Embolization of splenorenal shunt associated to portal vein thrombosis and hepatic encephalopathy

Hepatic encephalopathy (HE) is a cognitive disturbance characterized by neuropsychiatric alterations. It occurs in acute and chronic hepatic disease and also in patients with portosystemic shunts. The presence of these portosystemic shunts allows the passage of nitrogenous substances from the intestines through systemic veins without liver depuration. Therefore, the embolization of these shunts has been performed to control HE manifestations, but the presence of portal vein thrombosis is considered a contraindication. In this presentation we show a cirrhotic patient with severe HE and portal vein thrombosis who was submitted to embolization of a large portosystemic shunt. Case report: a 57 years-old cirrhotic patient who had been hospitalized many times for persistent HE and hepatic coma, even without precipitant factors. She had a wide portosystemic shunt and also portal vein thrombosis. The abdominal angiography confirmed the splenorenal shunt and showed other shunts. The larger shunt was embolized through placement of microcoils, and the patient had no recurrence of overt HE. There was a little increase of esophageal and gastric varices, but no endoscopic treatment was needed. Since portosystemic shunts are frequent causes of recurrent HE in cirrhotic patients, portal vein thrombosis should be considered a relative contraindication to perform a shunt embolization. However, in particular cases with many shunts and severe HE, we found that one of these shunts can be safely embolized and this procedure can be sufficient to obtain a good HE recovery. In conclusion, we reported a case of persistent HE due to a wide portosystemic shunt associated with portal vein thrombosis. As the patient had other shunts, she was successfully treated by embolization of the larger shunt. (C) 2014 Baishideng Publishing Group Inc. All rights reserved.

Acute partial Budd-Chiari syndrome and portal vein thrombosis in cytomegalovirus primary infection: a case report

BACKGROUND: Splanchnic vein thrombosis may complicate inherited thrombotic disorders. Acute cytomegalovirus infection is a rare cause of acquired venous thrombosis in the portal or mesenteric territory, but has never been described extending into a main hepatic vein. CASE PRESENTATION: A 36-year-old immunocompetent woman presented with acute primary cytomegalovirus infection in association with extensive thrombosis in the portal and splenic vein. In addition, a fresh thrombus was evident in the right hepatic vein. A thorough evaluation for a hypercoagulable state was negative. The clinical course, biological evolution, radiological and histological findings were consistent with cytomegalovirus hepatitis complicated by a partial acute Budd-Chiari syndrome and portal thrombosis. Therapeutic anticoagulation was associated with a slow clinical improvement and partial vascular recanalization. CONCLUSION: We described in details a new association between cytomegalovirus infection and acute venous thrombosis both in the portal vein and in the right hepatic vein, realizing a partial Budd-Chiari syndrome. One should be aware that this rare thrombotic event may be complicated by partial venous outflow block.

Treatment of portal vein thrombosis by thrombectomy and regional thrombolysis

BACKGROUND. Portal vein thrombosis is a rare disorder. The prognosis of both the acute and the chronic forms is determined by the resulting acute or chronic portal hypertension. The therapeutic approach of choice is controversial. METHODS. A case of etiologically unclear thrombosis of the portal vein system in a young man is reported, which was treated successfully by means of portal vein thrombectomy combined with intraoperative and postoperative thrombolysis with recombinant tissue plasminogen activator (rTPA). RESULTS. Initial thrombectomy established sufficient venous return. However, rethrombosis of the portal vein occurred 2 days later. In a second operation rethrombectomy was followed by intraoperative regional application of rTPA, which was continued after operation during a period of 48 hours through a catheter inserted in a mesenteric vein. Patency of the portal system was confirmed 1 week after the procedure. The 1-year follow-up reconfirmed this result (through indirect portography and Doppler sonography). The patient received the anticoagulant phenprocoumon. CONCLUSIONS. The combination of surgical thrombectomy and regional thrombolysis with rTPA could offer a feasible therapeutic option for selected patients with acute prehepatic portal vein thrombosis.

Deep vein thrombosis and caesarean section

Deep vein thrombosis (DVT) presents a significant risk for women requiring Caesarean section.
Venous thromboembolism (VTE) remains the leading direct cause of maternal death in the
UK and is the second most common cause of maternal death worldwide, accounting for 11%
of maternal deaths (RCOG 2009). This article uses a reflective cycle to explore the role of the
preoperative practitioner in the prevention of DVT for women undergoing elective Caesarean
section.

Tissue plasminogen activator for hepatic vein thrombosis in paroxysmal nocturnal haemoglobinuria

Paroxysmal nocturnal haemoglobinuria (PNH) is an acquired clonal disorder thought to arise in a multipotent haemopoietic stem cell. A distinct clinical feature is a tendency to thrombosis, with a particular predilection for the hepatic veins (Budd-Chiari syndrome). We report here on two patients with PNH who developed hepatic vein thrombosis (HVT) and who were treated with tissue plasminogen activator (t-PA). Both patients had a marked clinical and radiological improvement following the t-PA treatment and remain well over 2 years and 6 years after the treatment. This method of thrombolysis for HVT occurring in PNH has only been reported in two previous patients with limited follow-up. We suggest that this therapy is a useful first-line treatment for PNH patients who develop HVT.

