Abstract
Outcomes of a single-center experience with classification and treatment of endothermal heat-induced thrombosis after endovenous ablation
LM Korepta, JJ Watson, MA Mansour, et al.
J Vasc Surg: Venous and Lym Dis 2017; 5: 332–338
The analysis included all patients aged >18 years who underwent radiofrequency ablation or endovenous laser ablation at our institution between January 1, 2008, and December 31, 2014. Electronic medical records were queried retrospectively to identify patients with EHIT during the study interval by International Classification of Diseases-Ninth Revision code. Demographic data, including age, gender, comorbidities (eg, history of deep venous thrombosis, hypercoagulable state, family history of blood clots, etc), body mass index, CEAP classification, and use of preoperative anticoagulation were collected for each patient in the registry. Each patient had a required postoperative duplex ultrasound (US) examination within 1 to 2 weeks of the procedure. Preoperative and postoperative US imaging data and procedure-specific data were also recorded for each patient. EHIT was graded from 1 to 4 by review of the US studies. Each patient’s treatment course was reviewed for type of anticoagulation, duration of treatment, follow-up imaging, and outcome. From 2008 to 2014, 4799 ablations were performed and EHIT was identified in 70 patients. At presentation, 87% of patients were asymptomatic, 10% reported pain, and 2.9% reported swelling. Patients with EHIT grades 1 or 2 were treated with daily aspirin, and most of those with grades 3 or 4 were treated with systemic anticoagulation. Repeat US imaging was performed at 1 to 2 weeks to evaluate progression. Progression was not seen in any patients treated with systemic anticoagulation (grades 3–4). Thrombus progression occurred in two patients with grades 1 or 2 EHIT treated with aspirin. A bleeding complication occurred in one patient. In conclusion, EHIT after endovenous ablation occurred in 1.5% of patients, which is similar to that reported in the literature. Our review shows that systemic anticoagulation is effective in the prevention of progression with a low risk of bleeding complications. Patients with EHIT grades 1 or 2 can be treated with aspirin alone with a low risk of progression (3%).
The role of laser power and pullback velocity in the endovenous laser ablation efficacy: an experimental study
NY Ignatieva, OL Zakharkina, CV Masayshvili, SV Maximov, VN Bagratashvili, VV Lunin.
Lasers Med Sci 2017 May. doi: 10.1007/s10103-017-2214-x. [Epub ahead of print]
The authors, in an experimental study, wanted to assess the parameters required for vein wall destruction and to evaluate the role of fiber pullback velocity on vessel wall degradation. The veins were treated with 1470-nm diode laser with power settings from 3 to 9.5 W. Pullback speed was from 0.7 or 1.5 mm/s and the applied linear endovenous energy density (LEED) was 40-95 J/cm. The temperature of the vein surface was checked by infrared thermography. The increase in the surface temperature with applied energy was found to be about three times lower for the pullback velocity of 0.7 mm/s than that of 1.5 mm/s. The collagen in the tissue was totally denatured in the case of the surface temperature of about 91°C. The critical values of LEED that ensured complete degradation of vein wall were of 53 and 71.5 J/cm for velocities of 1.5 and 0.7 mm/s, respectively.
The authors’ experimental study supports the conception that it is laser power and pullback velocity that determine the temperature as well as the collagen framework degradation.
Outcomes of iliac vein stents after pregnancy
M Dasari, E Avgerinos, S Raju, R Tahara, RA Chaer.
