Adjunctive primary stenting of Zenith endograft limbs during endovascular abdominal aortic aneurysm repair: implications for limb patency

OBJECTIVE: Endograft limb occlusion is an infrequent but serious complication of endovascular abdominal aortic aneurysm (AAA) repair. The insertion of additional stents within the endograft limb may prevent future occlusion. This study evaluates limb patency with and without adjunctive stenting of endograft limbs at the time of endovascular AAA repair. METHODS: We performed a retrospective review of 248 patients who underwent endovascular abdominal aortic aneurysm repair with the Zenith AAA endovascular graft between 1999 and 2004. Among these patients, two groups were identified: 64 patients with adjunctive stents placed in 85 limbs and 184 patients without additional bare stent placement in endograft limbs at the time of endovascular AAA repair. RESULTS: Women comprised 23% of stented and 11% of unstented patients (P = .02). The mean length of follow-up in the stented and unstented groups was 2.0 years. There were 13 instances of limb thrombosis in 13 patients (5.2% of patients, 2.7% of limbs), all in the unstented group. No limb occlusions occurred in the presence of adjunctive bare metal stents. Seventy-three percent of the occlusions occurred < or = 6 months of endovascular AAA repair. Two patients (15%) had no symptoms of lower-extremity ischemia despite graft limb occlusion and did not undergo intervention. The others underwent thrombectomy (n = 2), thrombectomy with bare stent placement (n = 3), femoral-femoral bypass (n = 4), thrombolysis (n = 1), and thrombolysis with bare stent placement (n = 1). Of the seven who underwent thrombectomy or thrombolysis, three had no additional stents placed at the secondary procedure, and two of these three went on to rethrombose. By life-table analysis, primary patency at 3 years in the stented and nonstented limbs was 100% +/- 0% and 94% +/- 3%, respectively (P = .05). CONCLUSIONS: The intraoperative insertion of additional bare metal stents appeared to eliminate the risk of thrombosis and was without complication. Of the 85 stented limbs in this series, not one occluded. The overall rate of limb thrombosis was low, with most limb occlusions occurring < or = 6 months of stent-graft insertion, and would probably have been even lower had we been able to identify all high-risk cases for prophylactic adjunctive stenting. Limb occlusion denotes an underlying problem with the graft, which if left untreated after thrombectomy or thrombolysis will lead to rethrombosis. Postoperative imaging was of little value in detecting impending limb occlusion. Based on these findings, we believe one should identify and stent any limbs that appear to be at risk for thrombosis, but this study lacks the data to predict which limbs need stenting.     

Utility of retrievable vena cava filters and mechanical thrombectomy in the endovascular management of acute deep venous thrombosis

Endovascular interventions of symptomatic deep venous thrombosis (DVT) using various therapeutic modalities, such as thrombolysis, mechanical thrombectomy, and inferior vena cava (IVC) filter placement, have received increased focus owing in part to advances in catheter-based interventional technologies. Although systemic anticoagulation remains the primary treatment modality in DVT, catheter-based interventions can provide rapid removal of large thrombus burden and possibly preserve venous valvular function in patients with symptomatic DVT. This article reviews current endovascular treatment strategies for acute DVT. Specifically, the utility of mechanical thrombectomy along with various temporary IVC filters in the setting of DVT is examined. Lastly, an illustrative case of acute DVT that was treated with endovascular intervention with IVC filter placement is presented.     

髂静脉受压综合征并下肢深静脉血栓形成的综合性腔内治疗

目的：探讨综合性腔内治疗髂静脉受压综合征合并下肢深静脉血栓形成的临床效果。 方法：选取2004年10月—2012年10月,315例髂静脉压迫综合征合并急性下肢深静脉血栓形成患者,左侧277例,右侧38例。均行局麻下患侧股静脉穿刺,并在导丝引导下,采用12~14 F鞘管机械性血栓抽吸或配合Fogarty球囊取栓,对髂静脉狭窄或闭塞病变行血管成形术或支架植入,术后根据血栓清除情况,行抗凝或置管溶栓治疗。 结果：患肢肿胀、疼痛均于术后1~2 d内开始消退或减轻。血栓清除III级（清除率>95%）80.32%、II级（清除率50%~95%）18.09%、I级（清除率<50%）1.59%。支架植入后,治愈86.03%、显效10.79%、好转2.54%、无效0.64%。出院时健、患肢膝上、下15 cm处周径差均小于入院时（均P<0.05）。随访通畅率分别为3~6个月95.87%,7~12个月95.53%,13~24个月94.25%,25~36个月92.33%。 结论：综合性腔内治疗髂静脉受压综合征合并下肢深静脉血栓形成,疗效显著、恢复时间短,是安全有效的方法。     

