Study Questions: Chapter 20 Chapter 20: Endovascular and Surgical Treatment of Venous Disease ROBERT M. SCHAINFELD, DO Study Questions : Chapter 20 * 1.) What additional diagnostic testing may be appropriate in a 41-year-old woman who underwent successful endovenous ablation and, despite duplex ultrasound confirmation of left great saphenous vein (GSV) thrombosis, failed to heal the venous ulcer? Ankle-brachial index (ABI) MRI of ankle looking for osteomyelitis MRA of lower extremity MR venogram of abdomen/pelvis Show answerThe correct answer is 4, Ankle-brachial index (ABI). In select cases of advanced chronic venous insufficiency, when the clinical manifestations are discordant with the objective findings, investigation for “occult” proximal deep venous pathology (eg, nonocclusive iliac vein compression) may be appropriate. Recurrence of ulcers or failure to heal in the face of a successful endothermal GSV ablation should trigger a search for concomitant venous pathology. * 2.) A 25-year-old woman underwent radiofrequency ablation of the left great saphenous vein (GSV). At the 48-hour duplex ultrasound follow-up study, the GSV was confirmed to be thrombosed; however, there was evidence of hyperechoic thrombus extending up to the saphenofemoral junction, but not into the common femoral vein. What is the best option for management of this patient? Commencement of warfarin for 4 weeks Commencement of low-molecular-weight heparin Serial venous duplex ultrasound studies Placement of inferior vena cava filter Show answerThe correct answer is 3, Serial venous duplex ultrasound studies. Endothermal heat-induced thrombosis (EHIT) following endovenous ablation procedures can be encountered at time of follow-up duplex ultrasound exams done to confirm saphenous vein thrombosis. The natural history of such findings is poorly understood and has yet to be studied, but presumed to be a benign process. If there is no propagation into the deep venous system, treatment strategies have been to manage expectantly with serial duplex ultrasounds and observe for regression of clot back into the superficial saphenous vein. Only in cases of propagation into the deep venous system or embolization has anticoagulation been advocated. * 3.) A 21-year-old lobster fisherman presents to the emergency room with a 3-day history of right arm/hand swelling and discomfort. Duplex ultrasonography confirms acute thrombosis of the axillosubclavian veins extending into the basilic vein. What would be the most appropriate management strategy to optimize a favorable clinical outcome? Anticoagulate with heparin and concomitant warfarin for 6 months Systemic thrombolysis via peripheral intravenous line Catheter-directed thrombolysis via basilic vein Anticoagulate for 3 months, followed by first rib resection Show answerThe correct answer is 3, Catheter-directed thrombolysis via basilic vein. Paget-Schroetter syndrome, or effort-induced thrombosis, may be associated with long-term morbidity due to genesis of postthrombotic syndrome (PTS), especially in young athletic/vocationally active individuals when it involves the dependent limb. Thus, expeditious diagnosis and recanalization of the vein are of paramount importance. Catheter- directed thrombolysis followed by prompt surgical first-rib resection would be the best strategy to obviate the potential complication of PTS. Anticoagulation alone would not ensure patency of occluded vein, and thus, the patient might be plagued with a chronically edematous limb. The same argument holds true with resecting rib after 3 months, without initially restoring patency of vein. There is no role for systemic thrombolysis in venous disease; it must be catheter-directed to facilitate a favorable outcome. * 4.) Which one of the following candidates would benefit most from catheter-directed thrombolysis? 60-year-old patient with acute iliofemoral DVT of 3 weeks’ duration Inferior vena cava thrombosis from filter of 6 months’ duration Left iliofemoral DVT in woman 5 months pregnant Phlegmasia cerulea dolens Show answer The correct answer is 4, Phlegmasia cerulea dolens. Phlegmasia cerulea dolens is deemed a “vascular emergency,” which warrants immediate catheter-directed thrombolysis (pharmacomechanical) or surgical thrombectomy, given the risk of major limb amputation. A DVT of 3 weeks’ duration, although it might respond to CDT, in a 60-year-old would not represent an absolute indication for CDT. If pharmacologic thrombolysis could not be used, and if there was evidence of compromised cardiopulmonary reserve, an optional retrievable IVC filter might have a role. IVC thrombosis of 6 months’ duration likely would not respond to lysis, and as such primary venoplasty and stenting of IVC and filter might be appropriate. Pregnancy is a contraindication to the use of thrombolytic agents, due to safety concerns for fetus and mother. * 5.) Which one of the following statements is true regarding iliac vein revascularization? Pharmacomechanical thrombolysis is essential in all cases. Balloon-expandable stents are preferred. Access via the ipsilateral common femoral or popliteal veins. Inferior vena cava filters are mandated prior to endovascular intervention. Show answerThe correct answer is 3, Access via the ipsilateral common femoral or popliteal veins. Iliac vein recanalizations are best performed when access is obtained via the ipsilateral vein in antegrade fashion. Ideally, this is done with ultrasound guidance and through a patent vein, when feasible, so as not to compromise the integrity of the venous valves during manipulation. This technique ensures adequate “inflow” into the iliac veins following stenting. Furthermore, in cases of iliac vein compression, the proximal position of the stent must be apposed into the vena cava, so as to adequately cover the area of compression in the left common iliac vein. CDT is not essential in all cases, only when there is acute thrombosis (<14 days’ duration). Balloon-expandable stents are prone to extrinsic compression and thus not appropriate for iliac vein revascularizations. IVC filters should not be routinely employed in all cases, but reserved for those when the patient may have appropriate indications or when there is compromised cardiopulmonary reserve that would justify its added complexity. Retrievable filters with intent to remove postprocedure should be advocated.