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Congestion, related to pressure and/or fluid overload, plays a central role in the pathophysiology, presentation and prognosis of heart failure and is an important therapeutic target. While symptoms and physical signs of fluid overload are required to make a clinical diagnosis of heart failure, they lack both sensitivity and specificity, which might lead to diagnostic delay and uncertainty. Over the last decades, new ultrasound methods for the detection of elevated intracardiac pressures and/or fluid overload have been developed that are more sensitive and specific, thereby enabling earlier and more accurate diagnosis and facilitating treatment strategies. Accordingly, we considered that a state-of-the-art review of ultrasound methods for the detection and quantification of congestion was timely, including imaging of the heart, lungs (B-lines), kidneys (intrarenal venous flow), and venous system (inferior vena cava and internal jugular vein diameter).

European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

Aim: The aim of this study is to compare the diameter of the inferior vena cava with tricuspid annular plane systolic excursion (TAPSE) measurement in order to determine the volume loss before and after blood donation in healthy volunteers. Methods: This Institutional Review Board-approved single center, prospective, cross-sectional study included 60 healthy blood donors donating in a tertiary care hospital's blood bank. After obtaining written consent, systolic, diastolic, and mean arterial blood pressures along with pulse rate of the donors were measured in sitting and supine positions by the attending physician, then, inferior vena cava (IVC) and TAPSE measurements were made before and after blood donation. Results: Statistically significant differences was found between standing systolic blood pressure and pulse rate, lying systolic blood pressure and pulse rate, IVC and TAPSE values before and after blood donation (p < 0.05). There was no difference between the other variables before and after blood donation. Conclusion: Our study revealed that, low IVC and TAPSE values correlated in determining blood loss after blood donation. TAPSE may be useful to predict blood loss in early stages of hypovolemic shock. (c) 2021 Published by Elsevier Inc.

Aim: The aim of this study is to compare the diameter of the inferior vena cava with mitral annular plane systolic excursion measurement in order to determine the volume loss before and after blood donation in healthy volunteers. Material and methods: The study was a singlecenter, prospective, cross-sectional study which included 46 healthy blood donors donating in a tertiary care hospital's blood bank. The inclusion criteria for the study were: volunteers aged 18-65 years, over 50 kg in weight, who met blood donation criteria, with hemoglobin values of 13.5 g/dL for males and >12.5 g/dL for females. After obtaining written consent, the systolic, diastolic, and mean arterial blood pressure along with the pulse rate of the donors were measured in standing and lying positions by the attending physician. Next, inferior vena cava and mitral annular plane systolic excursion measurements were made both pre and post blood donation. Results: The decrease in both inferior vena cava diameter and mitral annular plane systolic excursion values measured pre and post blood donation was found to be statistically significant (p

Objective: Radical excision of retroperitoneal or intra-abdominal soft tissue sarcomas may necessitate vessel resection and reconstruction. The aim of this study was to assess surgical results of retroperitoneal or intra-abdominal sarcomas involving major blood vessels. Methods: This was a retrospective single centre cohort study and a comprehensive review of literature. Patients with retroperitoneal or intra-abdominal sarcomas treated by the oncovascular team in Helsinki University Hospital from 2010 to 2018 were reviewed for vascular and oncological outcomes. A comprehensive literature review of vascular reconstructions in patients with retroperitoneal sarcoma was performed. Results: Vascular reconstruction was performed in 17 patients, 11 of whom required arterial reconstructions. Sixteen of the operations were sarcoma resections; the post-operative diagnosis for one patient was thrombosis instead of the presumed recurrent leiomyosarcoma. Early graft thrombosis occurred in two venous and one arterial reconstruction. Late thrombosis was detected in three (18%). The median follow up was 27 (range 0-82) months. Of the patients with sarcoma resections 5 (31%) died of sarcoma and further 4 (25%) developed local recurrence or new distant metastases. The comprehensive review of literature identified 37 articles with 110 patients, 89 of whom had inferior vena cava reconstruction only. Eight arterial reconstructions were described. Late graft thrombosis occurred in 14%. The follow up was 0-181 months, during which 57% remained disease free and 7% died of sarcoma. Conclusion: Vascular reconstructions enable radical resection of retroperitoneal and intra-abdominal sarcomas in patients with advanced disease. The complex operations are associated with an acceptable rate of serious perioperative complications and symptomatic thrombosis of the repaired vessel is rare. However, further studies are needed to assess the performance of the vascular reconstructions in the long term.