血管腔内治疗下肢深静脉血栓形成

目的 探讨下肢深静脉血栓的介入联合手术的血管腔内治疗方法.方法 76例下肢深静脉血栓形成的患者,在数字减影血管造影术(digtal subtraction angiography,DSA)监视下行下腔静脉滤器置入,采用手术取栓,辅以临时性股动静脉瘘,取栓后即刻造影观察有无血栓残留及髂静脉病变情况.残留血栓在DSA监视下用双腔取栓管取栓或大的鞘管吸栓.对髂静脉狭窄大于60%的患者予以血管成形术,其中62例置入髂静脉支架.结果 支架置入技术成功率100%,1例死于腰升静脉破裂出血.71例患者得到随访,其中髂静脉支架患者60例,随访3～30个月,平均随访21个月.65例下肢肿胀明显缓解,发现血栓复发6例(8.45%,6/71)其中支架内血栓形成4例(6.66%,4/60),支架移位6例(10.0%,6/60),支架断裂1例(1.66%,1/60).结论 在DSA监视下,取栓联合髂静脉支架置入可提高取栓后静脉通畅率,是治疗下肢深静脉血栓的重要方法.     

Catheter-directed therapy for DVT after pancreas transplantation

INTRODUCTION: Iliac vein deep venous thrombosis (DVT) ipsilateral to the pancreas transplant can lead to severe leg edema and compromise graft function. Treatment modalities for iliac vein DVT in the pancreas transplant recipient are limited. METHODS: Medical records of patients receiving pancreas transplants at a single center from November 1989 to July 2003 were reviewed retrospectively, identifying patients with iliac vein DVT. There were 287 pancreas transplants performed during this time. Pancreas transplantation in all recipients was performed in the right iliac fossa with the arterial supply consisting of a donor iliac artery Y interposition graft. Systemic venous drainage was to the iliac vein. Exocrine drainage was enteric or to the bladder. RESULTS: Four (1.4%) cases of iliac DVT were identified. All patients manifested lower extremity edema ipsilateral to the pancreas transplant. DVT was detected by ultrasound on days 4, 5, 13, and 60 post-transplant. In all cases, the iliac vein caudad to the pancreatic venous anastomosis was noted to be stenotic. Management involved balloon dilatation and endovascular stent placement in one patient, thrombolysis with tissue plasma antigen (t-PA) followed by stent placement in one patient, and percutaneous mechanical thrombectomy in two patients. All patients had improvement in leg edema and two patients continue to have good pancreatic allograft function. CONCLUSIONS: Iliac DVT is a rare complication of pancreas transplantation that usually develops in an area of stenosis caudad to the pancreatic venous anastomosis. Catheter-based treatment modalities with use of endovascular stents for treatment of underlying stenoses can serve as an adjunct in treating these complications.     

Pharmacomechanical thrombectomy for treatment of symptomatic lower extremity deep venous thrombosis: safety and feasibility study

