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Radiologic Classification of Iliac Vein Compression and Patterns of Pelvic Collateralization in Patients with Chronic Venous Disease
JOURNAL OF VASCULAR SURGERY: VENOUS AND LYMPHATIC DISORDERS Volume 1, Number 1
thrombomodulin (TM), plays an integral role in clot formation by catalyzing the conversion of fibrinogen to fibrin. Plasmin, which is formed by the action of urokinase and tissue plasminogen activator (uPA and tPA), is responsible for the enzymatic degradation of the fibrin clot, a process known as fibrinolysis. The goal of this study was to determine the thrombotic reactivity of the pulmonary artery and iliac vein endothelial beds. Methods: Human iliac vein endothelial cells (HIVEC) and human pulmonary artery endothelial cells (HPAEC) were incubated at 37 C in the presence or absence of thrombin (1 nM, 10 nM, 25 nM, and 100 nM) for 24 hours. Plasminogen activator inhibitor-1 (PAI-1), uPA, tPA, EPCR, PAR-1, and TM expression in cell lysates were evaluated by Western blot analysis. Results: While thrombin had no effect on the expression of uPA in HPAEC, there was a w20% decrease in uPA expression in HIVEC in the presence of both 1 nM and 100 nM thrombin. Similarly, when tPA expression was examined, there was no change in HPAEC and a marked increase in HIVEC in response to thrombin. In contrast, thrombin stimulation caused a decrease in PAI-1 expression in HPAEC while having no effect on HIVEC. There was no change in EPCR expression in HPAEC; however, after stimulation with 25 nM and 100 nM thrombin, there was >20% decrease in expression of EPCR in HIVEC. HPAEC demonstrated decreased expression of PAR1 in the presence of 25 nM and 100 nM thrombin, and, in contrast, an almost 40% increase in PAR1 expression was observed in HIVEC. Thrombin produced no change in HIVEC recombinant TM expression; however, 10 nM and 100 nM thrombin produced >20% increased expression of recombinant TM in HPAEC. In addition, there was also w20% increase in the expression of pre-cursor TM in both HPAEC and HIVEC after stimulation with 25 nM thrombin. Conclusions: Endothelial cells from the deep vein and pulmonary artery venous beds differentially express markers of the fibrinolytic and coagulation pathways, and this variance in expression may play a role in the thrombotic reactivity of these vascular beds. This data may aide in the prevention and treatment of patients with pulmonary emboli. Radiologic Classification of Iliac Vein Compression and Patterns of Pelvic Collateralization in Patients with Chronic Venous Disease A. S. Gaweesh1, M. H. Kayed2, T. Y. Gaweesh2, 1Department of Vascular Surgery, Alexandria Faculty of Medicine, University of Alexandria, Egypt, Alexandria, Egypt; 2Department of Radiology, Alexandria Faculty of Medicine, University of Alexandria, Egypt, Alexandria, Egypt Background: Iliac vein compression is an anatomic variant that has been associated with the development of deep venous thrombosis (DVT) and is increasingly diagnosed in patients presenting with non-thrombotic primary chronic venous disease (CVD). However, different patterns of compression of the iliac vein as well as the nature of compressing agents have been poorly described and inadequately reported. The aim of this study is to: 1) Describe different patterns of iliac vein compression diagnosed in patients with CVD; 2) Demonstrate different collateral pathways that can appear in the presence of iliac vein lesions. Methods: CVD patients (CEAP2-6) who had undergone direct computed tomography venography (DCTV) with pedal contrast injection from 2009 to 2012 included 31 patients with iliac vein lesions (23 primary; 8 secondary to previous DVT). Two blinded radiologists described different patterns of iliac vein compression in patients with primary lesions. Pathways of venous collateralization were traced in patients with primary or secondary lesions. Vertebral-arterial distance <6 mm at site of maximal vein compression was considered significant (denoting at least 50% caliber reduction). Results: Five types of iliac vein compression were identified: Type I (7/23;30%): Compression of LCIV by RCIA (focal/proximal), classical May-Thurner; Type II (4/23;18%): Compression of LCIV by LCIA 6 LEIA 6 LIIA (diffuse/distal); Type III (9/23;39%): Double focal LCIV compression by RCIA and LCIA; Type IV (2/23;8.5%): Double diffuse LCIV compression by RCIA and LCIA; Type V (1/23;4.5%): Bilateral
