Coagulation-monitored, dose-adjusted catheter-directed thrombolysis or pharmaco-mechanical thrombus removal in deep vein thrombosis

Background: Pharmaco-mechanical thrombectomy (PMT) and catheter-directed thrombolysis (CDT) are therapeutic options for selected patients with acute deep vein thrombosis (DVT) to prevent post-thrombotic syndrome (PTS). Patients and methods: We aimed to describe the clinical characteristics and outcomes of 159 patients with symptomatic iliofemoral DVT undergoing PMT alone, CDT alone, or CDT followed by PMT (bail-out) in the Swiss Venous Stent Registry. The primary outcome was the incidence of peri-interventional major and minor bleeding complications (ISTH criteria). Secondary outcomes included the incidence of PTS and stent patency after 3 years. Results: Mean age was 49±20 years and 58% were women. DVT involved the iliac veins in 99% of patients, whereas 53% had an underlying iliac vein compression. PMT alone was used in 40 patients, CDT alone in 77, and 42 received initial CDT followed by bail-out PMT due to insufficient thrombus clearance. Single-session PMT was the preferred approach in patients with iliac vein compression, patent popliteal vein, and absence of IVC thrombus. Patients treated with PMT alone received a lower r-tPA dose (median 10 mg, IQR 10-10) vs. those treated with CDT (20 mg, IQR 10-30). The rate of peri-interventional major bleeding was 0%, 1%, and 2%, whereas that of minor bleeding was 0%, 1%, and 12%, respectively, all occurring during CDT. After 3 years, PTS occurred in 6%, 9%, and 7% of patients, respectively. The primary stent patency rate was 95%, 88%, and 83%, respectively. Conclusions: The use of PMT and CDT for iliofemoral DVT was overall safe and resulted in high long-term patency and treatment success. Given the less severe presentation of DVT, single-session PMT appeared to be characterized by numerically better primary patency and lower perioperative bleeding event rates than CDT

Clinical presentation of simple and combined or syndromic arteriovenous malformations.

OBJECTIVES Arteriovenous malformations of the lower extremities (AVMLE) can present as simple or complex combined or syndromic forms (e.g. Parkes Weber Syndrome). We aimed to characterize the differences in clinical presentation and natural history of these potentially life and limb threatening congenital vascular malformations. METHODS We conducted a retrospective analysis of a consecutive series of patients with AVMLE, who presented to a tertiary referral center in Switzerland between 2008 and 2018. Clinical baseline characteristics, D-dimer level and course were summarized and differences between simple, non-syndromic and combined or syndromic AVMLE determined. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression models. RESULTS Overall, 506 patients were prospectively enrolled in the Bernese Congenital Vascular Malformation Registry, 31 (6%) with AVMLE. There were 16 women and 15 men with a mean age of 18 years at first diagnosis (1 month - 72 years). Simple AVMLE was present in 22 (71%), combined or syndromic AVMLE with limb overgrowth in 9 patients (29%), respectively. Common symptoms and signs were pain 25 (81%), swelling 21 (68%) and soft tissue hypertrophy 13 (42%). Among combined or syndromic patients, 3 patients died from wound infection with sepsis or disseminated intravascular coagulation with bleeding complications (intracranial hemorrhage and bleeding from extensive leg ulcers). Combined or syndromic patients presented more often with bleeding (67% vs. 5%; p<0.001), malformation related infection (44% vs. 5%; p=0,017) and leg length difference (56% vs. 14%; p=0.049). D-dimer levels were elevated (mean 17256 μg/L, range 1557 μg/L to 80000 μg/L) and angiographic appearance showed complex, mixed type of AVMs, including interstitial type IV, in all patients with combined or syndromic AVMLE. CONCLUSION Patients with congenital simple AVMLE most often present with benign clinical features and rarely complications related to hemodynamic changes. Patients with combined or syndromic AVMLE often face serious outcomesdominated by complications other than direct high flow related heart failure