PURPOSE: The current standard of care for deep venous thromboembolism (DVT) is anticoagulation; however, this treatment method does not rapidly relieve clot burden or clinical symptoms. We describe a rapid and effective method of thrombus removal, with simultaneous percutaneous mechanical thrombectomy (PMT) and thrombolysis. METHODS: Over 26 months 20 patients (22 men, 2 women; mean age, 52 +/- 6 years [range, 38-79 years]) with extensive lower extremity DVT were treated with PMT with the AngioJet thrombectomy device in combination with lytic agent (urokinase, tissue plasminogen activator, or reteplase) added to the infusion. Three patients underwent treatment twice, because of recurrent DVT. The primary end point was angiographic evidence of restoration of venous patency at completion of the procedure. Complications, recurrent ipsilateral DVT, and improvement in clinical symptoms were evaluated. RESULTS: Complete thrombus removal was obtained in 15 procedures (65%), and partial resolution in the remaining 8 procedures (35%). Inciting occlusive lesions responsible for acute DVT were revealed in 14 patients (61%), and angioplasty with or without stenting was performed when necessary. In the 8 procedures with partial resolution additional catheter-directed thrombolysis was carried out on average for 5.7 hours, with further thrombus reduction. Overall, immediate (<24 hours) improvement in clinical symptoms was noted in 17 patients (74%). There were no complications related to either PMT or the short duration of lytic agent infusion. At average follow-up of 10.2 +/- 0.3 months (range, 3-26 months), 3 patients had recurrent ipsilateral DVT, and underwent repeat treatment. CONCLUSIONS: Addition of lytic agent to PMT facilitates thrombus extraction, decreases overall interventional treatment time, and improves patient outcomes. In addition, definitive management of underlying anatomic lesions can be performed in the same setting. Further outcome measures are necessary to study the long-term efficacy of this treatment method on preservation of valve function, reduction of chronic venous insufficiency, and improved quality of life.     

机械性血栓抽吸术治疗髂股静脉血栓形成

目的:探讨机械性血栓抽吸治疗髂股静脉血栓形成的临床疗效。方法:回顾性分析236例急性髂股深静脉血栓(DVT)患者的临床资料。均经健侧股静脉预防性放置下腔静脉滤器,在数字减影血管造影(DSA)透视下患侧股静脉插入12～14 F大腔鞘管,50 mL注射器负压抽吸髂股静脉血栓。112例合并髂静脉狭窄或闭塞患者,行经皮血管成形术(PTA)和支架植入;术后给予肝素抗凝。结果:出院时膝上、下15 cm处健、患侧周径差分别降为(1.34±0.57)cm和(0.93±0.42)cm,与入院时比较差异有统计学意义(t=19.37、23.99,P均<0.05);随访36个月,随访率97.88%(231/236)。术后水肿、色素沉着和溃疡等后遗症发生率12.99%(30/231)、8.23%(19/231)和0;随访疗效优92.21%(213/231)。支架植入患者随访均通畅。结论:机械性血栓抽吸治疗髂股DVT疗效显著,并发症少,住院周期短,能够明显降低后遗症的发生率。     

下肢深静脉血栓形成的血管腔内治疗

目的探讨腔内治疗下肢深静脉血栓形成（LEDVT）的临床效果。方法回顾性分析2000年1月至2010年12月收治的1068例LEDVT患者临床资料,其中中央型311例,混合型549例,周围型208例。足背静脉、股静脉穿刺造影,下腔静脉滤器植入,进行机械性血栓抽吸,取栓后造影髂静脉存在严重狭窄（〉50％）或闭塞时则球囊扩张和支架植入,残留血栓术后辅助溶栓治疗。随访评估患者腔内治疗的近期、中期疗效。结果近期疗效I级65．45％,Ⅱ级25．75％,Ⅲ级8．05％,1V级0．75％;总有效率99．25％,不同分型的疗效差异均有统计学意义（P〈0．05）。术后2年随访,优76．06％,良16．41％,中6．28％,差1．25％;支架通畅率88．62％。结论LEDVT腔内治疗,能尽早清除深静脉主干血栓,迅速恢复血流,缩短病程,近、中期疗效显著。     

Thrombolysis for experimental deep venous thrombosis maintains valvular competence and vasoreactivity

