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

Objective Stenting of the iliac veins is increasingly considered in the presence of symptomatic obstructive chronic lesions in the iliac vein segment. However, it is often necessary to extend the stented zone into the inferior vena cava, increasing the risk of contralateral iliac vein thrombosis. This study aims to review the current literature concerning the incidence of contralateral deep vein thrombosis after stenting across the iliocaval confluence. Methods A systematic review from potentially relevant published articles reporting contralateral deep vein thrombosis after iliac venous stenting between January 2007 and February 2019 was performed. Results A total of 764 references were retrieved initially. Twelve studies reporting events of contralateral deep vein thrombosis were selected for review, with a total of 1864 patients. Contralateral deep vein thrombosis incidence varied between 0% and 15.6%. The post-interventional and follow-up anticoagulation regimens were heterogeneous between studies. The decision to maintain patients on anticoagulation and the duration of treatment was based on the presence of comorbidities, hypercoagulable states, post-thrombotic syndrome and history of recurrent deep vein thrombosis. Patients with non-thrombotic iliac vein lesions were either anticoagulated for three or six months after stenting or received no anticoagulation. Patients with post-thrombotic syndrome were anticoagulated for longer periods. Most studies (eight studies) used an oral vitamin K antagonist agent. The data on compliance with anticoagulation treatment is scarce and few references present data on whether contralateral deep vein thrombosis occurred during anticoagulation treatment. The use of antiplatelet agents in addition to the anticoagulant treatment in the follow-up period was also variable. Conclusion The incidence of contralateral deep vein thrombosis due to iliac vein jailing is not negligible and reported being as high as 15.6%. Large-scale studies on the ideal antithrombotic treatment and its impact are necessary. It is possible that patients with stent crossing the iliocaval confluence might benefit from long-term antithrombotic treatment.

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.

Thrombus removal has for many years been attractive to investigate. The reasons were to relieve the acute symptoms with painful swelling and even to avoid tissue loss, but also with focus to decrease the incidence of late complications. Surgical procedures in the beginning and systemic thrombolysis years later were practiced in few dedicated centers. The breakthrough came 30 years ago in order to concentrate the lysis procedure directly into the thrombus material. This minimal invasive catheter-directed procedure was soon combined with stenting of the well-known iliac vein compression syndrome. Further development of this modality has taken place with some adjunctive mechanical devices primarily to minimize bleeding, which is the major concern of the methods. Less than ten RCT’s have been published over time, but conclusively supporting the rationale of early thrombus removal for iliofemoral DVT with reduction of PTS.

Introduction Measurement of systolic ankle and to some extent toe pressure in patients suffering from combined type 2 diabetes mellitus (T2DM) and peripheral arterial disease (PAD) face several obstacles due to complex changes in the vascular bed. The aim of this review was to address the current literature on blood flow during exercise in patients with PAD and T2DM and assess the feasibility of these methods to diagnose and grade arterial insufficiency. Evidence acquisition A systematic review of the PubMed and EMBASE databases, supplemented by hand searching was performed according to PRISMA guidelines. Clinical studies evaluating methods to investigate peripheral blood flow in patients with PAD and T2DM during exercise were included. Evidence synthesis In total nine eligible studies consisting of 1105 non-diabetic PAD patients, 336 diabetic PAD patients, 161 diabetic patients without PAD and 69 healthy controls were included in the review. Near-infrared spectroscopy (NIRS) was described in three studies, transcutaneous oxygen pressure measurement (TcpO2) in two and the following methods described in single studies: thermodilution, contrast enhanced ultrasound (CEUS), scintigraphy and TcpO2 in combination with ultrasound. These studies shows that patients with PAD and T2DM compared with patients with only PAD suffers different atherosclerotic lesions characterised by increased arterial stiffness and microcirculation abnormalities, not well differentiated by pressure measurement alone. Investigating patients with PAD and T2DM during exercise reveals that NIRS, TcpO2, CEUS, and scintigraphy have distinct advantages over ankle and toe-pressure. Conclusions Using methods like NIRS, TcpO2, CEUS and scintigraphy, peripheral blood flow during exercise can be measured at a detailed level and potentially improve future severity grading in patients with combined T2DM and PAD.