J Vasc Surg: Venous and Lym Dis 2017; 5: 353–357
Female patients of reproductive age (18–45 years old) who underwent iliocaval stenting between May 2007 and March 2014 were identified from a three-center prospectively maintained database. Medical records were reviewed for demographics, baseline risk factors, operative data, and clinical follow-up to identify pregnancy and postpartum stent imaging. The primary end point was stent patency. Standard descriptive statistics were used. There were 310 women of reproductive age who received iliocaval stenting; 12 were identified to have had at least one pregnancy after stenting. The mean age was 28 6 5 years. One patient received thrombolysis and stenting at 14 weeks of pregnancy for deep venous thrombosis (DVT) and May-Thurner syndrome, three for a previous postpartum DVT (2, 4, and 6 weeks postpartum), three for DVT before any pregnancy with a history of factor V Leiden, and the remaining five for unprovoked DVT. All stents were self-expanding with a diameter range of 14 to 16 mm. Mean time from stenting to pregnancy was 23.3 +/− 28 months. All patients had patent stents during pregnancy and were prescribed therapeutic low-molecular-weight heparin by their obstetrician. One had asymptomatic left-sided stent compression 1 year after her second delivery, treated with balloon dilation. At average follow-up of 61 +/− 56 months, all patients had patent stents with no ultrasound-identified structural damage or thrombosis. The authors concluded that pregnancy does not negatively affect the outcomes of iliocaval stents after lysis of DVT or May-Thurner syndrome. Iliocaval stenting is not contraindicated in women of reproductive age, although close clinical and ultrasound follow-up is warranted during and after pregnancy.
Endovenous laser in children: applications and outcomes
PA Patel, AM Barnacle, S Stuart, JG Amaral, PR John.
Pediatr Radiol 2017 May. doi: 10.1007/s00247-017-3863-4. [Epub ahead of print]
The authors wanted to demonstrate the efficacy and safety in a variety of pediatric venous conditions in 37 patients in 43 veins over a seven-year period. Median age and weight at first treatment was 14 years (range: 3–18 years) and 56 kg (range: 19–97 kg) respectively. Underlying diagnoses were common venous malformation (15), Klippel-Trenaunay syndrome (8), superficial venous reflux with varicose veins (5), verrucous hemangioma-related phlebectasia (4), venous varix (2), and arteriovenous fistula (1). Thirty-four patients had treatment in the lower limbs and one patient in an upper limb. Ten of the veins treated with endovenous laser ablation had an additional procedure performed to close the vein. Complications occurred in two patients (6%). One patient experienced post-procedural pain; 1 patient developed a temporary sensory nerve injury. Median clinical follow-up was 13 months (range: 28 days-5.7 years). The goal was achieved in 29 of the 35 (83%) patients.
The authors concluded that endovenous laser ablation is technically feasible and safe in children with good outcomes.
Scoring Systems for Postthrombotic Syndrome
HS Wik, W Ghanima, PM Sandset, SR Kahn.
Semin Thromb Hemost 2017 May. doi: 10.1055/s-0037-1599142. [Epub ahead of print]
This article is to reviewed the existing scoring systems for PTS and to present our view on the advantages and disadvantages of these diagnostic tools. There is no single objective test to diagnose the presence of PTS and it is usually diagnosed on the basis of typical symptoms and signs in a limb previously affected by DVT. Scoring systems for PTS are primarily developed as research tools, but could possibly also be useful in the clinical setting. A main advantage of a good scoring system is standardization of the diagnostic process. An optimal scoring system should be both sensitive and specific for PTS, but this has been difficult to achieve because the symptoms and signs of PTS can be similar to other conditions leading to complaints in the lower limb. In an effort to standardize the definition of PTS, in 2009, the International Society on Thrombosis and Haemostasis Subcommittee on Control of Anticoagulation reviewed available scales and recommended use of the Villalta scale as the most appropriate measure to diagnose and grade the severity of PTS.
Incidence of venous leg ulcer healing and recurrence after treatment with endovenous laser ablation
WA Marston, J Crowner, A Kouri, CA Kallbaugh.