Abstracts 115
compression (RCIV by RCIA and LCIV by LCIA). The venous collaterals were classified into two groups: 1) Cross-pelvic collaterals (suprapubic; ilio-hypogastric ‘from LCIV to RIIV’; pre-sacral; trans-sacral; periuterine/peri-ovarian); and 2) Ascending collaterals (lumbar; intraspinal; ilio-caval; ilio-renal; abdominal wall). Conclusions: DCTV enables satisfactory visualization of pelvic veins, assessment of their surrounding structures, and tracing of contrast flow through abnormal pathways. RCIA compressing LCIV remains by far the commonest anomaly (77.5%) detected in patients with CVD either alone (Type I) or associated with LCIA compression (Types III & IV). LCIA may compress LCIV alone (18%) but is more often found in combination with RCIA (47.5%). LCIA compresses the vein more distally and diffusely. New classification for iliac vein compressions according to the compressing agent will hopefully increase awareness about the condition and improve reporting standards in future studies.
Surgical Desobstruction of the Common Femoral Vein in Deep Venous Occlusive Disease M. A. F. de Wolf1, J. Grommes2, C. W. Arnoldussen1, M. W. de Haan1, R. de Graaf1, C. H. A. Wittens3, 1Maastricht University Medical Center, Maastricht, Netherlands; 2Aachen University Hospital, Aachen, Germany; 3 Maastricht University Medical Center, Aachen University Hospital, Maastricht, Aachen, Netherlands Background: As complete recanalization of the proximal deep venous segments, especially the iliac veins, occurs in a minority of patients after a proximal deep venous thrombosis (DVT), recanalization by endovascular means has emerged as the treatment modality of choice in patients with severe postthrombotic symptoms. However, rapid reocclusion of treated veins might occur if inflow into these segments shows to be inadequate pre- or peri-procedural. Surgical desobstruction (endophlebectomy) of the common femoral vein increases inflow from the profunda femoral, femoral, and great saphenous vein into the treated proximal deep venous tract. In this study, we present our clinical experience and surgical technique with this procedure in patients with chronic deep venous occlusions treated in a hybrid approach. Methods: Patients with severe venous symptoms and complaints (CEAP score C4-6 and/or severe venous claudication), treated between May 2010 and August 2012, are included in this observational study. Diagnosis of chronic occlusive disease was done with duplex ultrasonography and magnetic resonance venography. Patients were primarily treated with percutaneous transluminal angioplasty (PTA) and stenting or deep venous bypass surgery combined with an endophlebectomy. Primary stenting procedures were performed in a hybrid setting with both an interventional radiologist and vascular surgeon present. Patients were followed at regular intervals, and patency of the treated venous segments was performed by duplex ultrasonography. Results: A total of 22 patients were treated in the study period; 18 underwent primary PTA and stenting and 4 venous bypass surgery. Mean age of patients was 39 years. Twelve patients were female. Eleven patients presented with skin changes (CEAP score C4-6). Patients were treated a mean of 8.3 years after their initial DVT. Surgical desobstruction was performed in the same session as the primary intervention in 19 cases; in 3 patients, the endophlebectomy, combined with PTA and restenting, was performed to treat stent reocclusion. In 16 patients creation of an arteriovenous fistula was performed in the same session. Patency at last control was achieved in 17 patients (77%), during a mean follow-up duration of 7.9 months (range, 2-20 months). Conclusions: Inadequate inflow in venous segments treated with stenting or bypass surgery for chronic venous occlusive disease is one of the most common reasons for treatment failure. Surgical desobstruction of the common femoral vein is an effective ancillary treatment option to secure venous flow in these venous tracts. Hereby, good (midterm) patency rates can be achieved in chronic venous occlusive disease with poor inflow from femoral veins.
