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[ 18 F]Fluorodeoxyglucose positron emission tomography (FDG-PET) is increasingly used to demonstrate inflammation in specific sites typical for polymyalgia rheumatica (PMR). Scoring systems based on FDG uptake have been proposed to increase diagnostic accuracy., Methods: Retrospective inclusion of 198 consecutive patients ≥40 years of age referred for FDG-PET from the Department of Rheumatology. We assessed the degree of FDG uptake in predilection sites visually, as well as semiquantitatively, and through logistic regression analyses, we evaluated the performance of existing scoring systems as well as a new, simplified scoring system, against the final clinical diagnosis at 6 months after the FDG-PET scan., Results: We found high diagnostic accuracy for the diagnosis of PMR (range 0.74-0.91) using most of the existing scoring systems in glucocorticoid-naïve patients. A simplified scoring system including only periarticular FDG uptake in the shoulders and the ischiogluteal bursae retained high sensitivity and specificity (0.92 and 0.86, respectively). We found a detrimental effect on diagnostic accuracy in all scoring systems in patients treated with glucocorticoids within 4 weeks prior to FDG-PET., Conclusion: Most FDG-PET scoring systems perform well for the diagnosis of PMR, and there is no loss of either sensitivity or specificity in the simplest scoring systems evaluating FDG uptake in only a few selected anatomical regions. However, systemic glucocorticoid treatment up to 4 weeks prior to FDG-PET has a markedly detrimental effect on the diagnostic accuracy of all scoring systems.

Background: Use of 11 C-Choline PET/CT is gaining ground in detecting hyperfunctioning parathyroid glands in primary hyperparathyroidism. The purpose of this study was to evaluate the robustness of 11 C-Choline PET/CT by assessing intra- and inter-observer agreement to determine whether the method was reader sensitive and therefore should only be performed at highly specialised sites with a high number of cases. PET/CT images of 40 patients diagnosed with primary hyperparathyroidism were anonymised and evaluated three times by three readers: an expert reader and two non-experts (non-experts were experienced in PET/CT imaging, but not in 11 C-Choline PET/CT in the setting of primary hyperparathyroidism). Number of hyperfunctioning parathyroid glands, location relative to the thyroid gland and confidence of each assessment (low, moderate or high) were noted, and intra- and inter-observer agreement calculated using Fleiss' kappa method. Sensitivities and specificities of the non-experts were calculated using the expert reader as gold standard., Results: Intra-observer agreement was 'good' to 'near perfect' for all readers. Inter-observer agreement was good between non-experts and the expert, with kappa values ≥ 0.74. Sensitivities between non-experts and the expert were high, > 81%, when assessing which side and 75% when assessing thyroid quadrant. All specificities were > 94%. Reader certainties were 'high' in > 80% of cases for the expert and > 70% and > 65%, respectively for the two non-experts., Conclusion: 11 C-Choline PET/CT is not reader sensitive for the localisation of hyperfunctioning parathyroid glands and may therefore be safely implemented at sites that have a moderate number of cases. Access to a cyclotron laboratory is, however, a necessity for the production of 11 C-Choline. The study was conducted in accordance with the Helsinki 2 declaration and The International Council for Harmonisation Guideline for Good Clinical Practice (ICH_GCP) clinical trial, approved by the Research Ethics Committee of the Capital Region of Denmark (Journal-nr.:H-18012490, date of approval: 18 June 2018) and the Danish Medicines Agency (EudraCT no. 2018-000726-63, date of approval: 6 June 2018). The GCP unit in Eastern Denmark has carried out regular monitoring of the trial according to GCP (ID: 2018-1050).

Objective: 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)., Methods: 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., Results: 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., Conclusion: 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., (Copyright © 2019 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Individuals with cerebral palsy (CP) participate in reduced levels of physical activity and spend an increased amount of time in a sedentary state compared with healthy control subjects. Whether this in part can be explained by impaired muscle function is still unclear. The aim of the present study was to elucidate differences in muscle fibre recruitment during treadmill exercise between CP subjects and healthy age-, sex- and BMI-matched controls. This is a case-control study. Acoustic myography (AMG), a method recording fibre use and efficiency from contracting muscles, was applied during a period of treadmill exercise. The recorded AMG parameters revealed that the CP subjects had a significantly lower initial S-score (spatial summation) than the controls (P < 0.01). However, the T-score (temporal summation) and the E-score (efficiency) showed no significant differences between individuals with CP and the healthy control subjects. The present findings indicate that CP subjects use a higher degree of spatial summation (more fibres recruited) to keep up the same speed during treadmill exercise when compared to healthy matched control subjects. Our results suggest that individuals with CP have a tendency to recruit far more muscle fibres during bouts of exercise than healthy individuals. This may partly explain why CP subjects experience premature fatigue.