PURPOSE: Thrombolysis protects the structural and functional integrity of vein wall in an experimental model of acute deep venous thrombosis (DVT) immediately after treatment, but late sequelae have not been studied. We designed experiments to compare the effects of thrombolysis and surgical thrombectomy at 4 weeks after the treatment of DVT. METHODS: DVT was produced bilaterally in male mongrel dogs by proximal and distal femoral vein ligation. Five dogs underwent sham operation. After 48 hours, the ligatures were removed, and the thrombosis was treated with either Fogarty balloon catheter thrombectomy (shear force, 60 g; n = 6) or catheter-directed urokinase infusion (4000 U/min for 90 minutes; n = 6). At 4 weeks, patency and valvular competence were determined by duplex ultrasound scanning. Thrombogenicity was studied by the measurement of radiolabeled fibrin and platelet deposition. Veins were explanted and prepared for histologic examination, scanning electron microscopy, and functional studies in organ chambers. RESULTS: All veins were patent at 1 month. Recanalized thrombus was observed histologically in four (66%) thrombectomized veins, one (17%) thrombolyzed vein, and none of the sham-operated veins (P =.04). Scanning electron microscopy demonstrated similar luminal endothelial cell loss (11%-25%) in all three groups. Platelet and fibrin depositions were not different among groups. Valvular incompetence (reflux duration, >0.5 sec) did not differ significantly in the groups (thrombectomized veins, 2 of 12 (17%); thrombolyzed veins, 0 of 12 (0%); P = NS). In organ chamber studies, endothelium-dependent relaxations to calcium ionophore, but not adenosine diphosphate, were inhibited by an antagonist of nitric oxide production after thrombectomy (P <.05, thrombectomy vs sham- and thrombolysis-treated veins). All veins relaxed to exogenous nitric oxide. CONCLUSION: Both thrombectomy and thrombolysis restored patency and achieved similar valvular competence. Surgical thrombectomy, however, resulted in more residual thrombus and contributed to changes in endothelium-mediated relaxations at 4 weeks. Thrombolysis maintained both structural integrity and endothelial function.     

Long-term Results of Primary Stent Placement to Treat Infrarenal Aortic Stenosis

OBJECTIVE: To determine the safety and the long-term results of primary stent placement for localized distal aortic occlusive disease. DESIGN: Retrospective observational study. PATIENTS AND METHODS: From July 1998 to July 2005 17 patients (14 female and 3 men, mean age 57 years (39-80)) were treated for intermittent claudication. Five of these patients underwent additional endovascular treatment of focal iliac lesions. RESULTS: Technical success defined as residual stenosis of less than 50% or a trans-stenotic systolic pressure gradient <10% was achieved in 14 of 17 (82%) patients. Major complications included dissection at the puncture site in one patient and thrombosis of additional iliac stents in another patient. Both of these complications were successfully treated. During a mean follow-up of 27 months (range 1-86), four patients had recurrence of symptoms due to in-stent restenoses (n=2), femoral (n=1) or iliac occlusion (n=1), respectively. By Kaplan-Meier analysis, primary aortic hemodynamic patency was 83% at 3 years. Secondary aortic hemodynamic patency was 100%. The primary clinical patency was 68% at 3 years. CONCLUSION: Primary stent placement for distal aortic stenoses is an alternative to surgical treatment because of its high patency and relatively low complication rates.     

Stenting of common iliac vein obstructions combined with regional thrombolysis and thrombectomy in acute deep vein thrombosis.

OBJECTIVES: To evaluate the efficacy of stent placement after infrainguinal loco-regional thrombolysis and iliac thrombectomy (surgical TT) of acute deep vein thrombosis (DVT) in patients with May-Thurner-Syndrome. MATERIAL AND METHODS: We retrospectively analysed a group of 11 patients (9 women) (mean age 34 years, range 16-64 years) with surgical TT and additional intra-operative stenting due to compression of the common iliac vein. Patients underwent venography to demonstrate outflow patency after surgical TT, and to identify any obstruction at the level of the left-sided common iliac vein ("Beckenvenen-Sporn"). Obstruction at the level of arterial crossing was treated using Wallstents placed via an introducer sheath from the inguinal access site. Stents were fully deployed using balloons adjusted to the size of vein. Patients were treated with oral anticoagulants for 6 months, and followed using duplex ultrasonography. RESULTS: Technical success defined as complete vein patency and normal valve function was documented in all 11 patients. One patient needed early stent extension due to residual stenosis. At 6 months follow-up one patient (9%) had an asymptomatic occlusion of the stented common iliac vein. In all 11/11 (100%) patients the femoral segment was found to be patent, and in 1/11 (9%) there was mild reflux with few clinical symptoms of post-thrombotic syndrome. The calculated cumulative primary patency rate for venous iliac stents was 82%, and assisted patency rate was 91%, which remained unchanged over a mean follow-up of 22 months. CONCLUSION: Combining surgical TT and stenting of common iliac vein obstructions in DVT is safe, effective, and results in a acceptable venous patency.     

