Extensive iliofemoral and femoropopliteal venous thrombosis in a young patient with iliocaval atresia

Inferior vena cava (IVC) atresia is a rare congenital anomaly. Standardized treatment is not well defined due to its uncommon presentation, with this pathology associated with an increased risk of unprovoked lower extremity deep vein thrombosis (DVT). We present a case of a 32-year-old man who was admitted for bilateral lower extremity edema and pain and was found to have bilateral extensive iliofemoral and femoropopliteal DVT, absence of IVC filling, and extensive tortuous collateralization arising from the pelvic veins to the azygos vein. Bilateral mechanical thrombectomy and endovascular iliocaval reconstruction was performed. Three months later, the patient demonstrated widely patent iliocaval stents and the absence of DVT. Endovascular treatment of IVC atresia is feasible and optimizes the reduction of thrombus burden.

Association between cardiac conditions with venous leg ulcers in patients with chronic venous insufficiency

INTRODUCTION

Venous leg ulcers (VLUs) are the final stage of chronic venous insufficiency. This study aims to characterize the association between cardiovascular diseases and VLU.

METHODS

A multicentric case-control study analyzed 17,788 patients between 2015 and 2020. Cases were matched (1:2) by age and sex, and odds ratios (OR) were analyzed with conditional logistic regressions adjusted by risk factors.

RESULTS

The prevalence of VLU was 15.2%. 2390 cases were analyzed. Diseases found to be associated with VLU were atrial fibrillation (OR, 1.21; 95% CI: 1.03-1.42), pulmonary hypertension (OR, 1.45; 95% CI: 1.06-2.00), right heart failure (OR, 1.27; 95% CI: 1.13-1.43), peripheral artery disease (OR, 2.21; 95% CI: 1.90-2.56), and history of pulmonary embolism (OR, 1.45; 95% CI: 1.06-2.00).

CONCLUSIONS

Certain cardiovascular conditions showed an association with VLU. Further studies are warranted to evaluate the effect that treating concomitant cardiovascular diseases might exert on the natural history of venous leg ulcers.

Two-Year Results of a First-In-Human Study in Patients Surgically Implanted With a Bioprosthetic Venous Valve, the VenoValve in Patients With Severe Chronic Venous Insufficiency

OBJECTIVE

Two-year follow-up results from a first-in-human study of patients implanted with the VenoValve are evaluated for supporting the long-term clinical safety and performance of the device.

BACKGROUND

Chronic Venous Insufficiency (CVI) involves improper functioning of lower limb vein valves and inability of these valves to move blood back towards the heart. CVI symptoms include swelling, varicose veins, pain, and leg ulcers. Currently, there is no cure for this condition and treatment options are limited. This study provides 2-year outcomes for 8 patients who were implanted with the bioprosthetic VenoValve for treating severe CVI with deep venous reflux measured at the mid-popliteal vein. The 6-month and 1-year results were previously published.

METHODS

Eleven patients with C5 & C6 CVI were implanted with VenoValve into the midthigh femoral vein and followed for 2 years. Assessed clinical outcomes include device-related adverse events, reflux time, disease severity, and pain scores.

RESULTS

All 11 implant procedures were successful. Two-year follow-up data was obtained for 8 subjects: 1 patient died of non-device related causes, 1 was lost to follow-up, and 1 refused to follow-up due to the COVID-19 pandemic. No device-related adverse events occurred between the first and second years of follow-up. Reported 2-year clinical performance outcomes included significant decreases in mean reflux times of the mid-popliteal vein (61%), and significant improvements in mean scores for disease severity rVCSS (56%) and VAS pain (87%).

CONCLUSIONS

Results from this study support long-term safety and effectiveness of the VenoValve for improving CVI severity by reducing reflux and thereby venous pressures in the lower extremities. With limited treatments for valvular incompetence involved in severe, deep venous CVI, the device may be considered as a novel therapy. A pivotal trial in the United States is currently being conducted to assess the device in a larger number of patients.