Many factors are known to be important in order to achieve optimal results after thrombus removal for iliofemoral DVT. Not much is published in the literature about timing the treatment, though many guidelines recommend treatment within 14 days. This time span lies within the phrase of acute DVT according to the definition given in many reporting standards. This article will highlight the value of information acquired from patients directly regarding onset of symptoms versus information acquired from imaging with the purpose of a more precise selection of patients for catheter-directed thrombolysis for iliofemoral DVT. What is the value of clinical information acquired from patients and does the information from imaging have additional value?

BACKGROUND This study elucidates the effects on muscle mitochondrial function in patients suffering from combined peripheral arterial disease (PAD) and type 2 diabetes (T2D) and the relation to patient symptoms and treatment. METHODS Near infrared spectroscopy (NIRS) calf muscle exercise tests were conducted on 40 subjects, 15 (PAD), 15 (PAD+T2D) and 10 healthy age matched controls (CTRL) recruited from the vascular outpatient clinic at Gentofte County Hospital, Denmark. Calf muscle biopsies (~80 mg, gastrocnemius and anterior tibial muscles) were sampled and mitochondrial function tested applying high resolution oxygraphy on isolated muscle fibers. RESULTS The NIRS exercise tests showed evidence of mitochondrial dysfunction in the PAD+T2D group by a longer recovery of the deoxygenation resulting from exercise in spite of a higher exercise oxygenation level compared to the PAD group. This was confirmed by a ~30% reduction in oxygen consumption in the muscle biopsy tests for the PAD+T2D compared to the PAD group (P

Many factors are necessary for obtaining satisfactory results after catheter-directed thrombolysis (CDT) for iliofemoral deep venous thrombosis (DVT). Selections of patients, composition of the thrombolytic fluid, anticoagulation per- and post-procedural, recognition and treatment of persistent obstructive lesions of the iliac veins are the most important contributors. Stenting has been known for 15 to 20 years. The first publication on CDT in 1991 was combined with ballooning the iliac vein, an additive procedure which has been abandoned as an isolated procedure. This chapter will discuss selection, indication, such as an iliac compression syndrome, and outcome of iliac stenting in combination with CDT. The reported frequency of stenting used after CDT is very inconsistent, therefore this will be discussed in details. It is concluded that selection for stenting is of the greatest importance, when CDT is used for iliofemoral DVT, but strict criteria for stenting are not available in the existing literature. The potential value of intravascular ultrasound (IVUS) is also discussed.

Objective: To assess the safety and efficacy of low-molecular-weight heparin (LMWH) in pregnancy and puerperium in women with previous acute iliofemoral deep venous thrombosis (DVT) treated with catheter-directed thrombolysis (CDT). Materials and methods: Consecutive patients treated for acute iliofemoral DVT using CDT between June 1999 and June 2009 were followed yearly by colour duplex ultrasound scanning. A subgroup of these patients who became pregnant during the follow-up period, three months to 10 years after CDT, was included in the present study. During pregnancy, thromboprophylaxis using LMWH was prescribed according to individual risk assessment, and the women were regularly assessed for adverse events. Women on warfarin had this treatment discontinued before the sixth week of pregnancy in order to prevent potential teratogenic adverse effects. Administration of LMWH was started at international normalized ratio ≤Results: A total of 33 women completed 45 pregnancies, 44 singletons and 1 gemelli. In 24 (53%) of the cases, the mother had been treated with adjunctive stenting immediately following the CDT. In nine (21%) of the pregnancies, the mother had been on long-time anticoagulation treatment using warfarin prior to conception due to permanent severe risk factors. Thrombophilia was demonstrated in 31 (69%) of the pregnancies, and in 29 (64%) of the patients, the previous DVT was oestrogen-related. Thromboprophylaxis using tinzaparin was given in 41 (91%) and using dalteparin in four (9%) of the pregnancies. Doses of LMWH during pregnancy were adjusted according to risk assessment. One pregnancy was terminated by induced delivery at week 22 due to fetal malformations, and two of the pregnancies (4%) were complicated by intrauterine fetal death, one in week 39 due to severe fetal infection and one in week 23 due to intrauterine fetal growth restriction caused by severe antiphospholipid syndrome. All but one of the pregnancies was carried out without recurrence of DVT or maternal pulmonary embolism and the mother remained having patent deep veins postnatal. The mother with the antiphospholipid syndrome had a recurrent DVT complicated by iliac stent occlusion. This mother was prior to pregnancy on long-time treatment using warfarin. During pregnancy, she was erroneously treated with LMWH in standard prophylaxis doses instead of therapeutic doses and without adding aspirin. Conclusions: After CDT for acute iliofemoral DVT including adjunctive stenting, pregnancy can be carried out almost uneventful even in women at high risk of thromboembolism. Thromboprophylaxis during pregnancy using LMWH in a dosage adjusted to individual risk assessment, is essential.

