Prevalence of hypercoagulable states in stented thrombotic iliac vein compression syndrome with comparison of re-intervention and anticoagulation regimens

BACKGROUND Endovascular therapy is playing an increasing role in the treatment of iliofemoral venous disease.Iliac stent patency is multifactorial,and current management is based on best clinical practices,varying by institution.AIM To evaluate how thrombophilia influences management and outcomes of patients who undergo venous stenting for thrombotic iliac vein compression syndromes.METHODS A retrospective observational analysis was performed on 65 patients with thrombotic iliac vein compression syndrome that underwent common iliac vein(CIV)stenting between December 2013 and December 2019 at a large academic center.Search criteria included CIV stenting and iliac vein compression.Nonthrombotic lesions and iliocaval thrombosis and/or occlusions were excluded.A total of 65 patients were selected for final analysis.Demographic information,procedural data points,and post-procedural management and outcomes were collected.Statistical analyses included Fisher's exact and Chi-square tests to compare discrete variables and the Wilcoxon rank-sum test to compare continuous variables between thrombophilia positive and negative patients.RESULTS 65 patients underwent successful balloon angioplasty and CIV stenting.Of these patients,33(50.8%)underwent thrombophilia testing,with 16(48.5%)testing positive.Stent patency on ultrasound did not significantly differ between thrombophilia positive and negative patients at 1 mo(92.3%vs 81.3%,P=0.6),6 mo(83.3%vs 80%,P>0.9),or 12 mo(77.8%vs 76.9%,P=0.8).Immediately after stent placement,thrombophilia patients were more likely to be placed on dual therapy(aspirin and anticoagulation)or triple therapy(aspirin,clopidogrel,and anticoagulation)(50%vs 41.2%,P>0.9),and remain on dual therapy at 6 mo(25%vs 12.5%,P=0.5)and 12 mo(25%vs 6.7%,P=0.6).There was no significant difference in re-intervention rates(25%vs 35.3%,P=0.7)or number of reinterventions(average 2.3 vs 1.3 per patient,P=0.4)between thrombophilia positive and negative patients.CONCLUSION Half of patients with stented thrombotic iliac vein compression syndrome and thrombophilia testing were positive.The presence of thrombophilia did not significantly impact stent patency or re-intervention rates.

Review of imaging and endovascular intervention of iliocaval venous compression syndrome

Iliocaval venous compression syndrome(ICS)is the extrinsic compression of the common iliac vein by the overlying iliac artery against the vertebra.Chronic compression can lead to venous stenosis and stasis,which manifests as chronic venous disease and treatment resistance.Therefore,early recognition of ICS and prompt treatment are essential.Clinical presentations of ICS can be ambiguous and diagnosis requires a high index of suspicion with the relevant imaging studies.The initial imaging test is typically a Duplex ultrasound for vessel assessment and pelvic ultrasound to exclude a compressive mass,which is followed by computed tomography(CT)or magnetic resonance(MR)venography.CT and MRI can identify the anatomical causes for venous compression.In patients with high clinical suspicion for ICS,negative findings on CT and MR venography would still warrant further investigations.Definitive diagnosis can be established using catheter-based venography complemented with intravascular ultrasonography but the nature of their invasiveness limits its utility as a routine imaging modality.In this review paper,we will discuss the evidence,utility and limitations of the existing imaging modalities and endovascular intervention used in the management of ICS.

