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Historically, the stents used in the venous system were not dedicated scaffolds. They were largely adapted arterial stents. An essential feature of a venous stent is compliance, in order to adapt its crosssectional area to the vein. It should also be crush resistant, corrosion resistant and fatigue resistant. The material should be radiopaque, for follow-up. Another characteristic of the ideal venous stent is flexibility, to adapt its shape to the vein, not vice versa. The scaffold should be uncovered too, in order to avoid the occlusion of collaterals. The ideal venous stent should not migrate, so it is necessary a large diameter and a long length. The radial force is important to prevent migration. However, current stents derived from arterial use display high radial force, which could affect the patency of the thin venous wall. Alternatively, if the stent has an anchor point, that permits a passive anchoring, the radial force required to avoid migration will be lower. Dedicated venous stents were not available until very recently. Furthermore, there is a preclinical study about a new compliant nitinol stent, denominated Petalo CVS. Out of the commonest causes of large veins obstruction, dedicated venous stent could also treat other diseases described more recently, such as the jugular variant of the Eagle syndrome, JEDI syndrome and jugular lesions of the chronic cerebrospinal venous insufficiency that result unfavorable for angioplasty according to Giaquinta classification. [ABSTRACT FROM AUTHOR]

Cardiac output during exercise increases by as much as fivefold in the untrained man, and by as much as eightfold in the elite athlete. Increasing venous return is a critical but much overlooked component of the physiological response to exercise. Cardiac disorders such as constrictive pericarditis, restrictive cardiomyopathy and pulmonary hypertension are recognised to impair preload and cause exercise limitation; however, the effects of peripheral venous obstruction on cardiac function have not been well described. This manuscript will discuss how obstruction of the iliocaval venous outflow can lead to impairment in exercise tolerance, how such obstructions may be diagnosed, the potential implications of chronic obstructions on sympathetic nervous system activation, and relevance of venous compression syndromes in heart failure with preserved ejection fraction. [ABSTRACT FROM AUTHOR]

The two main mechanisms for pelvic venous disease (PeVD) are reflux of ovarian vein and obstruction of left common iliac or left renal vein. Some patients have a combination of the two. Adequate assessment of the location and degree of stenosis and delineation of venous anatomy are the key elements in the success of interventions to treat chronic obstructions causing PeVD. While venography is more accessible and less expensive to perform than intravascular ultrasound (IVUS), an increasing number of studies have demonstrated that IVUS is significantly more sensitive than venography in identifying stenotic lesions and real-time anatomical alterations of the affected venous segments. In this paper, we discuss the derived information and the clinical applications of IVUS during such interventions. The definitive diagnosis of PeVD can be achieved with venography combined with IVUS to evaluate for obstructive lesions in the iliac veins and compression of the left renal vein. Venography has poor sensitivity and specificity in the detection of venous stenosis. However, IVUS can detect fine intraluminal trabeculae and outside compression that can be missed with standard multiplanar venography. The IVUS can confidently confirm the persistent venous stenosis regardless of the hemodynamical alterations of venous pressure, as well. Moreover, it is possible to precisely measure the diameter of ovarian vein with IVUS. This may be helpful to decide about the diameter of the coils or the plugs needed to avoid migration. In conclusion, IVUS enables us to accurately evaluate the underlying cause of PeVD and apply a patient's tailored treatment on table. [ABSTRACT FROM AUTHOR]

Objectives: To determine the incidence of possible obstacles and patients' characteristics when performing endovenous laser treatment (EVLT) and suggestions to improve the ability to overcome them. Method: A prospective study with 215 limbs treated with EVLT. A sequence of maneuvers was performed to move the fiber forward when difficulty was found and if unsuccessful another entry site was punctured. Results: In 29 of 215 (13.48%) limbs, resistance was encountered while navigating the fiber; 16 (55.17%) solved with lower limb extension; 13 (44.82%) needed ultrasound guided maneuvers; five (17.24%) needed a saline flush and in three patients (10.34%) another entry site was necessary. In 214 of 215 cases (99.53%), ablation was accomplished and no complications were observed. Conclusions: Both obstruction and higher patients' BMI are the main obstacles during endovenous laser ablation and usually needs additional maneuvers to accomplish the procedure in our study and the use of tricks to overcome these issues is feasible. [ABSTRACT FROM AUTHOR]

Introduction: Deep venous stenting has gained increasing interest. More flexible venous stents are thought to gain superior clinical outcomes. This research evaluated the patency and clinical outcomes between more rigid stents and more flexible stents. Material and methods: The Venous Clinical Severity Score, Villalta, complication rates and patency rates were evaluated. The more rigid stents included the Sinus XL, the Veniti VICI and the Sinus Obliquus. The flexible group included the Zilver Vena or the Sinus Venous stents. Results: Differences in Venous Clinical Severity Score (p = 0.09) and Villalta score were found (p = 0.28). Tapering (0 versus 5, p = 0.03) and bad alignment were found (0 versus 5, p = 0.03). The rigid stents showed patency rates of 80, 86 and 92% compared to 88, 96 and 98% in the flexible group. Conclusion: Dedicated venous stents show good patency outcomes and clinical results. Tapering and bad alignment between connecting stents are more frequently seen in more rigid stents. [ABSTRACT FROM AUTHOR]

