RESUMO
OBJECTIVE: This study aims to evaluate the association between the degree of iliac venous outflow obstruction (IVOO) identified by Intravascular Ultrasound (IVUS) and venous reflux presentation in lower limbs on Duplex Ultrasound (DU). METHODS: Patients with bilateral chronic venous insufficiency, CEAP C3-6 (Clinical-Etiology-Anatomy-Pathophysiology classification), and with Visual Analogic Scale score for pain > 5, underwent DU for reflux evaluation: deep venous system (reflux ≥ 1 s); superficial system, great saphenous vein (GSV) and small saphenous vein (SSV) (reflux ≥ 0.5 s); perforator system (reflux ≥ 0.35s). All patients underwent IVUS in the iliac venous territory. The area of the impaired venous segments was categorized as obstructions< 50% (Cat. 1); 50-79% (Cat. 2), and ≥ 80% (Cat. 3). Venous clinical severity scale (VCSS) and reflux multisegment score (RMS) were assessed. RESULTS: 51 patients (n=102 limbs; 50.53 ± 14.5 years, 6 men) were included. The predominant clinical severity CEAP class was C3 in 54/102 (52.9%) limbs. VCSS mean was 14.3 ± 6.7. Severe RMS (≥ 3) was registered in 63,4% of the limbs. In 51/102 limbs (50%) presented cat. 1, 27/102 (26.5%) cat. 2, and 24/102 (23.5%) cat. 3. Previous DVT was associated with critical obstruction (OR 3.65; 95% CI: 1.29-10.38; p=0.015). Superficial and perforator venous systems had no association with the degree of iliac obstruction. Deep venous reflux (DVR) had a significant association with significative IVOO (obstruction ≥ 50%) (OR 6.44; 95% CI: 2.19-18.93; p=0.001) and critical IVOO (obstruction ≥ 80%) (OR 4.57; 95% CI: 1.70-12.27; p=0.003), and significant linear association with IVOO degree and reflux in femoral veins (p<0.001) and popliteal vein (p=0.008). Significant lesions had 5.76 (95% CI: 2.46-13.50; p<0.001) more odds of happening in the left limb. After a multivariate analysis, DVR remained as predictor for significant and critical obstruction (p<0.003, p< 0.012; respectively). Left limb and previous DVT remained as predictors for IVOO ≥50% and IVOO≥ 80% (p<0.001, p=0.043; respectively) CONCLUSIONS: There is a significant linear association between the degree of iliac venous outflow obstruction and reflux in the deep venous system on DU. Limbs with DVR, severe RMS, loss of respiratory variation on DU, and previous DVT, were more likely to be affected by IVOO ≥ 50%, especially with the left leg involvement.
Assuntos
Ultrassonografia Doppler Dupla , Extremidade Inferior , Veia Ilíaca , Ultrassonografia de IntervençãoRESUMO
Background: Varicose pubic collateral veins are a rare phenomenon secondary to obstruction of the common femoral vein, left external iliac, or common iliac vein. This article aims to describe the clinical case of a 75-year-old female patient who presented with varicose collateral suprapubic veins.Case report: A 75-year-old female patient from a rural area in Colombia presented to the emergency department complaining of a 4-day history of edema, erythema, and pain in the suprapubic region. The patient presented with large varicose veins in the suprapubic region with erythema, warmth, and pain on palpation. A computer tomography scan of the abdomen and pelvis showed suprapubic varicose veins and contrasted in venous phase ruled out iliac vein obstruction. To rule out paraneoplastic syndrome, tumor markers, a transvaginal ultrasound, esophagogastroduodenoscopy and rectosigmoidoscopy were obtained and found to be negative. Anticoagulation with warfarin 5 mg daily and bridge therapy with enoxaparin was initiated.Conclusion: We presented the case of a patient with varicose collateral suprapubic veins of unknown origin, who received anticoagulation with warfarin and analgesic management with subsequent resolution of symptoms.
