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European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

The aim was to assess the anatomical distribution of acute deep venous thrombosis (DVT) with a focus on iliofemoral DVT, and, in particular, to characterise thrombus in the common femoral vein (CFV) and the deep femoral vein (DFV).A one year prospective study including patients older than 18 years of age with an acute first time DVT according to ultrasound examination at one of three university hospitals in Copenhagen, Denmark. Thrombus location and extent were registered and divided into five segments: calf veins; popliteal vein; femoral and deep femoral vein; common femoral vein; and iliac veins and/or the inferior vena cava. Thrombus appearance of the CFV and the DFV (partial or occlusive) was examined in detail.Acute DVTs were identified in 203 extremities in 200 patients (58% male). The median age of the patients was 68 years (range 19-92 years), and left-sided DVT was observed in 56%. Iliofemoral DVT was present in 54 (27.0%) patients. Thrombus involving the CFV but not the iliac veins (CFV group) was seen in 28 patients; the remaining 26 had involvement of the iliac veins (iliac group). Thrombus in the CFV was more likely to be occlusive in the iliac group than in the CFV group (77% vs. 4%; p .001). Thrombus in the DFV was more often occlusive in the iliac group than in the CFV group (81% vs. 11%; p .001). The DFV was free of thrombus in 12% of patients in the iliac group and in 64% of those in the CFV group.The presence of occlusive thrombus in the CFV and/or in the DFV pointed to a DVT also involving the ipsilateral iliac veins. Thrombosis of the deep leg veins extending into the CFV below the inguinal ligament was more likely to be partial in the CFV, mainly due to inflow from the DFV.

Respiratory variability of peak velocities (RVPV) in the common femoral vein measured with ultrasound can reveal venous outflow obstruction. Pulse wave (PW) Doppler is the gold standard for venous velocity estimation of the lower extremities. PW Doppler measurements are angle dependent, whereas vector flow imaging (VFI) can yield angle-independent measures. The hypothesis of the present study was that VFI can provide RVPV estimations without the angle dependency of PW Doppler for an improved venous disease assessment. Sixty-seven patients with symptomatic chronic venous disease were included in the study. On average, VFI measured a lower RVPV than PW Doppler (VFI: 14.11 cm/s; PW: 17.32 cm/s, p = 0.002) with a non-significant improved precision compared with PW Doppler (VFI: 21.09%; PW: 26.49%, p = 0.08). In a flow phantom, VFI had improved accuracy (p0.01) and equal precision compared with PW Doppler. The study indicated that VFI can characterize the hemodynamic fluctuations in the common femoral vein.

Objective To identify factors associated with long-term treatment success after catheter-directed thrombolysis (CDT) for acute deep venous thrombosis (DVT) involving the ilio-femoral vein. Material and methods This was a non-randomised observational cohort study. From 1999 to 2013, 191 consecutive patients (203 limbs) attending a tertiary vascular centre at Gentofte University Hospital, Denmark underwent CDT. All patients had ultrasonically verified acute ilio-femoral DVT with open distal popliteal vein and calf veins. Patients were seen in the outpatient clinic 6 weeks, 3, 6, and 12 months, and annually thereafter following the DVT. Successful outcome was defined as patent deep veins without reflux on Duplex ultrasound scanning (DUS). Data were collected prospectively as per protocol and analysed retrospectively. Results Median age was 27 years (range 14–74 years) and overall median lysis time was 56 h (range 22–146 h). A stent was placed in 106 limbs (52%). Six patients had major bleeding. The median follow-up was 5 years (range 1 month–14.3 years). The cumulative rate of patients with deep patent veins without reflux at 7 years was 79%. Multivariate Cox regression analyses showed that symptom duration >2 weeks (hazard ratio (HR) 2.78, 95% CI 1.14–6.73) and chronic post-thrombotic lesions (HR 19.3, 95% CI 7.29–51.2) were significantly associated with poorer outcome, while the pulse-spray technique (HR 0.15, 95% CI 0.05–0.48) was associated with better outcome. Age, gender, side, IVC atresia, stenting, and lysis duration did not affect outcome. Conclusion In this observational study of CDT for ilio-femoral DVT it was demonstrated that symptom duration less than 2 weeks, absence of chronic post-thrombotic lesions and use of the pulse-spray technique for CDT resulted in better primary patency including normal valve function in the long term.