thrombomodulin (TM), plays an integral role in clot formation by catalyzing the conversion of fibrinogen to fibrin. Plasmin, which is formed by the action of urokinase and tissue plasminogen activator (uPA and tPA), is responsible for the enzymatic degradation of the fibrin clot, a process known as fibrinolysis. The goal of this study was to determine the thrombotic reactivity of the pulmonary artery and iliac vein endothelial beds. Methods: Human iliac vein endothelial cells (HIVEC) and human pulmonary artery endothelial cells (HPAEC) were incubated at 37 C in the presence or absence of thrombin (1 nM, 10 nM, 25 nM, and 100 nM) for 24 hours. Plasminogen activator inhibitor-1 (PAI-1), uPA, tPA, EPCR, PAR-1, and TM expression in cell lysates were evaluated by Western blot analysis. Results: While thrombin had no effect on the expression of uPA in HPAEC, there was a w20% decrease in uPA expression in HIVEC in the presence of both 1 nM and 100 nM thrombin. Similarly, when tPA expression was examined, there was no change in HPAEC and a marked increase in HIVEC in response to thrombin. In contrast, thrombin stimulation caused a decrease in PAI-1 expression in HPAEC while having no effect on HIVEC. There was no change in EPCR expression in HPAEC; however, after stimulation with 25 nM and 100 nM thrombin, there was >20% decrease in expression of EPCR in HIVEC. HPAEC demonstrated decreased expression of PAR1 in the presence of 25 nM and 100 nM thrombin, and, in contrast, an almost 40% increase in PAR1 expression was observed in HIVEC. Thrombin produced no change in HIVEC recombinant TM expression; however, 10 nM and 100 nM thrombin produced >20% increased expression of recombinant TM in HPAEC. In addition, there was also w20% increase in the expression of pre-cursor TM in both HPAEC and HIVEC after stimulation with 25 nM thrombin. Conclusions: Endothelial cells from the deep vein and pulmonary artery venous beds differentially express markers of the fibrinolytic and coagulation pathways, and this variance in expression may play a role in the thrombotic reactivity of these vascular beds. This data may aide in the prevention and treatment of patients with pulmonary emboli. Radiologic Classification of Iliac Vein Compression and Patterns of Pelvic Collateralization in Patients with Chronic Venous Disease A. S. Gaweesh1, M. H. Kayed2, T. Y. Gaweesh2, 1Department of Vascular Surgery, Alexandria Faculty of Medicine, University of Alexandria, Egypt, Alexandria, Egypt; 2Department of Radiology, Alexandria Faculty of Medicine, University of Alexandria, Egypt, Alexandria, Egypt Background: Iliac vein compression is an anatomic variant that has been associated with the development of deep venous thrombosis (DVT) and is increasingly diagnosed in patients presenting with non-thrombotic primary chronic venous disease (CVD). However, different patterns of compression of the iliac vein as well as the nature of compressing agents have been poorly described and inadequately reported. The aim of this study is to: 1) Describe different patterns of iliac vein compression diagnosed in patients with CVD; 2) Demonstrate different collateral pathways that can appear in the presence of iliac vein lesions. Methods: CVD patients (CEAP2-6) who had undergone direct computed tomography venography (DCTV) with pedal contrast injection from 2009 to 2012 included 31 patients with iliac vein lesions (23 primary; 8 secondary to previous DVT). Two blinded radiologists described different patterns of iliac vein compression in patients with primary lesions. Pathways of venous collateralization were traced in patients with primary or secondary lesions. Vertebral-arterial distance <6 mm at site of maximal vein compression was considered significant (denoting at least 50% caliber reduction). Results: Five types of iliac vein compression were identified: Type I (7/23;30%): Compression of LCIV by RCIA (focal/proximal), classical May-Thurner; Type II (4/23;18%): Compression of LCIV by LCIA 6 LEIA 6 LIIA (diffuse/distal); Type III (9/23;39%): Double focal LCIV compression by RCIA and LCIA; Type IV (2/23;8.5%): Double diffuse LCIV compression by RCIA and LCIA; Type V (1/23;4.5%): Bilateral