Assuntos
Varizes , Varfarina , Feminino , Humanos , Idoso , Flebografia/métodos , Resultado do Tratamento , Varizes/diagnóstico por imagem , Varizes/terapia , Pelve/irrigação sanguínea , Veia Ilíaca , Dor , AnticoagulantesRESUMO
OBJECTIVE: This study aims to report two cases of symptomatic extrinsic compression of the inferior vena cava and left iliac vein caused by vertebral osteophytes. METHODS: We present two case reports of extrinsic venous compression by vertebral osteophytes. Both cases were endovascularly treated, with a successful outcome. A review of the literature of this unusual condition is also presented. RESULTS: The first patient is an 80-year-old woman who presented to the vascular surgery clinic with bilateral lower extremity edema and pain. A computed-tomography angiography (CTA) revealed extrinsic compression of the inferior vena cava from enlarged osteophytes. Venography and intravascular ultrasound were performed, confirming the diagnosis. A self-expanding venous stent was successfully deployed in the inferior vena cava relieving the extrinsic compression. The edema resolved the following day and was discharged without complications. The second patient is a 61-year-old male that presented to the emergency department with a left iliofemoral deep venous thrombosis. CTA showed left iliac vein compression by a lumbar osteophyte. Percutaneous thrombectomy was successfully achieved and an expanding stent was deployed covering the entire lesion. One month after the procedure the patient died from COVID-19-associated respiratory failure. CONCLUSION: Osteophytes must be considered when dealing with extrinsic venous compression, especially in elderly people.
Assuntos
COVID-19 , Osteófito , Doenças Vasculares , Trombose Venosa , Masculino , Feminino , Humanos , Idoso , Idoso de 80 Anos ou mais , Pessoa de Meia-Idade , Trombose Venosa/terapia , Veia Ilíaca , Veia Cava Inferior , StentsRESUMO
PURPOSE: Anterior lumbar spine arthrodesis has been increasingly prescribed. In order to obtain better exposure of the intervertebral discs, it is necessary to identify vascular structures depending on the level to be approached. Systematic ligation of the iliolumbar vein has been suggested for access to the L4-L5 level, which may be technically challenging. The goal of the present study was to determine a safe limit for separating the iliolumbar vein safely without the need for its ligation. METHODS: In total, 2284 patients involving the topography of the iliolumbar vein were included. If this vein was up to 5 mm distant from the inferior border of the L4-L5 intervertebral disc, its ligature was performed. In cases that the distance was greater than 5 mm, only the retraction was performed without ligature. RESULTS: A total of 115 ligatures were necessary (5% of cases). Among the 2169 cases with no ligature, bleeding due to ruptures occurred during traction in only 55 patients (3% of cases). The time taken for ligation ranged from five minutes to thirty-two minutes, with an average of 18.3 min per ligature. In cases in which ligatures were needed (distance less than 5 mm), there was loosening of the ligatures leading to bleeding in 23 cases (20% of ligatures). CONCLUSIONS: Systematic ligature is not necessary for accessing the anterior route to the L4-L5 level, leading to a reduction in the time of surgery and avoiding serious vascular injuries that can occur.
