussed.