Successful treatment of extensive splanchnic arterial and portal vein thrombosis associated with ulcerative colitis

Venous and arterial thromboembolism is a significant cause of morbidity and mortality in patients with ulcerative colitis (UC). Arterial thrombosis of the splanchnic region is a rare event with a very high mortality rate. Furthermore, it represents a challenging complication since it tends to be overlooked and misinterpreted as a clinical exacerbation of UC. We present the case of a 62-year-old female with pancolonic UC complicated by an extensive arterial thrombosis involving the aorta, the celiac trunk, the hepatic, gastric and splenic arteries and the superior mesenteric artery. A thrombosis of the splenic vein extending into the proximal portal vein was also present. The patient was successfully treated by a combined interventional-radiological and surgical treatment. We discuss the rationale behind our management of this case and review the literature on splanchnic arterial thrombosis associated with UC.

Short-term natural history of isolated gastrocnemius and soleal vein thrombosis

OBJECTIVE

Lower extremity deep vein thrombosis is often isolated to the sinusoidal veins draining the gastrocnemius and soleus muscles. The purpose of this study was to establish the incidence rate of propagation of isolated gastrocnemius and soleal vein thrombosis (IGSVT) into the deep veins of the calf and thigh.

METHODS

All patients who were referred for color flow duplex ultrasonography (CFDU) for suspected deep vein thrombosis were prospectively evaluated for IGSVT. Patients with IGSVT received no systemic anticoagulation therapy and underwent serial CFDU at 5, 9, 14, 30, and 90 days after recruitment. The incidence and extent of IGSVT propagation were noted. Factors predictive of IGSVT extension were sought, including age, gender, side, symptoms, ambulatory status, and the presence of comorbid illness, including cardiac disease, cancer, hypercoagulable states, recent surgery or trauma, and previous venous disease.

RESULTS

One hundred thirty-five limbs with IGSVT were studied for 3 months, and 16.3% of cases with IGSVT extended the thrombus to the level of the adjacent tibial, or peroneal, veins or higher. Only 3% of the cases with IGSVT propagated as cephalad as the popliteal vein, and 90.9% of IGSVT propagation occurred within 2 weeks of CFDU diagnosis. No IGSVT propagated to the level of the popliteal vein beyond 2 weeks from the time of CFDU diagnosis. No IGSVT extended into the deep veins of the thigh. By the end of the 3-month study period, 45.9% of thrombi had completely resolved. Only the presence of cancer was prognostic for IGSVT progression.

CONCLUSION

During the 3-month study period, the short-term incidence rate of untreated IGSVT propagation to the level of the popliteal vein, even in the presence of cancer, was only 3%. Follow-up imaging to detect IGSVT propagation beyond 2 weeks from the time of diagnosis may not be necessary.

Hemispheric stroke following cardiac surgery: a case-control estimate of the risk resulting from ipsilateral asymptomatic carotid artery stenosis

A case-control study was undertaken to determine if asymptomatic carotid artery stenosis (ACS) is independently associated with ipsilateral hemispheric stroke following cardiac surgery (CS). All CS patients (3069) who were at two hospitals between 1989 and 1994 were reviewed. Cases (31) selected for this study were those with hemispheric stroke within 30 days following CS. Controls (69) were taken from those without hemispheric stroke. Case-control analysis demonstrated that ACS of 50-90% and of 80-90% increased the risk of ipsilateral stroke 5.2-fold (95% confidence interval [CI] = 1.5-16.3, p = 0.01) and 24.3-fold (CI = 2.6-114.9, p = 0.002), respectively. Other variables with significant odds ratios (OR) were age > or =65 years (OR = 4.0, CI = 1.3-10.5, p = 0.01), peripheral vascular disease (OR = 3.4, CI = 1.3-8.8, p = 0.02), hypertension (OR = 3.0, CI = 1.2-7.0, p = 0.02), and female gender (OR = 3.0, CI = 1.2-7.1, p = 0.04). A second conservative analysis for missing data demonstrated a significant association for ACS of 80-90% alone (OR = 13.1, CI = 1.5-60.9, p = 0.01). This association remained significant after multivariate adjustment with propensity score stratification. ACS (80-90%) appears to be independently associated with ipsilateral hemispheric stroke following CS when evaluated against the present study variables. This finding supports the need for a properly conducted prospective natural history study, including an evaluation of aortic arch atherosclerosis, to determine the clinical relevance of this observation.

The utility of selective screening for carotid stenosis in cardiac surgery patients

PURPOSE

To determine if any of 8 categorical clinical variables can be used to select patients and improve the yield of a screening program for severe carotid stenosis (> or = 80%) in elective cardiac surgery patients.

METHODS

A prospective cohort analysis of 200 consecutive patients prior to elective cardiac surgery for the following variables: age, gender, smoking carotid bruit, peripheral vascular disease, hyperlipidaemia, previous neurologic symptoms and diabetes mellitus. All patients were subsequently screened with carotid duplex scanning for the presence of severe carotid stenosis. Positive scans were confirmed by angiography.

RESULTS

Sixteen patients (8%) were identified with severe carotid stenosis. Univariate analysis identified three variables that increase risk for carotid stenosis: carotid bruit (relative risk (RR)=16.4, 5.4-57.6 95% confidence interval, p<0.001), neurological history (RR=10.3, 3.9-23.2, p<0.001) and peripheral vascular disease (RR=5.3, 1.9-14.9, p<0.001). Stepwise logistic regression analysis identified previous neurologic history and carotid bruit as independent predictors of stenosis. If screening for carotid stenosis was limited to patients with these two variables, then 37 (18.5% of total) patients would have been screened. Fourteen of these 37 (37.8%) had a severe carotid stenosis. Two patients with stenosis (12.5% of those with carotid stenosis, 1% of total patient population) would not have been screened.

CONCLUSIONS

Clinical variables can be used to improve the yield of a preoperative screening program for carotid stenosis.

Venous duplex scanning for unilateral symptoms: when do we need a contralateral evaluation?

OBJECTIVES

Determine the need for bilateral duplex scanning (DS) in patients with unilateral symptoms of acute DVT of the leg.

DESIGN

Prospective study.

MATERIALS

One thousand, one hundred and sixty-one consecutive patients with recent unilateral symptoms of pain or swelling.

METHODS

Bilateral DS were performed and demographic data including risk factors for DVT were entered into a computerised database.

RESULTS

Of the 250 cases (22%) of acute DVT, thrombus was confined to the symptomatic limb in 80% (200/250) and to the asymptomatic limb (AL) in 5% (12/250), while bilateral DVT was found in 15% (38/250). The management was not altered by the contralateral DS findings in any patient with bilateral thrombus. Ten of the 12 cases of DVT confined to the AL were localised to the infrapopliteal level; advanced malignancy, recent joint surgery or hypercoagulability were noted in nine patients, including all those requiring treatment.

CONCLUSIONS

In the presence of unilateral symptoms of DVT, we recommend DS of the symptomatic extremity only; bilateral examination should be confined to patients with normal duplex findings in the symptomatic limb following recent joint surgery, or in the presence of advanced malignancy or hypercoagulability. Bilateral DS would therefore be required in approximately 11% of cases with unilateral symptoms of DVT.