International audience; Congestion, related to pressures and/or fluid overload, plays a central role in the pathophysiology, presentation and prognosis of heart failure and is an important therapeutic target. While symptoms and physical signs of fluid overload are required to make a clinical diagnosis of heart failure, they lack both sensitivity and specificity, which might lead to diagnostic delay and uncertainty. Over the last decades, new ultrasound methods for the detection of elevated intracardiac pressures and/or fluid overload have been developed that are more sensitive and specific, thereby enabling earlier and more accurate diagnosis and facilitating treatment strategies. Accordingly, we considered that a state-of-the-art review of ultrasound methods for the detection and quantification of congestion was timely, including imaging of the heart, lungs (B-lines), kidneys (intrarenal venous flow), and venous system (inferior vena cava and internal jugular vein diameter). This article is protected by copyright. All rights reserved.

Venous hemodynamics and volume homeostasis are important aspects of cardiovascular physiology. However, today their relevance is still very much underappreciated. Their most important role is maintenance and control of venous return and, as such, cardiac output. A high-flow/low-resistance circulation, remaining constant under physiological circumstances, is mandatory for an uncomplicated course of pregnancy. In this article, characteristics of normal and abnormal venous and volume regulating functions are discussed with respect to normal and pathologic outcomes of pregnancy, and current (non-invasive) methods to assess these functions are summarized. Copyright (C) 2017 ISUOG. Published by John Wiley & Sons Ltd.

Guidelines summarize and evaluate available evidence with the aim of assisting health professionals in proposing the best management strategies for an individual patient with a given condition. Guidelines and their recommendations should facilitate decision making of health professionals in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.

ZusammenfassungHintergrund: Nach einer femoro-iliakalen und kavalen tiefen Venenthrombose (TVT) entwickeln bis zu 50 % der Patienten ein postthrombotisches Syndrom (PTS), was zu einer erheblichen Einschränkung der Lebensqualität führen kann.Ergebnisse: Die Behandlungsmöglichkeiten bei einem PTS sind die konservative Therapie, klassische offene Bypass-Operationen sowie die endovaskulären Verfahren.Zu den offenen Operationsverfahren liegen lediglich Studien mit geringer Fallzahl vor, deren Offenheitsrate 58–100 % beträgt. Die Komplikationen dieser invasiven Methode sind thrombotische Bypassverschlüsse, Hämatome und Wundheilungsstörungen.Mit dem endovaskulären Verfahren können Offenheitsraten von 73–100 % erreicht werden. Zu diesem Verfahren liegen Studien mit größeren Fallzahlen vor. Als Komplikationen kann man einen thrombotischen Verschluss und Hämatome nennen.Im Gegensatz zur konservativen Therapie gibt es zu den operativen Behandlungsmethoden keine randomisierten Studien. Aus diesem Grund kann für die operativen Verfahren nur eine schwache Empfehlung ausgespro-chen werden (Evidenzlevel II b).Schlussfolgerung: Bei Vorliegen eines post-thrombotischen Syndroms mit chronisch venöser Obstruktion sollten zunächst alle konservativen Behandlungsmöglichkeiten ausgeschöpft werden. Bei weiterhin bestehenden Beschwerden mit deutlicher Einschränkung der Lebensqualität sollte ein invasives Therapieverfahren erwogen werden. In diesem Fall stellt die endovaskuläre Rekanalisation die Therapiemethode der ersten Wahl dar. Randomisierte Studien sind notwendig, um einen aussagekräftigeren Empfehlungsgrad zu erreichen.