Muscle contractures are a common complication in patients with central nervous system (CNS) lesions which limit range of movement and cause joint deformities. Furthermore, it has previously been shown that muscles with contractures have a reduced number of capillaries, indicating decreased tissue vascularization. The aim of the present study was to investigate the microvascular volume (MV) at rest and after acute exercise in the muscle tissue of individuals with cerebral palsy (CP) and healthy control individuals. Contrast-enhanced ultrasound (CEUS) was used before and after 30 min of walking or running on a treadmill in 10 healthy control participants and 10 individuals with CP to detect MV of their skeletal muscle tissue. A significant increase in the MV was observed after exercise both in the adult CP group (21-53 yr) and in the control group (21-52 yr) (1.8 ± 0.8 ΔdB to 3.1 ± 0.9 ΔdB or 42.9% and 1.5 ± 0.6 ΔdB to 2.5 ± 0.9 ΔdB or 39.0%, respectively). Furthermore, a difference in the resting MV was observed between the most severe cases of CP [gross motor function classification scale (GMFCS) 3 and 4] (2.3 ± 0.5 ΔdB) and the less severe cases (GMFCS 1 and 2) (1.5 ± 0.2 ΔdB). When the CP group was walking (3.4 km/h), the lactate levels, Borg score, and heart rate matched the level of controls when they were running (9.8 km/h). In conclusion, individuals with CP become exhausted at much lower exercise intensities than healthy individuals. This is not explained by impaired microvascularization, since the MV of the individuals with CP respond normally to increased O 2 demand during acute exercise. NEW & NOTEWORTHY Cerebral palsy (CP) patients were less physically active compared with typically developed individuals. This may affect the microvascularization. We observed that the CP group became exhausted at much lower exercise intensities compared with healthy individuals. However, impaired microvascularization was not the reason for the decreased physical activity as the CP group responded normally to increased O 2 demand during acute exercise. These results indicate that walking may be recommended as an intervention to train and maintain skeletal muscle tissue in individuals with CP.

Contrast-enhanced ultrasound (CEUS) is used to visualize the microvascularization in various tissues. The purpose of this study was to investigate whether CEUS could be used to visualize the microvascular volume (MV) in the plantar fascia, and to compare the method to clinical symptoms and B-mode ultrasound (US) in patients with plantar fasciitis (PF). Twenty patients with unilateral PF were included and were divided by US in insertional thickening (10), midsubstance thickening (5), and no US changes (5). The MV was measured simultaneously in both heels. Four areas in the plantar fascia and plantar fat pad were measured independently by two observers. Inter- and intra-observer correlation analyses were performed. The asymptomatic heels showed a constantly low MV, and for the whole group of patients, a significantly higher MV was found in the symptomatic plantar fascia and plantar fat pad. Inter-observer correlation as well as intra-observer agreement was excellent. The MV in the plantar fascia and plantar fat pad can be measured reliably using CEUS, suggesting that it is a reproducible method to examine patients with plantar fasciitis., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Paget disease (PD) of bone is a benign but chronic disorder of bone metabolism. We report a case of an 85-year-old man with several fractures in the pelvis and radiograph raising suspicion of metastases. An F-NaF PET/CT demonstrated high F-NaF uptake in the same regions. The integrated assessment of imaging findings, supported by biochemistry, allowed diagnosing PD. The F-NaF PET/CT is a supplementary diagnostic instrument in the diagnosis of PD, and use of F-NaF PET/CT in this context, especially finalized to the differential diagnosis with metastatic lesions, requires the physician to be familiar with imaging patterns of this disease.

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., (Copyright © 2016 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Distal blood pressure and local skin perfusion pressure were compared to measurement of blood flow rate (BFR) measured by the heat-washout method in orthopaedic patients with and without diabetes, all with a foot ulcer in one foot, compared to healthy controls. The correlation was good between heat-washout and distal blood pressure in patients with diabetes with and without an ulcer (P = 0·024 and 0·059, respectively). The correlation was weak in patients without diabetes with and without an ulcer, most probably due to power problems (P = 0·118 and 0·116, respectively). The correlation in the healthy controls was poor (P = 0·333 and 0·685 for right and left 1. Toe, respectively) probably because not all measurements were performed under optimal conditions with maximally dilated arterioles and warm hands and feet. The patients already have maximally dilated arterioles to extract the maximal amount of oxygen from the surrounding tissue, and therefore, measurements are easier made in these subjects. BFR in the first toe increased significantly in all patients when the foot was moved from heart level to 50 cm below heart level (P = between 0·03 and 0·05) as previously seen in patients with claudication. There was no statistical difference in the healthy controls, consistent with previous findings. These results may indicate that the heat-washout method can be used as an alternative to strain gauge blood pressure in the evaluation of peripheral artery disease and wound healing potentials. Furthermore, the heat-washout measurements can be used bedside., (© 2015 Scandinavian Society of Clinical Physiology and Nuclear Medicine. Published by John Wiley & Sons Ltd.)