Upper limb deep vein thrombosis due to Langer's axillary arch

Langer's axillary arch is a recognized muscular anomaly characterized by an accessory muscular band crossing the axilla that rarely causes symptoms. We describe a patient who presented with an upper limb deep vein thrombosis caused by this aberrant muscle, which we believe is the first reported case. Axillary surgery with division of the aberrant muscle relieved upper limb venous obstruction in this patient. (J Vase Surg 2012;55:234-6.)

Evaluation of airline exercises prescribed to avoid deep vein thrombosis using fiber Bragg grating sensors

Various leg exercises have been recommended to prevent deep vein thrombosis (DVT), a condition where a blood clot forms in the deep veins, especially during long-haul flights. Accessing the benefit of each of these exercises in avoiding the DVT, which can be fatal, is important in the context of suggesting the correct and the most beneficial exercises. Present work aims at demonstrating the fiber Bragg grating (FBG)-based sensing methodology for measuring surface strains generated on the skin of the calf muscle to evaluate the suggested airline exercises to avoid DVT. As the dataset in the experiment involves multiple subjects performing these exercises, an inertial measurement unit has been used to validate the repetitiveness of each of the exercises. The surface strain on the calf muscle obtained using the FBG sensor, which is a measure of the calf muscle deformation, has been compared against the variation of blood velocity in the femoral vein of the thigh measured using a commercial electronic-phased array color Doppler ultrasound system. Apart from analyzing the effectiveness of suggested exercises, a new exercise which is more effective in terms of strain generated to avoid DVT is proposed and evaluated. (C) 2013 Society of Photo-Optical Instrumentation Engineers (SPIE)

Adjuvant portal-vein infusion of fluorouracil and heparin in colorectal cancer: A randomised trial

Background. There is conflicting evidence on the efficacy of regional adjuvant chemotherapy, via portal-vein infusion (PVI), after resection of colorectal cancer. We undertook a randomised controlled multicentre trial to investigate the efficacy of PVI (500 mg/m2 fluorouracil plus 5000 IU heparin daily for 7 days). Methods. 1235 of about 1500 potentially eligible patients were randomly assigned surgery plus PVI or surgery alone (control). The patients were followed up for a median of 63 months, with yearly screening for recurrent disease. The primary endpoint was survival; analyses were by intention to treat. Findings. 619 patients in the control group and 616 in the PVI group met eligibility criteria. 164 (26%) control-group patients and 173 (28%) PVI-group patients died. 5-year survival did not differ significantly between the groups (73 vs 72%; 95% CI for difference -6 to 4). The control and PVI groups were also similar in terms of disease-free survival at 5 years (67 vs 65%) and the number of patients with liver metastases (79 vs 77%). Interpretation. PVI of fluorouracil, at a dose of 500 mg/m2 for 7 days, cannot be recommended as the sole adjuvant treatment for high-risk colorectal cancer after complete surgical excision. However, these results cannot eliminate a small benefit when PVI is used at a higher dosage or in combination with mitomycin.

Portal vein embolization before right hepatectomy: prospective clinical trial.

OBJECTIVE: To assess the impact of liver hypertrophy of the future liver remnant volume (FLR) induced by preoperative portal vein embolization (PVE) on the immediate postoperative complications after a standardized major liver resection. SUMMARY BACKGROUND DATA: PVE is usually indicated when FLR is estimated to be too small for major liver resection. However, few data exist regarding the exact quantification of sufficient minimal functional hepatic volume required to avoid postoperative complications in both patients with or without chronic liver disease. METHODS: All consecutive patients in whom an elective right hepatectomy was feasible and who fulfilled the inclusion and exclusion criteria between 1998 and 2000 were assigned to have alternatively either immediate surgery or surgery after PVE. Among 55 patients (25 liver metastases, 2 cholangiocarcinoma, and 28 hepatocellular carcinoma), 28 underwent right hepatectomy after PVE and 27 underwent immediate surgery. Twenty-eight patients had chronic liver disease. FLR and estimated rate of functional future liver remnant (%FFLR) volumes were assessed by computed tomography. RESULTS: The mean increase of FLR and %FFLR 4 to 8 weeks after PVE were respectively 44 +/- 19% and 16 +/- 7% for patients with normal liver and 35 +/- 28% and 9 +/- 3% for those with chronic liver disease. All patients with normal liver and 86% with chronic liver disease experienced hypertrophy after PVE. The postoperative course of patients with normal liver who underwent PVE before right hepatectomy was similar to those with immediate surgery. In contrast, PVE in patients with chronic liver disease significantly decreased the incidence of postoperative complications as well as the intensive care unit stay and total hospital stay after right hepatectomy. CONCLUSIONS: Before elective right hepatectomy, the hypertrophy of FLR induced by PVE had no beneficial effect on the postoperative course in patients with normal liver. In contrast, in patients with chronic liver disease, the hypertrophy of the FLR induced by PVE decreased significantly the rate of postoperative complications.