This article in our point-of-care ultrasound (PoCUS) series discusses the benefits of focused cardiac ultrasound (FoCUS) for the regional anesthesiologist and pain specialist. Focused cardiac US is an important tool for all anesthesiologists assessing patients with critical conditions such as shock and cardiac arrest. However, given that ultrasound-guided regional anesthesia is emerging as the new standard of care, there is an expanding role for ultrasound in the perioperative setting for regional anesthesiologists to help improve patient assessment and management. In addition to providing valuable insight into cardiac physiology (preload, afterload, and myocardial contractility), FoCUS can also be used either to assess patients at risk of complications related to regional anesthetic technique or to improve management of patients undergoing regional anesthesia care. Preoperatively, FoCUS can be used to assess patients for significant valvular disease, such as severe aortic stenosis or derangements in volume status before induction of neuraxial anesthesia. Intraoperatively, FoCUS can help differentiate among complications related to regional anesthesia, including high spinal or local anesthetic toxicity resulting in hemodynamic instability or cardiac arrest. Postoperatively, FoCUS can help diagnose and manage common yet life-threatening complications such as pulmonary embolism or derangements in volume status. In this article, we introduce to the regional anesthesiologist interested in learning FoCUS the basic views (subcostal 4-chamber, subcostal inferior vena cava, parasternal short axis, parasternal long axis, and apical 4-chamber), as well as the relevant sonoanatomy. We will also use the I-AIM (Indication, Acquisition, Interpretation, and Medical decision making) framework to describe the clinical circumstances where FoCUS can help identify and manage obvious pathology relevant to the regional anesthesiologist and pain specialist, specifically severe aortic stenosis, hypovolemia, local anesthetic systemic toxicity, and massive pulmonary embolism.

New findings What is the central question of this study? At near-term gestation, foramen ovale blood flow accounts for a significant proportion of fetal left ventricular output. Can the foramen ovale increase its volume blood flow when right ventricular afterload is increased by main pulmonary artery occlusion? What is the main finding and its importance? Foramen ovale volume blood flow increased during main pulmonary artery occlusion. However, this increase was attributable to an increase in fetal heart rate, because left ventricular stroke volume remained unchanged. These findings suggest that the foramen ovale has a limited capacity to increase its volume blood flow. Abstract The foramen ovale (FO) accounts for the majority of fetal left ventricular (LV) output. Increased right ventricular afterload can cause a redistribution of combined cardiac output between the ventricles. To understand the capability of the FO to increase its volume blood flow and thus LV output, we mechanically occluded the main pulmonary artery in seven chronically instrumented near-term sheep fetuses. We hypothesized that FO volume blood flow and LV output would increase during main pulmonary artery occlusion. Fetal cardiac function and haemodynamics were assessed by pulsed and tissue Doppler at baseline, 15 and 60 min after occlusion of the main pulmonary artery and 15 min after occlusion was released. Fetal ascending aorta and central venous pressures and blood gas values were monitored. Main pulmonary artery occlusion initially increased fetal heart rate (P P C O 2 increased. Left ventricular systolic dysfunction developed while LV diastolic function was preserved. Right ventricular systolic and diastolic function deteriorated after the occlusion. In conclusion, the FO has a limited capacity to increase its volume blood flow at near-term gestation.

Endovenous stenting has become the treatment of choice for chronic (thrombotic or non-thrombotic) venous obstructive iliac disease. This review aims to focus on the role of venous stents in the management of chronic conditions affecting the deep venous systems of the lower limbs. In addition, the review provides an overview on chronic venous outflow obstructive diseases.