Objective: To investigate the biological effects of a novel endovenous scaffold in a porcine model. Methods: Petalo is a compliant venous scaffold implanted into the internal jugular veins of 12 healthy pigs. The pigs were sacrificed at one, two, three, and six months, respectively. Microscopic investigations were performed at two blinded laboratories. Results: Neo-intima formation progressively covering up the stent metallic bars was observed. The inflammatory response of the venous wall showed a peak after three months by the implant, followed by marked reduction after six months. The device induced a significant (p<0.01) increase of the thickness respect to the control regions, but was comparable in sections obtained after three and six months. Conclusions: The implant of Petalo compliant venous scaffold in the venous wall of this porcine model is characterized by neointima formation and by an inflammatory reaction which tends to decrease after six months. Our data point against the induction of smooth muscle cells proliferation and migration as confirmed by electronic transmission microscopy analyses. [ABSTRACT FROM AUTHOR]

Symptomatic obstruction related to malignant involvement of large veins may occur in central veins both in the thoracic and pelvic regions, and in the abdominal region of the body. Both cases represent a therapeutic challenge, and endovascular revascularization, consisting of angioplasty and stent placement, is safe and effective. Superior vena cava stenting has become widespread in the management of occlusive venous disease. The percutaneous placement of large expandable metal stents allows rapid restoration of normal blood flow in the majority of patients, thus improving symptoms. Published data on the diagnosis and treatment of symptomatic cancer-related iliocaval obstructions are limited and mainly consist of case reports and small case series. The present review reports the current state of endovascular treatment for both superior vena cava occlusion and iliac compression syndrome in cancer patients. [ABSTRACT FROM AUTHOR]

Background Venous stenting with an endophlebectomy and arteriovenous fistula can be performed in patients with extensive post-thrombotic changes. However, these hybrid procedures can induce restenosis, sometimes requiring stent extension, into a single inflow vessel. This study investigates the effectiveness of stenting into a single inflow vessel. Methods All evaluated patients had temporary balloon occlusion of the arteriovenous fistula to evaluate venous flow into the stents. When stent inflow was deemed insufficient, AVF closure was postponed and additional stenting was performed. Patency rates and clinical outcomes were evaluated. Results Twenty-four (38%) of 64 patients had additional stenting. The primary, assisted primary and secondary patency were 60 %, 70% and 70% respectively. Villalta score reduced by 6.1 points (p < 0.001), and venous clinical severity score by 2.7 points (p = 0.034). Conclusion Stenting through the femoral confluence into a single inflow vessel is a feasible bailout option if primary hybrid intervention fails with relative high patency rates and clinical improvement. [ABSTRACT FROM AUTHOR]

Introduction Venous recanalization of obstructed femoral and iliac veins is associated with good results regarding the feasibility and patency rate. If the common femoral vein with its inflow vessels is involved, open surgical desobliteration or endophlebectomy has been described as a crucial part of the intervention. However, when performing the hybrid procedure, a number of specific complications have been described. We present our results after venous recanalization including an endophlebectomy, focussing on wound complications and its impact on outcome. Material and methods A retrospective analysis of prospective recorded data of all patients who underwent a hybrid procedure for chronic obstruction of iliofemoral veins between 2010 and 2015 was performed. The patients were treated by recanalization of the affected veins combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation. Data assessment focussed on complications and patency rates. Results This study includes 96 patients, thereof 58 females with a mean age of 44.1 years. The mean procedure time was 344 ± 140 min (range 124–663). Median follow-up time was 12.5 months (2–33 months). Primary patency was 62.5% and secondary patency was 90%. Re-intervention due to early occlusion within the first 30 post-intervention days was necessary in 37.5% of all cases. Besides bleeding complications, wound complications, mainly classified as Szilagyi I, occurred in 33% of all patients. A multivariate analysis showed a significant impact of wound complications on primary as well as secondary patency rate (p = 0.032, respectively 0.015). Conclusion Recanalization of obstructed iliac veins and/or the inferior vena cava combined with endophlebectomy of the common femoral vein and arteriovenous fistula implantation is a safe and feasible treatment option in the post-thrombotic syndrome. As wound complications are a common and associated with a significant impact on patency rate, further attempts to improve the procedure are crucial. [ABSTRACT FROM AUTHOR]

Venous obstruction in the cancer population can result in substantial morbidity and, in extreme cases, mortality. While venous obstruction can be caused by both benign and malignant etiologies in this population, the management of malignant venous obstruction as a palliative measure can be somewhat nuanced with respect to nonprocedural and procedural management, both with respect to treatment of the underlying malignancy as well as treatment of venous hypertension, which may be associated with venous thrombosis. Symptom severity, primarymalignancy, functional status, and prognosis are all fundamental to the patient workup and dictate both the timing and extent of endovascular intervention. The morbidity and mortality associated with malignant obstructions of central venous structures, specifically the superior vena cava and inferior vena cava, can be significantly improved with endovascular management in appropriately selected patients. Thus, the pertinent literature regarding the clinical presentation, workup, and endovascular management of malignant central venous obstruction syndromes, with directed attention to superior vena cava syndrome and inferior vena cava syndrome, will be reviewed in this article. [ABSTRACT FROM AUTHOR]