Aspirex机械清栓治疗创伤后急性下肢深静脉血栓形成的临床疗效

背景与目的 下肢深静脉血栓形成（DVT）行早期血栓清除减容可恢复静脉通畅及缓解症状,目前AngioJet是国内最常用的静脉血栓清除系统,而Aspirex应用较少,本研究探讨Aspirex机械血栓清除治疗在创伤后急性DVT患者中的疗效及安全性。方法 回顾性分析2016年5月—2020年8月在北京积水潭医院血管外科收治的54例创伤后急性DVT患者的病例资料。所有患者行下腔静脉可回收滤器置入术,其中有Dneali 35例（64.8%）、Celect 3例（5.6%）、Cordis 14例（25.9%）、Octoparms及临时滤器（贝朗）各1例（1.9%）。患者创伤经手术及固定治疗后均行彩超检查或造影明确为髂股静脉及下腔静脉血栓形成。其中,22例（40.7%）为髂股静脉血栓、4例（7.4%）为髂及下腔静脉血栓、11例（20.4%）为下腔静脉血栓、17例（31.5%）为股髂静脉及下腔静脉血栓。所有患者在局麻下行经腘静脉或股静途径Straub Aspirex机械血栓清除手术（PMT）,术中联合导管取栓（MAT）、导管接触性溶栓（CDT）、髂静脉球囊扩张及髂静脉支架置入术。统计技术成功率、即刻临床成功率（症状缓解率）、围手术期出血发生率及术后滤器取出率。术后随访1年,超声评价目标静脉通畅率及血栓后综合征（PTS）的发生率。结果 54例患者中,3例（5.6%）行单纯机械血栓清除手术,17例（31.5%）行血栓清除联合导管取栓术,3例（5.6%）行血栓清除联合置管溶栓术,18例（33.3%）行血栓清除联合导管取栓及置管溶栓术,12例（22.2%）行血栓清除联合导管取栓及髂静脉球囊扩张术,1例（1.9%）行血栓清除联合导管取栓及支架置入术。技术成功率及即刻临床成功率均为100%。12例（22.2%）血栓III级清除,33例（61.1%）为II级清除,9例（16.7%）为I级清除,血栓清除成功率为83.3%。围手术期1例（1.9%）出现脑出血,给予停止溶栓及抗凝,2周复查头颅CT见血肿吸收,无后遗症;2例（3.7%）出现鼻出血及穿刺点血肿,给予压迫后缓解,无症状性肺栓塞及死亡等发生。滤器留置时间为（61.4±84.8）d,51例（94.4%）患者尝试行滤器取出,所有患者均成功取出。术后无血栓复发,术后1年PTS的发生率为33.3%,目标静脉通畅率为75.9%。结论 对于创伤后急性髂股及下腔静脉DVT患者,应用Aspirex机械血栓清除疗效显著,较为安全可靠,与导管吸栓、CDT、髂静脉球囊扩张及支架置入结合应用可改善静脉通畅率。     

药物机械偶联式血栓清除治疗急性左髂股静脉血栓形成的近期疗效

目的:探讨药物机械偶联式血栓清除(Angio Jet血栓清除系统)治疗急性左髂股静脉血栓形成的近期疗效。方法:回顾性分析2016年1月—2017年4月期间两个血管外科中心连续收治的38例急性左髂股静脉血栓形成(病程≤14 d)行药物机械血栓清除治疗患者的临床资料。根据术中血管造影评价即时血栓清除效果,根据术后第3、6、12个月患者随访时的CEAP分级、多普勒超声检查或血管造影检查评价近期疗效。结果:38例中37例在使用Angio Jet吸栓过程中喷注尿激酶,31例吸栓后一期置入髂静脉支架,11例患者辅助接触性导管溶栓术(CDT);术后3级血栓清除(完全清除)18例(47.4%),2级血栓清除(50%~99%清除)20例(52.6%),无1级血栓清除病例(50%清除)。37例患者术后出现不同程度的血红蛋白尿,均在12~24 h内消。随访期间,1例患者(3.3%)进行了再次手术干预,无手术相关的严重并发症和死亡发生。结论:对于急性左髂股静脉血栓形成的治疗,药物机械血栓清除术的近期疗效显著且安全性好,联合CDT或支架置入术可以提高血栓清除效率。     

