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20.12 Catheter directed thrombolysis for acute thrombosis of the subclavian vein
23rd World Congress of the ISCVS significant morbidity and mortality. Contrast venography has its known morbidity. On the other hand, duplex scanning permits a detailed visualization of the deep venous system and facilitates Doppler flow evaluation. During 1.5 consecutive months (March 1995 to July 1996) at King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia, a total of 112 patients referred to our Division of Vascular Surgery with a clinical suspicion of deep vein thrombosis (DVT) underwent continuous wave Doppler and Duplex evaluation of both lower limbs. The mean age was 48 years (range 18-100). There were 77 males and 35 females. In 35 patients, contrast ascending venography was carried out in addition to the Doppler and Duplex scanning. Venography was positive for DVT in 31 patients (88.5%). Sensitivity and specifity for Doppler study was 92% and 98% when compared with Duplex and 90% and 97% when compared with venography. The Duplex scan showed sensitivity of 97% and specifity of 99% and when compared with venography at above knee level while corresponding values were 87% and 96% at below knee level. The associated risk factors and physical findings were reported and tabulated. In conclusion, continuous wave Doppler is an accurate reliable method for initial diagnosis of DVT while the Duplex scan is the gold standard for the diagnosis of DVT in lower limbs.
20.10 Vein Valve Autotransplantation in Non-obstructive Chronic Venous Insufficiency (New Technique) M.M. ZAKZ, Giza, Egypt Chronic venous insufficiency of the lower limb is a significant problem to both patients and vascular surgeons. In this study we introduced a new technique (Zaki technique); brachial to upper pophteal; end to side anastomosis and wrapping the valved harvested segment by the wall of the excluded popliteal segment. The 31 patients with non-obstructing disease that underwent this technique showed nearly complete absence of the clinical symptoms (93.5%). This coincides with similar indices of perfect valve function in the postoperative follow up period (1.4-4 years) as assessed by Duplex and/or venography. Rapid healing to ulcers has been encountered in nine out of the 12 patients (75%). Late recurrence of ulcers has been encountered in one patient (3.2%). By using this technique we have overcome the difficulties of the previous operations. Also, we achieved improvement in the incidence of surgical success of vein valve autotransplantation operation when done by the conventional methods. Further evaluation of the operation is needed to confirm its definitive place.
20.11 Suprarenal Placement of the Greenfield Filter G.A. RO]AS, J. CERVANTES, L. ARCOS, R. PONTE and ].A. GALZCZA, Mexico City, Mexico From August 1987 to January 1995, 117 patients at the ABC Hospital required the placement of a Greenfield filter, of which
102
in 12 cases (10.81%), it was placed in the suprarenal position, due to the presence of. thrombus in the infrarenal vena cava. All the patients were female with an average age of 48.5 years. The reasons for deployment of the filter were: contraindication for anticoagulation 50%, failure of anticoagulant therapy 41.66% and one patient with a huge, floating thrombus in the inferior vena cava (IVC). These 12 patients required the use of 15 filters; three stainless steel and 12 titanium. The site of access was the right internal jugular vein (RIJV) in all of them, in three with a venous cutdown and in nine with percutaneous insertion. All were carried out under fluoroscopy and cavography. There was no operative mortality. There was operative morbidity in two patients (16.66%): one pneumothorax during the percutaneous puncture of RIJV and one minor episode of air embolism without hemodynamic repercussions. Three patients required the placement of two filters each because of technical difficulties. Follow-up was from 1 to 48 months (average 15 months) during which five patients (41.66%) died at a mean follow-up of 11 months from unrelated causes. Seven patients (58.33%), survived to a mean follow-up of 20.5 months. Neither the patients who died nor the ones that survived had signs or symptoms of recurrent pulmonary embolism (PE) or renal vein thrombosis. In conclusion, in those patients that required the surgical interruption of the IVC above the renal veins, the placement of a Greenfield filter in the suprarenal position is secure, with no mortality, minimal morbidity, without evidence of recurrent PE or renal vein thrombosis.
20.12 Catheter Directed Thrombolysis for Acute Thrombosis of the Subclavian Vein N.A. SARATZZS, K. GZAVROGLOU, A. HATZZBALOGLOU, T. PROZOS, D. KZSKZNZS, I. MOROS and V. DALAZNAS, Thessaloniki, Greece The purpose of this study was to evaluate the efficacy and safety of the catheter directed thrombolysis for acute spontaneous thrombosis of the subclavian vein. In a 5 year period, 17 patients, (11 male, six female), age range from 24 to 53 years, presented with acute symptomatic thrombosis of the subclavian vein in our department. All patients underwent local thrombolysis within 5 days from the onset of the symptoms. Venography was used to confirm the diagnosis. When the thrombus was visualized a guidewire via the basilic vein was used to transverse the clot to establish a channel. Then a catheter was positioned in the clot and infusion of urokinase was started at dose of ZOOOIU/kg/h. Low molecular weight heparin was used to prevent pericatheter thrombosis. The progress of clot dissolusion and possible repositioning of the catheter was made by venography on 4th, 8th, 12th and 24th h from the beginning of the procedure. Vein recanalization was achieved in all except one patient. The mean thrombolysis time was 17 h. Fibrinogen levels ranged above 160 mg %. No haemorrhagic complications were noted. All patients were discharged from the hospital with additional warfarin anticoagulation regimen for 3 months. In conclusion local transcatheter thrombolysis is an effective and safe method to restore venous patency after acute spontaneous subclavian vein thrombosis.