Objectives It has been proposed that varicose veins may be caused by a degree of impeded proximal venous drainage (pelvic venous obstruction) in the same way that biological tubes dilate in response to an obstruction. The venous drainage index (VDI) of air-plethysmography (APG) was used to test this hypothesis. A dependency to elevation manoeuvre was used to provoke gravitational venous drainage. A rapid reduction in calf volume implied good drainage. Methods This was a single centre, proof-of-concept study comparing gravitational venous drainage in varicose vein patients and controls. Leg filling and drainage manoeuvres (elevation to dependency and dependency to elevation) were performed three times per leg in 15 patients (7 male, 8 right) and 16 controls (3 male, 8 right). The VDI was measured in the same way the established venous filling index (VFI) is calculated to quantify filling: VDI = 90% of venous drainage volume (90VDV)/90% venous drainage time (VDT90). Results The patients were significantly older at 58 (41–75) years versus the controls 47 (18–58), p = 0.001. There was no significant difference between the groups in weight, height, BMI or common femoral vein diameter. The patients were (C2 = 8; C3 = 1, C4 = 6), VCSS 4 (1–11) with a median refluxing proximal thigh saphenous diameter of 6 (5–11) mm. The median (inter-quartile range) VFI and VDI (both in mL/s) in the control tests (n = 48) were 1.3 (0.9–1.9) and 33.8 (21.5–55), respectively. The VFI and VDI in the patient tests (n = 41) were significantly faster at 6.2 (3.5–9.4), p < 0.0005, and 47.1 (36.1–66.3), p = 0.002, respectively. Adjusted to a standard mean for each leg, the reproducibility limits (×3) of the VDI was very good at 39.7 (95% CI: 36.5–42.9) in controls and 52.9 (95% CI: 49.7–56.1) in patients. Conclusion The VDI was significantly greater in patients with varicose veins compared to controls. It is unlikely that impeded gravitational drainage is a significant factor in the pathophysiology of varicose veins. [ABSTRACT FROM AUTHOR]

Aims: Despite not being uncommon, limited evidence exists about predisposing factors for venous obstruction in patients with implantable electronic devices. We aimed to assess the prevalence of severe venous obstruction in patients with intravenous devices and identify predictor factors.Methods and Results: A total of 184 patients underwent venography to detect venous obstruction associated with the inserted lead. Vessel obstruction was graded as venous occlusion (complete flow interruption), severe obstruction (narrowing >90%), or mild-moderate obstruction (narrowing 50-90%). Severe venous obstruction/occlusion prevalence was 11.4% (n = 21) and was always asymptomatic. Collateral circulation was found in 80.9% of patients with severe obstruction/occlusion. Twelve patients (6.5%) had 3 leads. The rates of patients with secondary prevention of sudden cardiac death as indication for implantable devices and of those of patients with 3 leads were significantly greater in the group with severe obstruction/occlusion than in the non-severe obstruction/occlusion group (respectively, P = 0.004 and P = 0.03). Logistic analysis adjusted for venous thromboembolic risk factors confirmed that secondary prevention of sudden cardiac death as indication for implantable devices [odds ratio (OR), 7.1; 95% confidence interval (CI): 1.4-35.3; P = 0.017] and the presence of 3 leads (OR, 8.5; 95% CI: 1.75-41.35; P = 0.008) were predictors of severe obstruction/occlusion.Conclusion: In patients with implantable devices, severe venous obstruction prevalence is not negligible and the lack of symptoms does not exclude it. The presence of three leads and sudden cardiac death as indication for implantable devices seem to be associated with the presence of severe venous obstruction/occlusion. [ABSTRACT FROM AUTHOR]

Phlebosclerotic colitis is a rare disease of intestinal ischemia and differentiating it from the typical ischemic colitis. It is caused by venous obstruction due to colonic and mesenteric venous calcification. We report a 36-year-old woman presenting with intermittent abdominal pain. Initial radiologic findings showed multiple tortuous thread-like calcifications in the region of the right side of the colon and transverse colon on plain abdominal radiographs and computed tomography images. In the colonoscopy, edematous darkbluish colonic mucosa, sclerotic colon wall, and multiple ulcers without clear boundaries were observed from the ascending colon to the transverse colon. In the sigmoid colon only showed the edematous dark-bluish colonic mucosa, sclerotic colon wall. On the basis of these findings, we diagnosed the patient as having phlebosclerotic colitis. We report a rare case of phlebosclerotic colitis in healthy young woman. [ABSTRACT FROM AUTHOR]

Objectives: This study was performed to precisely define the underlying pathophysiology in patients with active venous ulcers. Methods: A PubMed search was conducted from 1991 to 2013 to select papers reporting the anatomic and physiologic etiology of ulceration in CEAP Class 6 patients. Studies which did not decipher between active and healed ulcers, did not use clear definitions, or did not give detailed accounts on the distribution/extent of venous pathology were excluded. Using the PRISMA guidelines, 12 studies were selected for further analysis. Results: Primary insufficiency was reportedly the most common etiology of ulcers. Reflux most frequently occurred in the superficial system, either isolated or in conjunction with perforating and/or deep systems. Combined superficial and deep disease was observed in a median of 11.6% of limbs (range of 0-48%). Triple system disease was seen in a median of 31.6% of limbs (range of 22-52%). Isolated deep reflux was infrequently reported (2.1-28.4% of limbs). Previous deep venous thrombosis, reported in a median of 33% of patients, is likely underreported as it may resolve without detectable damage. Conclusion: There is a lack of data in the literature regarding the etiology of chronic active venous ulcers. Insufficiency of the superficial venous system from the micro- to the macro-vasculature has been frequently implicated in the development of venous ulceration. A prospective randomized controlled study is required for more conclusive results. [ABSTRACT FROM AUTHOR]

Popliteal venous aneurysms have always been linked to death from pulmonary embolism. Incidental finding of an asymptomatic popliteal venous aneurysm during duplex scan performed for patients with chronic venous disease is increasingly diagnosed but the relation between popliteal venous aneurysms and chronic venous disease remains unknown. We report the incidental finding of three asymptomatic popliteal venous aneurysms associated with iliac vein compression in patients with chronic venous disease who had undergone computed tomography venography with direct pedal contrast injection. An association between popliteal venous aneurysms and iliac vein compression is postulated. [ABSTRACT FROM PUBLISHER]