Abstracts 115
compression (RCIV by RCIA and LCIV by LCIA). The venous collaterals were classified into two groups: 1) Cross-pelvic collaterals (suprapubic; ilio-hypogastric ‘from LCIV to RIIV’; pre-sacral; trans-sacral; periuterine/peri-ovarian); and 2) Ascending collaterals (lumbar; intraspinal; ilio-caval; ilio-renal; abdominal wall). Conclusions: DCTV enables satisfactory visualization of pelvic veins, assessment of their surrounding structures, and tracing of contrast flow through abnormal pathways. RCIA compressing LCIV remains by far the commonest anomaly (77.5%) detected in patients with CVD either alone (Type I) or associated with LCIA compression (Types III & IV). LCIA may compress LCIV alone (18%) but is more often found in combination with RCIA (47.5%). LCIA compresses the vein more distally and diffusely. New classification for iliac vein compressions according to the compressing agent will hopefully increase awareness about the condition and improve reporting standards in future studies.
Surgical Desobstruction of the Common Femoral Vein in Deep Venous Occlusive Disease M. A. F. de Wolf1, J. Grommes2, C. W. Arnoldussen1, M. W. de Haan1, R. de Graaf1, C. H. A. Wittens3, 1Maastricht University Medical Center, Maastricht, Netherlands; 2Aachen University Hospital, Aachen, Germany; 3 Maastricht University Medical Center, Aachen University Hospital, Maastricht, Aachen, Netherlands Background: As complete recanalization of the proximal deep venous segments, especially the iliac veins, occurs in a minority of patients after a proximal deep venous thrombosis (DVT), recanalization by endovascular means has emerged as the treatment modality of choice in patients with severe postthrombotic symptoms. However, rapid reocclusion of treated veins might occur if inflow into these segments shows to be inadequate pre- or peri-procedural. Surgical desobstruction (endophlebectomy) of the common femoral vein increases inflow from the profunda femoral, femoral, and great saphenous vein into the treated proximal deep venous tract. In this study, we present our clinical experience and surgical technique with this procedure in patients with chronic deep venous occlusions treated in a hybrid approach. Methods: Patients with severe venous symptoms and complaints (CEAP score C4-6 and/or severe venous claudication), treated between May 2010 and August 2012, are included in this observational study. Diagnosis of chronic occlusive disease was done with duplex ultrasonography and magnetic resonance venography. Patients were primarily treated with percutaneous transluminal angioplasty (PTA) and stenting or deep venous bypass surgery combined with an endophlebectomy. Primary stenting procedures were performed in a hybrid setting with both an interventional radiologist and vascular surgeon present. Patients were followed at regular intervals, and patency of the treated venous segments was performed by duplex ultrasonography. Results: A total of 22 patients were treated in the study period; 18 underwent primary PTA and stenting and 4 venous bypass surgery. Mean age of patients was 39 years. Twelve patients were female. Eleven patients presented with skin changes (CEAP score C4-6). Patients were treated a mean of 8.3 years after their initial DVT. Surgical desobstruction was performed in the same session as the primary intervention in 19 cases; in 3 patients, the endophlebectomy, combined with PTA and restenting, was performed to treat stent reocclusion. In 16 patients creation of an arteriovenous fistula was performed in the same session. Patency at last control was achieved in 17 patients (77%), during a mean follow-up duration of 7.9 months (range, 2-20 months). Conclusions: Inadequate inflow in venous segments treated with stenting or bypass surgery for chronic venous occlusive disease is one of the most common reasons for treatment failure. Surgical desobstruction of the common femoral vein is an effective ancillary treatment option to secure venous flow in these venous tracts. Hereby, good (midterm) patency rates can be achieved in chronic venous occlusive disease with poor inflow from femoral veins.