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Aim In this study, we aimed to investigate the effect of vacuum-assisted closure therapy on venous stasis wound healing in patients with chronic venous leg ulcers. Methods Vacuum-assisted closure therapy was applied on a total of 14 venous leg ulcers. All patients had post-thrombotic syndrome. Quantitative wound culture samples were obtained before the procedure and local wound assessments were performed. The primary outcome measures included wound healing as assessed by a local wound examination during each dressing change and the rate and velocity of ulcer reduction. Wound healing was defined as the complete closure of the ulcer, while rapid wound healing was defined as a ≥ 30% reduction in the ulcer size by week four. Results No surgical debridement or surgical corrective procedure was applied in any patient. The mean length of hospital stay was 32.3 days. The mean number of vacuum-assisted closure therapies for each case was 17.8 and the mean time to dressing change was 72.3 hours. Multidrug-resistant Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus were detected in three and four patients, respectively. Wound culture results became negative after a mean duration of vacuum-assisted closure therapy of 12.1 days. None of the patients needed antibiotic therapy until the procedure was completed. Compared to baseline, the mean ulcer reduction rates were 46.4% for the first six applications and 72.8% for the subsequent applications. Conclusions Our study results suggest that vacuum-assisted closure therapy promotes rapid wound healing in patients with severe post-thrombotic syndrome with venous stasis leg ulcers, and reduces the need for antibiotics by reducing the biological burden.

Summary Purpose The aim of this study was to prove the hypothesis that intraoperative fluorescence-angiography using indocyanine-green (ICGFA) can be used to predict the occurrence of perfusion-associated complications following microvascular reconstruction. Materials and Methods Consecutively perioperative data of patients who received microvascular reconstruction of the head and neck region and underwent ICGFA immediately after anastomosis was established were analyzed. The flow parameters analyzed in the investigation were (1) the baseline (IntMin) and (2) peak intensity (IntMax) of fluorescence, (3) the quotient of the two aforementioned parameters (Fmax/min) as an expression of the relative total increase, (4) the absolute difference in the two parameters (DiffInt) in terms of amplitude, (5) the duration of the intensity increase (TRise) until the peak, and (6) the percent intensity increase per second (Rise/secrel). Within the first 2 weeks postoperatively, every flap complication was documented. Subsequently, statistical analysis of the flap outcome was performed based on the flow parameters obtained intraoperatively. Results Data of 67 patients (male/female: 41/26) with an average age of 64 years (range 29-84 years) were analyzed. In 10 of these patients, postoperative perfusion-associated complications were observed (arterial/venous/microcirculatory: 4/4/3; p=0.12). The analysis of the intraoperatively obtained flow parameters showed a significant difference in the ratio of maximum and minimum intensity in arterial pedicle perfusion (Fmax/min) of patients with and without complications (with vs. without complications: 2.3±1.0 vs. 5.0±4.9; p Conclusion The ratio of maximum and minimum intensity (Fmax/min) is a predictor for postoperative venous stasis, arterial hypoperfusion and impaired microcirculation of a microvascular flap. Anastomoses with Fmax/min

Deep venous thrombosis is a hitherto under-recognized complication occurring in patients with polysplenia syndrome, despite the high prevalence of venous anomalies such as interrupted inferior vena cava (IVC) with azygos/hemiazygos continuation. Here we report the first case of concurrent polysplenia (as evidenced by interrupted IVC with azygos/hemiazygos continuation, multiple left-sided spleens, bowel malrotation with inverted mesenteric veins, preduodenal portal vein, and pancreatic hypoplasia/partial agenesis of the dorsal pancreas) and sickle cell trait, complicated by extensive deep venous thrombosis refractory to medical and interventional radiologic management.

Livedoid vasculopathy (LV) is a rare, chronic, and occlusive disease of the veins supplying the upper parts of the skin. The pathogenesis of the disease is not precisely understood, and its attacks are often unpredictable but tend to worsen during the summer. LV affects women more often. This increased risk for LV in women might be related to sex-specific physiological conditions, such as pregnancy, or a higher incidence of LV-associated conditions, such as connective tissue diseases, hypercoagulable states, and venous stasis in women. The typical clinical appearance of LV consists of three main findings: livedo racemose, atrophie blanche, and skin ulcers. The purpose of this comprehensive review was to analyze LV in all aspects and mainly focus on early diagnosis for successful clinical management with a holistic and multidisciplinary approach. A detailed history, dermatological examination, and laboratory testing are essential for a diagnosis of LV. When LV is clinically suspected, a skin biopsy should be taken to confirm the diagnosis. Another critical step is to investigate the underlying associated conditions, such as connective tissue diseases, hypercoagulable states, thrombophilia, and malignancy. Unfortunately, no associated conditions can be detected in approximately 20% of all cases (idiopathic LV) despite all efforts. The diagnosis of the disease is delayed in most patients. Thus, irreversible, permanent scars appear. Early and appropriate treatment reduces pain and prevents the development of scars and other complications. Antiplatelet drugs and anticoagulants can be preferred as the first-line treatments along with general supportive measures. Other therapeutic options might be considered in unresponsive cases. Preference for refractory cases is based on availability, clinical experience, and patient-related factors (comorbidities, age, sex, and compliance). These include anabolic steroids, intravenous immunoglobulin, hyperbaric oxygen therapy, psoralen-ultraviolet A, vasodilators, fibrinolytics, immunomodulators, and immunosuppressives.

Objective: To establish a possible relationship between the Giacomini vein and osteoarticular pathology of the lower extremities in chronic venous diseases (CVD).Materials and methods. In 115 examined patients (out of 321), we identified the Giacomini vein (92 women, 23 men). The average age of men was 44.82 ± 1.62 years; women – 45.36 ± 3.31 years. All patients were divided into 3 groups by anatomical randomization. The first group was without pathology, the second group of patients had only CVD, and the third group included patients with CVD and osteoarticular pathology. The criteria for inclusion in the groups were: the presence of Giacomini vein in patients, chronic venous disease and osteoarticular pathology on one or both lower extremities. Exclusion criteria: age of patients less than 18 years, the presence of CVD C5-C6 according to the CEAP classification, post-traumatic changes in the osteoarticular system, post-thrombotic transformation of the veins of the lower extremities. Using triplex angioscanning, the anatomical features of the structure of the venous system of the lower extremities were assessed. The study of the condition of the foot was carried out using the Friedland method.Results. Group I with an absolute norm of the venous and osteoarticular systems included 30 people (26 %). The second group consisted of 45 patients (39.22 %) with CVD C0-C4 according to CEAP, and the third group consisted of 40 patients (34.78 %) who, in addition to venous, osteoarticular pathology. Chronic venous diseases in patients of groups II and III were distributed as follows: C0 – 25.6 %; C1 – 16.4 %; C2 – 49.4 %; C3 – 4.3 %; C4 – 4.3 % on the CEAP scale. Among the osteoarticular pathology, the most numerous group consisted of changes in the configuration of the foot, non-traumatic deformities – 32 (27.81 %) cases. To confirm the relationship between venous and osteoarticular pathology, we used the Pearson criterion. We found a significant correlation in the presence of nontraumatic deformities of the foot in the group of patients with CVD (Pearson's criterion 0.749642; p < 0.22). A strong correlation was established between the age of patients and changes in the venous and osteoarticular systems of the lower extremities (Pearson's criterion 0.7677696; p < 0.22), which confirms the relationship between the development of nontraumatic changes in the foot and CVD in patients with Giacomini vein with age.Conclusion. It was found that the presence of an altered Giacomini vein leads to an aggravation of venous stasis in the lower extremities, which in turn increases the likelihood of developing venous pathology. Chronic diseases of the veins of the lower extremities contribute to dystrophic changes in soft tissues, most pronounced in the distal part of the extremity and, as a consequence, predispose to the development of osteoarticular pathology.