急性左下肢深静脉血栓形成合并Cockett综合征的治疗

目的 探讨急性左下肢深静脉血栓形成(DVT)合并Cockett综合征(CS)的有效治疗方法.方法 回顾性分析2004年8月-2008年1月收治16例急性左下肢DVT合并CS的临床资料.16例均行下腔静脉滤器置人术及左下肢股静脉切开取栓术,其中13例患者同时行左髂总静脉PTA及支架置入术,另3例行PTA术,术后均予抗凝,祛聚,溶栓治疗.结果 全组无手术死亡及肺栓塞的发生,14例患者取得了满意的疗效.16例中2例术后第2天再发生左下肢急性血栓形成,予药物抗凝、溶栓、祛聚治疗,出院时肢体肿胀明显好转.随访14例,随访时间1～25个月(平均11个月),2例出现下肢DVT后综合征,余12例左下肢无肿胀,无静脉曲张及色素沉着.结论 急性左下肢DVT并CS行手术取栓加左髂总静脉PTA术及支架置入术可获得满意疗效.     

Endovascular treatment of abdominal aortic aneurysm is associated with a low incidence of deep venous thrombosis

OBJECTIVE: This study was performed to define the incidence of acute deep venous thrombosis (DVT) after endovascular treatment of abdominal aortic aneurysms (AAAs). Because aortic endograft placement requires prolonged femoral vessel instrumentation, it may be hypothesized that these patients are at increased risk for development of an acute DVT. PATIENTS AND METHODS: Fifty consecutive patients (42 men, eight women) ranging in age from 48 to 85 years (mean, 72 years) underwent endovascular treatment of an AAA from January 2000 to August 2001. Clinical examination and bilateral lower extremity duplex ultrasonography for DVT were performed on the first postoperative day and at the 1-month follow-up visit. No patient had a prior DVT or identifiable hypercoagulable state. Seven patients (14%) had concurrent malignant disease. Preoperative antiplatelet agents were administered in 26 patients (52%), and nine (18%) were on warfarin sodium therapy before surgery. No new DVT prophylaxis was initiated perioperatively. Epidural anesthesia was used in 60% of the patients, with general endotracheal anesthesia used in the remainder. Risk factors for DVT were evaluated with univariate statistical analysis. RESULTS: Three patients (6%) had an acute postoperative DVT develop. Two occurred in the femoral veins, and one occurred in the popliteal vein. Of these patients, one had been continued on perioperative anticoagulation therapy, and the remaining two were started on low-molecular weight heparin and warfarin sodium therapy on recognition of the DVT. One patient had an intraoperative injury of the affected common femoral vein, and this individual was the only one to have clinical signs of a DVT. The mean follow-up period was 8 +/- 0.8 months. In this experience, factors that may have placed patients at increased risk for an acute DVT were not identified. CONCLUSION: Six percent of patients undergoing endovascular repair of AAAs had postoperative DVT develop. These patients had a number of risk factors for the development of a DVT; however, no specific factor was identified that predisposed to DVT.     