Ernest Henry Starling laid the groundwork for our modern understanding of how the interstitial fluid, which he referred to as 'lymph', is regulated. Together with his colleague, William Bayliss, he provided the crucial insight into how fluid is driven out of the capillary to form interstitial fluid. That was to measure (estimate) the capillary pressure in different parts of the circulation and to relate changes in these pressures to altered lymph formation. In addressing how interstitial fluid re-enters the circulation, he was able to show that this occurs not only via the lymphatics, but also by re-entering the capillaries, mediated by the oncotic pressure of the plasma proteins. Starling's discoveries put to rest all notions that the processes of filtration and reabsorption of fluid are mediated by the 'vital activity' of cells. They could be explained entirely on the basis of physic-chemical forces. Based upon his insights from animal experiments, he was able to explain the genesis of edema (dropsy) in a number of disease states, including venous obstruction, cardiac disease and inflammatory conditions. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Aims: The number of procedures involving upgrade or revision of cardiac implantable electronic devices (CIEDs) is increasing and the risks of adding additional leads are significant. Central venous occlusion in patients with pre-existing devices is often asymptomatic and optimal management of such patients in need of device revision/upgrade is not clear. We sought to assess our use of laser lead extraction in overcoming venous obstruction.Methods and Results: Patients in need of device upgrade/revision underwent pre-procedure venography to assess venous patency. In patients with venous occlusion or stenosis severe enough to preclude passage of a hydrophilic guide wire, laser lead extraction with retention of the outer sheath in the vasculature was performed with the aim of maintaining a patent channel through which new leads could be implanted. Data were recorded on a dedicated database and patient outcomes were assessed. Between July 2004 and April 2012, laser lead extractions were performed in 71 patients scheduled for device upgrade/revision who had occluded or functionally obstructed venous anatomy. New leads were successfully implanted across the obstruction in 67 (94%) cases. There were two major complications (infection) and four minor complications with no peri-procedural mortality. Device follow-up was satisfactory in 65 (92%) cases with mean follow-up up to 26 ± 19 months.Conclusion: Laser lead extraction is a safe and effective option when managing patients with central venous obstruction in need of CIED revision or upgrade. [ABSTRACT FROM AUTHOR]

Aims The number of procedures involving upgrade or revision of cardiac implantable electronic devices (CIEDs) is increasing and the risks of adding additional leads are significant. Central venous occlusion in patients with pre-existing devices is often asymptomatic and optimal management of such patients in need of device revision/upgrade is not clear. We sought to assess our use of laser lead extraction in overcoming venous obstruction. Methods and results Patients in need of device upgrade/revision underwent pre-procedure venography to assess venous patency. In patients with venous occlusion or stenosis severe enough to preclude passage of a hydrophilic guide wire, laser lead extraction with retention of the outer sheath in the vasculature was performed with the aim of maintaining a patent channel through which new leads could be implanted. Data were recorded on a dedicated database and patient outcomes were assessed. Between July 2004 and April 2012, laser lead extractions were performed in 71 patients scheduled for device upgrade/revision who had occluded or functionally obstructed venous anatomy. New leads were successfully implanted across the obstruction in 67 (94%) cases. There were two major complications (infection) and four minor complications with no peri-procedural mortality. Device follow-up was satisfactory in 65 (92%) cases with mean follow-up up to 26 ± 19 months. Conclusion Laser lead extraction is a safe and effective option when managing patients with central venous obstruction in need of CIED revision or upgrade. [ABSTRACT FROM PUBLISHER]

Objectives: To report our initial experience using direct multidetector computed tomography venography (MDCT-V) for imaging lower limb deep veins. CT findings in limbs with chronic venous disease (CVD) were compared with contralateral healthy limbs. Methods: MDCT-V with bilateral direct pedal injection of contrast was used to image the deep veins in both lower limbs. Eight patients with unilateral lower limb CVD of varying severity (according to the Clinico-Etiological-Anatomical and Pathological classification [CEAP] class 2-6) were studied. Five patients had primary CVD, while three patients had CVD secondary to previous deep vein thrombosis. Results: Deep venous obstruction (>50%) or occlusion was identified in all CVD limbs and was not seen in contralateral healthy limbs. These lesions were not only iliac, were not exclusively present in advanced CVD and were independent of the presence or absence of deep venous reflux. Conclusion: Morphologically significant lesions could be underlying in patients with clinically significant CVD. Direct MDCT-V provides clear reconstructable cross-sectional images of the whole deep venous tree, including infrainguinal areas, beyond the reach of intravascular ultrasound. Utilization of new venous imaging modalities may uncover previously undiagnosed and potentially treatable venous pathology in patients with CVD. [ABSTRACT FROM AUTHOR]

A 26-year-old man presented with acute renal insufficiency, and severe lower extremity swelling. Computed tomographic scan revealed retroperitoneal lymphadenopathy encasing both ureters and the inferior vena cava. He underwent placement of ureteral stents to relieve the obstruction and afterward underwent lymph node biopsy, which revealed Kaposi's sarcoma. He subsequently was diagnosed with acquired immunodeficiency syndrome. Abdominal and lower extremity venous duplex ultrasound did not show any evidence of deep vein thrombosis. The inferior vena cava measured 3.5 mm in diameter and was encased by retroperitoneal lymphadenopathy. Bilateral transfemoral venography and intravascular ultrasound demonstrated significant compression of the inferior vena cava below the renal veins. Endovascular treatment was followed with primary stenting under intravascular ultrasound guidance. His symptoms improved with reduction in swelling. At 1-year follow-up, the patient was ambulatory with mild symptoms, and on venography the iliac vein and inferior vena cava stents were widely patent. [ABSTRACT FROM AUTHOR]