Assuntos
Disco Intervertebral , Fusão Vertebral , Humanos , Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Veia Ilíaca/cirurgia , Veia Cava Inferior , Fusão Vertebral/efeitos adversosRESUMO
OBJECTIVE: Venous stenting for acute and chronic venous disease has been increasingly used as more evidence has accumulated on the efficacy and durability of these interventions for symptomatic patients. Inferior vena cava (IVC) filters that could have been present for years will often be implicated in the obstructive pathology and removal can be challenging. The purpose of the present study was to evaluate whether stenting across an indwelling IVC filter is a safe and effective alternative to removal. METHODS: Consecutive patients who had undergone iliocaval stenting at our institution from 2007 to 2020 were identified and divided into groups stratified by the presence of an IVC filter. The operative notes, venography findings, and the electronic health records were queried to obtain the operative details, patient characteristics, postoperative outcomes, stent patency, and survival outcomes. The primary end point was iliocaval stent patency. The patients were divided into two groups according to the presence of an IVC filter with or without overstenting. We used the χ2 test and survival analysis as appropriate. RESULTS: A total of 224 consecutive patients were identified, of whom 71 were found to have undergone iliocaval stenting (age, 48 ± 18 years; 47.9% male; body mass index, 31 ± 9 kg/m2). Of the 71 patients, 15 had had stents placed across an indwelling IVC filter (overstented group) and 56 had not had an IVC filter present (non-overstented group). No differences were found in presentation between the overstented group (acute occlusion, 4 of 15 [26.7%]; chronic occlusion, 8 of 15 [53.3%]; and nonocclusive lesions, 3 of 15 [20%]) and the non-overstented group (acute occlusion, 29 of 56 [52%]; chronic occlusion, 18 of 56 [32%]; nonocclusive lesions, 9 of 56 [16%]; P = .2). Comparisons between the two groups revealed no differences in the baseline characteristics except for age (overstented, 57 ± 15 years; non-overstented, 46 ± 18 years; P = 0.03), preoperative anticoagulation therapy (overstented, 66.6%; non-overstented, 26.9%; P = .01), and bilateral leg symptoms (overstented, 86.7%; non-overstented, 23.2%; P < .001). Primary patency at 30 months was 85.6% in the overstented group and 86.1% in the non-overstented group (P = .78). At follow-up, no adverse events related to filter crushing were reported, and no differences were found in 30-month survival. CONCLUSIONS: In our single-center, retrospective study of iliocaval stenting, patients who had undergone overstenting across an indwelling IVC filter had had patency rates similar to those whose stents had been placed with no IVC filter in place. Thus, complex IVC filter removal, when not possible or when the risk of operative complications is too high, can be forgone in favor of stenting across the IVC filter, with no implications on midterm patency or adverse events.
Assuntos
Filtros de Veia Cava , Trombose Venosa , Humanos , Masculino , Adulto , Pessoa de Meia-Idade , Idoso , Feminino , Trombose Venosa/terapia , Fatores de Risco , Filtros de Veia Cava/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento , Veia Cava Inferior , Stents/efeitos adversos , Veia Ilíaca , Doença CrônicaRESUMO
ABSTRACT: Objective: To perform an analysis of the anatomy of the great vessels relevant to the access for anterior lumbar interbody fusion (ALIF), determining the level of their bifurcation, the distance between the iliac vessels at L5-S1, the morphological configuration of the left iliac vein and the presence of fatty tissue between the vessel and the disc. Methods: Two hundred magnetic resonance imaging (MRI) scans of the lumbar spine of patients (18-80 years old) were evaluated using axial, coronal, and sagittal cuts at levels L1-S1 in T2 weighting. The interiliac distance was defined as the measurement between the left iliac vein and the right iliac artery. The presence of fatty tissue was defined as the identification of space between the vessel and the disc. Vessel morphology was divided into oval and flat. Results: The population's average age was 49.6 years, with 52% being female. The average interiliac distance at L5-S1 was 27.48mm. The bifurcation of the aorta artery was identified at the level of L4 in 56.3%, as well as the confluence of the iliac veins (37.2%). The left iliac vein was identified as oval in 69% of patients and flat in 31% of patients. Fat tissue was evidenced in 60.5% of the exams. Conclusion: As a routine preoperative examination and surgical planning, lumbar MRI is fundamental in investigating the anatomy regarding anterior approach surgeries, allowing an effective assessment of the relationships between the great vessels and the lumbar spine. Level of Evidence IV; Retrospective Investigation.