Pelvic congestion syndrome is a relatively recent, but actual and separate nosological form. Pelvic varicocele is a form of varicose disease, which is increasingly regarded as the main cause of chronic pelvic pain in women with various clinical manifestations. A woman with chronic pelvic pain is a difficult patient with combative behavior, who contacts with physicians in various specialties. There are many causes of chronic pelvic pain, but pelvic congestion syndrome has a special place. In recent years, in addition to widespread use of diagnostic radiology, the relevance of this pathology is beyond any doubt. The aim of the study was to summarize and present literature data on the etiology, pathogenesis, clinical manifestations, diagnosis and treatment of pelvic congestion syndrome by analyzing the literature data. Materials and methods. A non-systematic review was conducted using PubMed, Web of Science, Google and Google Scholar databases. The review included free full-text articles published between 1974 and 2021 using key words: pelvic congestion syndrome, pelvic varices, pelvic venous disorders, pelvic varicocele, pelvic venous stasis, chronic pelvic pain, gonadal veins, ovarian veins, vena ovarica, Nutcracker syndrome, May–Thurner syndrome. Conclusions. Pelvic congestion syndrome is still a rarely diagnosed pathology in patients with chronic pelvic pain. Detailed medical history, physical examination as well as maintaining diagnostic algorithm would allow the disease to be diagnosed correctly and timely. The choice of method for surgical intervention is a key point in the treatment of patients with pelvic congestion syndrome, but today there are no criteria for the choice of one, so the problem is far from being resolved and requires further study and research.

We report a case of intracranial thrombosis (IT) after ventriculoperitoneal shunting (VPS). We reviewed the literature to highlight the importance of considering the possibility of cerebral venous thrombosis following VPS, even though it is a rarely reported complication. A 14-year-old boy underwent distal catheter replacement due to its short size that was detected during a routine consultation. Five days postoperatively, he experienced nausea, vomiting, seizures, and headache. Although a diagnosis of meningitis was considered, diagnosis of IT was eventually confirmed through computed tomography venography and gadolinium magnetic angioresonance. The patient subsequently underwent anticoagulant therapy, which led to complete resolution of symptoms. In this report, we suggest a possible association between VPS and IT, which is a complication that is not commonly reported. The literature suggests that decreased blood flow due to over-drainage of CSF after VPS causes decreased head pressure, culminating in venous stasis and consequent thrombosis. In addition, the literature describes associations between IT and lumbar puncture (LP); therefore, it is important to consider the possibility of IT following these procedures.

May-Thurner syndrome (MTS) belongs to a group of uncommon vascular syndromes. It consists in left common iliac vein (LCIV) compression between the right common iliac artery (RCIA) anteriorly and the lumbar spine posteriorly. A compression of LCIV by the left common iliac artery (LCIA) or by both iliac arteries were described. We present a rare case of "double MTS" which consist in double stenosis of LCIV by both RCIA and LCIA. Double MTS can cause acute or chronic DVT; this latter could be clinical manifest or well compensated. A 58-year-old woman with chronic mild pelvic pain underwent Doppler Ultrasound (US) of the pelvis and lower extremity vessels which showed thrombosis of both LCIV and ipsilateral common femoral vein caused by the extrinsic compression by both common iliac arteries against the spine. CT angiography confirmed the US data and ruled out other causes of compression. CT scan also showed the development of a natural venous femoro-femoral bypass which allowed to counteract the venous stasis and compensate venous drainage. Therefore, we decide for a long-term prophylaxis with anticoagulant drugs and doppler US follow-up at 6 months. In conclusion, doppler US is a non-invasive, low-cost, repeatable and sensitive method which allows to diagnose MTS and associated DVT. It may be considered the first level exam which allows to easily detect pelvic vascular compression syndrome.

Infection by COVID-19, being a respiratory disease caused by SARS-CoV-2, can predispose to arterial and venous thrombotic disease, in response to excessive inflammation, platelet activation, endothelial dysfunction, and venous stasis. During the COVID-19 pandemic period, the technological and resource availability for the care of these patients with thrombotic disease is critical, marking a factor of morbidity and poor prognosis in these cases. We describe a case of priapism in a patient with COVID-19, during the course of systemic inflammatory response syndrome and respiratory distress syndrome with a procoagulant state, seeking to relate the pathophysiological factors of ischemic priapism in patients with infection with SARS-Cov-2

Summary Background Perforator flaps yield the best results for the patient with the least morbidity, and they should be considered the gold standard in head and neck reconstruction. Although deep inferior epigastric perforator (DIEP) flap is considered as the gold standard in breast reconstruction, its use in head and neck reconstructive surgery does not seem so widespread. The objective of this study is to conduct a systematic review of the use, applications and results of the DIEP flap in the head and neck area. Methods Search was conducted in different indexed databases (PubMed/MEDLINE, the Cochrane Library, Scielo and Web of Science) and through meta-searcher Trip Database with deep inferior epigastric perforator flap AND head neck keywords. Studies on animal and human experiments published in peer-reviewed journals, where investigators assessed the use of DIEP flap, according to the Koshima criteria, in the head and neck area were considered. Results A total of 31 articles and 185 flaps with 95% of survival were found. Thrombosis or venous stasis is the most frequent cause of flap loss and 16.1% presented some type of complication, the most frequent being the dehiscence. The most use was in the reconstruction of glossectomy defect secondary to squamous cell carcinoma (30.51%), being able potentially to re-establish sensory innervation in oral cavity. The assessment of risk bias (National Institutes of Health) highlights the lack of uniformity, with no standardisation of the outcome variable collection and monitoring. Discussion By virtue of its versatility, reliable vascular supply and high flap survival rate, the DIEP flap reconstruction could be an option in complicated 3-dimensional head and neck defects while maintaining the standard of low donor site morbidity.

Arteriovenous malformations are abnormal tangled blood vessels with multiple irregular connections between arteries and veins. These malformations can occur anywhere with a preponderance to the spinal cord and brain.AV-malformations are usually congenital and patients might also have an associated intracranial aneurysm. Ophthalmic manifestations of AVM depend upon the location, varying from being asymptomatic to visual phenomena, field defects, diplopia, nystagmus etc.AV malformations in the cortical or occipital lobe produce visual symptoms which are transient. They can be associated with scotomas and migraine type headache. Signs and symptoms of brainstem AVMs are nonspecific and may include diplopia, nystagmus, dizziness, ocular motor nerve palsy, gaze palsy, anisocoria, or pupillary light–near dissociation. Findings are usually unilateral. There can be transient monocular vision loss due to the “steal phenomenon” in rare cases.Diagnosis of an AVM are based on angiographic findings which demonstrate an engorged arterial system, rapid filling of the malformation and outflow of the venous system.

Objective The purpose of this case series is to identify the clinical characteristics of women with uterine fibroids who developed venous thromboembolisms (VTE) and possible risk factors for the development of VTE in this group. Data Sources We conducted a systematic search of the Medline, Embase, Cochrane and Scopus databases to retrieve case reports and case series that describe women with an enlarged uterus and VTE. The databases were searched up to August 2019. Study Selection A total of 1485 articles were identified by a librarian. All case series and case reports that reported uterine weight and size of the fibroids were included. Data Extraction and Synthesis A total of 27 articles were included, describing 35 patients who developed VTE in the presence of uterine fibroids. On average, the uterus measured 22.9 ± 5.0 weeks gestational age and occupied a volume of 2715 cm3 (interquartile range 1296.3–3878.8) on imaging. Two-thirds (60%) of VTEs occurred on the left side, and 87% showed signs of venous compression on imaging. Most patients (89%) required surgical management to relieve the compression caused by the enlarged uterus. Conclusion VTE in cases of large uterine leiomyomas can be associated with mechanical compression, which requires surgical management to relieve compression. There is an obvious increased risk of VTE in patients with venous stasis secondary to uterine compression; however, there is no current evidence evaluating the use of anticoagulation in such patients. Further research is required to determine the role of prophylactic anticoagulation in reducing the risk of VTE in high-risk patients with large uterine fibroids.

