Diabetic ketoacidosis complicated by axillary vein thrombosis

A case is presented of a 39-year-old male with Down's Syndrome, who also had type 1 diabetes of 22 years duration. He presented with diabetic ketoacidosis (DKA)-arterial blood pH 7.17, plasma bicarbonate 13.6mmol/l, plasma glucose 26.4mmol/l and urine heavily positive for ketones. He recovered with standard intravenous fluid and insulin treatment, but on the third day of admission developed a swollen left arm (which had not been used for intravenous cannulation). Doppler ultrasound confirmed a left axillary vein thrombosis. This slowly resolved with anticoagulation. Review of the available literature revealed that though arterial thrombosis is a common complication of DKA, venous thromboembolism is surprisingly rare, and there appear to be no previous specific reports of axillary vein thrombosis complicating DKA.     

Iliac vein compression and pulmonary embolism in a long distance runner: computed tomography and magnetic resonance imaging-a case report

Iliac vein compression is invoked as the explanation for deep venous thrombosis occurring more often in the left iliofemoral system than the right. The authors report a previously undescribed variant of iliac compression whereby a left iliac arterial aneurysm caused venous compression and resultant thrombosis. In this case the patient suffered a pulmonary embolism without symptoms of lower extremity venous thrombosis.     

Initial and long term outcomes of stent implantation for iliac compression syndrome

OBJECTIVES: The initial and long term outcome of stenting in the iliac vein were investigated in patients with iliac compression syndrome. METHODS: Iliac compression syndrome was diagnosed with venography and intravascular ultrasonography that demonstrated severe stenosis at the iliac venous compression site. Fourteen patients with symptomatic iliac compression syndrome were treated with stent implantation. The patency of the stents was examined at short and long term follow-up examinations. RESULTS: Thirteen patients presented with left iliac venous compression and only one patient presented with right iliac venous compression. Twelve of the 14 patients had acute deep venous thrombosis, so temporary vena cava filter implantation was performed during the procedure in these 12 patients. Procedural success was defined as less than 50% stenosis after stent implantation with good flow and without major complication (death, surgical repair for vein, or symptomatic pulmonary embolization). Procedural success was achieved in 13 of 14 patients, and these 13 patients showed improvement of symptoms. In the unsuccessful case, the compression site was resolved by stenting, but good flow was not obtained due to remaining femoral vein occlusion. The self-expandable stent was used for 6 patients, and the balloon-expandable stent was used for 8 patients. Angiographic or ultrasonographic follow up was performed in 10 patients at mean follow up of 8 months, but no restenosis was documented. CONCLUSIONS: Stent implantation for symptomatic iliac compression syndrome is a safe and effective procedure to resolve venous disease symptoms. Despite the small number of patients, long term outcome has been excellent in this study.     

Angiojet rheolytic thrombectomy in infants following cardiac surgery

Objectives: To present our experience with the Angiojet thrombectomy system for percutaneous thrombectomy in infants following cardiac surgery. Background: Arterial and venous thrombosis after pediatric cardiac surgery is life threatening, particularly in infants. The best method for treating these patients has not been determined. Angiojet rheolytic thrombectomy (Possis Medical, Minneapolis, MN) is a percutaneous method of thrombus removal with proven safety and efficacy in adults. Methods: We reviewed the medical records and angiograms of all procedures in which Angiojet thrombectomy was used in infants following cardiac surgery at our institution during the years 2005 through 2007. Results: Ten procedures were performed in eight infants. The procedure was performed a mean of 23 days from surgery. The mean age was 74 days with a mean weight of 4.3 kg. All patients had life or limb threatening thrombosis. Indications for thrombectomy included severe cyanosis, chronic pleural effusions secondary to extensive venous thrombosis, and acute iliac artery thrombosis. Thrombus was evacuated from pulmonary arteries in four patients, systemic veins in two patients, a surgical aorto‐pulmonary shunt in two patients, and an iliac artery in one patient. Balloon angioplasty following thrombectomy was performed in eight procedures (80%), and stents were placed in addition to angioplasty in two procedures. All patients had significant improvement in flow across the affected area. There was one major complication and three minor complications with no procedural‐related deaths. Survival to discharge from the hospital was 62.5%. Conclusion: Angiojet thrombectomy is an effective treatment for life‐threatening postoperative thrombosis in infants following cardiac surgery. © 2010 Wiley‐Liss, Inc.     

Cerebral venous sinus thrombosis and ulcerative colitis]

Hypercoagulability is a extraintestinal manifestation of inflammatory bowel disease, which could provoke thromboembolic phenomena. Central nervous system venous thrombosis is a rare complication and could be unnoticed. We report on a patient with ulcerative colitis who presented cerebral venous sinus thrombosis as the first manifestation of a hypercoagulable state. We review the literature and discuss about the pathogenic mechanisms of such complication.     