Median arcuate ligament syndrome often poses a diagnostic challenge: A literature review with a scope of our own experience

The median arcuate ligament syndrome(MALS)is recognized as a rare clinical entity,characterized by chronic post-prandial abdominal pain,nausea,vomiting,and unintentional weight loss.Due to its vague symptomatology,it is mainly regarded as a diagnosis of exclusion.Patients can often be misdiagnosed for several years before a correct diagnosis is established,also due to a medical team’s clinical suspicion.We present a case series of two patients who suffered from MALS and were treated successfully.The first patient is a 32-year-old woman,presenting with post-prandial abdominal pain and weight loss that have lasted for the past ten years.The second patient,a 50-year-old woman,presented with similar symptomatology,with the symptoms lasting for the last five years.Both cases were treated by laparoscopic division of the median arcuate ligament fibers,which alleviated extrinsic pressure from the celiac artery.Previous cases of MALS were retrieved from PubMed,to assemble a better diagnostic algorithm and propose a treatment method of choice.The literature review suggests an angiography with a respiratory variation protocol as the diagnostic modality of choice,along with the laparoscopic division of the median arcuate ligament fibers as the proposed treatment of choice.

Endovascular treatment of iliac vein compression syndrome

Background Iliac vein compression syndrome （IVCS）, the symptomatic compression of the left common iliac vein between the right common iliac artery and the vertebrae, is not an uncommon condition. The aim of this research was to retrospectively evaluate long-term outcome and the significance of endovascular treatment in patients with left IVCS. Methods Between January 1997 and September 2008, 296 patients received interventional therapy in the left common iliac vein. In the second stage, 170 cases underwent saphenous vein high ligation and stripping. Two hundred and thirty-one cases were followed up over a period of 6 to 120 months （average 46 months） and evaluated for symptom improvement with color ultrasound and ascending venography. Results The stenotic or occlusive segments of the left iliac vein were successfully dilated in 285 cases, of whom 272 received stent implantation therapy. Most of the patients achieved satisfactory results on discharge. During the follow-up period, varicose veins were alleviated in 98.7% of the patients, and leg swelling disappeared or was obviously relieved in 84% of cases. About 85% of leg ulcers completely healed. The total patency rate was 91.7% as evaluated with color ultrasound and 91.5% with ascending venography. Conclusions Endovascular treatment of IVCS provides effective symptomatic improvement and good long-term patency in most patients.

Iliac Vein Compression Syndrome in an Asymptomatic Patient Population： A Prospective Study

Background： Iliac vein compression syndrome （1VCS） is an important cause of deep vein thrombosis, but the incidence oflVCS is still unclear. The purpose of this prospective study was to determine the incidence of IVCS in an asymptomatic patient population and to evaluate the risk factors in patients with and without 1VCS. Methods： From October 2011 to November 2012, a total of 500 patients （228 women and 272 men; mean age of 55.4 ± 14.7 years） with no vascular-related symptoms were enrolled in this study. Computed tomography was performed to evaluate all patients. The degree of venous compression was calculated as the diameter of the common iliac vein at the site of maximal compression divided by the mean diameter of the uncompressed proximal and caudal left common iliac vein （LCIV）. We compared the stenosis rate of the common iliac vein in women and men according to age and followed up patients to evaluate outcomes. Results： The mean compression degree of the LCIV was 16% （4%, 36%）： 37.8% of patients had a compression degree ≥25% and 9.8% had a compression degree ≥50%. There was a significant difference between men and women in the LCIV compression degree （9% [3%, 30%] vs. 24% [8%, 42%]; U = 4.66, P 〈 0.01）. In addition, the LCIV compression degree among younger women （≤40 years） was significantly different compared with that in older women （〉40 years） （42% [31%, 50%] vs. 19% [5%, 39%]; U = 5.14, P 〈 0.001 ）. Follow-up was completed in 367 patients with a mean follow-up of 39.5 months （range, 6-56 months）. The incidence of IVCS in the follow-up period was 1.6%. Stenosis rate and the diameter of the site of maximal compression correlated with the incidence of IVCS. Multivariable Cox regression analysis showed that the stenosis rate was an independent risk factor of IVCS （Wald x2 = 8.84, hazard ratio = 1.13, P 〈 0.001 ）. Conclusions： The incidence of IVCS was low and correlated with the stenosis rate ofiliac vein. Preventative therapy may be warranted for common iliac vein compression in patients at an increased risk of venous thromboembolism, especially patients with a higher iliac vein compression degree.