Background and aims. Prospective data on development of venous obstruction after electrode implantation are limited. We performed a prospective study on 150 patients undergoing first pacemaker implantation. Methods. Venographies at base-line and 6 months postimplantation in all patients, 50 patients included into a long-term follow-up of a mean of 2.4 years after implantation. Results. At 6 months 14% had obstructions, but only 1 patient (0.7%) developed acute symptomatic upper extremity venous thrombosis. Pulmonary embolism (PE) was encountered in 5 (3.3%). After 6 months only 2 patients experienced pain in ipsilateral arm, but none had edema of arm, neck or head, or clinical PE. The 5 patients with total venous occlusion (TVO) at 6 months had no localized symptoms. Late venographic abnormalities developed in 5 (10%) patients: 4 TVOs and 1 stenosis. Two of the new lesions developed among 25 patients with normal 6-month venograms. Overall, TVO was detected in 9 of 150 patients. No factors emerged as independent predictors of total occlusion in multiple regression analysis. Conclusions. TVO is not uncommon after pacemaker implantation, and mostly occurs without any localizing symptoms. Most venous lesions seem to develop during the first months postimplantation, but late and unpredictable TVO may also occur. [ABSTRACT FROM AUTHOR]

Aim: Venous obstruction following transvenous device implantation rarely cause immediate clinical problems. When lead revision or device upgrade is indicated, venous obstruction become a significant challenge. The aim of this study was to determine the predictors of venous obstruction after transvenous device implantation, and to asess likely effects of antiplatelet/anticoagulant drugs in preventing venous thrombosis. [ABSTRACT FROM PUBLISHER]

Background: Venous occlusion is a recognized complication of transvenous pacing, and lead cross-sectional area indexed to body surface area (BSA) has been used to predict venous obstruction in children. Objective: The aim of this study was to identify the risk factors and incidence of angiographic venous obstruction after transvenous lead implantation in both children and young adults. Methods: Contrast venography was obtained in 85 of 90 consecutive patients undergoing repeat pacemaker or ICD procedures from 2002 to 2004 at a single cardiac center. Venograms were graded as complete venous obstruction, significant partial obstruction (>70% with collaterals), or patent. Results: The cohort had a median age of 15.0 years at implant and was divided into two age groups: 3–12 years (n = 35) and 13 years and over (n = 50). After a median interval of 6.5 years, complete obstruction was seen in 11 of 85 patients (13%) and partial obstruction in another 10 patients (12%). No significant differences were seen in the incidence of obstruction between the two age groups although younger patients had a larger lead indexed to BSA ratio (6.82 vs 5.05, P = 0.005). There were no significant differences between obstructed and nonobstructed patients in relation to age, size, growth, or lead factors. Conclusion: Transvenous lead systems implanted in young children have a similar incidence of venous occlusion compared to older patients. Furthermore, patient age, body size, and lead characteristics at implant do not clearly predict venous occlusion. [ABSTRACT FROM AUTHOR]

Background: High capture thresholds, decreased electrical sensing, and lead fractures continue to be a problem in children undergoing transvenous pacing. The clinician must therefore decide at the time of pacing system revision to either abandon chronically implanted transvenous pacing leads or extract them. Methods: We report our experience using an excimer laser-assisted (LA) strategy for removing chronically implanted pacing (36) and implantable cardioverter/defibrillator (ICD) (7) leads in children and young adults. The study population consisted of 25 patients, in whom 29 procedures were performed. The patients ranged in age from 8.4 to 39.9 years, median age was 13.9 years, at the time of the extraction procedure. In all procedures, a Spectranectics™ locking stylet and excimer laser sheath were used to assist in lead extraction. Results: Lead removal was complete for 39 (91%) leads, and partial for four leads. In two patients, the pacing lead tip was retained and in two, the ring electrode from a bipolar pacing lead was left in situ . All ICD leads were removed completely. Two major complications occurred—cardiac perforation and tamponade (1), and thrombosis of the left subclavian/innominate vein (1). LA extraction facilitated the implantation of new pacing or ICD leads in three patients with obstructed venous access. Conclusions: Removal of pacing and ICD leads using an excimer LA technique was highly successful. Lead removal was complete in 91%. The most common indication for lead removal in our study was lead fracture. Complications were few, but may be significant. [ABSTRACT FROM AUTHOR]

This study was performed to assess the efficiency of computerized strain-gauge plethysmography for evaluation of venous volume (VV) and outflow capacity of the upper extremities and to receive reference values. For this purpose, we investigated 34 healthy controls; 16 males and 18 females with a mean age of 45 years (range 31–58 years). These results were compared with those obtained in 32 patients with earlier spontaneous deep venous thrombosis (DVT) in the upper extremities. In the control group, there was no difference between right and left arm and none of the variables were influenced by age and gender. Venous volume and rate of venous emptying (VE) were significantly lower in arms with earlier DVT than in those without (VV: DVT arms 3·7 ± 0·96 ml 100ml−1 and controls 4·6 ± 0·81 ml 100ml−1; VE: DVT arms 79 ± 24 ml 100ml−1 min−1 and controls 110 ± 21 ml 100ml−1 min−1). Repeated measurements had a coefficient of variation of approximately 10% in both groups. We found the device easy to handle and the results demonstrates that this is a useful method to study venous function in upper extremities. This implicates that computerized strain-gauge plethysmography is an efficient method both for clinical diagnostic routine and research studies of circulatory changes in acute and chronic DVT in the upper extremity. [ABSTRACT FROM AUTHOR]