Acute right lower extremity iliofemoral deep venous thrombosis secondary to an anomalous inferior vena cava: a report of two cases

A congenital anomaly of the inferior vena cava is an increasingly identified risk factor for iliocaval deep venous thrombosis in young patients. We present two cases of acute right lower extremity iliofemoral deep venous thrombosis in 16 and 18-year-old patients that were ultimately diagnosed with an underlying anomalous iliocaval venous system. In one patient, the inferior vena cava was congenitally absent and the right iliac vein was diffusely stenotic with a proximally located high-grade stricture. In the other subject, the infrarenal inferior vena cava and right iliac vein were diffusely hypoplastic. Compensatory venous flow in both subjects was via large perilumbar venous collateral veins and a prominent azygous system. Both patients were successfully treated with a combination of initial catheter-directed thrombolysis followed by balloon angioplasty and venous stent placement.     

Cerebral venous thrombosis associated with ulcerative colitis

Thromboembolic complications, such as deep venous thrombosis and pulmonary embolism, are well recognized in patients with inflammatory bowel disease (IBD). We describe three cases of cerebral venous thrombosis complicating ulcerative colitis. Cerebral venous thrombosis is a rare but potentially devastating complication of IBD, and the diagnosis needs to be considered in any patient with IBD presenting with neurological symptoms.     

Follow-up after deep venous thrombosis in azygos continuation

BACKGROUND: To determine the sequelae of patients after deep venous thrombosis inpatients with azygos continuation defined as agenesis of the inferior vena cava with collateral flow. PATIENTS AND METHODS: Five patients post deep venous thrombosis in the context of azygos continuation were followed up clinically and with colour duplex ultrasonography. RESULTS: All five patients had to our knowledge after the initial deep venous thrombosis no further thromboembolic events. Three patients after isolated iliac thromboses are symptom free or nearly symptom free, two after more extended thromboses still sufferfrom venous claudication. Four patients are without anticoagulation, one patient is permanently orally anticoagulated. CONCLUSIONS: Azygos continuation may not influence the risk of recurrent venous thrombo-embolism nor the outcome of a deep venous thrombosis. Careful deep venous thrombosis prophylaxis in patients with azygos continuation may be sufficient when a risk factor is present but conclusions lack due to the small numbers of patients of enough supportive data.     

Life-threatening hematoma associated with paracentesis: a case report.

Deep venous thrombosis prophylaxis is recommended in all high-risk hospitalized medical patients. We describe a unique complication of paracentesis in a patient receiving unfractionated heparin for deep venous thrombosis prophylaxis. Our patient developed a very large rectus sheath hematoma and hypotension gradually after paracentesis. Heparin should be used with caution for deep venous thrombosis prophylaxis in patients undergoing paracentesis.     

Radionuclide angiography in the evaluation of iliofemoral venous patency

Radionuclide angiography (RNA), was compared to contrast phlebography (CP) for evaluation of iliofemoral venous patency. Twenty-three patients that six months earlier had been treated for iliofemoral venous thrombosis were investigated. The reproducibility of RNA was good as the interindividual and intraindividual variation was 80-85% and 90-95% respectively. The sensitivity of RNA was 91% in the iliac and 65% in the femoral segment. The specificity was 78% in the iliac and 74% in the femoral segment. The advantages as compared to CP are: easy performance, easy to repeat, no adverse reactions and visualization of the whole venous system. The disadvantages are: e.g. difficulties in interpretation in bilateral disease or abnormal anatomy. RNA is recommended as a screening method for suspected iliac venous obstruction and for follow-up of venous patency after iliofemoral venous thrombosis.     

Fatal portal thrombosis after laparoscopic Nissen fundoplication.

Portal and mesenteric vein thrombosis is a very uncommon complication of laparoscopic surgery, especially after anti-reflux procedures. We report the case of a twenty-year-old man with a history of alcohol and cocaine consumption. A Nissen fundoplication was performed. The patient received a single 20-mg dose of enoxaparin (Clexane, Aventis Pharma, Spain) two hours before surgery for antithrombotic prophylaxis. On the seventh postoperative day the patient had a portal and mesenteric venous thrombosis, which was confirmed at laparotomy, with both extensive small-intestine necrosis and partial colon necrosis. Despite anticoagulant therapy, the patient died 24 hours later. Surgical findings were confirmed at necropsy. Portal and mesenteric venous thrombosis is an uncommon but severe and even fatal complication after laparoscopic anti-reflux surgery. When other pro-thrombotic, predisposing conditions such as laparoscopic surgery and cocaine consumption are present, the usual prophylactic doses of low molecular weight heparin might not be sufficient to protect against this life-threatening complication.     