Cytochrome C oxidase (CCO) acts as final electron acceptor in the respiratory chain, possibly providing information concerning cellular oxygenation. CCO is a chromophore with a broad absorption peak in the near-infrared spectrum in its reduced state (835 nm). However, this peak overlaps with deoxygenated haemoglobin (HHb; 755 nm) which is present in much higher concentrations. NIRO-300 measures CCO signals, but did not receive FDA approval for this use due to presumed lack of independency of the measured CCO changes. However, there is no proven evidence for this assumption. We hypothesized that the NIRO-300 provides a HHb independent measurement of CCO concentration changes. In this single-center crossover randomized controlled trial in healthy volunteers, subjects were randomized to receive arterial occlusion to the left arm and venous stasis on the right arm (n = 5) or vice versa (n = 5) during 5 min. After a resting period, the second part of the cross over study was performed. We placed the NIRO-300 optodes bilateral at the level of the brachioradial muscle in order to collect NIRS data continuously. Data was analysed using a generalized additive mixed model. HHb and CCO follow a significant different trend over time during the intervention period for both arterial occlusion (F = 20.645, edf = 3.419, p

Background To review long-term outcomes and saphenous vein (SV) occlusion rate after endovenous ablation (EVA) for symptomatic varicose veins. Methods A review of our EVA database (1998–2018) with at least 3-years of clinical and sonographic follow-up. The primary end point was SV closure rate. Results 542 limbs were evaluated. 358 limbs had radiofrequency and 323 limbs had laser ablations; 542 great saphenous veins (GSV), 106 small saphenous veins (SSV) and 33 anterior accessory saphenous veins (AASV) were treated. Follow-up was 5.6 ± 2.3 years; 508 (74.6%) veins were occluded, 53 (7.8%) partially occluded and 120 (17.6%) were patent. On multivariable Cox regression analysis, male sex (HR 1.6, 95% CI [0.46–018], p = 0.012) and use anticoagulation (HR 2.0, 95% CI [0.69–0.34], p = 0.044) were predictors of long-term failure. On Kaplan-Meier curve, we had an 86.3% occlusion rate. Conclusion Our experience revealed a 5-year closure rate of 86.3%. Ablations have satisfactory occlusion rate.

Background. Literature sources report conflicting results regarding the severity of clinical symptoms of hydrocephalus (HC) and their association with cerebral arterial blood flow (CABF); most studies do not show a direct relationship, while some suggest a link between clinical severity and progressive decrease in CABF. The study of hemodynamic changes in the brain of patients with chronic brain ischemia (CBI), elucidation of their relationship with cognitive impairments helps to improve diagnostic approaches and optimize the prognosis of the disease. The purpose of this study is to investigate the state of cerebral hemodynamics and to establish its relationship with changes in cognitive functions in patients with CBI and HC. Materials and Methods. A comprehensive examination of 110 patients with CBI and HC was performed. The localization of the HC and results of Montreal Cognitive Test (MoCA scale) were taken into account. Computed tomography of the brain was performed with subsequent determination of morphometric parameters and indices. The state of cerebral blood flow and structural changes of blood vessels were studied using transcranial color-coded duplex ultrasonography (TCCS) of intracranial vessels and extracranial divisions. Microsoft Excel 2011 and Statistica were used for statistical processing of the results. Results. It was found that there was a significantly larger diameter of both common carotid arteries (CCA), thickness of complex intima\media (CIM), maximum systolic velocity (Vs), velocity at the end of the diastolic cycle (Vd), as well as peripheral resistance (IR) in left CCA (p Conclusions. Functional parameters of blood flow and structural changes of cerebral arteries in patients with CBI with concomitant hydrocephalus differed significantly from those in patients without hydrocephalus and depended on the type and severity of hydrocephalus. ICA occlusion, ICA stenosis >50%, and intracranial venous stasis were significantly more common in patients with severe and moderate HC compared with those with mild HC. A weak relationship was found between the structure of carotid arteries and blood flow in intracranial arteries in patients with CBI and HC. There was a significant relationship between blood flow indices and the values of the MoCA scale, which indicated the effect of changes in the vessels of the anterior circular basin on the cognitive functions and the lack of such connection with blood flow indices in vertebrobasilar basin.

Background: Pretibial myxedema (PTM) is a local mucinous dermopathy associated with thyroid diseases. Since the etiology of PTM is unclear, the aim of this study is to identify the risk factors for PTM and their etiological roles in PTM occurrence. Methods: A large-scale case-control study (n = 1,200) was performed to identify risk factors for PTM by calculating odds ratio (OR) values and 95% confidential intervals. The PTM group entered a glucocorticoid treatment trial. Patients with complete response were followed up to the first relapse in a cohort study. The relative risk (RR) values of the main risk factors were calculated for PTM relapse to test their etiological roles. Results: Among the 19 factors, six risk factors were identified: thyroid-stimulating hormone (TSH) receptor antibody (TRAb) (OR 42.93), autoimmune thyroid disease (AITD) or AITD history (OR 10.30), local trauma (OR 6.55), venous stasis posture (OR 6.16), cigarette smoking (OR 4.48), and age (OR 1.05). Serum TRAb levels were positively correlated with the severity of PTM. Of note, 371/400 patients received glucocorticoid treatment, and 330 achieved complete response. The serum TRAb levels after treatment decreased dramatically compared with those before treatment. After stopping glucocorticoid treatment, serum TRAb levels increased significantly when PTM relapsed (P < 0.001). In 165 relapse cases, an increase in serum TRAb levels occurred first, followed by persistent venous stasis posture or local trauma and finally PTM. The RR of elevated serum TRAb levels was 6.73 in PTM relapse cases. In the elevated serum TRAb level group, the RRs of local trauma, venous stasis posture, and local trauma plus venous stasis posture were 8.81, 6.5, and 8.84, respectively, for PTM relapse cases. Conclusions: TSHR autoimmunity and local factors in the six identified risk factors are the main causes of PTM occurrence. J Clin Med Res. 2020;12(11):711-723 doi: https://doi.org/10.14740/jocmr4352

The dead animals have a pathomorphological picture with a brightly expressed hemorrhagic diathesis, in many organs there is venous stasis. Blood does not clot for several hours, and at autopsy of organs (heart, lungs, liver, kidneys) it is poured in significant amounts into the body cavity. Macroscopically, the most significant changes are observed in the respiratory system. The lungs are blood-filled, intensely swollen and unevenly colored, have a grayish-pink color with single or multiple spotted and spotted hemorrhages under the pleura. Red or almost colorless liquid flows down from the incision surface, foamy exudate is released from the bronchi when pressed on. There are no patterns in the localization of pathomorphological changes in any part of the lungs (apical, cardiac, diaphragmatic): all parts are damaged at once, or mainly in one or another part. The walls of the trachea, nasal cavities, to a lesser extent the larynx are distinctly hemorrhagic. Their red color is more often caused by venous hyperemia. The lumen of the trachea and larynx is filled with red or colorless foamy fluid. Changes in the liver are constant, but not always the same type and are due to the degree of its blood supply, which causes a change in color, amount and consistency. In the first hours after the death of the animal, the liver is usually completely blood-filled, enlarged, easily torn, has a reddish-brown color with a yellowish tinge in the central parts of the lobes. The capillary network of the body looks like red streaks and dots of irregular shape. Spotted hemorrhages are sometimes observed under the capsule of the organ. The gallbladder contains some bile, its mucous is rough, a bit exfoliated. The spleen is increased in size by 1.5–3 times, swollen, dark cherry in color with a typical purple tinge. The kidneys are completely blood-filled, reddish-brown and increased in several times. The thymus is slightly reddened, often with multiple spotted or spotted hemorrhages in the chest. Lymph nodes are pulpy, grayish-pink, rarely red, not significantly changed in size. The heart (especially its right half) is filled with a large amount of black and red blood, increased in size , the walls of the ventricles are stretched, thin, have flabby consistency. Multiple spotted and spotted hemorrhages under the epicardium and endocardium are common. Changes in the gastrointestinal tract characterize catarrhal (rarely catarrhal-hemorrhagic) inflammation, sometimes hemorrhage in the duodenum and rectum, exfoliation of the gastric mucosa. In the form of hemorrhage, pathological and anatomical changes are found in the uterus and adrenal glands, in the form of congestive hyperemia – in the genitals, goiter, brain.