Objective: To establish a method of implantation for device leads across total venous occlusions. Background: Indications for pacemaker and implantable cardiac defibrillator implantation continue to expand. Chronic venous occlusions are increasingly encountered with lead placement. Some degree of obstruction can be as high as 13% before device implantation and 50% after transvenous device implantation. We report an approach of venoplasty/dilatation of chronic total occlusions to allow lead placement. Methods: From January 1, 2002 through December 16, 2004, 1,356 systems (initial and upgrade) were implanted at the University of Virginia. At the time of device implant, seven patients were noted to have chronic venous occlusions and alternative access was precluded. Four of the seven patients had an existing system; the other three received initial implantations. Subsequently, these seven patients had a 5 Fr catheter placed in the basilic/axillary/subclavian vein and a venogram was obtained to demonstrate the area of chronic occlusion. A guide wire was advanced across the lesion for initial recanalization. Dilatation or venoplasty was performed at the occluded site. A guide wire was retained across the lesion and the patient underwent lead implantation. Results: In all seven patients, recanalization was achieved and leads were successfully placed. There were no complications or damage to the vessels or existing leads. Conclusions: Venoplasty or dilatation of chronic total venous occlusion is a safe and effective technique, which allows for placement of transvenous leads. [ABSTRACT FROM AUTHOR]

STOJANOV, P.,et al.: Prevalence of Venous Obstruction in Permanent Endovenous Pacing in Newborns and Infants: Follow-Up Study. Objective:We examined the prevalence of venous obstruction in 12 newborns and infants with permanent endovenous ventricular pacing, clinically, and by ultrasonographic assessment of hemodynamics (spontaneity, phasicity, velocity, and turbulence of flow) and morphologic parameters (compressibility, wall thickness, and thrombus presence).Material and Methods:All implantations of single ventricular unipolar endovenous steroid leads, were performed via cephalic vein, and pacemakers were placed in subcutaneous pocket in right prepectoral region. After the vascular surgeon has carefully examined all children for presence of venous collaterals in the chest wall, morphologic and hemodynamic parameters of the subclavian, axillary, and internal jugular veins, were assessed by linear-array color Doppler. Lead capacity (LC) was calculated for each patient.Results:Mean age of patients at implant was 6.2 months (range 1 day–12 months), mean weight 6.5 kg (range 2.25–10 kg), and mean height 60.9 cm (range 48–78 cm). Mean LC was 1.99 (range 1.14–3.07). Total follow-up was 1023 and mean follow-up 85.2 pacing months (range 3–156). No clinical signs of venous obstruction were observed. Mild stenosis (20%) of subclavian vein was found by color Doppler in 2/12 patients. Both had adequate lead diameter for body surface.Conclusion:Permanent endovenous pacing is a feasible procedure, even in children of body weight less than 10 kg, with quite acceptable impact on venous system patency.(PACE 2005; 28:361–365) [ABSTRACT FROM AUTHOR]

Aims The number of implantable cardioverter defibrillator (ICD) implantations, as well as follow-up procedures such as generator exchanges, lead revisions and lead system upgrades, is ever-increasing. Lead revisions and implantation of additional leads require venous access at the site of the previous ICD implantation. The aim of our study was therefore to evaluate the incidence of venous obstruction after chronic transvenous ICD system implantation. Methods and results One hundred and five consecutive patients admitted for their first elective ICD generator replacement were included. All patients underwent bilateral contrast venography and the images were analyzed by two attending radiologists. Venous obstruction was classified as moderate stenosis (50–75% diameter reduction), severe stenosis (>75%) or total occlusion. Venous obstruction of various degrees was found in 25% of the patients. Complete occlusion was found in 9%, severe stenosis in 6% and moderate stenosis in 10% of the patients. The incidence of venous obstruction was increased in patients with a pacemaker prior to the initial ICD system implantation (67%). No difference was found in patients with a single defibrillator lead compared with patients who had an additional superior vena cava (SVC) shocking coil. However, the presence of a second shocking coil in the SVC incorporated in a single ICD lead was associated with an increased incidence of venous obstruction. No difference was found between silicone and polyurethane insulated leads. Conclusion This study shows that venous obstruction occurs relatively frequently after ICD implantation. Therefore, contrast venography should always be obtained if malfunction of a preexistent lead is suspected or a system upgrade is considered. [ABSTRACT FROM PUBLISHER]

Objective: The aim of this study was to critically appraise and synthesize the published evidence regarding the short- and long-term efficacy/effectiveness of surgical techniques for patients with deep venous insufficiency (DVI) refractory to other forms of management. Methods: All original, published studies on non-pregnant human patients undergoing treatment for deep or mixed deep/superficial/perforator chronic venous insufficiency were identified by systematically searching PubMed, EMBASE, CINAHL, The Cochrane Library, Science Citation Index and the websites of various health technology assessment agencies, research registers and guidelines sites, from January 1990 to July 2003. No language restriction was applied. Results: A total of two randomized controlled trials and 12 non-randomized comparative studies reported on a variety of procedures ranging from superficial venous surgery (SVS) and subfascial endoscopic perforator surgery (SEPS), through to deep venous reconstruction (including valvuloplasty, transplantation and transposition) for the treatment of DVI. Limited evidence suggested that combined SVS/valvuloplasty is a relatively safe procedure that is potentially more effective than SVS alone in preventing ulcer recurrence in patients with primary DVI in both the short- and mid-term. Evidence for the efficacy of valvuloplasty, bypass, transplantation, SEPS and iliac stenting in the treatment of DVI was inconclusive. The optimal surgery for patients with deep venous obstruction or secondary valvular incompetence remains unclear. Conclusions: It is unlikely that a large randomized, or even non-randomized, controlled trial will be conducted to ascertain the safety and efficacy of surgery for DVI. However, standardized reporting and collection of data in a registry would be a move forward. In addition, professional bodies should consider providing guidance, in the form of an evidence-based treatment algorithm, that would define when to perform SVS in patients with mixed or deep venous insufficiency and what type of deep venous surgery is considered appropriate for different indications. A prime focus of future research may be to understand why less invasive treatments have failed in patients requiring surgery for DVI and to identify those patients who would benefit most from early surgical intervention. [ABSTRACT FROM AUTHOR]

