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William Oppat - One of the best experts on this subject based on the ideXlab platform.
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Posterior Tibial Vein approach to catheter directed thrombolysis for iliofemoral deep venous thrombosis
Journal of vascular surgery. Venous and lymphatic disorders, 2017Co-Authors: Scott Bendix, Ryan Nolan, Simpledeep Banipal, William OppatAbstract:Abstract Objective Deep venous thrombosis (DVT) remains a significant cause of morbidity in the American population. Catheter-directed thrombolysis for acute iliofemoral DVT is an effective therapy not only to restore venous patency but also to reduce the development of post-thrombotic syndrome (PTS), especially in patients with extensive thrombosis involving the iliac and femoral venous segments. We hypothesized that delivery of thrombolytics through an access site in a Vein distal to the segments containing thrombus would provide the greatest short- and long-term therapeutic clinical benefit with similar safety and efficacy. Methods All patients treated at a single institution between 2009 and 2016 undergoing mechanical and chemical thrombolysis for iliofemoral DVT were retrospectively reviewed. Patients were divided into groups by access site, including contralateral and ipsilateral femoral Vein, popliteal Vein, and Posterior Tibial Vein (PTV). Preoperative demographics, intraoperative data, and postoperative outpatient charts were analyzed. Primary end points included evidence of incompetence after the procedure by duplex ultrasound assessment and development of complications of PTS as defined by the Villalta scale. Results Fifty-eight patients underwent mechanical and chemical thrombolysis, and 51 patients met the inclusion criteria. Thrombolysis access was through PTV (n = 27), popliteal Vein (n = 20), or femoral Vein (n = 4). More patients were female (55%), and the mean age was 57 years. Forty patients had unilateral DVT, whereas 11 patients had bilateral involvement. After lysis, 44 patients underwent percutaneous venous angioplasty and 11 patients underwent venous stenting in the acute setting. Although not statistically significant, mean operative times were slightly longer in the Posterior Tibial approach (156.7 minutes vs 130.6 minutes; P = .08), and mean fluoroscopy time was higher in the Posterior Tibial group (18.1 minutes vs 14.3 minutes; P = .17). Overall 90-day morbidity was 9.8%, and no deaths were recorded. Patency of the deep venous system was similar between the Posterior Tibial and the popliteal or femoral approach (95% vs 88%; P = .29); 21.6% developed symptoms of PTS. There was no difference for development of PTS between Posterior Tibial and popliteal or femoral approaches (22% vs 20.8%; P = .52). There was no difference in development of chronic nonocclusive DVT (37% vs 35%; P = .61). Median follow-up was 8.7 months (range, 0.4-58.9 months). Conclusions The PTV approach to catheter-directed thrombolysis is a safe and sensible option for the treatment of iliofemoral and femoropopliteal DVT. A larger cohort will be necessary to demonstrate superiority of Tibial Vein access in the treatment of iliofemoral DVT with popliteal involvement.
Gerard J. O’sullivan - One of the best experts on this subject based on the ideXlab platform.
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Addressing Infra-popliteal Thrombus in Iliofemoral DVT: The Criss-Cross Technique
CardioVascular and Interventional Radiology, 2018Co-Authors: Duarte C. Rego, Ahmed Khairy Sayed Ahmed, Gerard J. O’sullivanAbstract:Purpose The purpose of this work was to describe the results of a technique of simultaneous antegrade and retrograde vascular access (“criss-cross”) to the popliteal Vein to achieve venous recanalization in patients with acute, extensive, iliofemoral DVT with concomitant popliteal and calf Vein thrombosis. Materials and Methods Seven patients were treated using this technique, in three patients as a bailout option after failed Posterior Tibial Vein puncture and in four as a first option. Antegrade popliteal venous access was performed according to the usual technique using duplex ultrasound (DUS) guidance and thrombolysis (CDT), or thrombectomy (PMT) was performed. Following this, the retrograde sheath was placed under DUS guidance, a Tibial Vein was selectively catheterized and CDT, and/or a PMT was performed. Results Three patients underwent isolated CDT, another three had associated PMT, and one patient underwent iliofemoral PMT and catheter thromboaspiration of the popliteal and calf Veins. Median thrombolysis duration was 72 h (24–72 h). SIR grade III thrombolysis was achieved in six patients and grade II in one patient. All patients underwent subsequent stenting of their iliac Vein lesions. Minor complications were observed in two patients (ecchymosis), while one patient developed a hematoma on the popliteal fossa. Conclusion This “criss-cross” technique represents a safe alternative to the distal (anterior or Posterior Tibial) Vein access both as a bailout option after failed distal venous access as well as a primary approach due to its potential advantage of clearing larger thrombus volume. Experience in ultrasound-guided popliteal Vein puncture is crucial to avoid complications. Level of Evidence Case series, Level IV.