CARDIOVASCULAR SURGERY
SEPTEMBER 1997
20.10 Vein Valve Autotransplantation in Non-obstructive Chronic Venous Insufficiency (New Technique) M.M. ZAKZ, Giza, Egypt Chronic venous insufficiency of the lower limb is a significant problem to both patients and vascular surgeons. In this study we introduced a new technique (Zaki technique); brachial to upper pophteal; end to side anastomosis and wrapping the valved harvested segment by the wall of the excluded popliteal segment. The 31 patients with non-obstructing disease that underwent this technique showed nearly complete absence of the clinical symptoms (93.5%). This coincides with similar indices of perfect valve function in the postoperative follow up period (1.4-4 years) as assessed by Duplex and/or venography. Rapid healing to ulcers has been encountered in nine out of the 12 patients (75%). Late recurrence of ulcers has been encountered in one patient (3.2%). By using this technique we have overcome the difficulties of the previous operations. Also, we achieved improvement in the incidence of surgical success of vein valve autotransplantation operation when done by the conventional methods. Further evaluation of the operation is needed to confirm its definitive place.
20.11 Suprarenal Placement of the Greenfield Filter G.A. RO]AS, J. CERVANTES, L. ARCOS, R. PONTE and ].A. GALZCZA, Mexico City, Mexico From August 1987 to January 1995, 117 patients at the ABC Hospital required the placement of a Greenfield filter, of which
102
in 12 cases (10.81%), it was placed in the suprarenal position, due to the presence of. thrombus in the infrarenal vena cava. All the patients were female with an average age of 48.5 years. The reasons for deployment of the filter were: contraindication for anticoagulation 50%, failure of anticoagulant therapy 41.66% and one patient with a huge, floating thrombus in the inferior vena cava (IVC). These 12 patients required the use of 15 filters; three stainless steel and 12 titanium. The site of access was the right internal jugular vein (RIJV) in all of them, in three with a venous cutdown and in nine with percutaneous insertion. All were carried out under fluoroscopy and cavography. There was no operative mortality. There was operative morbidity in two patients (16.66%): one pneumothorax during the percutaneous puncture of RIJV and one minor episode of air embolism without hemodynamic repercussions. Three patients required the placement of two filters each because of technical difficulties. Follow-up was from 1 to 48 months (average 15 months) during which five patients (41.66%) died at a mean follow-up of 11 months from unrelated causes. Seven patients (58.33%), survived to a mean follow-up of 20.5 months. Neither the patients who died nor the ones that survived had signs or symptoms of recurrent pulmonary embolism (PE) or renal vein thrombosis. In conclusion, in those patients that required the surgical interruption of the IVC above the renal veins, the placement of a Greenfield filter in the suprarenal position is secure, with no mortality, minimal morbidity, without evidence of recurrent PE or renal vein thrombosis.
20.12 Catheter Directed Thrombolysis for Acute Thrombosis of the Subclavian Vein N.A. SARATZZS, K. GZAVROGLOU, A. HATZZBALOGLOU, T. PROZOS, D. KZSKZNZS, I. MOROS and V. DALAZNAS, Thessaloniki, Greece The purpose of this study was to evaluate the efficacy and safety of the catheter directed thrombolysis for acute spontaneous thrombosis of the subclavian vein. In a 5 year period, 17 patients, (11 male, six female), age range from 24 to 53 years, presented with acute symptomatic thrombosis of the subclavian vein in our department. All patients underwent local thrombolysis within 5 days from the onset of the symptoms. Venography was used to confirm the diagnosis. When the thrombus was visualized a guidewire via the basilic vein was used to transverse the clot to establish a channel. Then a catheter was positioned in the clot and infusion of urokinase was started at dose of ZOOOIU/kg/h. Low molecular weight heparin was used to prevent pericatheter thrombosis. The progress of clot dissolusion and possible repositioning of the catheter was made by venography on 4th, 8th, 12th and 24th h from the beginning of the procedure. Vein recanalization was achieved in all except one patient. The mean thrombolysis time was 17 h. Fibrinogen levels ranged above 160 mg %. No haemorrhagic complications were noted. All patients were discharged from the hospital with additional warfarin anticoagulation regimen for 3 months. In conclusion local transcatheter thrombolysis is an effective and safe method to restore venous patency after acute spontaneous subclavian vein thrombosis.
CARDIOVASCULAR SURGERY
SEPTEMBER 1997