Prävention des postthrombotischen Syndroms

Post-thrombotic syndrome (PTS) is a complication which occurs after deep vein thrombosis in spite of optimal anticoagulation. The term ’post-thrombotic syndrome’ summarizes all clinical symptoms and skin lesions developing in the aftermath of deep vein thrombosis. In order to prevent PTS various therapeutic options exist, the choice is depending on the time lapse since the event of thrombosis. At the acute phase of pelvic vein thrombosis catheter-directed lysis has proved to be an efficient therapy. Starting from the acute phase up to the chronic phase compression therapy should be administered. In the chronic phase clinically relevant improvement of PTS can be achieved by recanalisation of the venous outflow tract in the pelvic axis by endovascular stenting. Surgery or endovenous thermal ablation of the insufficient superficial venous system are further and supplementary sensible treatment options.Das postthrombotische Syndrom (PTS) ist eine Komplikation, die nach tiefen Beinvenenthrombosen, trotz optimaler Antikoagulation auftritt. Der Terminus «postthrombotisches Syndrom» subsumiert alle klinischen Symptome und Hautveränderungen, die sich im Anschluss an eine tiefe Beinvenenthrombose entwickeln. Zur Prävention des PTS stehen therapeutische Möglichkeiten bereit, deren Anwendung abhängig von der zeitlichen Distanz zur Thrombose ist. In der Akutphase hat sich die Katheterlyse bei Beckenvenenthrombosen als effiziente Therapie bewährt. Beginnend in der Akutphase bis hin zur chronischen Phase sollte eine Kompressionstherapie durchgeführt werden. In der chronischen Phase kann die Rekanalisation des venösen Ausflusstraktes im Bereich der Beckenachse mittels endovaskulärem Stenting eine klinisch relevante Besserung des PTS erzielen. Die Behandlung des insuffizienten epifaszialen Venensystems mittels Chirurgie oder thermoablativen endovenösen Verfahren stellt dabei eine sinnvolle Ergänzung dar

[Contrast-Enhanced Ultrasound (CEUS) for Surveillance after Endovascular Aortic Aneurysm Repair (EVAR)]

Zusammenfassung. Das abdominale Aortenaneurysma wird heutzutage mehrheitlich mittels endovaskulärer Aneurysmaausschaltung minimalinvasiv behandelt. Allerdings ist diese Therapie mit möglichen Komplikationen im Langzeitverlauf assoziiert und die Patienten müssen lebenslang monitorisiert werden. Dieser Beitrag gibt eine Übersicht über Verlaufskontrollen bei Endoprothesen mit besonderem Augenmerk auf die Wertigkeit des kontrastmittelverstärkten Ultraschalls

Farbkodierte Duplexsonografie der Gefässe in der Praxis: Pitfalls.

Color Doppler ultrasound is the diagnostic cornerstone of vascular assessment. Almost all arteries and veins of the human body are accessible to this diagnostic imaging, which as a result is very often used as first-line diagnostic test. Recent technological developments in high-end ultrasound machines enable us to optimize image quality in color-coded duplex ultrasound of arteries and veins. To obtain an optimal instrument setting, all relevant adjustments of imaging must be considered. In B-Mode ultrasound, the basic vascular imaging method, the most important settings to optimize are ultrasound frequency, gain, dynamic range, and focus, whereas color Doppler depends on angle supersonic sounding and its application in clinical practice. Most mistakes in measuring blood flow velocities, a frequent cause of misinterpretation, result from insufficient angle correction. Cardiac pathologies may result in typical changes of arterial and venous Doppler curves

[Vascular Color-Coded Duplex Ultrasound in Practice: Artifacts].

Vascular Color-Coded Duplex Ultrasound in Practice: Artifacts Abstract. Ultrasound artifacts are technical phenomena which may cause diagnostic mistakes and do not correlate with the real target organ. These optical and acoustic phenomena of color-coded duplex ultrasound are very common in the real world and may lead to misinterpretations and diagnostic errors. The twinkling artifact, for example, imitates high-flow velocities and turbulences, which may lead to the misdiagnosis of a high-grade stenosis or of vascularization. Mirror image artifacts may irritate the sonographer and cause an impression of an additional - really not existing - vessel. The "seagull cry", whose origin is not well understood, is usually found in the region of a high-grade stenosis

Capillary-venule malformation a microfistulous variant of arteriovenous malformation.

OBJECTIVE To describe typical clinical presentation of patients with microfistular, capillary- venule (CV) malformation as a variant form of arterio-venous malformations (AVM). METHODS A retrospective clinical analysis of 15 patients with CV-AVM confirmed by a computational flow model enrolled in a prospective database of patients with congenital vascular malformation between January 2008 and May 2018. RESULTS Mean age of patients at first time of presentation was 30 years with balanced gender ratio. Presentation was dominated by soft tissue hypertrophy (n=12, 80.0%) and atypical varicose veins (n=11, 73.3%). Anatomical location of enlarged varicose veins gave no uniform pattern and did not correspond to the typical picture of primary varicose vein disease. Most often symptomatic CV-AVM was found at the lower extremities in this series of unselected patients. The most frequent compartment affected was the subcutis (n=14, 93.3%), involvement of muscle was recorded in a third and cutis in a fourth of patients. CONCLUSIONS A high grade of clinical suspicion is needed to recognize CV-AVM and to prevent inadequate therapy due to failed diagnosis