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Endovascular Thrombolysis and Mechanical Clot Removal for Acute Symptomatic Lower Extremity Deep Vein Thrombosis

The postthrombotic syndrome (PTS) is a debilitating complication of iliofemoral deep vein thrombosis (IFDVT) that markedly compromises patients’ quality of life. Postthrombotic morbidity is also associated with serious socioeconomic implications. Kahn and colleagues estimated the incidence of PTS to be 25% to 46% in all patients with DVT treated with anticoagulation alone. Patients with IFDVT have a greater incidence of and more severe PTS than those…

Warfarin-Induced Skin Necrosis

Warfarin-induced skin necrosis is a clinical–pathologic condition that arises in patients treated with vitamin K antagonists and that produces an activated blood coagulation state. The condition becomes manifest as a result of the relative loss of the protein C and S anticoagulation system in vivo. If not recognized and treated it can progress to skin mutilation, limb necrosis, and death. Its major treatment is prevention by understanding…

New and Alternative Anticoagulants

There are many pharmacologic options in current use to treat and prevent venous thromboembolism (VTE). These medications include unfractionated heparin (UFH), low-molecular-weight heparins (LMWHs), factor Xa inhibitors (anti-Xa drugs), direct thrombin inhibitors (anti-IIa drugs), and vitamin K antagonists. UFH and direct thrombin inhibitors (such as argatroban and bivalirudin) are used intravenously, requiring invasive administration and monitoring of dose effect. The LMWHs such as enoxaparin and the…

Nonoperative Treatment of Acute Lower Extremity Venous Thrombosis

Patients with Deep Vein Thrombosis The classic long-term treatment for deep vein thrombosis (DVT) is vitamin K–antagonist therapy overlapped with initial heparin or low-molecular-weight heparin (LMWH) therapy. Accurate, objective tests to detect venous thromboembolism (VTE) have led to randomized trials evaluating short-term therapy and long-term anticoagulant therapy for venous thrombosis, which have advanced our therapeutic understanding. Initial short-term LMWH therapy is effective and is preferred over…

Natural History of Acute Venous Thrombosis

Acute deep vein thrombosis (DVT) and its complications, including pulmonary embolism (PE), recurrent venous thromboembolism (VTE), and the postthrombotic syndrome (PTS), are important not only as the most common preventable cause of hospital death but also as a cause of substantial long-term morbidity. The early natural history of acute DVT is characterized by a balance between factors favoring restoration of the venous lumen and recurrent thrombosis.…

Invasive Methods of Diagnosing Acute and Chronic Venous Disease

The diagnosis of acute and chronic venous disease is usually made by compression ultrasound (US) of the extremities and by computed tomography (CT) or magnetic resonance imaging (MRI) in the chest, abdomen, and pelvis. Invasive contrast venography, including intravascular US (IVUS), is reserved for answering specific questions of venous anatomy or venous physiology, usually in the context of an endovascular or open surgical procedure. Intravascular Ultrasonography…

Ultrasonography for the Diagnosis of Venous Disease

Venous disease has high prevalence, affecting at least a third of the adult population in Western countries. In patients with venous disease, the venous return is impeded as a result of reflux, obstruction, or the combination of both pathologies. Reflux is the most common pathology found and in the majority of patients is primary. Obstruction can be acute, as in patients with venous thrombosis, or it…

Pathophysiology of Acute Venous Thrombosis

Venous thromboembolism (VTE) is a significant national health problem, with approximately 900,000 individuals affected annually. When compared with whites, African Americans have a 40% higher incidence of VTE. Despite improvements in prophylaxis and treatment of VTE, the incidence of this disease has not changed significantly over the past 25 years. Deep vein thrombosis (DVT) affects around 380,000 patients annually, and pulmonary embolism (PE) is diagnosed yearly…

Coagulation Cascade and Thrombosis

Basic Coagulation Pathways Hemostasis is generally initiated by damage to the vessel wall and disruption of the endothelium, but in venous thrombosis (VT), it may be initiated in the absence of vessel wall damage. Both arterial thrombosis and VT converge on platelets, tissue factor (TF), and thrombin ( Figure 1 ). However, thrombosis in the arterial system occurs somewhat differently than in the venous system. The…