Painful Ejaculation In A Patient With Pelvic Venous Insufficiency

Pelvic venous insufficiency (PVI) is common in women but has been rarely diagnosed in men. The clinical manifestations include varicocele and pelvic disturbances; however, we were unable to find a previous description of painful ejaculation as a symptom of PVI. We present the case of a 36-year-old man with a 7-year history of severe sharp ejaculatory pain. PVI was suspected after previous treatment attempts. The diagnosis was confirmed by descending phlebography, and he underwent coil embolization of the pelvic vessels and phlebotonic therapy. At 6 months after treatment, he reported a 75% improvement in his condition. Therefore, painful ejaculation should be considered an uncommon manifestation of PVI.

Telangiectasia diameter in response to thermal stimulus: experimental data and possible clinical applications

BACKGROUND

Telangiectasias are dilated blood vessels on the skin that develop progressively because of several diseases, including chronic venous disease. The skin blood flow has differences compared to the rest of the circulatory system. These vessels have a permanent vasoconstrictor tone that can respond to vasoconstriction/vasodilation stimulative substances and higher or lower temperatures. The aim of this study was to investigate any possible telangiectasias vasoconstriction or vasodilation in response to temperature changes.

METHODS

This study is a clinical trial with 26 outpatients of vascular surgery with telangiectasias in the lower limbs. We used direct skin digital microscopy to obtain telangiectasias images at room temperature and after the thermal stimulus with cold pads. These photographs were processed using AmScopeAmLite (United Scope LLC Euromex Optics Group b.v., Los Angeles, CA, USA) and the capillary diameter and area were measured in Adobe Illustrator (Adobe Inc., Mountain View, CA, USA). The data collected was analyzed in SPSS Statistics (SPSS Inc., Chicago, IL, USA) with a paired t-test for the telangiectasias area and a Wilcoxon matched-pairs signed-rank test for the telangiectasias diameter.

RESULTS

In comparison to telangiectasias measures at room temperature, we found a statistically significant decrease in the diameter (median of -0.04 mm; interquartile range: -0.10 mm to -0.01 mm; P<0.001) and area (mean of -26.54 mm²; 95% Confidence interval (-36.31, -16.76) mm²; P<0.001 in response to the cold stimulus.

CONCLUSIONS

Telangiectasias respond to cold patch application with a significantly statistical microscale quantifiable vasoconstriction. This intervention has the potential to improve the current state of telangiectasias sclerotherapy due to its mechanism helping to stabilize the applied foam. We speculate that topic cold used as a neoadjuvant treatment could improve the efficiency, stability, and other outcomes of sclerotherapy. Also, complementary use of topical cold stimulus application may be of interest in the therapeutic management of telangiectasias.

GREAT SAPHENOUS VEIN OCCLUSION RATES AFTER COMBINED TREATMENT WITH LASER AND FOAM SCLEROTHERAPY

BACKGROUND

Endovenous Laser Ablation (EVLA) and foam sclerotherapy are effective and safe treatments for chronic venous disease (CVD) with great saphenous vein (GSV) reflux. We report our experience combining both strategies as a merged approach to treat GSV incompetence to potentiate both methods' superiority and benefits. We aimed to determine the effectiveness of this treatment strategy.

METHODS

246 limbs with great saphenous vein incompetence (C2-C6) treated with EVLA and foam sclerotherapy between January 2016 and December 2019 were retrospectively analyzed. Outcomes of interest were the International Union of Phlebology type of anatomic closure (primary, primary assisted, secondary and therapeutic failure), identified with ultrasound in the GSV after the procedure. Clinical and ultrasound follow-up was conducted at two weeks, 3, 6, and 12 months post-intervention. We utilized Fisher's exact test to determine the significance of the association between the type of anatomic closure and the clinical stage according to the CEAP classification.