Uptake of new treatment strategies for deep vein thrombosis: an international audit.

OBJECTIVE: Study of the uptake of new medical technologies provides useful information on the transfer of published evidence into usual practice. We conducted an audit of selected hospitals in three countries (Canada, France, and Switzerland) to identify clinical predictors of low-molecular-weight (LMW) heparin use and outpatient treatment, and to compare the pace of uptake of these new therapeutic approaches across hospitals. DESIGN: Historical review of medical records. SETTING AND PARTICIPANTS: We reviewed the medical records of 3043 patients diagnosed with deep vein thrombosis (DVT) in five Canadian, two French, and two Swiss teaching hospitals from 1994 to 1998. Measures. We explored independent clinical variables associated with LMW heparin use and outpatient treatment, and determined crude and adjusted rates of LMW heparin use and outpatient treatment across hospitals. RESULTS: For the years studied, the overall rates of LMW heparin use and outpatient treatment in the study sample were 34.1 and 15.8%, respectively, with higher rates of use in later years. Many comorbidities were negatively associated with outpatient treatment, and risk-adjusted rates of use of these new approaches varied significantly across hospitals. CONCLUSION: There has been a relatively rapid uptake of LMW heparins and outpatient treatment for DVT in their early years of availability, but the pace of uptake has varied considerably across hospitals and countries.

Prophylaxis of deep-vein thrombosis after lower extremity amputation: Comparison of low molecular weight heparin with unfractionated heparin

OBJETIVO: Comparar a eficácia e segurança da profilaxia com heparina de baixo peso molecular (enoxaparina) versus heparina não fracionada (HNF). MÉTODOS: Setenta e cinco pacientes (59 homens e 16 mulheres ), submetidos a amputação maior dos membros inferiores (30 acima do joelho e 45 abaixo do joelho ), foram tratados ao acaso com HNF subcutânea (5,000 IU -2x/dia ) ou enoxaparina subcutânea (40mg/dia ) durante a hospitalização . A profilaxia teve início 12 horas antes da cirurgia ou , em casos emergenciais , no primeiro dia de pós-operatório. RESULTADOS: Os dois grupos de tratamento foram comparáveis em termos de características gerais . A avaliação da TVP foi feita por meio de exame clínico diário e pelo mapeamento dúplex antes e 5-8 dias após a cirurgia . A TVP foi documentada no lado operado em 9,75% dos pacientes tratados com enoxaparina e em 11,76% dos pacientes tratados com HNF (p=0,92) e houve um caso de TVP bilateral em cada grupo . Sangramentos não foram verificados nos 2 grupos . CONCLUSÃO: A enoxaparina e HNF foram igualmente eficientes e seguras para a profilaxia da TVP em pacientes submetidos à amputação de membros inferiores .

Prevalence of deep vein thrombosis and pulmonary embolism in superficial thrombophlebitis of the lower limbs: prospective study of 60 cases

Aim. Superficial thrombophlebitis (ST) ascending the lower limbs is a common disease, which may be associated with deep vein thrombosis (DVT) and pulmonary embolism (PE). The aim of this study was to investigate the prevalence of DVT and PE as complications of ascending ST of the lower limbs in the great saphenous vein (GSV) or SSV (SSV) and probable risk factors.Methods. For this study 60 consecutive patients were enrolled with ascending ST of the GSV or SSV, seen between 2000 and 2003 at a public hospital in Botucatu, SP, Brazil. All patients were assessed clinically, by venous Duplex scanning of the lower limbs to confirm ST and test for DVT, and by means of pulmonary scintigraphy to test for PE.Results. In 13 ST cases (21.67%) there was concomitant DVT and 17 ST patients (28.33%) also had PE. Eleven patients had a clinical status suggestive of DVT, but only in eight of these (61.5%), this clinical diagnosis was confirmed. Fourteen patients had a clinical status suggestive of PE, and this diagnosis was confirmed in six cases (35.30%). ST patients who also had DVT and/or PE were given anticoagulant treatment with heparin and warfarin. None of the variables studied was predictive of DVT or PE (P>0.05). However, the presence of varicose veins reduced the risk of patients having DVT (relative risk=9.09; 95%CI:1.75 - 50.00 and P=0.023).Conclusion. The prevalence rates of PE (28.3%) and DVT (21.6%) were elevated in this sample of ascending ST cases, indicating a need for detailed assessment of patients for signs of these complications, including for therapeutic management decision making. [Int Angiol 2009;28:400-8]