Ambulatory Treatment of Dialysis Access Stenosis

Dialysis access management was traditionally performed in the hospital setting. Now, newly developed percutaneous techniques have allowed some of these procedures to be transitioned to the outpatient office setting. The increased prevalence of diabetes and hypertension in an aging population has resulted in a steady rise of patients with chronic kidney disease (CKD) in need of hemodialysis. The autogenous arteriovenous fistula (AVF) is preferred over synthetic…

Thrombotic Complications of Arteriovenous Access

The achievement and maintenance of sites for hemodialysis is a persistent challenge. A hemodialysis access that remains patent and free of infection and complications is critical to ensuring a high standard of care for the patient with end-stage renal disease (ESRD). The updated Kidney Disease Outcomes Quality Initiative (KDOQI) provides evidence-based clinical practice guidelines for all stages of chronic kidney disease and reports autogenous fistulas (AVFs)…

Role of Surveillance for Hemodialysis Access

The role of surveillance for permanent hemodialysis arteriovenous access, both autogenous (arteriovenous fistula [AVF]) and prosthetic (arteriovenous graft [AVG]), remains unresolved. Simplistically, clinical monitoring refers to the “examination and evaluation of vascular access by means of physical examination to detect physical signs that suggest the presence of dysfunction,” and surveillance refers to the “periodic evaluation of the vascular access by using tests that may involve special…

Bridge Grafts for Angioaccess

The public health burden imposed by end-stage renal disease (ESRD) is significant and has increased in prevalence since the turn of the century. In 2005, the U.S. Renal Data System reported that the prevalent dialysis population was 341,000, having increased from 284,000 in 1996. The National Kidney Foundation estimates that chronic kidney disease (CKD) affects about 11% of the U.S. population. Dialysis access dysfunction continues to…

Direct Arteriovenous Communication Angioaccess

A major focus of the kidney disease outcomes and quality initiative is the creation of the national vascular access improvement initiative with a “fistula first” campaign. A goal of 66% prevalence of arteriovenous fistulas (AVFs) was suggested for 2009. This has resulted in an increase in the number of fistulas placed by access surgeons. However, this might not be the best approach for all patients undergoing…

External Methods of Angioaccess

Central venous access is required for temporary or permanent hemodialysis in many situations. It is estimated that several million central venous catheters (CVCs) are inserted annually in the United States. This widespread use has been accompanied by a concomitant abundance of catheter-related complications. With meticulous attention to proper techniques of insertion and maintenance, successful central venous access can be achieved while minimizing the incidence of complications.…

Treatment of Traumatic Arteriovenous Fistulas

Traumatic arteriovenous fistulas (AVFs) usually develop as a consequence of penetrating, blunt, or iatrogenic trauma. The clinical consequences of an AVF range from being asymptomatic to manifesting with complications of venous hypertension or high-output heart failure. The treatment options are equally varied, although endovascular therapies predominate in current practice. Etiology and Pathophysiology The vast majority of AVFs are caused by penetrating injuries as a result of…

Treatment of Congenital Vascular Malformations in Children and Adults

Since the 1990s, new concepts based on sound knowledge and a new classification system have led to a better understanding of the pathophysiology, anatomy, and embryology of congenital vascular malformations (CVMs). Recognition of the fundamental differences between extratruncular and truncular lesions has led to the development of better management principles. A proper understanding of the crucial differences between an extratruncular lesion that has origins from an…

Imaging of Peripheral Vascular Fistulas and Arteriovenous Malformations

Arterial and venous malformations, also referred to as vascular anomalies, are a result of anomalous development of the vascular system during embryogenesis and are present from birth. Imaging studies and arteriography support the classification adopted by the International Society for the Study of Vascular Anomalies (ISSVA), modified from an earlier classification proposed by Mulliken and Glowacki. This classification differentiates vascular anomalies into slow-flow malformations, high-flow malformations,…