Adrenocortical carcinoma (ACC) is a rare and in most cases steroid hormone-producing tumor with variable prognosis. The purpose of these guidelines is to provide clinicians with best possible evidence-based recommendations for clinical management of patients with ACC based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. We predefined four main clinical questions, which we judged as particularly important for the management of ACC patients and performed systematic literature searches: (A) What is needed to diagnose an ACC by histopathology? (B) Which are the best prognostic markers in ACC? (C) Is adjuvant therapy able to prevent recurrent disease or reduce mortality after radical resection? (D) What is the best treatment option for macroscopically incompletely resected, recurrent or metastatic disease? Other relevant questions were discussed within the group. Selected Recommendations: (i) We recommend that all patients with suspected and proven ACC are discussed in a multidisciplinary expert team meeting. (ii) We recommend that every patient with (suspected) ACC should undergo careful clinical assessment, detailed endocrine work-up to identify autonomous hormone excess and adrenal-focused imaging. (iii) We recommend that adrenal surgery for (suspected) ACC should be performed only by surgeons experienced in adrenal and oncological surgery aiming at a completeen blocresection (including resection of oligo-metastatic disease). (iv) We suggest that all suspected ACC should be reviewed by an expert adrenal pathologist using the Weiss score and providing Ki67 index. (v) We suggest adjuvant mitotane treatment in patients after radical surgery that have a perceived high risk of recurrence (ENSAT stage III, or R1 resection, or Ki67 >10%). (vi) For advanced ACC not amenable to complete surgical resection, local therapeutic measures (e.g. radiation therapy, radiofrequency ablation, chemoembolization) are of particular value. However, we suggest against the routine use of adrenal surgery in case of widespread metastatic disease. In these patients, we recommend either mitotane monotherapy or mitotane, etoposide, doxorubicin and cisplatin depending on prognostic parameters. In selected patients with a good response, surgery may be subsequently considered. (vii) In patients with recurrent disease and a disease-free interval of at least 12 months, in whom a complete resection/ablation seems feasible, we recommend surgery or alternatively other local therapies. Furthermore, we offer detailed recommendations about the management of mitotane treatment and other supportive therapies. Finally, we suggest directions for future research.

Venous hemodynamics and volume homeostasis are important aspects of cardiovascular physiology. However, today their relevance is still very much underappreciated. Their most important role is maintenance and control of venous return and, as such, cardiac output. A high-flow/low-resistance circulation, remaining constant under physiological circumstances, is mandatory for an uncomplicated course of pregnancy. In this article, characteristics of normal and abnormal venous and volume regulating functions are discussed with respect to normal and pathologic outcomes of pregnancy, and current (non-invasive) methods to assess these functions are summarized. Copyright (C) 2017 ISUOG. Published by John Wiley & Sons Ltd. We thank K. Tomsin, A. Staelens, S. Vonck, D. Lanssensand I. Dierickx for their critical review and constructivecomments on the presentation and content of thispaper.

This paper describes a thrombosis in the vena cava caudalis of a 15 year-old cat with ascites. Trauma and eventually feline enteric corona virus infection in the cat were not detected. In the intrahepatic region, a blockage of vena cava caudalis was brought to light by ultrasonographic imaging. An aspirate of abdominal fluid revealed modified transudate. Liver enzyme levels were increased in the serum sample of the cat. The levels of total oxidant status (TOS) and total antioxidant status (TAS) were elevated in the peritoneal fluid. Liver protection diet with L-carnitine, diuretic therapy and antimicrobial drugs were administrated for treatment of the cat. During the continuous treatment, the amount of abdominal fluid decreased, but never completely absorbed. L-carnitine was administered to the cat during the time of treatment, and subsequently the levels of liver enzymes decreased. However, the cat died because of recurrent ascites and persistent thrombosis. In conclusion, ultrasonographic examination was very reliable, non-invasive and highly useful diagnostic method for BCS and L-carnitine has crucial effects on the quality of life, energy metabolism and liver enzyme levels. However, the blockage of the vena cava caudalis could not completely respond to medical treatment and thrombosis should be eliminated by surgical intervention.

Primary leiomyosarcomas of vascular origin are rare tumors. They frequently arise within the inferior vena cava; however, the peripheral vein was also affected. To date, only a few hundred cases have been reported in the world literature. Although it is an extremely aggressive tumor, the symptoms may be unspecific, especially in the lower extremities. In this report, we present a case of primary vascular leiomyosarcoma, arising from the short saphenous vein, with symptoms mimicking thrombus in the initial diagnosis. The diagnosis of leiomyosarcomas was confirmed by standard H&E staining and immunohistochemical staining. Recurrence of the tumor has been observed five years after surgical treatment. Due to its rarity, experience in the management of this type of tumor is limited. The mainstay of treatment for these tumors is complete surgical resection. The purpose of the presented case is to discuss the clinicopathological features and management options of this tumor, under the light of the most recent literatures.