BackgroundPostthrombotic syndrome (PTS) is a common complication after iliofemoral venous thrombosis, often resulting in poor quality of life (QOL) among the affected patients. This study assessed development of PTS and its effect on QOL among patients treated for iliofemoral venous thrombosis by catheter-directed thrombolysis.MethodsPatients admitted with an iliofemoral venous thrombosis and treated with catheter-directed thrombolysis at Gentofte University Hospital from 1999 to 2008 were invited to participate. Duplex ultrasound imaging was used to assess venous patency and valve function. Each patient completed the generic Short-Form 36-item (SF-36) health survey assessment, producing physical component (PCS) and mental component summary (MCS) scores, and the disease-specific Venous Insufficiency Epidemiological and Economic Study (VEINES)-Quality of Life (QOL)/Symptoms (Sym), questionnaires to assess QOL. PTS was assessed using the Villalta scale.ResultsThe study included 109 patients. Median follow-up was 71 months. PTS developed in 18 patients (16.5%) and of those, initial thrombolysis was successful in 13. Patients with PTS had significantly worse mean ± standard deviation scores than patients without PTS on VEINES-QOL (34.2 ± 9.6 vs 53.1 ± 6.6; P < .0001), VEINES-Sym (34.0 ± 8.8 vs 53.2 ± 6.6; P < .0001), SF-36 MCS (44.2 ± 15.5 vs 52.3 ± 11.0; P = .005), and SF-36 PCS (42.3 ± 9.1 vs 53.5 ± 7.8; P < .0001) subscales. Patients with reflux or chronic occlusions, or both, had significantly lower mean ± SD scores than patients with patent veins without reflux on VEINES-QOL (43.5 ± 14.3 vs 51.0 ± 8.8; P = .044) and SF-36 PCS (47.2 ± 10.9 vs 52.4 ± 8.5; P = .049) scales.ConclusionPTS was associated with worse QOL, although only a few patients developed PTS after catheter-directed thrombolysis of iliofemoral venous thrombosis. Patients with patent veins and sufficient valves have higher QOL scores than patients with reflux and occluded veins.

Purpose To assess the effectiveness and clinical outcomes of catheter-directed thrombolysis in patients with atresia of the inferior vena cava (IVC) and acute iliofemoral deep vein thrombosis (DVT). Materials and Methods From 2001 to 2009, 11 patients (median age, 32 y) with atresia of the IVC and acute iliofemoral DVT in 13 limbs were admitted for catheter-directed thrombolysis. Through a multiple–side hole catheter inserted in the popliteal vein, continuous pulse-spray infusion of tissue plasminogen activator and heparin was performed. Thrombolysis was terminated when all thrombus was resolved and venous outflow through the paravertebral collateral vessels was achieved. After thrombolysis, all patients received lifelong anticoagulation and compression stockings and were followed up at regular intervals. Results Ultrasound or computed tomography revealed absence of the suprarenal segment of the IVC in two patients, and nine were diagnosed with absence of the infrarenal segment of the IVC. Median treatment time was 58 hours (range, 42–95 h). No deaths or serious complications occurred. Overall, complications were observed in four patients, one of whom required blood transfusion. Three patients were diagnosed with thrombophilia. Median follow-up was 37 months (range, 51 d to 96 mo). All patients had patent deep veins and one developed reflux in the popliteal fossa after 4 years. No thromboembolic recurrences were observed during follow-up. Conclusions Catheter-directed thrombolysis of patients with acute iliofemoral DVT and atresia of the IVC is a viable treatment option, as reasonable clinical outcomes can be obtained.

Objectives The study aimed to evaluate observer agreement between two experienced ultrasound operators examining deep venous reflux assessed by duplex ultrasound (DU) using either manual or pneumatic cuff compression. In addition, the two methods were compared with each other with regard to immediate "eyeballing" and direct measurements of reflux time from Doppler flow curves. Design This was a case control study. Material and Methods Cases were found among patients admitted to our department with deep venous thrombosis of the iliac, femoral or popliteal veins during the period 1999–2006. Controls were departmental staff. DU was used to assess valve function in the common femoral, femoral and popliteal veins in the standing position using manual and pneumatic cuff compression. The investigators were blinded to the other's observations. Observer agreement was assessed using the Rasch model for binary items. Results Twenty patients and 20 controls participated in the study and were analysed by the Rasch model. Quantitative measurement was found to be more reliable than "eyeballing", and cuff compression was more reproducible in identifying reflux than manual compression. We found that assessment by manual measurement by one investigator functioned at a lower level of expertise than for the other investigator. Conclusions Cuff measurements were more accurate in diagnosing deep venous reflux than manual measurements, and measurement was more accurate than "eyeballing". The fact that assessment by manual compression by one investigator functioned at a lower level of expertise suggests that cuff measurement might be the optimal assessment method, especially in the difficult cases.