Endovascular treatment of acute proximal deep venous thrombosis secondary to iliac vein compression syndrome： a novel technique for thrombus removal

Iliac vein compression syndrome （IVCS）,also known as May-Thurner syndrome or Cockett syndrome,is caused by compression of the left common iliac vein between the right common iliac artery and the vertebrae.A recent imaging study have demonstrated that at least a 25%compression of the left iliac vein at the arterial crossover point may be present in 66% of the asymptomatic patient population.1 With the development of interventional technique,endovascular management as a less invasive means is becoming the first-line treatment,which can not only treat the thrombosis but also correct the venous anatomic abnormalities.2 In this study,we described a novel technique combining percutaneous aspiration thrombectomy （PAT） with Fogarty catheter thrombectomy （FCT） as the thrombus removal therapy without femoral venotomy in patients with acute deep vein thrombosis （DVT） due to IVCS and evaluated its technical feasibility and short-term outcomes.

Primary spinal epidural non-Hodgkin’s lymphoma presentedwith spinal cord compression syndrome

The spinal epidural space is an uncommon presenting site in primary non-Hodgkin’s lymphomas,especially for children.A boy suffered spinal cord compression syndrome caused by primary spinal epidural non-Hodgkin’s lymphoma.Thoracolumbar magnetic reso-nance imaging(MRI)demonstrated an intraspinal mass.An operation was performed with gross total tumor removal.Histological examination revealed a non-Hodgkin’s B-cell lymphoma.Bone marrow aspiration was negative for lymphoma involvement.No other therapies(chemotherapy and/or radiotherapy)were per-formed according to the parents’opinion.The patient died approximately one year after the operation due to brain metastases.The clinical course and imaging features were discussed with a review of literatures.

A systematic review of DVT and stent restenosis after stent implantation for iliac vein compression syndrome

Iliac vein compression syndrome(IVCS)is a common venous disease caused by joint compression of the right common iliac artery and the lumbosacral vertebrae.The compression of iliac vein not only causes venous hypertension in the lower extremities,but also induces venous valve dysfunction and superficial varicose veins in lower extremities.Moreover,the compression of iliac vein is an important potential factor for iliofemoral vein thrombosis.Currently,open surgery and stent implantation are the main treatment for IVCS.Due to the advantages of minimally invasive and postoperative patency,stent implantation for IVCS has gradually become the standard treatment.However,when the stent is implanted into the iliac vein to treat IVCS,the complications,such as restenosis,deep vein thrombosis(DVT)appear,which affect the patency of stent and hamper the patient recovery.Up to now,the mechanism how the stent implantation induces the restenosis and DVT is still unclear.In this review,we summarized the clinical symptoms,treatment methods of IVCS and the complications after stent implantation,and analyzed the mechanism of stent restenosis and DVT,and finally discuss the iliac vein stent design specifically for treating IVCS.

“Treat-Repair-Treat”:Management of Left Main Coronary Compression by a Pulmonary Artery Aneurysm in a Patient with Atrial Septal Defect and Significant Pulmonary Hypertension

Left main coronary compression syndrome(LMCS)may complicate pulmonary artery aneurysms(PAA),usually developed in the context of pulmonary arterial hypertension(PAH).We report the case of a 51-year-old female patient with an atrial septal defect(unsuitable for device closure)complicated by a PAA generating a 90%left main stenosis.The significant PAH held us back from immediate surgery.After specific dual PAH-targeted therapy(sildenafil and bosentan),the atrial septal defect could be closed with a unidirectional valved patch;the PAAinduced LMCS was treated by reductive arterioplasty.The postoperative course was uneventful.Follow-up showed clinical improvement,but PAH treatment was still needed.After three months,coronary angiography showed only an insignificant residual left main stenosis,proving that reductive pulmonary arterioplasty was effective in treating LMCS.Any PAA requires further evaluation for LMCS,a dangerous but treatable complication.The“treat-repair-treat”strategy and shunt-closure with a unidirectional valved patch can both improve surgical prospects of LMCS with shunt-related PAH.