BACKGROUND: Rapid, accurate, and reproducible assessment of intravascular volume status is crucial in order to predict the efficacy of volume expansion in septic patients. The aim of this study was to verify the feasibility and usefulness of the internal jugular vein collapsibility index (IJV-CI) as an adjunct to the inferior vena cava collapsibility index (IVC-CI) to predict fluid responsiveness in spontaneously-breathing patients with sepsis. METHODS: Three stages of sonographic scanning were performed. Hemodynamic data were collected using the Ultrasonic Cardiac Output Monitor IA system (Uscom, Ltd., Sydney, NSW, Australia) coupled with paired assessments of IVC-CI and IJV-CI at baseline, after passive leg raise (PLR), and again in semi-recumbent position. Fluid responsiveness was assessed according to changes in the cardiac index (CI) induced by PLR. Patients were retrospectively divided into 2 groups: fluid responder if an increase in CI (Delta CI) >= I5% was obtained after PLR maneuver, and non-responder if Delta CI was

Objective We investigated whether combining the caval index, assessment of the global contractility of the heart and measurement of stroke volume with Noninvasive Cardiac Output Monitoring (NICOM) can aid in fluid management in the emergency department (ED) in patients with sepsis. Setting A prospective observational single-centre pilot study in a tertiary care centre. Primary and secondary outcomes Ultrasound was used to assess the caval index, heart contractility and presence of B-lines in the lungs. Cardiac output and stroke volume were monitored with NICOM. Primary outcome was increase in stroke volume after a fluid bolus of 500 mL, while secondary outcome included signs of fluid overload. Results We included 37 patients with sepsis who received fluid resuscitation of at least 500 mL saline. The population was divided into patients with a high (>36.5%, n=24) and a low caval index (

Intravenous leiomyomatosis is a rare smooth muscle tumour that arises from the myometrium and grows into the extrauterine venous system. It typically can extend into the vena cava inferior and even the cardiac chambers. This can lead to life threatening obstruction of cardiac valves. The only effective treatment is surgical resection. However, no clear guidelines with respect to surgical approach and further strategy are available in the literature. Especially the indications for a simultaneous thoracic approach and for either one-stage or two-stage approach are unclear. On the basis of two cases of intravenous leiomyomatosis with different levels of intracaval extension of the tumour, this article discusses a useful strategy for planning surgical resection, taking into account tumour characteristics and different levels of intracaval extension.

Currently, liver transplantation (LT) is an accepted method of treatment of end-stage liver disease, metabolic diseases with their primary defect in the liver and unresectable primary liver tumors. Surgical techniques in LT have evolved considerably over the past 40 yr. The developments have led to a safer procedure for the recipient reflected by continuously improving survival figures after LT. Also the new techniques offer the possibility of tailoring the operation to the needs and condition of the recipient as in partial grafting or in different revascularization techniques, or in techniques of biliary reconstructions. In addition, the new techniques such as split LT, domino transplantation and living donor LT have brought about an increase in the available grafts. In this review the evolution of surgical techniques in LT over the past 40 yr and their contribution to the current results are discussed.

The treatment of renal cell carcinoma (RCC) with cavoatrial involvement represents a major surgical challenge. To date, many surgical strategies have been proposed. However, general agreement on the best approach does not yet exist. Deep hypothermic circulatory arrest (DHCA) is the most commonly used method and allows complete tumor resection without increasing operative risk. Cardiopulmonary bypass (CPB) without circulatory arrest and methods using no CBP were also proposed, without a clear evidence of superiority of 1 technique over the others. Further studies are needed to evaluate the possible role of alternative techniques compared with deep hypothermic circulatory arrest.