下腔静脉滤器置放术在深静脉血栓-肺栓塞演变中的临床应用

目的探讨下腔静脉滤器(IVCF)在预防深静脉血栓(DVT)-肺栓塞(PE)演变中的临床应用价值。方法经造影和(或)彩色多普勒超声证实为下肢深静脉广泛血栓30例,其中有肺部临床表现21例,胸部影像学证实19例,DSA显示下腔静脉内血栓6例。溶栓介入治疗前置放IVCF 30例,下腔静脉内血栓形成未放IVCF 1例。置放IVCF后经患肢足背静脉滴注尿激酶或经导管血栓内抽吸、局部溶栓、导丝搅拌增加溶栓接触面积;经非患肢静脉给予抗凝、抗生素治疗。结果本组30例放置5种构型滤器32枚,其中2枚为临时滤器,置入取出均顺利,滤器无移位,术中无并发症。痊愈9例,有效14例,改善6例,无效1例。因没有及时置入IVCF进行溶栓治疗,深静脉血栓导致下腔静脉血栓6例,后置入IVCF 5例疗效良好,未放IVCF 1例,12天后因肺栓塞死亡。结论下腔静脉滤器对预防深静脉血栓向肺栓塞演变具有一定价值,其置放术安全可靠,便于临床及时溶栓抗凝治疗,但其应用价值需进行综合评价和进一步探讨。     

Salvage of thrombosed dialysis access grafts with venous anastomosis stents

BACKGROUND: Thrombosis of arteriovenous (AV) grafts caused by stenosis at the venous anastomosis is a well-described problem. Surgical thrombectomy and conventional angioplasty with mechanical thrombectomy have provided good success rates in achieving immediate graft patency but with generally dismal graft survival rates in the range of 11% to 36% at 6 months' follow-up. The role of intravascular stents in patients who have failed angioplasty or surgical revision at the venous anastomosis has not been fully elucidated, particularly in older grafts that have previously undergone multiple procedures. METHODS: In this series, 34 patients had self-expanding nitinol stents placed at the venous anastomosis following graft thrombectomy and angioplasty procedures. Patients were selected for stent placement if conventional angioplasty alone was unsuccessful due to immediate elastic recoil or residual stenosis. All patients were followed after stent placement and evaluated for duration of graft patency and need for repeated endovascular procedures. RESULTS: The average graft age at the time of stent placement was 17.9 months. Eight-eight percent of grafts were functioning at 6 months' follow-up, and 63% of the entire group had survived without the need for additional procedures. Among those with need for repeat interventions, 81% had new lesions outside of the stent, and 57% had new lesions within the stent. In 38% of cases, new stenoses were located both outside and within the stent. Among grafts no longer being used, only 19% of the time was it due to disease recurring within the stent. CONCLUSION: Polytetrafluoroethylene (PTFE) graft longevity is improved when venous anastomosis stenoses are treated with stents in selected cases of older grafts that would have normally undergone abandonment or surgical revision.     

急性混合型下肢深静脉血栓取栓与溶栓远期疗效分析

目的 比较手术取栓与系统溶栓对急性混合型下肢深静脉血栓形成(DVT)的远期疗效.方法 回顾分析1991年9月至2005年6月的142例急性混合型DVT病例的临床资料.手术取栓77例,其中合并髂总静脉狭窄或闭塞49例,对于髂总静脉严重狭窄或闭塞者采取不同方法处理.手术后辅以区域性尿激酶溶栓、肝素抗凝治疗.系统溶栓65例,均系统性应用尿激酶、肝素.结果 治疗后2周,手术取栓组双下肢周径差由(4.3±2.2)cm降为(0.6±0.5)cm,系统溶栓组由(3.9±2.5)cm降为(1.6±0.9)cm,差异有统计学意义(t=-8.346,P=0.00).平均随访(49±42)个月,手术取栓组周径差降为(0.5±0.4)cm,系统溶栓组降为(1.4±1.3)cm(t=-5.764,P=0.00);手术取栓组水肿、色素沉着、溃疡等后遗症发生率分别为29.9%、15.6%、0%,低于系统溶栓组的50.8%、84.6%、6.2%(P＜0.05).彩超发现,手术取栓组静脉通畅率(89.6%)和瓣膜功能正常率(72.7%),均高于系统溶栓组(分别为30.8%、9.2%)(Z=-8.502,P=0.00).手术取栓组治愈率70.1%,高于系统溶栓组治愈率30.8%(Z=-4.740,P=0.00).手术组死亡率为3.9%,溶栓组无住院死亡率.结论 本组资料显示手术取栓对急性混合型DVT的疗效好于系统溶栓,尤其在保护静脉瓣膜功能方面明显优于系统溶栓;但手术创伤较大、有一定的死亡率.     