Catheter-directed thrombolysis for deep venous thrombosis is considered the basic treatment modality for intrathrombus removal. This method is preferably used in patients with iliofemoral deep venous thrombosis due to poor spontaneous recanalization in this segment, especially on the left side. The method was published almost 25 years ago and has gained ground in the treatment because of poor results from systemic thrombolysis and because of the possibility of stenting any underlying iliac obstruction during the procedure. However, the publications of catheter-directed thrombolysis reveal a great heterogeneity concerning catheter-directed thrombolysis technique and the lack of high quality evidence about monitoring as a tool to minimize the risk of bleeding and pulmonary embolism. Strict inclusion and exclusion criteria, correct composition and infusion of thrombolysis agent, imaging thrombus clearance during catheter-directed thrombolysis, ensuring flow enhancement during the bedridden situation, careful evaluation of indication for stenting based on imaging, and sufficient conversion to anticoagulation treatment following catheter-directed thrombolysis are essential. The aim of this paper is to discuss different treatment aspects of catheter-directed thrombolysis for iliofemoral thrombosis and to suggest a monitoring model for future treatment.

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.

We report the prevalence of flash pulmonary edema in patients consecutively referred for balloon angioplasty of uni- or bilateral renal artery stenosis (PTRA), and describe the characteristics of this special fraction of the patients. We further report two unusual cases.Review of medical records from 60 patients consecutively referred for uni- or bilateral PTRA from 2004-2005 in Copenhagen County.Eight out of 60 patients had one or more episodes of flash pulmonary edema before PTRA. Compared with the remaining patients, they had a higher prevalence of bilateral stenosis (50% vs 27%) and coronary artery disease (75% vs 28%). However, only one of eight had severe systolic dysfunction of the left ventricle. After PTRA, two recurrences of flash pulmonary edema were observed. One was caused by severe restenosis and did not recur after aorto-renal bypass surgery. The other one was caused by rapid atrial fibrillation and did not recur after pacemaker and medical treatment.Flash pulmonary edema can be observed in patients with unilateral as well as bilateral stenosis. The prognosis is usually excellent upon treatment of the stenoses. Recurrences are rare unless restenosis occurs, and therefore, regular control, e.g. by Doppler-ultrasound examination is recommended.

Objective: To evaluate women who have been treated by venous thrombectomy in pregnancy because of iliofemoral venous thrombosis, reporting the outcome of their pregnancy and frequency of objectively measured venous insufficiency. Design: A retrospective study. The patients were assessed by questionnaire, clinical examination, tests of venous function and ultrasonography. Setting: Department of Vascular Surgery, Gentofte Hospital, University of Copenhagen. Patients: Nineteen women treated previously by venous thrombectomy during pregnancy, with a subsequent pregnancy. Results: None of the women had complications during subsequent pregnancies or deliveries, 47% had an occluded iliac segment and 53% had dilated or varicose veins. None had ulcers or skin changes. None of the women showed signs of of re-thrombosis. Conclusion: Women who have been treated for deep venous thrombosis in pregnancy by thrombectomy and arteriovenous fistula followed by anticoagulant therapy may undergo further pregnancies with a very low risk of obstetric complications and a low risk of developing re-thrombosis or chronic venous insufficiency.

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.