Background The study aimed to perform continuous and dynamic observation on the blood flow changes in a rat abdominal model of supercharged flaps to examine the roles of arterial and venous supercharging in preventing distal flap necrosis. Materials and methods Eighteen rats were divided into three experimental groups. The left-sided flaps in all groups were used as controls such that the subxiphoid perforator vessels served as the only pedicle. Experimental groups I, II, and III consisted of supercharged right-sided flaps. Group I, the arteriovenous supercharging group, had flaps supercharged by the suprapubic perforator arteries and veins. Group II, the arterial supercharging group, had flaps supercharged by the suprapubic perforator arteries. Group III, the venous supercharging group, had flaps supercharged by the suprapubic perforator veins. Laser-induced near-infrared fluorescence angiography was performed before and after surgery. Results As revealed by near-infrared fluorescence angiography, the control group and venous supercharging group exhibited rapid reductions in blood supply and loss of arterial perfusion in distal areas. The distal flap necrosis was much smaller in the venous supercharging group than in the control group. Both the arteriovenous supercharging group and the arterial supercharging group exhibited adequate perfusion and resulted in full postoperative survival of the flaps. Conclusions These findings indicated that the distal arterial hypoperfusion is the major cause of the distal venous stasis and necrosis in the flaps. Sufficient arterial supercharging ensures the distal arterial perfusion and therefore diminishes the occurrence of distal flap necrosis.

Venous stasis ulcers represent the majority of lower-extremity ulcers and place a considerable financial burden on the American health care system. Current standard of care therapies remain sub-optimal with 50% of venous stasis ulcers remaining unhealed after 4 months. Sixteen consecutive wounds were enrolled across 8 participants at a single center and underwent pH-driven therapy in addition to standard care as dictated by physicians. Following wound debridement, the pH of the wound bed was measured using pH strips. If acidic, normal saline was used to rinse the wound at every dressing change. If alkaline, nonsterile gauze was soaked in 0.25% acetic acid and applied to the wound for a minimum of 30 seconds. Participants were followed for 4 weeks with research staff observing compliance throughout. All 16 wounds had an alkaline pH at baseline, with an average pH of 8.25 ± 0.55 (range 7.5 to 9). Average area of the wound at the time of enrollment was (mean ± standard deviation) 285.48 ± 43.68 mm2, and average age of the wound was 37.5 ± 20.3 months (range 3 to 72). A simple linear regression model found a moderate relationship between pH and the rate of healing of chronic nonhealing venous stasis lower-extremity wounds (correlation coefficient = 0.61). For every 1-unit change in pH, we can expect to see a change in wound size of 116.05 mm2. This is the first US-based, open-label, prospective study that examined the effect of pH on the rate of healing in chronic nonhealing venous stasis ulcer lowerextremity wounds.

May-Thurner syndrome (MTS) is a congenital vascular alteration that is part of a restricted category of very rare vascular syndromes that have in common the compression of an arterial or venous vessel. MTS, first described in 1957, is due to compression of the left common iliac vein against the lumbar spine by the adjacent common iliac artery. It can cause chronic thrombosis of the left lower limb and can give edema, pain, claudication, thrombophlebitis, and, in severe cases, pulmonary embolism. Color Doppler and duplex Doppler ultrasound allow us to easily locate the deep vein thrombosis, to measure its extension, and to highlight the vascular changes typical of MTS: compression and consequent hypertension of the left common iliac vein. The therapy depends on the degree of venous stasis and on the presence of venous thrombosis; generally, it consists of the administration of short- or long-term anticoagulant and thrombolytic drugs. In cases of severe stenosis of the left common iliac vein, the first-choice treatment consists of positioning a vascular stent, which resolves compression and significantly reduces chronic thrombotic episodes. We describe a case of MTS with an unusual clinical onset with pulmonary embolism.

Inferior vena cava filters (IVCFs) are effective in preventing pulmonary embolism and their usage has rapidly increased over the past decades. However, complications have also significantly increased, as IVCF occlusion causes serious chronic venous insufficiency. Herein, we report a case of infrarenal IVCF occlusion that was successfully treated with the introduction of kissing stents through the IVCF into both iliac veins. A 54-year-old male presented with non-healing ulcers on his left leg. He had undergone IVCF implantation and warfarin medication due to deep vein thrombosis 4 years earlier in another hospital. Computed tomography (CT) revealed the filter-bearing IVC occlusion. Endovascular IVCF removal was attempted but failed. Kissing stents were deployed across the IVCF and extended into both iliac veins. Cone beam CT showed well-deployed stents just behind the occluded IVCF. Venous flow was restored without complications, and the recurrent ulcer healed immediately.

Introduction Reconstruction of large (>20 cm2) posttraumatic forehead defects, with esthetically pleasing results and without distorting the surrounding anatomical landmarks like eyebrow and hairline, is a significant surgical challenge. This study was aimed to determine the effectiveness of a triple-plane dissection technique of significantly-sized flaps, combining forehead, and scalp to cover large forehead defects. Materials and Methods A retrospective review from January 2009 to December 2019 revealed that 12 patients with large defects over the forehead were operated on. Significantly-sized rotation and advancement flaps, combining both the forehead and scalp tissues, were performed. Triple-plane dissection and careful galeal scoring recruited more tissues and increased the reach of these flaps while maintaining adequate flap vascularity. Results Large forehead posttraumatic defects in all 12 patients were covered in a single surgery with this combined flap. Eight patients were men and four were women (mean age, 58 years). Size of the defects ranged from 21 to 40 cm2 (mean, 27 cm2). Complications included deep marginal necrosis in one patient (8%), superficial necrosis in one patient (8%), and mild venous stasis in four patients (33%). Superficial necrosis and venous stasis resolved by itself. Good color and contour match, minimal alopecia, maintained positions of eyebrow, and hairline positions were found in most patients. Six months postoperatively, patient satisfaction measured on a visual analogue scale ranged between 3 and 9 out of 10 (mean, 7). Conclusion Primary forehead reconstruction with significant-sized flaps combining forehead and scalp tissues, with triple-plane dissection and galeal scoring, appears to be an effective option for covering large forehead defects.

OBJECTIVEAssessments of hemorrhage risk based on angioarchitecture have yielded inconsistent results, and quantitative hemodynamic studies have been limited to small numbers of patients. The authors examined whether cerebral hemodynamic analysis using quantitative digital subtraction angiography (QDSA) can outperform conventional DSA angioarchitecture analysis in evaluating the risk of hemorrhage associated with supratentorial arteriovenous malformations (AVMs).METHODSA cross-sectional study was performed by retrospectively reviewing adult supratentorial AVM patients who had undergone both DSA and MRI studies between 2011 and 2017. Angioarchitecture characteristics, DSA parameters, age, sex, and nidus volume were analyzed using univariate and multivariate logistic regression, and QDSA software analysis was performed on DSA images. Based on the QDSA analysis, a stasis index, defined as the inflow gradient divided by the absolute value of the outflow gradient, was determined. The receiver operating characteristic (ROC) curve was used to compare diagnostic performances of conventional DSA angioarchitecture analysis and analysis using hemodynamic parameters based on QDSA.RESULTSA total of 119 supratentorial AVM patients were included. After adjustment for age at diagnosis, sex, and nidus volume, the exclusive deep venous drainage (p < 0.01), observed through conventional angioarchitecture examination using DSA, and the stasis index of the most dominant drainage vein (p = 0.02), measured with QDSA hemodynamic analysis, were independent risk factors for hemorrhage. The areas under the ROC curves for the conventional DSA method (0.75) and QDSA hemodynamics analysis (0.73) were similar. A venous stasis index greater than 2.18 discriminated the hemorrhage group with a sensitivity of 52.6% and a specificity of 81.5%.CONCLUSIONSIn QDSA, a higher stasis index of the most dominant drainage vein is an objective warning sign associated with supratentorial AVM rupture. Risk assessments of AVMs using QDSA and conventional DSA angioarchitecture were equivalent. Because QDSA is a complementary noninvasive approach without extra radiation or contrast media, comprehensive hemorrhagic risk assessment of cerebral AVMs should include both DSA angioarchitecture and QDSA analyses.