Protein-losing enteropathy, deep venous thrombosis and pulmonary embolism in a patient with generalized inflammatory polyposis in remission stage of ulcerative colitis

We experienced a patient with severe protein-losing enteropathy and generalized inflammatory polyposis. In addition, this case was complicated by deep venous thrombosis and pulmonary embolism. Patients with inflammatory bowel disease are at increased risk for thromboembolic events, most commonly in the setting of active colitis. However, our patient was in the remission stage. We report the occurrence of deep venous thrombosis and pulmonary embolism as a complication of inflammatory polyposis and protein-losing enteropathy in the remission stage of ulcerative colitis.     

Femoral Arteriovenous Fistula Associated With Leg Swelling 6 Months After Removal of a Hemodialysis Catheter: A Case Report

Double-lumen catheters have been used widely to obtain temporary access in patients who are in need of acute hemodialysis (HD) because of acute renal failure. Several complications are associated with the insertion of these catheters, including bleeding, infection, injuries to arteries, and deep venous thrombosis. An arteriovenous fistula (AVF) is a rare but significant complication following catheterization for temporary HD. Herein, we present a case of AVF associated with leg swelling 6 months after the removal ofa double-lumen HD catheter.We describe a special case of a 42-year-old man who experienced acute renal failure secondary to diabetic ketoacidosis (DKA). A 12-Fr dialysis catheter was inserted in the right femoral vein. Six months after catheter removal, the patient was admittedfor pain and swelling in the right leg. Color Doppler ultrasound and three-dimensional computed tomography (CT) revealed an AVF between the right femoral vein and the right femoral superficial artery. The fistula was repaired successfully by vascular surgeons.This case highlights that an AVF is a rare but significant complication after catheterization for temporary HD. The nephrologist should be wary of the potential of this complication and perform clinical and medical examinations at the insertion and removal of temporary HD catheters.     

Vascular ultrasound imaging to study immediate postcatheterization vascular complications in children.

Vascular occlusion is the major complication of percutaneous cardiac catheterization in children. This is a prospective study to evaluate post catheterization vascular complications in 120 consecutive children with the help of vascular ultrasound and Doppler imaging. Ultrasound imaging of both iliac and femoral veins and arteries was done one hour prior and 24 hours after cardiac catheterization. Patients with prior thrombus or occlusion of femoral/iliac vein or artery due to previous cardiac catheterization were excluded from the study. Age of the patients ranged from 22 days to 12 years with a mean of 56 months and weight ranged from 3 to 57 kg with a mean of 14.3 kg. Procedure time was less than 60 minutes in 74 patients (61.66%) and more than 60 minutes in 46 patients (38.33%). 4F sized arterial sheath was used in 108 patients. 5F or bigger sized arterial sheath was used in remaining 12 patients. Incidence of arterial occlusion was higher in patients weighing less than 10 kg (16%) as compared with patients weighing more than 10 kg (5.5%) {P = 0.031}. Arterial thrombosis was more in infants (16%) as compared with older children (7%) {P = 0.203} Prolonged procedure time or use of larger sized sheath did not have higher incidence of arterial occlusion. Venous thrombosis was found in 2 patients (1.66%) who had 5F venous sheath. One patient had arterio venous fistula. Our study shows vascular ultrasound imaging can provide anatomical details of femoral and iliac vessels and is a easier and accurate method of assessing post-catheterization vascular complications in children.     

Acute pulmonary embolism unmasking underlying chronic thromboembolic pulmonary hypertension and iliac vein compression syndrome

We describe the case of a 72‐year‐old gentleman who was referred to our institution for management of cardiogenic shock from a massive pulmonary embolism. Right heart catheterization revealed a low cardiac index and markedly elevated pulmonary pressures, suggested long‐standing venous thromboembolic (VTE) disease that evolved into chronic thromboembolic pulmonary hypertension (CTEPH). The patient was cannulated to veno‐arterial extra‐corporeal membrane oxygenation and eventually treated with pulmonary embolectomy and thromboendarterectomy. Subsequently discovered inferior vena cava clot and left iliac deep vein thrombosis were treated with suction and mechanical thrombectomy. Intravascular ultrasound of the left lower extremity venous system identified iliac vein compression syndrome (IVCS) as the culprit of the patient's VTE and CTEPH. A left iliac stent was placed and the patient was discharged on Warfarin for anticoagulation. The case illustrates the rapidly expanding armamentarium for VTE treatment and proposes IVCS as a new, potentially underrecognized risk factor for CTEPH.     