Background: Measurement of the ankle and toe pressures are often performed using a plethysmograph, compression cuffs and a strain gauge. Usually, the strain gauge contains mercury but other alternatives exist. From 2014, the mercury-containing strain gauge will no longer be available in the European Union. The aim of this study was to compare an indium-gallium strain gauge to the established mercury-containing strain gauge., Methods: Consecutive patients referred to the Department of Clinical Physiology and Nuclear Medicine at Bispebjerg and Frederiksberg Hospitals for measurements of systolic ankle and toe pressures volunteered for the study. Ankle and toe pressures were measured twice with the mercury and the indium-gallium strain gauge in random order. Comparison of the correlation between the mean pressure using the mercury and the indium-gallium device and the difference between the two devices was performed for both toe and ankle level., Results: A total of 53 patients were included (36 male). Mean age was 69 (range, 45-92 years). Mean pressures at toe and ankle level with the mercury and the indium-gallium strain gauges were 77 (range, 0-180) mm Hg and 113 (range, 15-190) mm Hg, respectively. Comparison between the mercury and the indium-gallium strain gauge showed a difference in toe blood pressure values of - 0.7 mm Hg (SD: 7.0). At the ankle level, a difference of 2.0 mm Hg (SD: 8.6) was found., Conclusion: The two different devices agree sufficiently in the measurements of systolic ankle and toe pressure for the indium-gallium strain gauge to replace the mercury strain gauge.

Unlabelled: Upper extremity deep venous thrombosis (UEDVT) occurs either spontaneously, as a consequence of strenuous upper limb activity (also known as the Paget-Schroetter syndrome) or secondary to an underlying cause. Primary and secondary UEDVT differs in long-term sequelae and mortality. This review will focus on the clinical presentation, risk factors, diagnosis, and treatment strategies of UEDVT. In the period from January to October 2012 an electronic literature search was performed in the PubMed/MEDLINE database, and 27 publications were included., Clinical Presentation: swelling, pain and functional impairment are typical symptoms of UEDVT, although completely asymptomatic cases have been described. However life-threatening, massive pulmonary embolism (PE) can also be a sign of UEDVT., Risk Factors: for the primary condition anatomical abnormalities (Thoracic Outlet Syndrome, TOS) may dispose to the condition. Malignancy and therapeutic interventions are major risk factors for the secondary deep vein thrombosis in combination with the patient's characteristics, comorbidities and prior history of deep vein thrombosis., Complications: recurrent deep venous thrombosis, pulmonary embolism and Post Thrombotic Syndrome (PTS) are the major complications after UEDVT. PTS is a chronic condition leading to significant functional disability and impaired quality of life., Diagnosis: compression ultrasonography is noninvasive and the most frequently used objective test with a high accuracy in experienced hands. Treatment modalities and strategies: the treatment modalities include anticoagulation therapy, catheter-directed thrombolysis, surgical decompression, percutaneous transluminal angioplasty and stenting and they may be combined. However, the optimal treatment and timing of treatment remains controversial. Early diagnosis and treatment is essential to prevent PTS in primary UEDVT; however, there is no consensus on which treatment is the best. Anticoagulation is still considered the treatment of choice for at least 3-6 months, until Randomized Controlled Trials may have demonstrated otherwise.

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 ≤ 2.0, and continued during pregnancy, delivery and puerperium. Postnatal, the anticoagulation treatment was converted back to warfarin and LMWH discontinued after a bridging period. Women, who, prior to pregnancy, had discontinued anticoagulation treatment after CDT, were prescribed anticoagulation treatment using LMWH as early in pregnancy as practical. LMWH was continued during pregnancy, delivery and for six weeks postpartum. All women were prescribed graduated compression stockings., 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.

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.