RESUMO: Objetivo: Realizar uma análise da anatomia dos grandes vasos relevantes ao acesso para fusão intersomática lombar anterior (ALIF), determinando o nível de sua bifurcação, a distância entre os vasos ilíacos em L5-S1, a configuração morfológica da veia ilíaca esquerda e a presença de tecido gorduroso entre o vaso e o disco. Métodos: duzentos exames de ressonância magnética (RM) da coluna lombar de pacientes (18-80 anos) foram avaliados, utilizando cortes axiais, coronais e sagitais nos níveis L1-S1, na ponderação T2. A distância interilíaca foi definida como a medida entre a veia ilíaca esquerda e artéria ilíaca direita. A presença de tecido gorduroso foi definida como identificação de espaço entre o vaso e o disco. A morfologia do vaso foi dividida em oval e plana. Resultados: A idade média da população foi de 49,6 anos, sendo 52% mulheres. A distância média interilíacas em L5-S1 foi 27,48 mm. A bifurcação da artéria aorta foi identificada ao nível de L4 em 56,3%. A confluência das veias ilíacas também foi mais frequente ao nível de L4, representando 37,2%. A veia ilíaca esquerda foi identificada com o formato oval em 69% e plana em 31% dos pacientes. Tecido gorduroso foi evidenciado em 60,5% dos exames. Conclusão: Como rotina no exame pré-operatório e no planejamento cirúrgico, a RM lombar tem fundamental importância na investigação da anatomia visando cirurgias de abordagem anterior, pois permite uma avaliação eficaz das relações entre os grandes vasos e a coluna lombar. Nível de Evidência IV; Investigação Retrospectiva.
RESUMEN: Objetivo: Realizar un análisis de la anatomía de los grandes vasos relevantes para el acceso en artrodesis intersomática lumbar anterior (ALIF), determinando el nivel de su bifurcación, la distancia entre los vasos ilíacos en L5-S1, la configuración morfológica de la vena ilíaca izquierda y la presencia de tejido graso entre el vaso y el disco. Métodos: Se evaluaron 200 imágenes de resonancia magnética (RM) de la columna lumbar de pacientes (18-80 años) mediante cortes axiales, coronales y sagitales en los niveles L1-S1, en ponderación T2. La distancia interilíaca se definió como la medida entre la vena ilíaca izquierda y la arteria ilíaca derecha. La presencia de tejido graso se definió como la identificación de espacio entre el vaso y el disco. La morfología de los vasos se dividió en ovalados y planos. Resultados: La edad media de la población fue de 49,6 años, de los cuales 52% eran mujeres. La distancia interilíaca media en L5-S1 fue de 27,48 mm. La bifurcación de la arteria aorta se identificó a nivel de L4 en 56,3%, así como la confluencia de las venas ilíacas (37,2%). La vena ilíaca izquierda se identificó como ovalada en 69% y plana en 31%. Se evidenció tejido graso en 60,5% de los exámenes. Conclusión: Como rutina en examen preoperatorio, la RM lumbar es fundamental en la investigación de anatomía de cirugías de abordaje anterior, permitiendo una evaluación eficaz de las relaciones entre los grandes vasos y la columna lumbar. Nivel de Evidencia IV; Investigación Retrospectiva.