A case of portal vein thrombosis associated with acute pancreatitis and cholangitis]

Portal vein thrombosis is a rare complication accompanied with acute pancreatitis or cholangitis/cholecystitis. The main pathogenesis of portal vein thrombosis in pancreatitis or cholangitis/cholecystitis are suggested to be venous compression by pseudocyst and an imbalance between the blood coagulation and fibrinolysis. In this case report, we experienced a 63 year old male who developed portal vein thrombosis later in the course of the treatment of acute gallstone pancreatitis with cholangitis/cholecystitis without any symptom or sign. The diagnosis of portal vein thrombosis was given on follow up CT scan and serum protein S activity was decreased to 27% in laboratory study. Immediate anticoagulation therapy with heparin and thrombolytic therapy with urokinase and balloon dilatation were performed. Despite the aggressive treatment, complete reperfusion could not be obtained. With oral warfarin anticoagulation, the patient showed no disease progression and was discharged. We report a case of portal vein thrombosis as a complication of acute pancreatitis and cholangitis/cholecystitis with a review of literatures.     

Epidural hematoma mimicking transverse myelitis in a patient with primary antiphospholipid syndrome

Antiphospholipid syndrome (APS) is an autoimmune disease, and its most critical pathologic process is thrombosis, which may explain most of the clinical features. Acute management of thrombosis involves immediate anticoagulation. Acute proximal venous thrombosis can be managed with thrombolytic therapy to reduce the long-term complications of the postthrombotic syndrome (pain, swelling, skin discoloration, or ulceration) and perform recanalization of occluded vessels. However, thrombolytic therapies are associated with high risks of bleeding. To our knowledge, this is the first report of epidural hematoma mimicking transverse myelitis after catheter-directed thrombolysis in a patient with primary APS. A 42-year-old male was admitted with sudden onset pain and swelling on left lower extremity. Venography demonstrated multiple thrombi on superficial femoral vein, common femoral vein, common iliac vein, and external iliac vein. Laboratory tests indicated the presence of IgM anticardiolipin antibody. He was diagnosed with primary APS with multiple venous thrombi. He was treated with urokinase (200,000/h) as thrombolytic therapy. After 1 day, he complained both leg weakness and urinary dysfunction. T1- and T2-weighted magnetic resonance images of spine showed about 8 cm-sized mass, suggesting hematoma on the posterior epidural space at thoracolumbar area. Despite the successful evacuation of hematoma, neurologic symptoms persisted and he is now receiving aspirin, warfarin, and physical therapy.     

Replacement of the left common iliac vein with a custom-made bovine pericardium tubular graft

To date, venous reconstruction has not been as successful as arterial reconstruction. Prosthetic materials used as venous substitutes produce much lower patency rates with a higher incidence of early thrombosis than those used as arterial substitutes. We describe the case of a 38-year-old obese woman in whom we encountered an unexpected tear of the common iliac vein intraoperatively, during an anterior approach to the lumbar spine. Because of limited options, we replaced the vein with an interposition tubulargraft that was custom-made from bovine pericardium. Two years later, the patient remained asymptomatic with a patent graft. To our knowledge, there has been no other reported case in the world medical literature of replacement of medium-sized veins by this technique.     

Splenic vascular occlusion in the course of pancreatic cancer

INTRODUCTION: Pancreatic cancer is responsible for 6,000 deaths per year in France. During the course of the disease, venous thrombosis is common. Conversely, arterial thrombosis is rarely described. EXEGESIS: We report the case of a 59-year-old patient with pancreatic adenocarcinoma. Treatment by gemcitabine allowed rapid and persistent improvement of the body weight and a prolonged survival (18 months). Sudden complication, i.e. splenic arterial thrombosis, reversed the favorable outcome. CONCLUSION: Splenic venous thrombosis is a frequent complication occurring in the course of pancreatic cancer. It is easily diagnosed using abdominal computerized tomography. Arterial thrombosis is rarely observed. It might be due to either sporadic, unexpected, occurrence of cases related to the evolution of underlying pathological mechanisms, or to omitted treatment of vascular complications, as until the introduction of new anticancer drugs this disease was considered to be of very poor prognosis.     

In situ right ventricular thrombus secondary to heparin induced thrombocytopenia

Heparin induced thrombocytopenia (HIT) is a relatively common complication of heparin therapy, occurring in approximately 5% of patients treated with this drug. HIT may be associated with diffuse arterial and venous thrombosis. The case of a patient without underlying heart disease who developed a right ventricular thrombus and recurrent pulmonary emboli in association with and possibly as a complication of HIT is reported. Ancrod was used as an alternative to heparin for the time required to obtain an effective oral anticoagulant effect. The patient recovered completely and has no residual right ventricular thrombus.