RESULTS

67% of the treated limbs were C2-C4 and 33% C5-C6. International Union of Phlebology (IUP) primary closure was achieved in 229 limbs (93%), IUP primary assisted closure in 10 (4%), IUP secondary closure in 1 (0.4%), with therapeutic failure in 6 limbs (2%). Forty-five limbs (18%) required microthrombectomies of tributary veins due to local induration, 7 (2.8%) developed dyschromia, 4 (1.6%) had type 1 Endovenous Heat-Induced Thrombosis (E-HIT1), and one limb (0.4%) developed deep vein thrombosis (DVT), which was successfully treated with anticoagulation.

CONCLUSIONS

Our results demonstrate a high occlusion rate of incompetent GSVs with combined EVLA and foam sclerotherapy with infrequent non-serious complications and one case of subclinical isolated popliteal DVT. Combined therapy effectiveness and safety are comparable with other endovenous treatments for CVD with GSV reflux. The use of both thermal and chemical ablation combines the benefits of both techniques.

The Impact of COVID-19 on Vascular Surgery Practice: A Systematic Review

BACKGROUND

COVID-19 is characterized by a pulmonary interstitial compromise which can require intensive care unit (ICU) and mechanical ventilation. Covid patients develop a wide range of pathologies. This study aims to identify the impact of COVID-19 in diseases commonly treated by vascular surgeons.

METHODS

Four conditions were selected: venous thromboembolism (VTE), pulmonary embolism (PE), peripheral arterial disease (PAD), and microangiopathy. A systematic review of the literature using PRISMA guidelines was.

RESULTS

Out of 1195 papers reviewed for conditions in COVID-19 patients relevant to routine vascular surgery practice, 43 papers were included and analyzed. Venous thrombosis was found to be the most common COVID-19 associated pathology with a cumulative incidence of 25% at 7 days and 48% at 14 days. Additionally, D-dimer levels proved to be a good predictor, even in the early stages of the disease with a sensitivity of 85%, specificity of 88.5% and a negative predictive value of 94.7%. Patients in the ICU demonstrated a significantly higher risk of developing VTE, even when receiving pharmacologic thromboprophylaxis. Although evidence of arterial thrombosis was less common (1% to 16.3%), its consequences were typically more serious, including limb loss and death even in young individuals (OR = 25, 95% CI). Finally, microangiopathy has a wide spectrum of clinical presentations from retinal microangiopathy to other more severe manifestations such as myocardial injury, pulmonary compromise and potential multiple organ dysfunction syndrome.

CONCLUSIONS

Although the pathophysiological pathway by which COVID-19 produces thrombosis is not completely clear, the incidence of both arterial and venous thrombosis is increased. D-dimer screening should be done in all COVID-19 patients, as a predictor of thrombotic complications.

Inclusión de forrajes con distinta relación de fibra soluble e insoluble en la dieta de cerdos

Se evaluó la inclusión progresiva de dos forrajes con diferente contenido en fibra soluble (FS), en dietas de cerdos desde la recría a la terminación. Los tratamientos fueron: dieta base testigo (T0) formulada en base a maíz y harina de soja; dieta base con alfalfa (T1) (Medicago sativa var. Chaná) o con achicoria (T2) (Cichorium intibus var. Lacerta) para las fases (F) de recría I (F1, 40-60 kg de PV), recría II (F2, 60-80 kg de PV) y terminación (F3, 80 a 100 kg de PV). Se utilizaron 27 animales con un peso inicial de 42 kg (± 2.3), en un diseño de parcelas al azar en tres tratamientos con nueve repeticiones. El peso final y la ganancia diaria no difirieron entre tratamientos. El consumo de Fibra Dietaria fue mayor en los tratamientos con forraje (P

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

171 Follicular and luteal characteristics and pregnancy rates in Bos indicus suckled cows treated with two oestradiol/progesterone-based protocols with a prolonged pro-oestrus