We used photoplethysmography (PPG) to measure the relative changes in the anterior tibial muscle blood flow (MBF) in response to exercise when intramuscular pressure (IMP) was elevated (the test leg) or when IMP was normal (the control leg). The elevated IMP was induced by applying venous obstruction of 40 mmHg or 65 mmHg (thigh tourniquet) of a casted leg in eight healthy subjects. Subjects performed dorsiflexion of both feet in sitting position with or without venous obstruction. IMP at rest after exercise increased to 39.4±7.9 mmHg or to 58.3±8.4 mmHg, respectively. MBF at rest before exercise was 100%. At rest after exercise, it increased to 184±52.6% in the test leg when IMP was 39.4 mmHg, and to 279±108.3% in the control leg. MBF at rest after exercise was 156±58.2% in the test leg when IMP was 58.3 mmHg and 303±95.3% in the control leg. The abnormally elevated IMP induced by venous obstruction of a casted leg reduced MBF at rest after exercise. PPG seems to be a suitable method to measure changes in MBF in response to exercise and in experimental conditions with abnormally elevated IMP. [ABSTRACT FROM AUTHOR]

Several investigators have shown that the incidence of venous obstruction after pacemaker implantation was observed in 31–50% of pacemaker patients. However, these previous reports did not investigate the venous system prior to implantation. The aim of this study was to determine the incidence and risk factors for venous obstruction in patients with transvenous pacing leads. The study included 131 consecutive patients (64 men, 67 women; mean age 71.3 ± 9.8 years) who were investigated using intravenous digital subtraction angiography (DSA) before and after permanent pacemaker implantation. Follow-up DSA was performed for a mean interval of 44 ± 6 months after pacemaker lead implantation in 79 of 131 patients. A diameter narrowing > 60% was defined as an obstruction. Prior to implantation of pacing leads, venous obstruction was present in 18 (13.7%) of 131 patients. In 15 of these 18 patients, the obstruction was present at the site of the left innominate vein. Follow-up DSA, after implantation of pacing leads, showed that venous obstruction was observed in 26 (32.9%) of 79 patients. There were no significant differences between obstruction and nonobstruction groups in terms of age, sex, cardiothoracic ratio, left atrial dimension, left ventricular ejection fraction, baseline heart diseases for indication of pacemaker implantation, or number and body size of pacing leads. Neither clinical symptoms nor abnormal physical findings were observed in any patients. In conclusion, the incidence of venous obstruction after pacing lead implantation is less than that of previous reports, which might be related to the incidence of venous obstruction before pacing leads implantation. [ABSTRACT FROM AUTHOR]

A 43-year-old man with a large ancient schwannoma of the pelvis, presenting with varicose veins, is reported. Ancient schwannoma (neurilemmoma) is a benign tumour of nerve sheath origin characterised histologically by features of severe degeneration and which rarely can grow to a large size. Malignant transformation, though reported, is extremely rare. [ABSTRACT FROM AUTHOR]

Gianturco-Rösch expandable Z-stents were used in 22 patients with superior vena cava syndrome (SVCS). Stents were placed in all patients in the SVC and in 17 patients, also into the innominate veins. Stent placement resulted in complete relief of symptoms in all patients. Twenty-one patients had no SVCS recurrence from 1 to 16 months, to their death, or to the present time. SVCS recurred only in 1 patient 9 months after stent placement due to tumor ingrowth and secondary thrombosis. Based on ours and on other reported experiences, expandable metallic stents are effective devices for treatment of the SVCS which is difficult to manage by other means. [ABSTRACT FROM AUTHOR]

Erections were produced in dogs by stimulating the pudendal, the pelvic and the hypogastric nerves either singly or in combination and angiographic studies were then performed. During an erection an increase in blood flow to the erectile tissue could be demonstrated together with an impaired venous return. [ABSTRACT FROM AUTHOR]

Transvenous placement of permanent pacemaker leads is currently the most common method for permanent cardiac pacing. Venous abnormalities, in particular venous stenosis or thrombosis (or both) frequently have been described, although most patients remain asymptomatic because of the development of an adequate venous collateral circulation. Venous obstruction often first becomes apparent during pacemaker lead revision, when difficulty passing the new pacing lead is encountered. In this report, we present two cases of venous stenosis and thrombosis due to permanent transvenous pacemaker electrodes and the use of percutaneous transluminal balloon venoplasty to relieve the venous obstruction. [ABSTRACT FROM AUTHOR]

Palma and Esperon described the first femoro-femoral cross-over bypass for iliac vein obstruction in 1958, and Kistner performed the first valve reconstruction for deep vein reflux in 1968. Such surgical development has stimulated better diagnostic methods that now form the foundation for a classification of chronic venous disease, and surgery has been supported by, and sometimes replaced by, the rapid progress in endovascular procedures with angioplasty and stenting. The ability now exists to relieve obstruction and repair reflux in the deep veins, and the results in the successful cases demonstrate the improvement that follows correction of the physiologic abnormalities. The detail in workup required to achieve an accurate diagnosis that is adequate enough to guide surgical treatment in these cases has set a new standard for the diagnosis of chronic venous disease that incorporates the clinical state, etiology, pathophysiology and anatomic distribution of the venous problem, and is incorporated in the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification. The challenge at this time is to produce a reliable set of data that demonstrate the results of treatment in patients with chronic venous disease by conventional methods of bandaging, rest and elevation as well as specific surgical correction of venous obstruction and reflux and to follow these cases over a significant period of time. [ABSTRACT FROM AUTHOR]

