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Nonoperative Treatment of Acute Pulmonary Embolism

Pulmonary embolism (PE) is a serious and potentially life-threatening condition afflicting a broad spectrum of the population. It has been reported that approximately 600,000 patients experience a PE episode each year in the United States. Mortality rate exceeds 15% in the first 3 months after diagnosis, surpassing that of myocardial infarction. The majority of deaths from acute PE result from right ventricular (RV) pressure overload and…

Primary and Secondary Vena Cava Tumors

Primary and secondary tumors of the vena cava are rare and often malignant. They either originate in the vein wall, invade the walls secondarily, or grow within the vena cava as tumor thrombus. They can cause extrinsic compression of the vein lumen. Most patients have advanced local, regional, or distant metastatic disease at the time of diagnosis. Despite advances in adjuvant therapy, survival is measured in…

Open Surgical Treatment of Thrombotic Vena Cava Occlusion

Thrombotic occlusions of the superior vena cava (SVC) or the inferior vena cava (IVC) requiring open surgical reconstruction are uncommon in the endovascular era. Chronic caval obstruction is usually the result of a previous acute deep vein thrombosis (DVT), which is commonly caused by intravenous central lines or pacemaker wires. It can develop as an extension of a spontaneous DVT from the iliac or subclavian veins,…

Endovascular Treatment of Vena Cava Occlusion

The superior vena cava (SVC) and inferior vena cava (IVC) have a critical role in maintaining venous return to the heart. Their occlusion is a source of considerable hemodynamic morbidity. SVC occlusion is usually related to venous stenosis because of central lines or pacer electrodes and less commonly to neoplastic occlusion. IVC occlusion usually occurs in the setting of a thrombosed caval filter, but it is…

Pelvic Venous Flow Disorder

Pelvic venous flow disorder represents a group of venous maladies characterized by alterations in normal pelvic venous flow patterns. These maladies include pelvic congestion syndrome, nutcracker syndrome, and May–Thurner syndrome. Pelvic venous flow disorder is a significant cause of chronic pelvic pain, defined as noncyclical pelvic pain of longer than 6 months’ duration. An audit of primary care physicians in the United Kingdom found that the…

Renal Vein Entrapment: The Nutcracker Syndrome

The nutcracker syndrome is characterized by entrapment and compression of the left renal vein between the abdominal aorta and the superior mesenteric artery (SMA) ( Figure 1 ). The underlying anatomic anomaly, first described by Gant in 1937, can lead to left renal venous hypertension and variable degrees of hematuria and left flank pain. In women, it may be associated with pelvic congestion symptoms, including pelvic…

Nonoperative Treatment of Venous Ulcers

Chronic venous ulcers reflect a complex interplay that involves sustained venous hypertension, leukocyte activation and inflammation, changes in the microcirculation, cytokine and matrix metalloproteinase (MMP) expression, and altered cellular function. The fundamental of nonoperative therapy in venous ulcer pathology is correction of the chronic venous insufficiency (CVI) with compression therapy. Understanding the science involved in the pathophysiology of venous ulcer formation has led to the development…

Open Surgical, Endoscopic, and Endovascular Treatment of Perforating Veins

Treatment of incompetent perforating veins (ICPVs) has evolved through numerous approaches, each holding the promise of being less invasive and as a result associated with reduced morbidity. The goal of ablating ICPVs, however, has not changed. The interruption of ICPVs has been based on the theory that the transmission of deleterious high pressure from the deep venous system through incompetent calf perforating veins contributes significantly to…

Pathophysiology of Venous Varicosities and Venous Ulcers

Chronic venous insufficiency (CVI) is the seventh leading cause of chronic debilitating disease in the United States. An estimated 25 million people in the United States have varicose veins, 2 million to 6 million have more advanced forms of CVI (swelling, skin changes), and nearly 500,000 have painful venous ulcers. The chronicity of this disorder and the lack of effective therapies place a heavy economic burden…