Purpose of review Blood loss in orthotopic liver transplantation has declined during the past decade. Recent papers addressed this issue and emphasized its importance, because there is a significant correlation between intraoperative blood transfusion requirements and postoperative morbidity. This reduced blood loss. Recent findings Many preoperative variables that predict blood loss during orthotopic liver transplantation have been found. These vary between studies. Differences in perioperative blood loss, transfusion criteria and intraoperative management of coagulation may account for the interhospital variations in transfusion of red blood cells during orthotopic liver transplantation., Therefore, a risk index developed in one centre should not be applied without evaluation in other centres. Introduction of the piggyback technique and close monitoring of coagulation with thromboelastography have led to reduced blood transfusion requirements. Use of antifibrinolytics has shown to decrease blood loss. Recombinant factor Vila is not indicated for treatment of coagulation abnormalities during orthotopic liver transplantation, and its use is justified only as rescue therapy. Summary Recent changes in blood conservation practices in orthotopic liver transplantation are presented and discussed.

No consensus exists regarding the optimal reconstruction of the cavo-caval anastomosis in piggyback orthotopic liver transplantation (PB-LT). The aim of this study was to analyze our experience with end-to-side (ES) cavo-cavostomy. Outcome parameters were patient and graft survival and surgical complications. During the period 1995-2002 146 full-size PB-LT in 137 adult patients were performed with ES cavo-cavostomy without the routine use of temporary portocaval shunt (TPCS). In 12 patients (8%) this technique was used for implantation of second or third grafts. Veno-venous bypass was not used in any case and TPCS was performed only in eight patients (6%). One-, three- and five-yr patient and graft survival were 84%, 79% and 75%, and 81%, 74% and 69%, respectively. The median number of intraoperative transfusion of packed red blood cells (RBC) was 2.0 (range 0-33) and 30% of the patients (n = 43) did not require any RBC transfusion. Surgical complications of various types were observed after 49 LT (34%) and none of the complications was specifically related to the technique of ES cavo-cavostomy. Our experience indicates that PB-LT with ES cavo-cavostomy is a safe procedure, can safely be performed without the routine use of a TPCS, has a very low risk of venous outflow obstruction and can also be used effectively during retransplantations.

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines. ispartof: Journal of the American Society of Echocardiography vol:28 issue:1 pages:1-39 ispartof: location:United States status: published

Background/Aims: It is unclear whether treatment of patients with Budd-Chiari syndrome (BCS) should be based on liver histology, as large histopathological studies have not been performed. We investigated the relationship between the histopathological findings and survival.Methods: We studied the clinical features and findings on biopsy specimens in 45 patients with BCS who were admitted to four tertiary referral medical centers. Histological findings, i.e. congestion, necrosis, inflammation and fibrosis, were graded. Survival was assessed in relation to histological findings and clinical features at the time of diagnosis as well as in relation to subsequent treatment with or without portosystemic shunting.Results: Centrilobular congestion, centrilobular necrosis, lobular inflammation and portal inflammation were not significantly related to survival. In addition, there was no association between either pericentral or periportal fibrosis and survival. Univariate analysis revealed that the prothrombin time and Child-Pugh score were significantly related to survival (P = 0.005 and P-trend = 0.02, respectively). Multivariate analysis yielded the Child-Pugh score, serum alanine aminotransferase (ALT) and treatment with portosystemic shunting as independent prognostic indicators.Conclusions: We found no evidence for a relationship between early liver pathology and survival. Child-Pugh score, serum ALT and portosystemic shunting appeared to be prognostic indicators for patients with BCS. (C) 2001 European Association for the Study of the Liver. Published by Elsevier Science B.V. All rights reserved.

Chronic venous insufficiency (CVI) as an advanced stage of chronic venous disease is a common problem that occurs in approximately 1-5 % of the adult population. CVI has either a nonthrombotic (primary) or postthrombotic (secondary) cause involving reflux, obstruction, or a combination of both. The role of venous obstruction is increasingly recognized as a major cause of CVI, with obstructive lesions in the iliocaval segment being markedly more relevant than lesions at the levels of the crural and femoral veins. Approximately 70-80 % of iliac veins develop a variable degree of obstruction following an episode of acute deep venous thrombosis. Nonthrombotic iliac vein obstruction also known as May-Thurner or Cockett's syndrome is the most common cause of nonthrombotic iliac vein occlusion. While compression therapy is the basis of therapy in CVI, in many cases, venous recanalization or correction of obstructive iliac vein lesions may result in resolution of symptoms. This document reviews the current evidence on iliocaval vein recanalization and provides standards of practice for iliocaval stenting in primary and secondary causes of chronic venous disease.