Objectives Intravenous thrombolysis (IVT) has proven effective in the treatment of acute cerebral ischaemic attack in selected cases. In the presence of a carotid artery stenosis, such patients may be candidates for carotid endarterectomy (CEA). Few studies have been made on the safety of CEA performed after IVT. Design This was a retrospective study. Data including 30 days' follow-up were obtained from medical records and from a vascular registry. Materials A consecutive series of 306 patients were operated on for symptomatic carotid artery stenosis during a 5-year period. Among these, 22 (7%) patients had been treated with IVT for an acute cerebral ischaemic attack prior to CEA and 284 (93%) patients had CEA only. Methods IVT as well as CEA was performed following established guidelines. CEA was performed in median 11 days (25 and 75% percentiles: 7–13 days) after the neurological index event in patients having undergone IVT and 12 days (25 and 75% percentiles: 8–21 days) in patients undergoing CEA only. Results The 30 days' stroke and death rate was 0% (95% confidence interval (CI): 0–15%) in patients who had IVT before CEA and 2.4% (95% CI: 0.9–4.7%) in patients who underwent CEA only. Conclusion Our experience indicates that CEA performed after IVT for acute cerebral ischaemic attack is safe, confirming existing but sparse publications. However, our series is small and our study possesses a number of limitations. Thus, our results cannot necessarily be transferred to other units, who instead should perform similar studies, preferably together.

Coagulation and fibrinolysis were investigated in 14 claudicants undergoing percutaneous transluminal angioplasty (PTA) for femoropopliteal artery lesions. Cross-linked fibrin degradation products (XL-FDP), tissue plasminogen activator (t-PA) antigen, fibrinopeptide A (FPA), and plasminogen activator inhibitor-1 (PAI-1) activity were measured in peripheral blood. XL-FDP and t-PA increased, and FPA and PAI-1 decreased significantly after angioplasty. XL-FDP increased from baseline 266 +/- 72 ng/ml to 481 +/- 239 ng/ml (p0.0005) 30 min after PTA, indicating mural thrombus formation in spite of the significant fall in FPA influenced by heparin. A groin haematoma developed after PTA in 4/6 patients, who received more than 5600 IU heparin and in 1/8 patients receiving smaller dosages. The alterations in PAI-1 showed no correlation with those of t-PA, whereas heparin had a sparing effect on PAI-1 consumption. These findings may indicate that PAI-1 acts as a thrombin inhibitor following deep vessel wall injury by angioplasty. In two patients, who had signs of rethrombosis on the next day, residual FPA was relatively high, XL-FDP peaked at 3530 +/- 1170 ng/ml, and t-PA increased by 2.6 +/- 1.0 ng/ml. The corresponding values in patients with an uncomplicated course were 406 +/- 89 ng/ml (p0.0001) and 0.1 +/- 0.5 ng/ml (p0.02). We conclude that thrombin promotes activation of coagulation and fibrinolysis in femoropopliteal PTA. Instability between these counteracting systems resulting in thrombosis is not prevented by conventional heparin administration at dosages causing bleeding complications.

We have used T1 MR images to map the distribution of water contributing to the edema which follows femoropopliteal bypass surgery. Spin-echo images and true parametric T1 images were made at the same time. The spin-echo images were used to identify the tissue anatomy. The extra fluid contributing to the edema distributes in two phases: a volume equivalent to 5% of the leg volume is distributed throughout the leg tissue, while the excess fluid collects in a localized annulus lying adjacent to the fascia. The T1 in the annulus can be as high as 4 sec, indicating build up of free fluid in this region. Although most of this free fluid lies in the subcutaneous fat, there is a component which lies underneath the fascia in the muscle compartment.