Nonoperative Management of Chronic Venous Insufficiency

Chronic venous insufficiency (CVI) is common, ranging from primary varicose veins to valvular incompetence of the lower extremity veins. Most symptoms of CVI can be improved with bedrest and elevation of the legs. However, prolonged immobilization is impractical and dangerous for most patients. Nonoperative therapy remains the standard initial treatment for CVI. The goal of nonoperative therapy in CVI is to control symptoms and maintain a…

Open Surgical Treatment of Chronic Venous Insufficiency

The term chronic venous insufficiency (CVI) refers to a progression in the broad category of chronic venous disorders. In terms of the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, it refers to progression beyond uncomplicated varicose vein disease (C2) to swelling (C3) and onward to skin changes (C4) and ulceration (C5–C6). These venous problems seriously affect the quality of life in of approximately 15% of the adult…

Excision of Varicose Veins

There has been an explosion of new technologies for the treatment of truncal vein reflux, and a bewildering range of endovenous thermal and chemical ablation modalities are now available, many having replaced traditional saphenous junction disconnection and stripping operations. Although not to the same extent as truncal venous treatment, the treatment of varicosities has also evolved, with new technology and paradigm shifts. This is of great…

Injection Treatment of Lower Extremity Varicose Veins

Sclerotherapy has been employed for almost a century. It involves the endoluminal delivery of a chemical to destroy venous endothelial cells to produce occlusion and fibrosis. Venous hypertension and its effects are mitigated by closure of the incompetent venous circulation. Sclerosants ideally should be efficacious without untoward side effects, provide durable and duplicable results, and be readily available at low cost. Liquid sclerotherapy should be considered…

Endovascular Radiofrequency Treatment of Varicose Veins

Endovenous radiofrequency (RF) ablation is an effective therapy of varicose veins affecting the greater saphenous vein (GSV), the small saphenous vein (SSV), the anterior accessory greater saphenous vein (AAGSV), the posterior accessory greater saphenous vein (PAGSV), and straight venous segments. The most current therapy is RF-controlled segmental thermal ablation (ClosureFast, Covidien, Mansfield, MA). This catheter fits through a 7-Fr introducer sheath ( Figure 1 ). Venous…

Endovascular Laser Treatment of Varicose Veins

Since 2001, endovenous laser ablation procedures have been reported to be safe and effective methods of eliminating the proximal portion of the greater saphenous vein (GSV), the small saphenous vein (SSV), and even tributary and perforator veins from the venous circulation, with faster recovery and better cosmetic results than traditional surgical ligations and stripping. Lasers of varying wavelengths deliver light energy to the vein through an…

Endovascular Treatment of Chronic Venous Occlusion

The endovascular approach to venous obstructive lesions including stenoses and chronic total occlusions (CTOs) has replaced traditional open surgery. As a result, a broader spectrum of patients with comorbidities that might otherwise preclude an open approach have benefited. In addition, the results of venous stenting have been surprising enough to prompt a reexamination of fundamental pathophysiologic concepts in chronic venous disease: Venous obstruction seems to be…

Pathology and Classification of Chronic Venous Disease

Chronic venous disease (CVD) is the most common disorder of the peripheral vascular system. In population studies, 10% to 35% of adults manifested some form of the disease. Its most severe manifestation is cutaneous venous ulceration. CVD and related ulcers affect an estimated 76 and 18 per 100,000 person-years, respectively. Treatment is estimated to cost $3 billion annually, with an average yearly cost of $7460 per…

Treatment of Acute Upper Extremity Venous Occlusion

The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) has been estimated to exceed 900,000 cases annually in the United States. Upper extremity DVT can result in PE in 4% to 12% of the cases, and there are known case reports of fatal PE. The number of cases of upper extremity DVT is increasing as a result of widespread use of central venous catheters,…

Open Surgical Treatment of Acute Iliofemoral and Inferior Vena Cava Thrombosis

The options for early removal of an acute thrombus in the proximal veins of the leg are catheter-directed thrombolysis, percutaneous pharmacomechanical thrombectomy, and surgical thrombectomy. If either of the first two fail or are contraindicated, then surgical thrombectomy is a valid alternative, primarily in acute iliofemoral deep vein thrombosis (DVT). When a DVT occurs, the goals of therapy are to prevent the extension or recurrence and…