The most important vein segment to thrombolyse after deep venous thrombosis (DVT) is the outflow tract meaning the iliofemoral vein. Iliofemoral DVT is defined as DVT in the iliac vein and the common femoral vein. Spontaneous recanalization is less than 50%, particularly on the left side. The compression from adjacent structures, predominantly on the left side is known as the iliac vein compression syndrome. Therefore, it is essential that supplementary endovenous procedures have to be performed in case of persistent obstructive lesions following catheter-directed thrombolysis. Insertion of a stent in this position is the treatment of choice facilitating the venous flow into an unobstructed outflow tract either from the femoral vein or the deep femoral vein or both. The stent, made of stainless steel or nitinol, has to be self-expandable and flexible with radial force to overcome the challenges in this low-pressure system. The characteristics of the anatomy with external compression and often a curved vein segment with diameter difference make stent placement necessary. Ballooning alone has no place in this area. The proportion of inserted stents varies in the published materials with catheter-directed thrombolysis of iliofemoral deep venous thrombosis.

Objective: To describe the background for – and mechanism of – catheter-directed thrombolysis (CDT) for iliofemoral deep venous thrombosis (DVT) accessed via the popliteal vein. Focus is on safety and efficacy. Method: From the Copenhagen experience we have looked into the systematically registrated risk factors, peri- and postprocedure complications for patients consecutively treated from 1999 to 2006. The patients were treated in a clinical ward. The patients were followed yearly with ultrasonography for assessment of patency and valve function. Inclusion and exclusion criteria have been published earlier. Results A total of 89 patients with 91 extremities with iliofemoral DVT were included (70 women and 19 men, mean age 29 years [range 14–59]). Only 11% of the patients were without any risk factor for DVT. CDT was performed without mortality and pulmonary embolism. Major bleeding occurred in two patients and minor bleeding in 27 patients, mostly from the puncture site. Stenting was necessary in 54 limbs. Five stents revealed occlusion, three procedural (2 reopened) and two late. The median follow-up was 87 months (range 17–148). At six years, 86% had competent iliofemoral (and popliteal) vein segment. Conclusion: CDT of iliofemoral DVT is a safe procedure. The patients can stay in a clinical vascular ward. The long-term efficacy is still durable in producing competent veins as concluded in our earlier published results.

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.

Combined treatment with an angiotensin-converting enzyme (ACE) inhibitor and an angiotensin II (Ang II) receptor blocker (ARB) has been suggested in order to achieve a more complete blockade of the renin-angiotensin-aldosterone system in cardiovascular and renal disease. The present report describes a case of acute renal graft dysfunction following the addition of an ARB to existing ACE inhibition. This unmasked an unknown iliac artery stenosis. The case indicates a possible important role of Ang II generated by non-ACE pathways in this situation.

Objectives (1) To review the available information on mitochondrial function in type 2 diabetes mellitus (T2DM) and peripheral arterial disease (PAD) obtained by non-invasive phosphor magnetic resonance spectroscopy (31PMRS), near-infrared spectroscopy (NIRS) in vivo and respirometry on mitochondria isolated from muscle biopsies in vitro (2) to evaluate the usefulness of such data in the diagnosis, treatment and prognosis of these patients. Design Review. Methods Search strategy: PubMed ( http://www.ncbi.nlm.nih.gov/PubMed ) and manual literature search. Main results Fifty-three articles were retrieved, which included 31PMRS, 15, NIRS, 11, Combined, 1 and Respirometry, 2 and background literature, 24. Conclusion Muscle mitochondrial function is impaired in both T2DM and PAD patients, but differently. Patients suffering from both pathological conditions will display more serious impairment of the mitochondrial function. Mitochondrial function and the degree of ischaemic disease as evaluated by 31PMRS and NIRS are well correlated. The NIRS technique appears to determine the degree of PAD better than 31PMRS. It is argued that systematic testing of mitochondrial function may be a useful prognostic tool with PAD and T2DM, but clinical studies are needed.