Treatment of acute iliofemoral deep venous thrombosis (DVT) with catheter-directed thrombolysis (CDT) has been performed in Denmark since 1999. The purpose of CDT is to dissolve thrombus and to restore the venous lumen as fast as possible and thereby save venous valve function and prevent postthrombotic syndrome. Danish studies have shown that treatment of acute iliofemoral DVT using CDT results in good patency, preserves venous valve function, reduces the frequency of PTS, and is associated with a higher quality of life.

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.

Background: Postthrombotic 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., Methods: Patients 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., Results: The 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., Conclusion: PTS 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., (Copyright © 2011 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

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., (Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Patients with acute iliofemoral venous thrombosis treated with anticoagulation only are at high risk of developing postthrombotic syndrome. Immediate removal of the thrombus by catheter-directed thrombolysis (CDT) may increase patency, prevent damage of the venous valves, and prevent reflux and PTS. However, the indications for its use are not well established because of lack of data from randomised controlled trials. Aim of this review was to describe the treatment of iliofemoral venous thrombosis with CDT and to evaluate the effectiveness of this therapy. An electronic literature search was performed in the PubMed, EMBASE, and Cochrane Library on the largest studies (more than 40 legs treated) concerning catheter-directed thrombolysis of iliofemoral venous thrombosis. A total of 236 publications were identified but only 11 studies met the inclusion criteria with a total of 979 lower limbs. Early patency from 6-12 months was 60-95% and patency after six years was 82%, reported in one study. Mortality of up to 1% was reported in two studies. Major complications such as hematomas requiring surgery were observed in 1-11% whereas minor complications, mostly bleeding from the puncture site, were seen in up to 18%. CDT seems to be effective in the treatment of iliofemoral venous thrombosis and results are promising. Studies are, however, characterized by heterogeneity and are difficult to compare. Only one study reports long-term follow-up and incidence of postthrombotic syndrome is not reported. Further studies regarding the use of CDT, both alone and in combination with mechanical thrombectomy are needed.

Objectives: The long-term outcome of catheter-directed thrombolysis (CDT) in patients with acute iliofemoral venous thrombosis (IFVT) is evaluated in this study., Material and Methods: Patients 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 <14 days and open distal popliteal vein. Ultrasonography (US) was used to verify the diagnosis. The popliteal vein was punctured under local anaesthesia using US guidance, and a multi-side-hole catheter with tip occlusion was placed in the thrombus. A solution of r-TPA was infused either continuously or using the pulse spray technique together with heparin. Any occlusion or residual stenosis in the iliac vein system was treated by stenting. Compression stockings and anticoagulation treatment were given for at least 12 months. Patients with severe thrombophilias were treated for longer periods. The patients were assessed by colour-duplex US for assessment of patency and valve function after 6 weeks, 3, 6 and 12 months and afterwards on a yearly basis., Results: A total of 101 patients with 103 extremities affected by iliofemoral venous thrombosis were included (median age; 29 years, 78 women, and 79 had left-sided thrombosis). A stent was inserted in 57 limbs. The median follow-up time was 50 months (range 3 days-108 months). At 6 years, 82% of the limbs had patent veins with competent valves and without any skin changes or venous claudication., Conclusion: Treatment with CDT for IFVT achieves good patency and vein function after 6 years of follow-up in this highly selected group of patients. We suggest that results from future studies should be presented as Kaplan-Meier plots using venous patency without reflux as the main outcome, since it is an early indicator of the clinical outcome., (Copyright 2009 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Introduction: Proximal deep venous thrombosis (DVT) often leads to venous outflow obstruction in chronic venous insufficiency (CVI). This paper presents our clinical experience with iliac vein stent placement., Materials and Methods: Between January 2001 and November 2004 balloon dilation and stent placement for the relief of iliac vein obstruction was intended in ten patients suffering from venous claudication. Median age was 35 years (range 21-42). Eight patients had earlier been treated for proximal DVT on the left side and two patients had May-Thurner syndrome. Ultrasound scanning was performed on all patients for the detection of iliac vein obstruction. It was a requirement that all patients had an open deep venous system without reflux distally to the occlusion. The procedure was carried out under local anaesthesia and all patients were anticoagulated postoperatively., Results: There was one technical failure and nine patients were treated successfully. In one of these patients the stent rethrombosed after two days but the thrombus was lysed and the patient was restented more distally. All patients were discharged with an open venous system. At follow-up, eight of the nine stents were patent. Five patients had normal walking distance and three had improved. The median follow-up time was 32.5 months (range 6-53 months)., Conclusion: The correction of iliac vein obstruction with the placement of stents in patients with venous claudication seems to be an effective, safe method which is minimally invasive. Short term patency is satisfactory but the long term results of stents in the venous system are not known and longer follow-up is required.