Intracranial pial arteriovenous fistula (PAVF) is a rare cerebrovascular pathology characterized by abnormal direct high-flow connection between the pial or cortical feeding artery and draining vein. Dural arteriovenous fistula (DAVF) is a pathological shunt between the meningeal arteries and dural sinuses or meningeal veins. In case of association between PAVF and DAVF, diagnosis and treatment are more challenging. The high-flow arteriovenous shunt and deep venous drainage make PAVF more preferable for endovascular treatment; however, their embolization during single-session procedures can lead to extensive thrombosis of the draining veins and unfavorable outcomes. We present a case report of endovascular embolization of an intracranial PAVF–DAVF in a 2.5-year-old child. At the time of admission, the patient had hydrocephalus, mental retardation, pyramidal insufficiency, and seizures. Occlusion of the fistula was performed during two stages of embolization to reduce the risk of severe venous stasis and venous thrombosis. Guglielmi detachable coils (GDCs) and a liquid embolic agent (Histoacryl with Lipiodol) were used for embolization. The patient recovered well after the procedure, with significant mental improvement. This suggests that the deployment of GDCs in the afferent artery near a fistula before embolization with a liquid embolic agent can minimize the risk of uncontrolled penetration of the embolization into the draining veins and dural sinus. A multisession procedure can be an effective and reasonable method of PAVF and DAVF occlusion among existing treatment options.

Lymphocutaneous fistulas are an uncommon occurrence that can present after surgical intervention in lymphatic-rich areas. A spontaneous lymphatic leak can occur in conjunction with lymphedema or in the vicinity of venous stasis ulcers. However, spontaneous lymphocutaneous fistulas are extremely rare. Traditional treatments have included surgical ligation, negative pressure therapy, and embolization. We present the case of a lymphocutaneous fistula secondary to chronic venous stasis, which was treated via injection of autologous blood and subsequent thrombosis. In the present case report, we have demonstrated successful embolization of a lymphatic vessel via autologous blood injection, a nontraditional technique that, nonetheless, yielded positive and lasting results.

Sarcoidosis is described as a state of immune-mediated chronic systemic inflammatory disease that is typically characterized by non-caseating granulomas. It involves multiple organs like the lungs, lymph nodes, eyes, skin, and liver. Besides the solid organ involvement, it is also known to be associated with various pro-thrombotic states leading to pulmonary embolism and deep vein thrombosis. Mechanical factors causing the venous stasis were considered the major contributing factors. However, based on recent studies, chronic inflammation from macrophages and activated leukocytes are also hypothesized to further activate thrombin and fibrin formation. Regardless of the etiology, the management focuses on life-long anticoagulation to prevent further episodes of thrombosis. Herein we present a case of a 38-year-old male with a history of sarcoidosis who was admitted after having recurrent deep vein thromboses. Further investigations revealed a negative hypercoagulable workup or other auto-immune processes and the absence of any granulomas causing mechanical compression on large vessel venous vasculature. He was adequately managed with anticoagulation therapy and followed up outpatient with no further similar episodes. This case adds to the growing understanding that the mechanisms by which sarcoidosis induces thromboembolism is primarily pro-inflammatory rather than mechanical in nature.

Nuclear medicine extravasations and prolonged venous stasis may cause poor quality and quantification errors that can affect image interpretation and patient management. Radiopharmaceutical remaining near the administration site means that some portion of the radioactivity is not circulating as required for the prescribed uptake period. This case describes how detection of excess presence of99mTc-MDP near the injection site enabled the technologist to apply mitigation tactics early in the uptake process. It also suggests that detecting an extravasation or stasis early in the injection process can be important for image interpretation and minimizing radiation dose to tissue.

Compression of roots/nerves can disrupt some of their functions, but does not necessarily cause pain. This is illustrated by the frequency of nearly asymptomatic spinal stenosis or disc herniations. In fact, pain of radiculopathies (and nerve entrapments) may mostly be the consequence of intraneural oedema induced by microscopical venous stasis around roots/spinal ganglia (or nerves) not or poorly shown by imaging. This narrative review first lists arguments for a role of congestion of vasa-nervorum in the pathophysiology of radiculopathies, including those induced by disc herniation and spinal stenosis, but also other sources of overpressures in spinal venous plexuses (pregnancy, vena cava atresia and thrombosis, portal hypertension, epidural varices, arterio-venous fistula, vertebral hemangioma or hemangioblastoma). It also details sources of venous congestion around nerves outside the spine, from pelvis (May-Thurner syndrome, Nut-cracker syndrome) to buttocks (superior and inferior gluteal veins), and even thighs and legs. A better recognition of a preeminent role of venous congestion in radiculopathies, plexopathies, and nerve entrapments, should have major consequences: (i) discard the dogma that compression is mandatory to induce root/nerve suffering, since root/nerve adherences in two locations can impair blood flow in vasa-nervorum through root/nerve stretching; (ii) implementation of sensitive techniques to visualise impingement of blood flow around or within roots and nerves; (iii) better prevention of roots/nerves adherence, or arachnoiditis induced by extravascular fibrin deposition secondary to venous stasis.; (iv) optimizing treatments dampening clot formation and/or extravascular fibrin leakage in the intradural/peridural spaces, or around roots/nerves, like guided injection of tissue plasminogen activator.

Facial trauma can pose challenging reconstructive obstacles in both maintaining tissue viability and restoring aesthetic appearance. Medicinal leech therapy can help to promote vascular decompression in the setting of venous congestion. A retrospective chart review was conducted to identify patients who underwent medicinal leech therapy following venous stasis secondary to repair of a complex facial laceration. Three patients were identified; 2 suffered auricular avulsion, while 1 suffered a lip avulsion. All patients suffered from venous congestion and underwent medicinal leech therapy for 48 to 72 hours with reduction of edema and stasis. Decompression was successfully achieved with no further sequelae on last follow-up. Medicinal leech therapy is an adequate treatment for venous congestion following traumatic soft-tissue repair of the face. The authors advocate for the utilization of medicinal leeches to combat venous congestion after repair, particularly when arterial inflow remains intact.

Aim. To develop an ordinal scale for x-ray assessment of venous congestion in chronic heart failure based on the results of the standard assessment of chest radiographs. Methods. The ordinal assessment on the scale consists of a numerical expression of four radiological symptoms: cardiomegaly, pleural effusion, and changes in the pulmonary pattern due to vascular and interstitial components. The presence of each of these symptoms corresponds to a score of 1 point. In the result, ordinal X-ray assessment varies from 0 to 4 points. Simultaneously objective clinical, instrumental and laboratory measures of the severity of congestive heart failure were recorded in patients. Results. Cardiomegaly, the presence of pleural effusion and changes in the pulmonary pattern due to vascular and interstitial components was numerically estimated according to the standard assessment of chest X-rays for the scale of radiological assessment of venous congestion. Correlation between numerical estimates of the ordinal scale and objective clinical, instrumental and laboratory measures of venous stasis in the sample of 225 patients showed the validity of the assessment. The statistically significant direct relationships between value of the ordinal scale for X-ray assessment of venous congestion with functional class and stage of chronic heart failure, the level of NT-terminal fragment of brain natriuretic peptide, the frequency of respiratory movements, the scale of clinical state, the index of the left atrium, the systolic pressure in the pulmonary artery, as well as an inverse dependence with the 6-minute walk test values were proved. Sufficient internal consistency of the ordinal scale was demonstrated (Cronbach's alpha 0.73). We also found that the scale demonstrated predictive informativeness, which was manifested by a significant increase in the mortality of patients with chronic heart failure in cases where the scale values increase to 2. Conclusion. The proposed ordinal scale for x-ray assessment of venous congestion has sufficient reliability (internal consistency) for practical application, as well as criteria and prognostic validity; the scale can be considered as a simple, accessible and informative addition to the standard examination of polymorbid patients with chronic heart failure, which may be useful for advanced assessment of the patient's condition and risk of death within the next year.