Journal of Vascular Surgery: Venous and Lymphatic Disorders 2017 May https://dx-doi-org.web.bisu.edu.cn/10.1016/j.jvsv.2017.02.007
The authors retrospectively reviewed all C5 or C6 patients treated with Endovenous Laser Ablation (EVLA) to define the incidence of ulcer healing and recurrence. Patients with active ulcers were managed weekly until healed. After healing, patients were treated with compression stockings and returned at 6-month intervals for follow-up. Time to healing and time to ulcer recurrence were determined. Risk factors were studied to determine their association with ulcer recurrence. The great saphenous vein (n = 146), small saphenous vein (n = 20), or both (n = 7) in 173 limbs with active (n = 72) or healed (n = 101) ulcers were treated with EVLA. 31.2% of the cohort had deep venous insufficiency as well. Concomitant phlebectomy was performed in 59 limbs (34%). Median follow-up time was 2 years. Venous ulcers healed after EVLA in 57% of cases at 3 months, 74% at 6 months, and 78% at 1 year. There was a recurrent ulcer rate of 9% at 1 year after EVLA, 20% at 2 years, and 29% at 3 years of follow-up. There was a higher percentage rate of recurrent ulcers in patients with deep venous insufficiency and in patients who did not have concomitant laser ablation and phlebectomy with associated varicose veins.
The authors concluded that ulcers recurred in a minority of C5 and C6 patients after laser saphenous ablation. In addition, the authors suggested that laser ablation together with phlebectomy be performed for healed ulcer or open ulcer patients.
An important role of VEGF-C in promoting lymphedema development
E Gousopoulos, ST Proulx, SB Bachmann, et al.
J Invest Dermatol 2017 May. pii: S0022-202X(17)31534-8. doi: 10.1016/j.jid.2017.04.033. [Epub ahead of print]
The authors, in a mouse-tail model, studied secondary lymphedema, a common post-cancer treatment complication for which the pathomechanisms remain unclear. They found an increase in local and systemic levels of the lymphangiogenic factor VEGF-C, and identified CD68+ macrophages as a cellular source. Surprisingly, overexpression of VEGF-C in a transgenic mouse model led to aggravation of lymphedema with increased immune cell infiltration and vascular leakage in comparison to wild-type littermates. However, blockage of VEGF-C by overexpression of soluble VEGFR3 reduced edema development, diminishing inflammation and blood vascular leakage. Similar findings were obtained in a hind limb lymph node excision lymphedema model. Flow cytometry analyses and immunofluorescence stainings in lymphedematic tissue revealed that VEGFR3 expression was restricted to lymphatic endothelial cells.
The authors concluded that endogenous VEGF-C causes blood vascular leakage and fluid influx into the tissue, thus actively contributing to edema formation. This discovery may provide the basis for future clinical therapeutic approaches.
Recurrent Deep Vein Thrombosis After the First Venous Thromboembolism Event: A Single-Institution Experience
M Asim, H Al-Thani, A El-Menyar.
Med Sci Monit 2017 May; 23: 2391–2399
A retrospective study was conducted for patients with DVT between 2008 and 2012 with a 1-year follow-up. Patients were divided into 2 groups: single vs. recurrent DVT (RDVT). Of the 6420 patients screened for DVT, 662 (10.3%) had DVT. RDVT constituted 22% of cases. A single event was more frequent in left lower limb DVT (p = 0.01), while RDVT cases had more bilateral DVT (p = 0.01). Recurrent pulmonary embolism (PE) and comorbidities were significantly higher in the RDVT group (P < 0.05). Protein C, protein S, and anti-thrombin III deficiency were higher in patients with RDVT (P < 0.05). Post-thrombotic syndrome was significantly higher among RDVT cases (p = 0.01). In addition, obesity, abnormal coagulation, and prior history of PE and bilateral DVT were found to be independent predictors of RDVT. The PE rate was greater with RDVT than those with single events (22% vs. 9%, p = 0.001); however, during follow-up and after adjustment for age and sex, this effect was statistically insignificant (adjusted HR 1.23, 95% CI 0.43-3.57, p = 0.68). The age- and sex-adjusted mortality rate was higher in patients with single events with a HR 2.3; 95%CI 1.18–4.54 (p = 0.01); however, this effect disappeared after adjusting for the duration of warfarin therapy (p = 0.22). The investigators concluded that patients with RDVT are common and have characteristic features that required more attention and further evaluation. These findings should help identifying high-risk patients and set effective preventive measures for RDVT that may revise the duration of warfarin therapy.