Natural History of Deep Vein Thrombosis in Children
The Role of Duplex Ultrasound in the Pelvic Congestion Syndrome Workup
Pediatric venous thromboembolism in relation to adults
OBJECTIVE:This review was performed to analyze the current knowledge and controversies in the pathophysiology, diagnosis, treatment, and outcomes of pediatric venous thromboembolism (VTE) compared with adults. METHODS:Searches of the MEDLINE database and manual searches of the references of selected articles were performed to select reports for their relevance and quality of information on the similarities and differences in pathophysiology, diagnosis, and treatment of VTE in children and adults. RESULTS:Symptomatic VTE incidence is reported at a rate of 0.07 in every 10,000 children, which is significantly lower than the rate in adults. Pulmonary emboli in adolescents are rarely fatal, unlike in adults. VTE recurrence is also much lower in children. Young age has been shown to be protective of VTE, whereas central venous catheters are very important in pediatric venous thrombosis. The incidence of postthrombotic syndrome varies from 20% to 65%, with mild symptoms in most children. Cerebral and visceral vein thrombosis may lead to severe morbidity and death. Some factors of thrombophilia have a significant effect in the pediatric population; however, its overall significance is controversial. Most data on VTE treatment are extrapolated from studies in adults. Children with acute VTE should be treated with anticoagulation therapy. Treatment duration depends on the nature of the thrombosis and previous VTE events. CONCLUSIONS:There is a paucity of prospective randomized studies with data determining not only the effect of VTE but also the treatment options in children. Thrombophilia is a risk factor for pediatric VTE, but its significance has not been thoroughly investigated. Guidelines specific to children for antithrombotic therapy, prophylaxis, and optimal duration need re-evaluation and support by strong evidence.
Improving retrieval rates of temporary inferior vena cava filters
PURPOSE/OBJECTIVE:Most studies have shown that the rate of inferior vena cava filter (IVCF) retrieval rarely exceeds 30%. A review of practices in our own institution revealed similar results (18%). Within the last year, few centers have demonstrated improved retrieval rates. Our hypothesis was that developing a dedicated program would improve IVCF retrieval. We report the results of an ongoing study following the development of this program. METHODS:This is a cohort of nontrauma consecutive patients who had an IVCF placed by the vascular service over a 12-month period (January 2010-January 2011) and were followed prospectively. A dedicated nurse practitioner was responsible in developing a database, maintaining contact with all the patients, and ensuring that arrangements were made for retrieval when indications for IVCF protection were no longer present. Demographics, indication for filter placement, timing to filter retrieval, and complications during placement and retrieval were prospectively collected. Retrieval rate was compared to the baseline institution data. RESULTS:During the study period, 42 patients had an IVCF placed. There were 27 men and 15 women with a mean age of 58 (25 to 88 years old). Two patients were excluded (one due to mortality and one had multiple filters) leaving 40 patients in the study. Indications for IVCF placement were absolute in 23 of 40 patients (58%), relative in 10 of 40 patients (25%), while seven patients (17%) had an IVCF placed for prophylaxis as they were considered high risk for pulmonary embolism (PE) and could not receive any chemical regimen. During follow-up, five filters were converted to permanent. Therefore, retrieval was successful in 19 of 22 patients with an 86% success rate and no complications. Median time to retrieval was 21 days ranging from 4 to 140 days. Retrieval rate for IVCFs designated as temporary at the time of placement was 70% (19 of 27), which was significantly higher compared to our baseline data of 18% (P < .001). CONCLUSION/CONCLUSIONS:Initial data show that a dedicated program that closely monitors patients with temporary IVCFs for ongoing need of filter prophylaxis can result in high retrieval rates. The endurance and long-term success of such a program needs to be further validated.
Impact and clinical significance of recurrent venous thromboembolism
BACKGROUND:The purpose of this review was to analyse current knowledge and controversies associated with the diagnosis, treatment and prevention of recurrent venous thromboembolism (VTE). METHODS:MEDLINE and manual searches were performed to select prospective papers on the diagnosis, treatment and prevention of recurrent VTE for their relevance and quality. RESULTS:The cumulative incidence of recurrent VTE increases from 11 per cent at 1 year to 40 per cent at 10 years. The incidence of recurrence is higher in unprovoked thrombosis compared with provoked VTE. Patients with unprovoked deep vein thrombosis also have a greater number of multiple recurrences. Ultrasonography or D-dimer monitoring may have an impact on the duration of anticoagulation but further refinements are needed. The incidence of skin damage is higher in ipsilateral recurrence compared with contralateral or no recurrence. Legs with ipsilateral recurrence more often have both reflux and obstruction. CONCLUSION/CONCLUSIONS:The role and weight of the predictive factors for recurrent VTE and its sequelae, and the type and optimal duration of anticoagulation have not been studied adequately. Fatality associated with pulmonary embolism and rates of recurrent VTE remain unacceptably high.