Retrievable inferior vena cava filters: early clinical experience

AIM: Multiple-trauma patients often have injuries that prevent the use of anticoagulant or sequential compression device prophylaxis. Temporary inferior vena cava filters (IVCFs) offer protection against pulmonary embolism (PE) during the early, highest-risk perioperative and immediate injury period, while avoiding potential long-term sequelae of a permanent IVCF. The objective of this study was to evaluate the efficacy of prophylactic, temporary IVCF placement at the intensive care unit (ICU) bedside under real-time intravascular ultrasound (IVUS) guidance in multiple-trauma patients. METHODS: One hundred and three multiple-trauma patients between July 1, 2002, and July 1, 2004, under-went placement of Günther-Tulip (n=38), Recovery (n=30) or OptEase (n=35) retrievable IVCFs under real-time IVUS guidance. The mean+/-SD injury severity score of the patients was 27.7 (+/-2.2). All patients had abdominal X-rays to verify filter location. Before IVCF retrieval, all patients underwent femoral vein color-flow ultrasonography to rule out deep vein thrombosis (DVT) and pre and postprocedure vena-cavography for possible IVCF thrombus entrapment and postretrieval IVC injury. RESULTS: Twenty-four patients died of their injuries; no deaths were related to IVCF placement. One PE occurred during follow-up after filter retrieval, and 2 insertion site femoral vein DVT occurred. As verified by abdominal X-rays, 97.1% (100/103) of IVCFs were placed without complications at the L2-3 level. Filter-related complications included 3 groin hematomas (2.9%) and 3 IVCFs misplaced in the right iliac vein early in our experience; these filters were uneventfully retrieved and replaced in the IVC within 24 h. Forty-four patients underwent uneventful retrieval of IVCFs after DVT or PE anticoagulation prophylaxis was initiated. Thirty-five filters were not removed, including 32 because severity of injury prevented DVT or PE prophylaxis and 3 because of thrombus trapped with the filter. CONCLUSIONS: Prophylactic, temporary IVCFs placed at the ICU bedside under IVUS guidance in multiple-trauma patients serves as an effective bridge to anticoagulation until venous thromboembolism prophylaxis can be initiated. Further investigation of this bedside technique and the role of temporary IVCFs in these patients is warranted.     

Surgical thrombectomy followed by intraoperative endovascular reconstruction for symptomatic ilio-femoral venous thrombosis.

OBJECTIVES: To evaluate the efficacy of surgical thrombectomy combined with endovascular reconstruction for acute ilio-femoral/caval venous thrombosis. METHODS: Twenty consecutive patients with acute, symptomatic ilio-femoral/-caval thrombosis underwent valve-preserving thrombectomy with immediate endovascular repair between October 1996 and October 2003. Thrombectomy was classified by intraoperative venography as: TYPE I=complete, TYPE II=partial, TYPE III=complete with stenosis other than thrombus, TYPE IV=permanent occlusion. TYPEs I and IV were excluded from this analysis because endovascular repair was not performed. RESULTS: Left-sided venous thrombosis predominated (90%). Lesions were located in the common iliac vein (85%), the external iliac vein (10%), and the inferior vena cava (5%). Three TYPE II lesions and 17 TYPE III lesions (11 spurs, one hypoplasia, one fibrosis, one haematoma, and three others) were diagnosed. Catheter-directed recanalisation (thrombectomy/thrombolysis) resolved TYPE II lesions in three patients. Balloon angioplasty (one patient), iliac stenting (15 patients [two with thrombolysis]), and caval stenting (one patient) were employed in TYPE III stenoses. No serious complication or death occurred. Mean follow-up was 21 months. Of 20 patients clinical results were excellent in 18 patients who maintained patency of their reconstructed iliac veins. Primary and secondary patency rates were 80 and 90%, respectively. CONCLUSIONS: Ilio-caval venous obstructions detected intraoperatively can be reconstructed in a one-stage combined procedure. The specific endovascular approach depends on the type of residual venous obstruction. Excellent mid-term results indicate that the proposed thrombectomy classification (TYPE I-IV) and treatment algorithm optimises the results in selected patients with symptomatic venous thrombosis.