An experiment was designed to evaluate the effect of the length of insertion of a progesterone (P4)-releasing device on follicular and luteal characteristics and pregnancy rates to fixed-time AI (P/FTAI) in Bos indicus cows treated with oestradiol/P4-based treatments with a prolonged pro-oestrus. Multiparous Bos indicus suckled beef cows (n=659), 60-90 days postpartum, with a corpus luteum (CL) or at least one follicle ≥8mm in diameter and with a body condition score between 2 and 3.5 (1-to-5 scale) were synchronised using three treatments. On Day 0, all cows received 2mg of oestradiol benzoate (Sincrodiol, Ourofino) and an intravaginal device with 1g of P4 (Sincrogest, Ourofino). The P4 device was removed on Day 6 in cows in the J-Synch 6 group (n=195) and on Day 7 in cows in the J-Synch 7 group (n=262) and conventional group (n=202). All cows received 500μg of cloprostenol (Sincrocio, Ourofino) and 400IU of equine chorionic gonadotrophin (SincroeCG 6000UI, Ourofino) at the time of P4 device removal. Cows in the conventional treatment group also received 0.5mg of oestradiol cypionate (SincroCP, Ourofino) at the same time. In addition, all cows were tail-painted for oestrous detection (CeloTest, Biotay). Cows that had lost ≥50% of the tail paint 62-66h (J-Synch groups) or 48-52h (conventional group) after device removal were FTAI at that time. Cows not showing oestrus by 62-66h (J-Synch groups) or 48-52h (conventional group) received 10μg of GnRH (Sincroforte, Ourofino) at the same time and were FTAI 8h later. A subset of 20 cows per group was also examined using ultrasonography (Mindray DP50 Vet) every 12h from the time of device removal to determine the time of ovulation, 6 days after ovulation to determine CL diameter, and 30 days after FTAI to determine P/AI. Data were analysed using the GLM Mixed procedure (InfoStat). The results are shown in Table 1. The diameter of the dominant preovulatory follicle was larger and the interval from device removal to ovulation was longer in cows in the J-Synch groups compared with those in the conventional group (P&lt;0.05). Furthermore, the diameter of the CL was larger and P/FTAI was higher in cows in the J-Synch 7 group compared with those in the J-Synch 6 and conventional groups. In conclusion, delaying the removal of the P4 device by 1 day (i.e. Day 7 vs. Day 6) in the J-Synch groups and prolonging the pro-oestrus period by not giving oestradiol cypionate at P4 device removal (i.e. J-Synch 7 vs. conventional) resulted in a larger preovulatory follicle and CL and higher P/FTAI in Bos indicus suckled cows. Table 1.Mean (±s.e.m.) diameter of the preovulatory follicle (P/Foll) and corpus luteum (CL), interval from progesterone (P4) device removal to ovulation, and pregnancy rates to fixed-time AI (P/FTAI) in Bos indicus suckled cows Treatment P/Foll diameter, mm CL diameter, mm Interval to ovulation, h P/FTAI,% (n) J-Synch 6 15.5±0.3a 18.7±0.8a 83.0±4.0b 41.0 (80/195)a J-Synch 7 16.4±0.2b 21.9±0.8b 86.0±3.0b 52.0 (136/262)b Conventional 13.8±0.2a 16.8±0.9a 64.0±3.0a 37.1 (75/202)a a,bDifferent superscripts denote differences between means or P/FTAI.

Laparoscopic ureteral ligation (clipping): a novel, simple procedure for pediatric urinary incontinence due to ectopic ureters associated with non-functioning upper pole renal moieties

OBJECTIVE

A simplified approach for the surgical management of symptomatic ectopic ureters, associated with a non-functioning upper moiety, with laparoscopic ureteric clipping is presented in this research paper.

MATERIALS AND METHODS

Prospectively collected data on nine consecutive girls with ectopic ureters associated with urinary incontinence who underwent laparoscopic clipping between February 2011 and December 2013. Surgical technique consisted of cystoscopy and insertion of ureteral catheter in the lower pole ureter to aid in identification and clipping of the ectopic ureter, which was achieved by standard trans-peritoneal laparoscopy.