To determine the incidence and risk factors for venous obstruction in children with transvenous pacing leads, 63 children were evaluated clinically and echocardiographically. Patients with abnormal clinical and/or echocardiographic findings were further investigated by venography. Thirteen patients (21%) had evidence of venous obstruction. Venography in 11 (2 refused) showed that severity of obstruction (as defined by percentage of luminal narrowing) was complete (100%) in 3, severe (> 90%) in 4. and moderate (60%-90%) in 5 (1 patient having 2 sites of obstruction). Risk factors for obstruction in 55 patients with single implantation procedures (10 with ohstruction: 18%) were sought. Total cross-sectional area of lead(s) was indexed to body surface area at implantation (INDEX). Patients with obstruction had a higher mean INDEX (7.6 ± 1.6 mm²/m²) than patients without obstruction (4.9 ± 2.0 mm²/m²); P < 0.0002). Receiver-operator characteristic curves showed an INDEX > 6.6 mm²/m² to best predict obstruction, with a sensitivity of 90% and specificity of 84%. Since pacing is lifelong, sizing of transvenous leads to the child is important to prevent obstruction and preserve venous access. [ABSTRACT FROM AUTHOR]

An 85-year-old man presented with bilateral leg edema and urinary incontinence. Abdominal examination revealed a severely distended bladder. Venous duplex of the legs demonstrated monophasic waveforms bilaterally, suggesting obstruction of proximal lower extremity veins. Relief of urinary obstruction was associated with the prompt return of normal respiratory variation of flow in the veins and improvement of leg swelling. Non-thrombotic obstruction of the proximal veins of the lower extremities by a severely enlarged urinary bladder is an infrequent yet potentially reversible cause of lower extremity edema. Subtle clues in the Doppler waveforms of an otherwise normal lower extremity venous duplex examination are crucial in establishing this diagnosis. [ABSTRACT FROM AUTHOR]

Upper venous return to the heart can be obstructed by any number of pathologies and often leads to formation of collateral pathways around the obstruction. This case report describes a thrombotic obstruction of the left subclavian and brachiocephalic veins and a collateral pathway involving recanalization of the umbilical vein. Even more rare and unique is the anastomosis of the recanalized umbilical vein to the middle and left hepatic vein rather than the portal vein. The anatomy of the expected collateral pathways and the anastomotic vascular anomaly is described in detail, including a discussion of the embryological development of the system. [ABSTRACT FROM AUTHOR]

We describe a case of a 49-year-old woman with stage-IIIB lung adenocarcinoma who experienced an acute superior vena cava syndrome related to an implanted central venous catheter without associated venous thrombosis. The catheter was surgically implanted for chemotherapy. Superior vena cava syndrome appeared after the procedure and was due to insertion of the catheter through a subclinical stenosis of the superior vena cava. Complete resolution of the patient's symptoms was obtained using stent placement and endovascular repositioning of the catheter tip. [ABSTRACT FROM AUTHOR]

Colonic varices are a rare cause of lower gastrointestinal bleeding, with approximately 40 cases reported in the literature. Portal hypertension is by far the most common cause of colonic varices, with local mesenteric vein obstruction constituting a very rare cause. We present a case of colonic varices not associated with portal hypertension but secondary to prior sigmoid resection and inferior mesenteric vein occlusion. [ABSTRACT FROM AUTHOR]

The article presents a case study of osteochondroma in a 20-year old woman causing obstruction in the femoral vein. The woman reported a 5-year history of enlarging lump in the right groin. Examination of the lump indicated a pelvic exostosis causing femoral vein obstruction. The case was simplified by venography and the patient made complete recovery after a successful operation.

OBJECTIVES Superior venous outflow obstruction affects cerebral perfusion negatively by reducing cerebral perfusion pressure (CPP). We present a randomized study designed to compare two alternative strategies to preserve the CPP during superior vena cava (SVC) congestion and cardiopulmonary bypass (CPB). METHODS Fourteen pigs on bi-caval CPB were subjected to 75% occlusion of the SVC flow. CPP was restored either by vasopressor treatment (VP, n = 7) or by partial relief (PR) of the congestion (n = 7). The cerebral effects of the interventions were studied for 60 min with intracranial pressure (ICP) monitoring, cerebral blood flow measurement, the near-infrared light spectroscopy tissue oxygen saturation index (StO2), arterial and venous blood gas analyses and serial measurements of the glial cell damage marker protein S100β. RESULTS Both strategies restored the CPP to baseline levels and no signs of severe ischaemia were observed. In the PR group, the venous and ICPs were normalized in response to the intervention, while in the VP group those parameters remained elevated throughout the experiment. The haemoglobin oxygen saturation in the sagittal sinus (SsagO2) was increased by both VP and PR, while significant improvement in the StO2 was observed only in the PR group. The S100β concentrations were similar in the two groups. CONCLUSIONS Experimental SVC obstruction during CPB may reduce the CPP, resulting in impaired cerebral perfusion. Both vasopressor treatment and improved venous drainage can, in the short term, individually restore the CPP during these circumstances. [ABSTRACT FROM AUTHOR]