D. Eugene Strandness - One of the best experts on this subject based on the ideXlab platform.
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Deep venous insufficiency: The relationship between lysis and subsequent reflux
Journal of Vascular Surgery, 1993Co-Authors: Mark H. Meissner, Richard A. Manzo, Robert O. Bergelin, Arie Markel, D. Eugene StrandnessAbstract:Abstract Purpose: Although venous valvular insufficiency is well recognized as the most important etiologic mechanism in the development of the postthrombotic syndrome, the factors contributing to valve incompetence after deep venous thrombosis remain obscure. Methods: To establish the relationship between recanalization and valve competence, 113 patients with acute deep venous thrombosis were studied with serial duplex ultrasonography. Results: Median lysis times for segments developing reflux (214 to 474 days) were 2.3 to 7.3 times longer than for corresponding segments not developing reflux (65 to 130 days) for all except the Posterior Tibial Vein. In the Posterior Tibial Vein, median lysis times for those with and without reflux were nearly identical (72 vs 80 days). The median time to onset of reflux was significantly less than the median lysis time in the mid and distal superficial femoral Veins and was simultaneous with recanalization in all other segments. Conclusions: Early recanalization is important in preserving valve integrity for all but the Posterior Tibial segment. However, the small number of patients with reflux despite early lysis ( 9 to 12 months) suggests that other factors may also contribute to the development of valvular incompetence. These factors may be particularly important in the Posterior Tibial Vein, in which lysis time has little relationship to the ultimate development of reflux. (J VASC SURG 1993;18:596-608.)
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Valvular reflux after deep Vein thrombosis: Incidence and time of occurrence
Journal of Vascular Surgery, 1992Co-Authors: Arie Markel, Richard A. Manzo, Robert O. Bergelin, D. Eugene StrandnessAbstract:Abstract From December 1986 to December 1990, 268 patients with acute deep Vein thrombosis were studied in our laboratory. From this group 107 patients (123 legs with deep Vein thrombosis) were placed in our long-term follow-up program. The documentation of valvular reflux and its site was demonstrated by duplex scanning. The duplex studies were done at intervals of 1 and 7 days, 1 month, every 3 months for the first year, and then yearly thereafter. The mean follow-up time for these patients was 341 days. In addition, reflux was evaluated in 502 patients with negative duplex study results and no previous history of deep Vein thrombosis or chronic venous insufficiency. In the patients with acute deep Vein thrombosis, valvular incompetence was noted in 17 limbs (14%) at the time of the initial study. Reflux was absent in 106 limbs (86%). In this last group reflux developed in 17% of the limbs by day 7. By the end of the first month, 37% demonstrated reflux. By the end of the first year, more than two thirds of the involved limbs had developed valvular incompetence. The distribution of reflux at the end of the first year of follow-up was the following: (1) popliteal Vein, 58%; (2) superficial femoral Vein, 37%; (3) greater saphenous Vein, 25%; and (4) Posterior Tibial Vein, 18%. Reflux seems to be more frequent in the segments previously affected with deep Vein thrombosis. Among cases where segments were initially affected with thrombi, after 1 year the incidence of reflux was 53%, 44%, 59%, and 33% for the common femoral Vein, superficial femoral, popliteal Vein, and Posterior Tibial Vein, respectively. In contrast, among limbs without initial deep Vein thrombosis in these segments none of the proximal limbs and 8% of the Posterior Tibial Veins showed reflux after 1 year. In the patients without deep Vein thrombosis, reflux in either the deep or superficial system was present in 60 of 1003 legs (6%). Greater saphenous Vein reflux was present in 16 legs (2%); it was limited to this Vein in five limbs. (J Vasc Surg 1992;15:377–84.)
Scott Bendix - One of the best experts on this subject based on the ideXlab platform.