Background Sequential compression devices are often considered a mainstay of prophylaxis against deep venous thromboses in surgical patients. The devices are believed to produce a milking action on the deep veins to prevent venous stasis. A systemic fibrinolytic effect has also been proposed, adding a second mechanism of action. The plasma levels of tissue plasminogen activator and plasminogen activator inhibitor-1 reflect fibrinolytic activity. Methods A randomized trial was conducted among 50 consecutive plastic surgery outpatients undergoing cosmetic surgery performed by the author under total intravenous anesthesia and without paralysis. Patients were randomized to receive calf-length sequential compression devices or no sequential compression devices during surgery. Blood samples were obtained from the upper extremity preoperatively and at hourly intervals until the patient was discharged from the postanesthesia care unit. Tissue plasminogen activator and plasminogen activator inhibitor-1 levels were measured. Ultrasound surveillance was used in all patients. There was no outside funding for the study. Results All patients agreed to participate (inclusion rate, 100 percent). No patient developed clinical signs or ultrasound evidence of a deep venous thrombosis. There were no significant changes in tissue plasminogen activator levels or plasminogen activator inhibitor-1 levels from the preoperative measurements at any hourly interval and no differences in levels comparing patients treated with or without sequential compression devices. Conclusions No significant change in systemic fibrinolytic activity occurs during outpatient plastic surgery under total intravenous anesthesia. Sequential compression devices do not affect tissue plasminogen activator or plasminogen activator inhibitor-1 levels, suggesting no fibrinolytic benefit. Clinical question/level of evidence Therapeutic, I.

Konovalenko S. O. Morphometric analysis of structural arrangement of the testial arteries in postresectional arterial pulmonary hypertension. Journal of Education, Health and Sport. 2020;10(2):319-326. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2020.10.02.037 https://apcz.umk.pl/czasopisma/index.php/JEHS/article/view/JEHS.2020.10.02.037 https://zenodo.org/record/4277414 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2020; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 31.01.2020. Revised: 10.02.2020. Accepted: 28.02.2020. UDK 616.131-008.331.1-06.616.127-008 MORPHOMETRIC ANALYSIS OF STRUCTURAL ARRANGEMENT OF THE TESTIAL ARTERIES IN POSTRESECTIONAL ARTERIAL PULMONARY HYPERTENSION S. O. Konovalenko Ternopil National Medical University named after I. Ya. Gorbachevsky Ministry of Health Ukraine Abstracts Introduction. Removal of the right or left lung can lead to postresection pulmonary arterial hypertension, venous stasis in the organs of the great circle of blood circulation and structural and functional changes in them. Morphological changes in endothelial cells of arteries of testes in postresection pulmonary arterial hypertension are insufficiently studied. Objective of the research: to study features of structural reorganization of testicular arteries at postresection pulmonary arterial hypertension. Materials of the research and their discussion. Morphological methods were used to study the structural rearrangement of the testicular arteries of 40 rats, which were divided into 3 groups. The 1st group included 11 intact animals, the 2nd - 19 rats with arterial hypertension in the small circulation and compensated pulmonary heart, the 3rd - 10 experimental animals with pulmonary arterial hypertension and decompensated pulmonary heart. Postresection pulmonary arterial hypertension and pulmonary heart were modeled by performing right pulmonectomy in rats. One month after the start of the experiment, rats were euthanized by bloodletting under conditions of thiopental anesthesia. A separate weighing of the chambers of the heart, their planimetry. Pieces were cut from the testicles, which were fixed in 10% formalin solution, passed through ethyl alcohols of increasing concentration and placed in paraffin. Microtome sections after dewaxing were stained with different dyes. In the left and right testes, the outer and inner diameters of small-caliber arteries, media thickness, Kernogan index, endothelial cell height, diameter of their nuclei, nuclear-cytoplasmic ratios in endotheliocytes, and relative volume of damaged cells were measured. Quantitative indicators were processed statistically. Results of the research and their discussion. Morphometrically, it was found that with decompensation of the postresection pulmonary heart, the lumen of the small-caliber arteries of the left testicle decreased by 12.6 %. the Kernogan index - by 11.7 %, and the right - by 9.5 and 9.9 %, respectively. The relative volume of damaged endothelial cells of the studied vessels in right ventricular failure increased 11.6 times, and the right - 9.3 times. Histological examination of the testicles micropreparations of experimental animals after right-sided pulmonectomy showed severe vascular disorders (plethora of mostly venous vessels of the microhemocirculatory tract, stasis, thrombosis, diapedetic perivasal hemorrhage), stromal and perivasal edema, noncystic edema, dystrophy, dystrophy. Conclusions. It is established that in the conditions of the simulated pathology the wall thickens markedly, the lumen of the studied arteries narrows, endotheliocytes are damaged, structural cellular homeostasis is disturbed, which is complicated by their dysfunction, deterioration of blood supply, hypoxia, dystrophic, necrobiotic lesions. Structural changes in the arteries predominated in the left testis and in pulmonary heart decompensation. Key words: arteries; testis; rats; pulmonary arterial hypertension.

Background Gamma Knife radiosurgery (GKRS) obliterates 65% to 82% of brain arteriovenous malformations (BAVMs). Objective To explore the impact of hemodynamics on GKRS outcomes. Methods We retrospectively (2011-2017) included 98 patients with BAVMs who had received GKRS alone. Two evaluators, blinded to the outcomes, analyzed the pre-GKRS angiography and magnetic resonance images to obtain the morphological characteristics and quantitative digital subtraction angiography (QDSA) parameters. The venous stasis index was defined as the inflow gradient divided by the absolute value of the outflow gradient. Patients' follow-up magnetic resonance or digital subtraction angiography images were evaluated for the presence of complete obliteration (CO). Cox regression and Kaplan-Meier analyses were conducted to determine the correlations between the parameters and outcomes. Results Among the 98 patients, 63 (63.4%) achieved CO after GKRS at a median latency period of 31 mo. In multivariable analyses with adjustments for age and sex, increased BAVM volume (hazard ratio (HR) 0.949, P = .022) was an independent characteristic predictor, and venous stenosis (HR 2.595, P = .009), venous rerouting (HR 0.375, P = .022), and larger stasis index (HR 1.227, P = .025) were independent angiographic predictors of CO. BAVMs with a stasis index of >1.71 had a higher 36-mo probability of CO than those with a stasis index of ≤1.71 (61.1% vs 26.7%, P Conclusion BAVMs with a larger stasis index, indicating more stagnant venous outflow, may predict obliteration after GKRS. QDSA analysis may help in predicting BAVM treatment outcomes and making therapeutic decisions.

Purpose Since the development of antipsychotic drugs in the 1950s, a variety of studies and case reports have been published that suggest an association between exposure to typical antipsychotics and venous thromboembolisms (VTE). Therefore, when starting treatment with antipsychotics, especially low-potency typical antipsychotics and clozapine, health-care providers must account for the patient’s existing VTE risk factors. Design/methodology/approach In this case report, the authors describe the development of a pulmonary embolism associated with use of chlorpromazine in the treatment of an acute manic episode in a 51-year-old female patient with bipolar disorder type 1. Findings The patient was brought to the emergency room by the police on a legal hold for bizarre behaviors at a bus stop, which included incessantly yelling at bystanders. The patient was found to have disorganized thoughts, poor sleep, rapid speech, labile mood, distractibility, auditory hallucinations and grandiose delusions. During the course of her stay, the patient received extensive IM chlorpromazine for extreme agitation, in addition to chlorpromazine 200 mg IM Q8H, which was later decreased to chlorpromazine 100 mg chlorpromazine IM/PO Q8H. On day 4 of the treatment, the patient experienced difficulty breathing, hypoxia and tachycardia and was found to have bilateral expiratory wheezes. CT angiography showed sub-segmental pulmonary embolus and the patient was transferred to MICU service. The patient was then intubated and started on heparin by the medical team. Over the course of the next day, her respiratory distress resolved and the patient was extubated. Originality/value It is possible that chlorpromazine may indeed increase VTEs, and there are various physiological postulations regarding the mechanism of action. However, multiple confounding variables existed in the authors’ report, including venous stasis and the use of restraints, tobacco and valproic acid. Each of these variables has been shown to increase VTE occurrence. Further controlled studies are necessary to identify the true relationship between antipsychotics and VTEs.