A case of duplicated inferior vena cava with bilateral iliac vein compression

Duplicated inferior vena cava with bilateral iliac vein compression is extremely rare.We report a case of an 87-year-old man presented with bilateral lower extremity swelling,who was noted to have duplicated inferior vena cava,as revealed by computed tomography angiography(CTA).This revealed bilateral iliac vein compression caused by surrounding structures.Anticoagulant treatment combined with stent implantation completely alleviated this chronic debilitating condition during the follow-up of 2 months with no recurrence.

Median arcuate ligament syndrome complicated with gallbladder stones:A case report

BACKGROUND Median arcuate ligament syndrome(MALS)is a rare disease caused by compression of the celiac trunk artery by the median arcuate ligament(MAL).It can cause symptoms of postprandial abdominal pain,weight loss,and nausea and vomiting.CASE SUMMARY A 55-year-old woman was admitted due to abdominal pain,nausea and vomiting.On admission,the patient presented with epigastric pain that worsened after eating,without signs of peritoneal irritation.Computed tomography angiography of the upper abdomen showed compression of the proximal segment of the abdominal trunk,local luminal stenosis with angular“fishhook”changes,which changed significantly during forceful inspiration and expiration;gallbladder stones;and multiple cysts in the liver.Abdominal duplex ultrasonography showed that peak systolic velocity was 352 cm/s.After diagnosis of MALS was confirmed,an arch ligament release procedure was performed.MALS has no specific symptoms and can be misdiagnosed as other abdominal diseases.Awareness of MALS should be improved to avoid misdiagnosis.The commonly used treatment option is MAL release and resection of the peripheral ganglion of the celiac trunk artery.CONCLUSION The diagnosis and treatment of MALS must be individualized,and MAL release is effective and provides immediate symptomatic relief.

Challenging anticoagulation therapy for multiple primary malignant tumors combined with thrombosis:A case report and review of literature

BACKGROUND Venous thromboembolism significantly contributes to patient deterioration and mortality.Management of its etiology and anticoagulation treatment is intricate,necessitating a comprehensive consideration of various factors,including the bleeding risk,dosage,specific anticoagulant medications,and duration of therapy.Herein,a case of lower extremity thrombosis with multiple primary malignant tumors and high risk of bleeding was reviewed to summarize the shortcomings of treatment and prudent anticoagulation experience.CASE SUMMARY An 83-year-old female patient was admitted to the hospital due to a 2-wk history of left lower extremity edema that had worsened over 2 d.Considering her medical history and relevant post-admission investigations,it was determined that the development of left lower extremity venous thrombosis and pulmonary embolism in this case could be attributed to a combination of factors,including multiple primary malignant tumors,iliac venous compression syndrome,previous novel coronavirus infection,and inadequate treatment for prior thrombotic events.However,the selection of appropriate anticoagulant medications,determination of optimal drug dosages,and establishment of an appropriate duration of anticoagulation therapy were important because of concurrent thrombocytopenia,decreased quantitative fibrinogen levels,and renal insufficiency.CONCLUSION Anticoagulant prophylaxis should be promptly initiated in cases of high-risk thrombosis.Individualized anticoagulation therapy is required for complex thrombosis.

