Venographic classification and long-term surgical treatment outcomes for axillary-subclavian vein thrombosis due to venous thoracic outlet syndrome (Paget-Schroetter syndrome)

OBJECTIVE: We assessed the clinical presentation, operative findings, and surgical treatment outcomes for axillary-subclavian vein (AxSCV) thrombosis due to venous thoracic outlet syndrome (VTOS). METHODS: We performed a retrospective, single-center review of 266 patients who had undergone primary surgical treatment of VTOS between 2016 and 2022. The clinical outcomes were compared between the patients in four treatment groups determined by intraoperative venography. RESULTS: Of the 266 patients, 132 were male and 134 were female. All patients had a history of spontaneous arm swelling and idiopathic AxSCV thrombosis, including 25 (9%) with proven pulmonary embolism, at a mean age of 32.1 ± 0.8 years (range, 12-66 years). The timing of clinical presentation was acute (\u3c15 days) for 132 patients (50%), subacute (15-90 days) for 71 (27%), and chronic (\u3e90 days) for 63 patients (24%). Venography with catheter-directed thrombolysis or thrombectomy (CDT) and/or balloon angioplasty had been performed in 188 patients (71%). The median interval between symptom onset and surgery was 78 days. After paraclavicular thoracic outlet decompression and external venolysis, intraoperative venography showed a widely patent AxSCV in 150 patients (56%). However, 26 (10%) had a long chronic AxSCV occlusion with axillary vein inflow insufficient for bypass reconstruction. Patch angioplasty was performed for focal AxSCV stenosis in 55 patients (21%) and bypass graft reconstruction for segmental AxSCV occlusion in 35 (13%). The patients who underwent external venolysis alone (patent or occluded AxSCV; n = 176) had a shorter mean operative time, shorter postoperative length of stay and fewer reoperations and late reinterventions compared with those who underwent AxSCV reconstruction (patch or bypass; n = 90), with no differences in the incidence of overall complications or 30-day readmissions. At a median clinical follow-up of 38.7 months, 246 patients (93%) had no arm swelling, and only 17 (6%) were receiving anticoagulation treatment; 95% of those with a patent AxSCV at the end of surgery were free of arm swelling vs 69% of those with a long chronic AxSCV occlusion (P \u3c .001). The patients who had undergone CDT at the initial diagnosis were 32% less likely to need AxSCV reconstruction at surgery (30% vs 44%; P = .034) and 60% less likely to have arm swelling at follow-up (5% vs 13%; P \u3c .05) vs those who had not undergone CDT. CONCLUSIONS: Paraclavicular decompression, external venolysis, and selective AxSCV reconstruction determined by intraoperative venography findings can provide successful and durable treatment for \u3e90% of all patients with VTOS. Further work is needed to achieve earlier recognition of AxSCV thrombosis, prompt usage of CDT, and even more effective surgical treatment

Transcatheter arterial chemoembolization in recurrent unresectable hepatocellular carcinoma after orthotopic liver transplantation

Aim: To investigate the survivals and efficacy of the doxorubicin drug eluting beads transcatheter arterial chemoembolization (TACE) in patients with recurrent hepatocellular carcinoma (HCC) status post orthotopic liver transplantation.Methods: Consecutive patients with HCC who underwent orthotopic liver transplantation from 2005 to 2012 were reviewed. Patients who developed recurrent HCC after orthotopic liver transplantation and received doxorubicin drug eluting beads TACE therapy were identified and included in the study. Survivals were calculated from the time of 1st doxorubicin drug eluting beads TACE of recurrent HCC. Kaplan Meier estimator with log rank test was used for survival analysis.Results: Eight patients had recurrent HCC after orthotopic liver transplantation and received doxorubicin drug eluting beads TACE. The overall median survival of these patients was 15.6 months. Two patients had significantly poorer overall median survival from doxorubicin drug eluting beads TACE (3.4 months) and both showed elevated serum alpha-fetoprotein levels (> 400 ng/mL) and extra-hepatic metastases (P = 0.03). Patients with poorly differentiated HCC in explant liver had the poor median overall survival (3.6 months) compared to the patients with well-to-moderately differentiated HCC (21.7 months, P = 0.004).Conclusion: Doxorubicin drug eluting beads TACE appears to be an effective treatment option for patients with recurrent HCC after orthotopic liver transplantation

Seeing Central African forests through their largest trees

Large tropical trees and a few dominant species were recently identified as the main structuring elements of tropical forests. However, such result did not translate yet into quantitative approaches which are essential to understand, predict and monitor forest functions and composition over large, often poorly accessible territories. Here we show that the above-ground biomass (AGB) of the whole forest can be predicted from a few large trees and that the relationship is proved strikingly stable in 175 1-ha plots investigated across 8 sites spanning Central Africa. We designed a generic model predicting AGB with an error of 14% when based on only 5% of the stems, which points to universality in forest structural properties. For the first time in Africa, we identified some dominant species that disproportionally contribute to forest AGB with 1.5% of recorded species accounting for over 50% of the stock of AGB. Consequently, focusing on large trees and dominant species provides precise information on the whole forest stand. This offers new perspectives for understanding the functioning of tropical forests and opens new doors for the development of innovative monitoring strategies