AIM An investigator-initiated clinical study was carried out to evaluate the therapeutic potency of SR-0379 for the treatment of leg ulcers in patients with Werner syndrome. METHODS A multicenter, open-label study was carried out from September 2017 to February 2018. The inclusion criteria for leg ulcers were: (i) leg ulcers in patients with Werner syndrome, diabetes or critical limb ischemia/venous stasis; and (ii) a wound size of >1 cm and

Adults with congenital heart disease who underwent the Fontan operation to palliate single ventricle heart defects—by direct connection of caval venous return to the pulmonary circulation—have improved survival due to advancements in surgical and interventional techniques. However, cardiac and non-cardiac comorbidities often coexist, complicating management, and contributing to premature morbidity and mortality. Cardiac issues include heart failure symptoms related to systolic and diastolic dysfunction, atrial and ventricular arrhythmias and systemic atrioventricular valve regurgitation. Structural issues may be related to obstruction of the Fontan pathway, or to branch pulmonary artery stenosis, both of which exacerbate symptoms. Non-cardiac complications in adults involve hepatic congestion, fibrosis and cirrhosis, hepatocellular carcinoma, chronic kidney disease, stroke, venous stasis, lymphatic issues and involvement of other organ systems. ‘Fontan failure’ refers to circulatory dysfunction, either cardiac, non-cardiac, or both, diagnosed after exclusion or treatment of reversible contributors such as structural issues and arrhythmias. Counselling about reproductive health, mental health, perioperative management and overall wellness are paramount for patients’ well-being. Fontan patients are typically managed in highly specialised adult congenital heart centres, but may present to cardiologists or other practitioners with cardiac and non-cardiac emergencies or urgencies, sometimes after being out of care. In this review, we discuss the management of the adult Fontan patient, including surveillance, cardiac and non-cardiac complications, reproductive health, and advanced therapies.

Gemcitabine is a chemotherapeutic agent used in a wide variety of solid tumours. Known side effects include a dose-limiting myelosuppressive toxicity, mild rash, and radiation-dependent dermatitis. Rarely, localized inflammation in the form of pseudocellulitis has also been observed. We present the case of a 77-year-old woman with a history of a Whipple procedure for pancreatic adenocarcinoma who presented to the emergency department after the start of gemcitabine therapy with increased erythema, swelling, and tenderness in her lower legs. Relevant past medical history included peripheral vascular disease, dyslipidemia, and hypertension. A diagnosis of gemcitabine-induced pseudocellulitis aggravated by venous stasis was confirmed after an extensive workup. This case report and the literature review describe this rare reaction, highlighting the need for increased recognition to avoid unnecessary therapeutic intervention.

Carotid-cavernous fistula (CCF) is an abnormal communication - vascular connection between arteries and veins in the cavernous sinus. Classification according to etiology is traumatic vs spontaneous. According to blood flow rate per high flow vs low flow fistula. According to anatomy of direct vs indirect: Direct (direct) CCF arises through direct communication between the internal carotid artery (ICA) and the cavernous sinus. Indirect CCF originates through indirect communication through the meningeal branches of ICA, external carotid artery and cavernous sinus (not directly with ICA) and Barrow type A, B, C, D division. Patient‘s subjective complaints depend on the type of CCF. Most often it is pulsating tinnitus, synchronous with blood pulse. Typical findings include protrusion and pulsation of the eyeball, corkscrew vessels - arterialization of conjunctival and episleral vessels, increased intraocular pressure, not responding to local antiglaucomatous therapy, keratopathy a lagophthalmo, corneal ulcers. In the later untreated stages of CCF, secondary, venous stasis or central retinal vein occlusion can occur. Diagnostic procedures include B-scan and color Doppler ultrasonography, digital ophthamodynamometry, computer tomography, nuclear magnetic resonance and digital subtraction angiography. CCF can simulate orbitopathy, conjunctivitis symptoms, carotid occlusion, scleritis or cavernous sinus thrombosis. The ophthalmologist should recognize and indicate the necessary examinations in a timely manner. The therapy is ophthalmological, neuroradiological, sterotactic, surgical and conservative.

The propensity for venous thromboembolism in patients admitted to neurocritical care setups is high because of predilection toward venous stasis as well as pathological processes favoring embolus formation and dissemination. The application of routine thromboprophylaxis guidelines in the various subsets of neurologically injured patients is limited by the fear of bleeding inside neurologically significant closed locations. The aim of this review is to lay out thromboprophylaxis guidelines in various subsets of patients admitted to neurocritical care setups according to recent evidence base, which is still an evolving process.

A 58-year-old male patient with severe claudication due to thrombosis of the left ilio-femoro-popliteal artery aneurysm. He also had a venous stasis ulcer with a history of multiple embolotherapy of arteriovenous malformation. Duplex sonography revealed reflux and varicose veins of the left great saphenous vein (GSV). A sequential bypass surgery was performed that consisted of excision of the left external iliac and common femoral artery aneurysm, external iliac to deep femoral interposition with an expanded polytetrafluoroethylene graft, and femoro-posterior tibial artery bypass with the reversed left GSV. Symptoms of claudication were alleviated and the chronic ulcer was healed in time. To our knowledge, this is the first report of successful bypass in a patient with arterial aneurysm, arteriovenous malformation, and venous insufficiency that can be diagnosed as an atypical case of Parkes Weber syndrome. Long-term follow-up is needed to define the fate of aneurysms and varicose vein graft.

Background Non-healing wounds are becoming a growing concern for public health as a result of their increasing prevalence in progressively aging societies. Objectives The aim of this article is to evaluate the effects of wound etiology on a panel of circulating cytokines in patients with non-healing wounds of the lower extremities. Material and methods This prospective case-control study involved 104 individuals: healthy elderly people (n = 46) and patients with diabetes and/or cardiovascular disease (n = 58; among them 38 with chronic wounds of venous, ischemic or neurotrophic etiology). Selected serum cytokines - i.e. IL-1β, IL-4, IL-6, IL-8, FGF-2, G-CSF, GM-CSF, MCP-1, MIP-1α, TNF-α, VEGF-A, and PDGF-BB - were measured using the Luminex platform. Results Compared to healthy elderly people, presence of diabetes and/or cardiovascular disease was associated with elevated IL-6, IL-8, MCP-1 and G-CSF while non-healing wounds coexisted with the increase in the levels of all examined cytokines/growth factors except for G-CSF and GM-CSF. Among diseased elderly people, having wounds was associated with increased levels of IL-1β, IL-4, IL-6, IL-8, FGF-2, MIP-1α, PDGF-BB, and VEGF-A. Interleukin 1β elevation was a sole independent predictor of chronic wounds with an odds ratio (OR) of 6.3. Cytokines in healthy seniors were loosely interrelated, while the levels of cytokines in diseased patients with wounds displayed a tight pattern of association. When stratified by their etiology, the association pattern for IL-6, IL-8, MCP-1, and VEGF-A was disrupted in neurotrophic wounds. Conclusions The results presented herein may improve our understanding of the pathomechanisms which lead to chronic wounds and of the effects they exert on a systemic level, as well as providing potential targets for more effective therapies.