Costoclavicular Syndrome and MRI Evaluation, Our Experience at Tertiary Care Hospital, SKIMS Srinagar, J&K

Introduction: Cervical rib is a supernumerary rib springing from one of the cervical vertebrae, usually the seventh. About 1 in 200 people are born with cervical rib. About 1 in 10 people who have a cervical rib develop symptoms of thoracic outlet syndrome (TOS). Aims: The aim of this study was to identify normal and abnormal anatomy of thoracic outlet using MRI in symptomatic costoclavicular compression syndrome and to plan them for surgery thereafter. Methods: This was a prospective hospital based study. All the symptomatic cases of cervical rib syndrome admitted in the department of Cardiovascular and thoracic surgery SKIMS, Srinagar from May 2011 to May 2015 were taken up for the study. Results: A total of 40 cases of symptomatic cervical rib syndrome were reported from May 2011 to May 2015. Mean age of presentation was 26.3. The most prevalent age group was 21 - 30 years (47%). Majority of patients were females (83%) with male female ratio of 1:5. 67% had bilateral cervical rib, more in females (72%) than males (40%). 97% had neurogenic thoracic outlet syndrome and 3% had vascular thoracic outlet syndrome. 35% of cases with neurogenic thoracic outlet syndrome had subclavian artery compression on MR Angio of thoracic outlet after subjecting them to postural maneuvers. All the patients with subclavian artery compression were subjected to surgery. Conclusion: Costoclavicular compression syndrome affects mainly young females. MR Angio is complementary in finding vascular compression in cases presenting mainly with neurogenic symptoms of thoracic outlet syndrome.

Anterior subcutaneous transposition of the ulnar nerve improves neurological function in patients with cubital tunnel syndrome

Although several surgical procedures exist for treating cubital tunnel syndrome, the best surgical option remains controversial. To evaluate the efficacy of anterior subcutaneous transposition of the ulnar nerve in patients with moderate to severe cubital tunnel syndrome and to analyze prognostic factors, we retrospectively reviewed 62 patients（65 elbows） diagnosed with cubital tunnel syndrome who underwent anterior subcutaneous transposition. Preoperatively, the initial severity of the disease was evaluated using the Mc Gowan scale as modified by Goldberg： 18 patients（28%） had grade IIA neuropathy, 20（31%） had grade IIB, and 27（42%） had grade III. Postoperatively, according to the Wilson ＆ Krout criteria, treatment outcomes were excellent in 38 patients（58%）, good in 16（25%）, fair in 7（11%）, and poor in 4（6%）, with an excellent and good rate of 83%. A negative correlation was found between the preoperative Mc Gowan grade and the postoperative Wilson ＆ Krout score. The patients having fair and poor treatment outcomes had more advanced age, lower nerve conduction velocity, and lower action potential amplitude compared with those having excellent and good treatment outcomes. These results suggest that anterior subcutaneous transposition of the ulnar nerve is effective and safe for the treatment of moderate to severe cubital tunnel syndrome, and initial severity, advancing age, and electrophysiological parameters can affect treatment outcome.

Diagnosis and management of splanchnic ischemia

Splanchnic or gastrointestinal ischemia is rare and randomized studies are absent. This review focuses on new developments in clinical presentation, diagnostic approaches, and treatments. Splanchnic ischemia can be caused by occlusions of arteries or veins and by physiological vasoconstriction during low-flow states. The prevalence of significant splanchnic arterial stenoses is high, but it remains mostly asymptomatic due to abundant collateral circulation. This is known as chronic splanchnic disease (CSD). Chronic splanchnic syndrome (CSS) occurs when ischemic symptoms develop. Ischemic symptoms are characterized by postprandial pain, fear of eating and weight loss. CSS is diagnosed by a test for actual ischemia. Recently, gastro-intestinal tonometry has been validated as a diagnostic test to detect splanchnic ischemia and to guide treatment. In single- vessel CSD, the complication rate is very low, but some patients have ischemic complaints, and can be treated successfully. In multi-vessel stenoses, the complication rate is considerable, while most have CSS and treatment should be strongly considered. CT and MR-based angiographic reconstruction techniques have emerged as alternatives for digital subtraction angiography for imaging of splanchnic vessels. Duplex ultrasound is still the first choice for screening purposes. The strengths and weaknesses of each modality will be discussed. CSS may be treated by minimally invasive endoscopic treatment of the celiac axis compression syndrome, endovascular antegrade stenting, or laparotomy-assisted retrograde endovascular recanalization and stenting.The treatment plan is highly individualized and is mainly based on precise vessel anatomy, body weight, co- morbidity and severity of ischemia.