The distribution and significance of varicosities in the saphenous trunks
OBJECTIVE:The purpose of this study was to determine the prevalence, distribution, and extent of varicosities and focal dilatations in the saphenous trunks, their association with the sites of reflux, and their correlation with CEAP classes. METHODS:This prospective study included patients belonging to different CEAP classes (2-6) and a control group of age- and gender-matched healthy volunteers (group C). Color-flow duplex scan imaging was used to evaluate the entire venous system from groin to ankle for reflux and obstruction. Varicose segments and focal dilatations of the great and small saphenous veins (GSV and SSV) were recorded, and the diameters throughout the length of the saphenous trunks were measured. The presence of varicosities in the tributaries and accessory veins were documented. RESULTS:From the 739 consecutive patients, 239 were excluded due to superficial venous thrombosis (SVT), deep venous thrombosis (DVT), both SVT and DVT, previous interventions, or C3-C6 presentation with no chronic venous disease (CVD). The included 500 patients (681 limbs) were divided into two groups based on CEAP class: group A (C2 + C3) and group B (C4-6). Group A had significantly more women than group B and a younger mean age (48 vs 56 years). Overall, GSV reflux (86%) was more prevalent than SSV reflux (17%), P < .0001. Saphenous trunk diameters, saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) involvement were greater in group B, (P < .01). Group C had smaller saphenous diameters compared to group A in all locations (P < .05) but the malleoli. The prevalence of the saphenous varicose segments in both groups was small with the GSV in group B being the highest (4.3%) and the SSV in group A being the smallest (1.2%). Focal dilatations were significantly more prevalent than varicosities in the saphenous trunks (P < .0001). Varicosities of tributaries and accessory veins were more prevalent than those of saphenous trunks (P < .0001). The mean length of varicose segments in the saphenous trunks was short (3.8 cm, range, 2.1-6.4 for group A vs 4.1 cm, range, 2.3-8.3 for group B, P = .09). CONCLUSION/CONCLUSIONS:A novel definition for varicosities in the saphenous trunks was established. Using this definition, it was determined that focal dilatations are far more common than varicosities. Because both of these entities are more prevalent in the accessory saphenous veins and tributaries, and CEAP class correlates positively with the extent of reflux and saphenous trunk diameter, studies on earlier interventions are warranted to prevent CVD progression.
Clinical significance of recurrent venous thromboembolism
Recurrent venous thromboembolism is a significant problem leading to increased morbidity and mortality. It has a high impact on patients' quality of life and imposes a great financial burden on society. Cumulative recurrence has been reported as 40% at 10 years, while the chance of developing postthrombotic signs and symptoms in the lower extremities almost quadruples when ipsilateral. There is also a higher chance of developing pulmonary hypertension. Important factors for recurrence are unprovoked episodes of deep vein thrombosis, malignancy and older age. The evidence for other factors is controversial. Accurate diagnosis and treatment tailored to the patients' history, thrombotic events and risk factors are necessary to optimize management and prevent recurrence
The evaluation of lower-extremity ulcers
Lower-limb ulceration is prevalent in Western countries. There are many different types of ulcers with several causes. The most prevalent are those due to vascular disease, of which venous is the most common, accounting for over two-thirds of all types of ulcers. There are also many other causes for ulceration such as malignancy, infections, and skin, drug-induced, and autoimmune diseases. The ulcers have different characteristics, which may be differentiated by the history and clinical examination of the patients. However, objective documentation for the ulcer etiology is necessary prior to instigating treatment. The methods for diagnosing the causes for the ulcers include plethysmography, ultrasound, angiography, computer tomography, magnetic resonance imaging, and skin biopsy. All these tests should be used in conjunction with the clinical presentation of the patient. They should be performed in a cost-effective manner to avoid delays in diagnosis and reduce costs and usage of resources.
Zygomaticofacial, zygomaticoorbital and zygomaticotemporal foramina: anatomical study
The zygomatic nerve may be disrupted when elevating periorbita from the lateral wall during orbital surgery, and care should be taken to prevent injury to this nerve during lateral orbitotomy approaches to access intraorbital soft-tissue tumors. Furthermore, the precise introduction of anesthetics to the zygomaticoorbital (ZO), zygomaticofacial (ZF) and zygomaticotemporal (ZT) foramina could be important data for the plastic and reconstructive surgeon operating in the area. The aim of the present study was to investigate the morphologic and topographic anatomy, and variations of the ZO, ZF and ZT. The present study was performed using 200 dry human skulls. The ZF, ZO and ZT foramina varied from being absent to as many as four small openings. We classified each of these foramina as types I-V for single, double, triple, quadruple and absent foramina, respectively. The relative frequency was as follows: type I, ZO 50%, ZF 40%, ZT 30%; type II, ZO 20%, ZF 15%, ZT 15%; type III, ZO 10%, ZF 5%, ZT 5%; type IV, ZO 3%, ZF 1%, ZT-; and type V, ZO 17%, ZF 39%, ZT 50%. A detailed knowledge of the anatomic morphometry of this area is necessary for a surgeon when performing maxillofacial surgery and regional block anesthesia. Anatomic variations in this area may be present and a surgeon must take this into consideration so as to increase surgical success.
Ruggero Ferdinando Antonio Guiseppe Vincenzo Oddi [Historical Article]
Long forgotten in his motherland but for a single discovery-a small circular tissue whose workings are as mysterious as its discoverer-a brilliant anatomist and physiologist, Oddi, gained his fame at the age of 23 years with his identification of the sphincter that would later be named in his honor. In 1984 Ruggero Oddi, was celebrated and revered in his native town of Perugia with a monument. Ruggero Oddi lived a tumultuous life, full of grief and tragedy, only to culminate in a lonely death while exiled in a foreign land. We now review the life of this contributor to modern anatomy.