Assuntos
Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Ortopedia , Artrodese , Veia IlíacaRESUMO
OBJECTIVE: Intravascular ultrasound (IVUS) examination is increasingly used in the treatment of iliofemoral venous disease and provides more sensitive and specific detection of stenotic lesions when compared with traditional multiplanar venography alone. Correlations with deep venous stent patency, however, have not yet been investigated. The objective of the study was to evaluate the impact of the use of IVUS examination in addition to multiplanar venography on iliofemoral venous patency. METHODS: Consecutive patients who underwent stenting for symptomatic thrombotic or nonthrombotic iliofemoral venous lesions (NIVLs) between 2014 and 2020 at a single institution were identified and divided into two groups based on whether IVUS examination was used before stent deployment in addition to multiplanar venography compared with venography alone. A retrospective review of demographic, operative, and follow-up data was performed. Thirty-day and 2-year stent patency were measured as primary end points. χ2 analysis, logistic regression models, and Kaplan-Meier survival analysis were used to determine outcomes. Technical details and outcomes were additionally examined among patients treated for acute deep venous thrombosis, post-thrombotic syndrome, or NIVLs separately on subgroup analysis. RESULTS: We identified 150 patients (173 limbs, 23 bilateral) who underwent iliofemoral stenting during the study period at our institution (mean age: 48.8 ± 16.8 years, 61% female). Adjunctive IVUS utilization before stent deployment was reported in 69 of 173 (39.9%) treated limbs. IVUS examination was more likely to be used in patients who underwent stenting for NIVLs compared with thrombotic disease (41.0% vs 11.2%, P < .01). There was no difference in the number of stents deployed between IVUS and non-IVUS cohorts. However, IVUS examination was associated with the increased total length of the stent deployed (126 ± 56 vs 112 ± 48 mm, P = .04) and a higher rate of infrainguinal stent extension (17.4% vs 6.7%, P = .03). In addition, mean stent diameter was significantly higher when IVUS examination was performed before stent placement (16.3 ± 3.7 vs 15.2 ± 1.9 mm, P < .01). Both 30-day (98.5% vs 89.4%, P = .02) and 2-year (90.3% vs 78.7%, P = .03) primary patency were significantly higher in the IVUS cohort. Adjunctive IVUS use was found to significantly protect against stent reintervention at 2 years on adjusted Cox regression analysis (hazard ratio: 0.22, 95% confidence interval: 0.07-0.71, P = .01). CONCLUSIONS: Adjunctive IVUS utilization is associated with differences in stent diameter and length selections as well as landing segments in the treatment of thrombotic and nonthrombotic iliofemoral venous disease. IVUS examination before stent deployment significantly protects against 30-day and 2-year stent reintervention when compared with the use of multiplanar venography alone. These data provide stronger evidence for routine IVUS use in addition to venography before iliofemoral venous stenting.
Assuntos
Veia Ilíaca , Doenças Vasculares , Adulto , Idoso , Feminino , Humanos , Veia Ilíaca/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Resultado do Tratamento , Ultrassonografia de Intervenção , Grau de Desobstrução VascularRESUMO
OBJECTIVES: To propose a contemporary management strategy for venous injury during anterior lumbar spinal exposure that incorporates endovascular treatment. METHODS: Vein injuries suffered by patients treated in a single practice were reviewed. A treatment algorithm based on these experiences was formulated. RESULTS: Between 2015 and 2018, 914 patients received anterior access procedures for indicated lumbar interbody fusions. Of these patients, 15 (1.6%) suffered minor vascular injuries treated with manual pressure or suture repair. Four (0.4%) patients undergoing anterior lumbar spine surgery suffered major venous injuries, all of whom received the indicated spinal hardware following endovascular rescue. Primary repair was attempted in three patients before endovascular control and not at all in one. Vascular access was obtained via the bilateral femoral veins in 2 patients, unilateral femoral in one, and bilateral femoral plus right internal jugular vein in one. Stent choice included both uncovered (5, 63%) and covered stents (3, 38%). Deep venous thrombosis occurred in 2 patient's post-treatment. 1 DVT was encountered in the setting of a covered stent and 1 uncovered stent thrombosis was treated with catheter-directed lysis 4 weeks post-operatively. Ultimately, 3 patients were therapeutically anticoagulated. Mean follow-up is 13 months (range 1-36) with duplex ultrasounds available at 6 months or later in 3 of 4 patients. There is no evidence of post-thrombotic syndrome in the 2 patients that developed DVT's or in-stent stenosis in the 3 patients with available follow-up imaging. CONCLUSIONS: Endovascular techniques are important adjuncts when controlling large-volume hemorrhage associated with venous tears during anterior spinal exposure. Adequate direct compression allowing occlusion balloon inflation are key steps to reduce blood loss. Covered and uncovered stents are both appropriate choices to treat injuries. Patients must be anticoagulated post-operatively and surveilled for the sequelae of venous insufficiency. With expedient hemostasis, the indicated spinal surgery may be safely completed.