Increased gene and protein expressions of the transient receptor potential vanilloid receptor 4 following sustained pure mechanical pressure on rat dorsal root ganglion neurons

Dorsal root ganglion （DRG） neurons from newborn Wistar rats cultured in vitro were pressurized with 20, 40, 80 or 120 mm Hg compressive Ioadings （1 mm Hg = 0.133 kPa） for 12, 24, 48 or 72 hours, respectively. The 3-[4, 5-dimethylthiazol-2-yl]-2, 5-diphenyltetrazolium bromide test showed that pressures less than 80 mm Hg had no obvious impact on the activity of DRG neurons. The protein expression levels of transient receptor potential vanilloid receptor 4 （TRPV4）, transient receptor potential vanilloid receptor 1, transient receptor potential channel of melastatin type 8, and transient receptor potential subtype ankyrin 1 were assessed by western blot analysis. The mRNA expression of TRPV4 was assessed by real-time PCR. The results showed that sustained mechanical compression up-regulated TRPV4 mRNA and protein expression in the rat DRG neurons, in a time-dependent fashion. Similar changes were not found in the protein expression of transient receptor potential vanilloid receptor 1, transient receptor potential channel of melastatin type 8, and transient receptor potential subtype ankyrin 1. Images of cells using a laser scanning confocal microscope showed that the sustained mechanical pressure increased the number of responsive DRG neurons and was synergistic on the enhanced Ca^2＋ responses to the TRPV4 phorbol ester agonist 4a-phorbo112, 13-didecanoate and hypotonic solutions. These findings demonstrate that sustained mechanical compressive loading in vitro increases the expression of TRPV4 mRNA and protein in DRG neurons and sensitizes TRPV4 Ca^2＋ signals. Mechanical compression does not impact other ion channels in the transient receptor potential family.

Simultaneous laparoscopic and arthroscopic excision of a huge juxta-articular ganglionic cyst compressing the sciatic nerve:A case report

BACKGROUND A large ganglionic cyst extending from the hip joint to the intrapelvic cavity through the sciatic notch is a rare space-occupying lesion associated with compressive lower-extremity neuropathy.A cyst in the pelvic cavity compressing the intrapelvic-sciatic nerve is easily missed in the diagnostic process because it usually presents as atypical symptoms of an extraperitoneal-intrapelvic tumor.We present a case of a huge ganglionic cyst that was successfully excised laparoscopically and endoscopically by a gynecologist and an orthopedic surgeon.CASE SUMMARY A 52-year-old woman visited our hospital complaining of pain and numbness in her left buttock while sitting.The pain began 3 years ago and worsened,while the numbness in the left lower extremity lasted 1 mo.She was diagnosed and unsuccessfully treated at several tertiary referral centers many years ago.Magnetic resonance imaging revealed a suspected paralabral cyst(5 cm×5 cm×4.6 cm)in the left hip joint,extending to the pelvic cavity through the greater sciatic notch.The CA-125 and CA19-9 tumor marker levels were within normal limits.However,the cyst was compressing the sciatic nerve.Accordingly,endoscopic and laparoscopic neural decompression and mass excision were performed simultaneously.A laparoscopic examination revealed a tennis-ball-sized cyst filled with gelatinous liquid,stretching deep into the hip joint.An excisional biopsy performed in the pelvic cavity and deep gluteal space confirmed the accumulation of ganglionic cysts from the hip joint into the extrapelvic intraperitoneal cavity.CONCLUSION Intra-or extra-sciatic nerve-compressing lesion should be considered in cases of sitting pain radiating down the ipsilateral lower extremity.This large juxta-articular ganglionic cyst was successfully treated simultaneously using laparoscopy and arthroscopy.