Objective. The status of metabolites of the nitric oxide (NO) pathway in patients with chronic wounds in the course of cardiometabolic diseases is largely unknown. Yet arginine supplementation and citrulline supplementation as novel therapeutic modalities aimed at increasing NO are tested. Material and Methods. Targeted metabolomics approach (LC-MS/MS) was applied to determine the concentrations of L-arginine, L-citrulline, asymmetric and symmetric dimethylarginines (ADMA and SDMA), and arginine/ADMA and arginine/SDMA ratios as surrogate markers of NO and arginine availability in ulnar and femoral veins, representing systemic and local levels of metabolites, in patients with chronic wounds in the course of cardiometabolic diseases (n=59) as compared to patients without chronic wounds but with similar cardiometabolic burden (n=55) and healthy individuals (n=88). Results. Patients with chronic wounds had significantly lower systemic L-citrulline and higher ADMA and SDMA concentrations and lower L-arginine/ADMA and L-arginine/SDMA as compared to healthy controls. The presence of chronic wounds in patients with cardiometabolic diseases was associated with decreased L-arginine but with increased L-citrulline, ADMA, and SDMA concentrations and decreased L-arginine/ADMA and L-arginine/SDMA. Serum obtained from the ulnar and femoral veins of patients with chronic wounds differed by L-arginine concentrations and L-arginine/SDMA ratio, both lower in the femoral vein. Wound etiology affected L-citrulline and SDMA concentrations, lower and higher, respectively, in patients with venous stasis, and the L-arginine/SDMA ratio—lower in venous stasis. The wound type affected L-arginine/ADMA and citrulline—lower in patients with ulcerations or gangrene. IL-6 was an independent predictor of L-arginine/ADMA, VEGF-A of ADMA, G-CSF of L-arginine/SDMA, and GM-CSF of L-citrulline and SDMA. Conclusion. Chronic wounds in the course of cardiometabolic diseases are associated with reduced NO and arginine availability due to ADMA and SDMA accumulation rather than arginine deficiency, not supporting its supplementation. Wound character seems to affect NO bioavailability and wound etiology—arginine bioavailability. Arginine concentration and its availability are more markedly reduced at the local level than the systemic level.

Background Electroconvulsive therapy (ECT) is indicated for critical psychiatric conditions, which themselves constitute a risk for deep venous thrombosis (DVT) owing to prolonged immobility, dehydration, and venous stasis. Objective We describe challenging instances of ECT implementation while taking direct oral anticoagulants (DOACs). Method We report on 8 patients receiving DOACs for DVT who were successfully treated with ECT at the University of Yamanashi Hospital. We also provide a literature review on this topic. Results There were 6 female patients (the average age was 60.9+/-13.4 y.o.) and diagnoses included major depression, bipolar depression and schizophrenia. DOACs were edoxaban for 4 patients, rivaroxaban for 2, and apixaban for 2. A total of 92 ECT sessions were cautiously and safely completed in collaboration with multidisciplinary medical professionals without problematic adverse events, such as bleeding. A literature search found one case series of warfarin but currently available evidence is confined to sporadic case reports regarding ECT and DOACs for DVT. These reports were represented by successful implementation of ECT to patients receiving treatment with anticoagulants for DVT or thromboembolism. Ours is the first of a successful treatment with ECT while taking apixaban or edoxaban. Conclusion A clinical dilemma is that ECT is indicated for critical conditions that are likely to predispose patients to developing DVT. Paucity of data clearly highlights the need for more studies to support a contention that ECT, when carefully performed in consultation with other medical experts, is a viable treatment for those with DVT receiving oral anticoagulants.

The article presents the results of prospective longitudinal study, in which the dynamics of fibrinogen, D-dimer, the platelet count levels have been evaluated in comparison with clinical changes within the application of endovenous electric welding (EVEW) in automatic mode for varicose vein treatment in 33 patients. The statistical analysis of the results was performed using SPSS Inc. software. (Chicago, IL, USA, version 22.0). One week after the operation, a complete obliteration of the great saphenous vein, as determined by ultrasonography, was observed in 26 patients (78.8%), while in 7 patients, a remaining lumen was registered (21.2%); after 12 months, the complete occlusion of the trunk without signs of recanalization or varicose disease progression was determined in 100% patients. After 1 week, the symptoms of venous stasis (edema, heaviness in the lower extremities) disappeared in 32 (97%) patients; in one case, the edema remained until the day 12. The great saphenous vein occlusion after EVEW application was accompanied by changes in coagulation homeostasis, which reflected in the dynamics of D-dimer, fibrinogen and the platelet count. One week after surgery, these parameters were higher in patients with incomplete occlusion, indicating the maintenance of coagulation activity of the body as a component of treatment aimed to complete the process of insufficient vein obliteration. Gradual decrease in platelet count as one of the markers of cell apoptosis indicates a continuous decrease in the activity of venous wall inflammation. No blood flow impairment in the deep veins of the lower extremities or thrombophlebitic changes in the trunk of the great saphenous vein or its tributaries have been detected.

Background Entrapment neuropathies include a wide field of locations. In most cases, the microsurgical decompression is still the therapy of choice. However, the role of venous stasis and ischemia is still discussed controversially. Here the authors evaluated the visualization of microvessels and the microperfusion at peripheral nerves with a contact endoscope during the surgical decompression for the first time. Methods Eight patients were subjected to endoscopic or endoscopically assisted peripheral nerve decompression. In 3 patients with nerve tumors, the tumor carrying nerve was inspected endoscopically proximal and distal to the tumor site before and after resection. Microcirculation was assessed by a contact endoscope, allowing a 150-fold magnification, at superficial areas proximal and distal to the compression site. The electronically stored records were analyzed retrospectively using image processing software. Vessel diameter, red blood cell velocity, and blood flow, before and after decompression, were extracted. Results The contact endoscope was easy to handle intraoperatively without problems. All minimally invasive procedures were performed without complications. In the offline computer-assisted analysis, single arterioles and veins were visualized showing decreased red blood cell velocity prior to decompression. After surgical treatment, a statistically significant increase of blood flow was observed. Conclusions Basically, the application of a contact endoscope for visualization of peripheral nerves' microcirculation is feasible. The observed effect of increased blood flow after decompression should be compared with the clinical outcome in a further prospective randomized study.

BackgroundPlasma cardiac troponin (cTn) elevation occurs in acute ischemic stroke and intracranial hemorrhage and can suggest a poor prognosis. Because acute cerebral venous thrombosis (CVT) might lead to venous stasis, which could result in cardiac stress, it is important to evaluate whether cTn elevation occurs in patients with CVT.MethodsInpatients at Johns Hopkins Hospital from 2005 to 2015 meeting the following criteria were included: CVT (ICD-9 codes with radiologic confirmation) and available admission electrocardiogram (ECG) and cTn level. In regression models, presence of ECG abnormalities and cTn elevation (>0.06 ng/mL) were evaluated as dependent variables in separate models, with location and severity of CVT involvement as independent variables, adjusted for age, sex, and hypertension.ResultsOf 81 patients with CVST, 53 (66%) met the inclusion criteria. Participants were, on average, aged 42 years, white (71%), and female (66%). The left transverse sinus was most commonly thrombosed (47%), with 66% having >2 veins thrombosed. Twenty-two (41%) had cTn elevation. Odds of cTn elevation increased per each additional vein thrombosed (adjusted OR 2.79, 95% CI [1.08–7.23]). Of those with deep venous involvement, 37.5% had cTn elevation compared with 4.4% without deep clots (p = 0.02). Venous infarction (n = 15) was associated with a higher mean cTn (0.14 vs 0.02 ng/mL, p = 0.009) and was predictive of a higher cTn in adjusted models (β = 0.15, 95% CI [0.06–0.25]).ConclusionsIn this single-center cohort study, markers of CVT severity were associated with increased odds of cTn elevation; further investigation is needed to elucidate causality and significance.

Venous thromboembolism (VTE) is a leading cause of in-hospital morbidity and mortality, particularly in patients at intensive care units (ICU) (1). Hypercoagulability, venous stasis and vascular injury, but also the frequent use of highly coagulable catheters and extracorporeal support devices predispose this patient group to thromboembolic complications. Therefore, efficient strategies for the prevention of thrombosis that do not cause excessive bleeding are paramount in critically ill patients.