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Posterior Tibial Vein approach to catheter directed thrombolysis for iliofemoral deep venous thrombosis
Journal of vascular surgery. Venous and lymphatic disorders, 2017Co-Authors: Scott Bendix, Ryan Nolan, Simpledeep Banipal, William OppatAbstract:Abstract Objective Deep venous thrombosis (DVT) remains a significant cause of morbidity in the American population. Catheter-directed thrombolysis for acute iliofemoral DVT is an effective therapy not only to restore venous patency but also to reduce the development of post-thrombotic syndrome (PTS), especially in patients with extensive thrombosis involving the iliac and femoral venous segments. We hypothesized that delivery of thrombolytics through an access site in a Vein distal to the segments containing thrombus would provide the greatest short- and long-term therapeutic clinical benefit with similar safety and efficacy. Methods All patients treated at a single institution between 2009 and 2016 undergoing mechanical and chemical thrombolysis for iliofemoral DVT were retrospectively reviewed. Patients were divided into groups by access site, including contralateral and ipsilateral femoral Vein, popliteal Vein, and Posterior Tibial Vein (PTV). Preoperative demographics, intraoperative data, and postoperative outpatient charts were analyzed. Primary end points included evidence of incompetence after the procedure by duplex ultrasound assessment and development of complications of PTS as defined by the Villalta scale. Results Fifty-eight patients underwent mechanical and chemical thrombolysis, and 51 patients met the inclusion criteria. Thrombolysis access was through PTV (n = 27), popliteal Vein (n = 20), or femoral Vein (n = 4). More patients were female (55%), and the mean age was 57 years. Forty patients had unilateral DVT, whereas 11 patients had bilateral involvement. After lysis, 44 patients underwent percutaneous venous angioplasty and 11 patients underwent venous stenting in the acute setting. Although not statistically significant, mean operative times were slightly longer in the Posterior Tibial approach (156.7 minutes vs 130.6 minutes; P = .08), and mean fluoroscopy time was higher in the Posterior Tibial group (18.1 minutes vs 14.3 minutes; P = .17). Overall 90-day morbidity was 9.8%, and no deaths were recorded. Patency of the deep venous system was similar between the Posterior Tibial and the popliteal or femoral approach (95% vs 88%; P = .29); 21.6% developed symptoms of PTS. There was no difference for development of PTS between Posterior Tibial and popliteal or femoral approaches (22% vs 20.8%; P = .52). There was no difference in development of chronic nonocclusive DVT (37% vs 35%; P = .61). Median follow-up was 8.7 months (range, 0.4-58.9 months). Conclusions The PTV approach to catheter-directed thrombolysis is a safe and sensible option for the treatment of iliofemoral and femoropopliteal DVT. A larger cohort will be necessary to demonstrate superiority of Tibial Vein access in the treatment of iliofemoral DVT with popliteal involvement.
Duarte C. Rego - One of the best experts on this subject based on the ideXlab platform.
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Addressing Infra-popliteal Thrombus in Iliofemoral DVT: The Criss-Cross Technique
CardioVascular and Interventional Radiology, 2018Co-Authors: Duarte C. Rego, Ahmed Khairy Sayed Ahmed, Gerard J. O’sullivanAbstract:Purpose The purpose of this work was to describe the results of a technique of simultaneous antegrade and retrograde vascular access (“criss-cross”) to the popliteal Vein to achieve venous recanalization in patients with acute, extensive, iliofemoral DVT with concomitant popliteal and calf Vein thrombosis. Materials and Methods Seven patients were treated using this technique, in three patients as a bailout option after failed Posterior Tibial Vein puncture and in four as a first option. Antegrade popliteal venous access was performed according to the usual technique using duplex ultrasound (DUS) guidance and thrombolysis (CDT), or thrombectomy (PMT) was performed. Following this, the retrograde sheath was placed under DUS guidance, a Tibial Vein was selectively catheterized and CDT, and/or a PMT was performed. Results Three patients underwent isolated CDT, another three had associated PMT, and one patient underwent iliofemoral PMT and catheter thromboaspiration of the popliteal and calf Veins. Median thrombolysis duration was 72 h (24–72 h). SIR grade III thrombolysis was achieved in six patients and grade II in one patient. All patients underwent subsequent stenting of their iliac Vein lesions. Minor complications were observed in two patients (ecchymosis), while one patient developed a hematoma on the popliteal fossa. Conclusion This “criss-cross” technique represents a safe alternative to the distal (anterior or Posterior Tibial) Vein access both as a bailout option after failed distal venous access as well as a primary approach due to its potential advantage of clearing larger thrombus volume. Experience in ultrasound-guided popliteal Vein puncture is crucial to avoid complications. Level of Evidence Case series, Level IV.