Background Only 20% of iliac veins will recanalize on anticoagulation (AC) treatment alone and may, therefore, develop venous obstruction after iliofemoral deep venous thrombosis (DVT). A considerable number of these patients will suffer from post-thrombotic syndrome (PTS) leading to impaired quality of life in more than 50%. Endovascular treatment for iliac vein obstruction using stents is known to alleviate PTS symptoms in selected patients. Purpose To report the Danish long-term results of endovascular treatment with iliac stenting. Material and Methods From 2000 to 2013 consecutive patients were evaluated and 19 patients with severe venous claudication were identified and subsequently underwent angioplasty and stenting. AC treatment was prescribed for 6 months, and knee-high class II compression stocking recommended for 1 year. Scheduled follow-up was done in the outpatient clinic at 6 weeks, 3 months, and annually thereafter. Results Nineteen patients, all women, all with left-sided iliac vein obstruction, and all with severe PTS symptoms were included. The median follow-up time was 81 months (range, 1–146 months; mean, 69 months). Primary patency rate of the inserted iliac stent was 89% (17/19) and 16 patients (84 %) had almost or total symptom relief at follow-up. Conclusion Endovascular stenting of iliac obstruction in local anesthesia is minimally invasive and shows excellent long-term outcomes for patients suffering from PTS.

A case of buttock claudication due to isolated internal iliac artery stenoses is presented. Although ankle systolic pressure at rest was within normal limits and distal pulses were palpable, an angiogram demonstrated severe stenoses. A computed tomography scan showed no spinal stenosis. The patient was successfully treated with angioplasty. This diagnosis may be elusive if ankle pressure or distal pulses are normal, thereby directing the clinician's suspicion away from vascular pathology.

ObjectivesThe long-term outcome of catheter-directed thrombolysis (CDT) in patients with acute iliofemoral venous thrombosis (IFVT) is evaluated in this study.Material and methodsPatients presenting for treatment with IFVT between June 1999 and May 2007 were considered for treatment using CDT. The following inclusion criteria were used: first episode of IFVT, age below 60 years, age of thrombus

Objectives To investigate the results of catheter directed thrombolysis offered to patients with acute femoro-iliac deep venous thrombosis (DVT). Design Retrospective analysis of all patients treated with this modality at Gentofte Hospital until December 2003. Material Forty-five consecutive patients treated between June 1999 and December 2003 with a median age of 31 years. All patients had femoro-iliac DVT with an average anamnesis of 6 days. Methods All patients were treated by catheter directed infusion of alteplase into the popliteal vein. After thrombolysis residual venous stenoses were treated by percutaneous balloon angioplasty (PTA) and stenting. Patients were followed with color-duplex scanning for assessment of venous patency and reflux. Results Forty-two of 45 (93%) of cases were treated successfully with reopening of the thrombosed vein segments. In 30 of 45 cases a residual stenosis was treated by PTA and stenting. Only one serious complication was observed: Compartment syndrome of the forearm where arterial punctures had been taken. After an average of 24 months follow-up were no cases of re-thrombosis among the 42 patients discharged with open veins. Only two of 41 with presumed normal venous valve function prior to DVT developed reflux during follow-up. Conclusion In this selected patient group, catheter directed thrombolysis seems effective in treating acute DVT, it appears durable and preserves venous valve function in the majority. The method needs to be tested in a randomised controlled trial.

The Monk Duopleet femoral interlocking uncemented two-component endoprosthesis consists of a polyethylene cup covered by a metal cap and an Austin-Moore type stem. Seventy-two patients (average age, 71 years) were treated by this arthroplasty: 27 for subcapital femoral neck fracture, 36 for osteoarthritis, and nine as an exchange operation. Three patients died following operation. After a mean follow-up time of 50 months, 47 patients were reexamined clinically and radiographically. Because of loosening, four patients had the prosthesis removed. Twenty-six patients were classified as excellent, 12 as good, six as fair, and three as poor. There were no cases of acetabular intrusion. The Monk Duopleet prosthesis may solve the problem of the loosening that had been associated with femoral component alone. The long-term results are promising and appear to be better than the results of the standard Moore prosthesis. The Monk Duopleet prosthesis is an alternative to other two-component endoprostheses for the treatment of subcapital hip fractures and in the group of patients suffering from osteoarthritis, where an arthroplasty with a cemented prosthesis may be considered hazardous because of age or general disease.