RESULTS

Median age was eight years (range 4-17 years). Diagnosis was based on clinical findings, which were supported by: ultrasound (US), nuclear scans and magnetic resonance urography in Cases 9, 8 and 5, respectively. Bilateral complete duplication was present in two patients; the combination of cystoscopy and laparoscopy allowed adequate identification of the ectopic ureter causing incontinence in both. All nine patients were immediately dry after surgery and remain asymptomatic after a maximum follow up of 27 months. Eight out of nine patients had developed some degree of asymptomatic upper pole hydronephrosis on follow-up US.

CONCLUSION

Laparoscopic clipping holds promise as a simple alternative to other more-complex surgical procedures in the treatment of incontinence due to an ectopic ureter. Despite favorable and encouraging initial results, further follow up is warranted in order to determine the fate of expected associated upper-pole hydronephrosis.

Single-center experience with botulinum toxin endoscopic detrusor injection for the treatment of congenital neuropathic bladder in children: effect of dose adjustment, multiple injections, and avoidance of reconstructive procedures

OBJECTIVE

Since 2007, intra-detrusor OnabotulinumtoxinA (OnabotA) injections have been selectively offered at our institution for cases in which maximal anticholinergic therapy failed or was not tolerated. Herein we present our experience with this approach.

MATERIALS AND METHODS

We prospectively obtained data on 17 patients who underwent OnabotA injections over a 4-year period. Demographic information, number of injections, and dose delivered were captured. Children were monitored with baseline and post-injection renal ultrasound, urodynamics, and assessed for side effects, satisfaction, and symptom improvement.

RESULTS

Forty-three sessions were performed with injections given every ∼ 6 months. Mean patient age was 10.7 years (range, 3-17). Compared with baseline, after the first injection, mean bladder capacity adjusted for age and compliance improved by 27% (p = 0.039) and 45.2% (p = 0.041), respectively. After subsequent injections, these values increased to 35.7% (p = 0.043) and 55.1% (p = 0.091), respectively. Out of 13 symptomatic patients, ≥ 50% improvement was reported in ten (76.9%) and complete resolution in seven (53.8%). However, all three patients in whom the maximum dose of OnabotA was reduced from 300 to 200 units complained of recurrent symptoms. Fourteen children avoided surgical reconstruction as a second line of treatment. Overall patient/parental reported satisfaction rate was 70.6% (12/17).

CONCLUSIONS

Intra-detrusor OnabotA injection is a promising intervention for management of neuropathic bladder in selected patients. Our data demonstrate improvement in symptoms and urodynamic parameters. Although an optimal dose has not been determined for children, we found optimal response with a maximum administration of OnabotA up to 300 units.

Importancia clínica de la proteinuria en la Diabetes Mellitus

 Justificación: Ante la creciente incidencia de Diabetes Mellitus en la población joven, y en vista del pobre nivel de control metabólico alcanzado mundialmente para dicha enfermedad, es necesario encontrar métodos sencillos, prácticos y a nuestro alcance, para detectar en forma muy temprana la aparición de las complicaciones crónicas propias de la Diabetes. Así se lograría evitar, ó al menos enlentecer, la evolución natural de una enfermedad muy limitante para quien no conoce lo suficiente de cómo vivir con ella, o una vez advertido y debidamente instruido en sus implicaciones, hace caso omiso de lo que se recomienda.Objetivo: Revisar la más reciente evidencia de utilidad y disponibilidad de los distintos métodos de evaluación de la albuminuria, para mejorar el abordaje del paciente diabético, con o sin nefropatía.Metodología: Revisión bibliográfica de publicaciones de los últimos 10 años.Conclusiones: 1) A todo paciente DM Tipo 1 luego de 5 años de ser diagnosticado y a todo paciente DM tipo 2 al momento del diagnóstico, debe realizársele medición de proteinuria. 2) Las tiras reactivas para determinar la micro y macroalbuminuria son confiables en relación con la medición de la orina de 24 horas. 3) Los factores más importantes dentro de la evolución de la nefropatía diabética y que exigen un agresivo manejo son: un buen control metabólico y el manejo antihipertensivo. 4) Los otros factores son importantes, pero su intervención es discutible.