Assuntos
Perda Sanguínea Cirúrgica/prevenção & controle , Procedimentos Endovasculares , Técnicas Hemostáticas , Veia Ilíaca/lesões , Vértebras Lombares/cirurgia , Fusão Vertebral/efeitos adversos , Lesões do Sistema Vascular/terapia , Adulto , Anticoagulantes/uso terapêutico , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/instrumentação , Feminino , Técnicas Hemostáticas/instrumentação , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome Pós-Trombótica/tratamento farmacológico , Síndrome Pós-Trombótica/etiologia , Stents , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/etiologia , Trombose Venosa/tratamento farmacológico , Trombose Venosa/etiologia , Adulto JovemRESUMO
BACKGROUND: Iliac venous stenting (IVS) for thrombotic and nonthrombotic venous disease is increasingly used as evidence of the safety, efficacy and durability of these interventions increases. Female gender has been implicated as a predictor of failure in arterial endovascular interventions. We hypothesize that female gender could be predictive of patency rates of iliac vein stenting. METHODS: Consecutive patients who underwent IVS for thrombotic or nonthrombotic venous disease at our institution from 2007 until 2019 were identified and divided into groups based on gender. Operative notes, venograms, and the electronic health record were then queried to obtain operative details, co-morbid conditions, postoperative outcomes and stent patency. Study outcome was long term patency rate. The data was analyzed using chi-square, logistic regression, and Kaplan-Meier analysis as appropriate. RESULTS: A total of 200 consecutive patients (231 limbs) were identified in our retrospective analysis, with a mean age of 48.8 ± 17.3, and BMI of 31.6 ± 8.6. Of those, 119 (59.5%) patients, (131 [56.8%] limbs) were female. Comparisons between the gender groups revealed no difference in age, BMI, or preoperative comorbidities. There was no difference in type of venous disease between male (85% thrombotic, 15% nonthrombotic) and female (84% thrombotic, 16% nonthrombotic), P= 0.830. The male cohort was more likely to present with leg ulceration (17% vs. 4.6%, P = 0.002), and the female cohort was more likely to present with leg edema (98.5% vs. 93.0%, P= 0.03). The male cohort had a higher rate of caval (48% vs. 33.6%, P= 0.027) and infrainguinal stent extension. (11% vs. 6.9%, P= 0.02). Females had a higher rate of left sided stenting (80.9% vs. 66/0%, P= 0.010). There was no difference in the median stent diameter used between the cohorts. Primary patency at 5 years was significantly higher for the male cohort (94.1% vs. 74.4%, P= 0.01) On adjusted multivariable cox regression female gender was a predictor of loss of primary patency within 5 years (HR, 4.04; P= 0.007). CONCLUSIONS: In this single center retrospective analysis of IVS, male patients were found to have better primary stent patency compared to female.
Assuntos
Procedimentos Endovasculares/instrumentação , Disparidades nos Níveis de Saúde , Veia Ilíaca/fisiopatologia , Stents , Grau de Desobstrução Vascular , Trombose Venosa/terapia , Adulto , Idoso , Procedimentos Endovasculares/efeitos adversos , Feminino , Humanos , Veia Ilíaca/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores Sexuais , Fatores de Tempo , Resultado do Tratamento , Trombose Venosa/diagnóstico por imagem , Trombose Venosa/fisiopatologiaRESUMO
May-Thurner syndrome (MTS) was described sixty years ago. Once ignored for several years, it is currently a recognized pathology in the vascular surgery community; but not long ago due to several factors, it was underdiagnosed and sub-optimally treated. In the last 20 years, with renewed interest in venous pathology, technical imaging advances and the recent interventional procedures, it has become a better known disease. On the other hand, nowadays the easiness in diagnosis and treatment of the syndrome has lead to overtreatment of such patients. In this article, we do a historical review and describe the significant advances and current management of May-Thurner syndrome.