Comparative anatomy was used to collect more evidence for a thermoregulatory function of the internal vertebral venous plexus (IVVP). The venous connections of the IVVP were studied and compared in various mammals in order to find evidence for the existence of climate related anatomical adaptations. Humans and vervet monkeys were chosen as representatives of mammals living in moderate climates, the IVVP of the dolphin was studied because this animal is always surrounded by cold water. The springbok was chosen as a representative of mammalian species living under very hot conditions. The present study was exclusively performed on post mortem material. After filling the venous system with latex the IVVP and its venous connections were dissected. It appeared that in the dolphin, veins from the trunk muscles were directly and exclusively connected to the IVVP in the absence of an azygos vein. In the vervet monkey and human specimens, veins originating in the muscles drained both into the caval veins and into the IVVP. In these mammals veins draining from brown fat areas were also connected to the IVVP. In the springbok, drainage of blood from the muscles was prevented to enter the IVVP by the presence of valves. In humans and vervet monkeys we found that the lumbar parts of the IVVP were connected to subcutaneous veins of the back. It was concluded that the anatomy of the IVVP and its connecting veins may serve to thermoregulate the spinal cord and that climate related anatomical adaptations were present in the species studied.

Intravenous leiomyomatosis is a rare smooth muscle tumour that arises from the myometrium and grows into the extrauterine venous system. It typically can extend into the vena cava inferior and even the cardiac chambers. This can lead to life threatening obstruction of cardiac valves. The only effective treatment is surgical resection. However, no clear guidelines with respect to surgical approach and further strategy are available in the literature. Especially the indications for a simultaneous thoracic approach and for either one-stage or two-stage approach are unclear. On the basis of two cases of intravenous leiomyomatosis with different levels of intracaval extension of the tumour, this article discusses a useful strategy for planning surgical resection, taking into account tumour characteristics and different levels of intracaval extension.

BACKGROUND: Platelet transfusions have been identified as an independent risk factor for survival after orthotopic liver transplantation (OLT). In this study, we analyzed the specific causes of mortality and graft loss in relation to platelet transfusions during OLT.METHODS: In a series of 449 consecutive adult patients undergoing a first OLT, the causes of patient death and graft failure were studied in patients who did or did not receive perioperative platelet transfusions.RESULTS: Patient and graft survival were significantly reduced in patients who received platelet transfusions, compared with those who did not (74% vs 92%, and 69% vs 85%, respectively at 1 yr; P CONCLUSIONS: These findings suggest that platelet transfusions are an important risk factor for mortality after OLT. The current study extends previous observations by identifying acute lung injury as the main determinant of increased mortality. The higher rate of graft loss in patients receiving platelets is related to the higher overall mortality rate and does not result from specific adverse effects of transfused platelets on the grafted liver.

BACKGROUND: Intraoperative transfusion of red blood cells (RBC) is associated with adverse outcome after orthotopic liver transplantation (OLT). Although experimental studies have shown that platelets contribute to reperfusion injury of the liver, the influence of allogeneic platelet transfusion on outcome has not been studied in detail. In this study, we evaluate the impact of various blood products on outcome after OLT.METHODS: Twenty-nine variables, including blood product transfusions, were studied in relation to outcome in 433 adult patients undergoing a first OLT between 1989 and 2004. Data were analyzed using uni- and multivariate stepwise Cox's proportional hazards analyses, as well as propensity score-adjusted analyses for platelet transfusion to control for selection bias in the use of blood products.RESULTS: The proportion of patients receiving transfusion of any blood component decreased from 100% in the period 1989-1996 to 74% in the period 1997-2004. In uni- and multivariate analyses, the indication for transplantation, transfusion of platelets and RBC were highly dominant in predicting 1-yr patient survival. These risk factors were independent from well-accepted indices of disease, such as the Model for End-Stage Liver Disease score and Karnofsky score. The effect on 1-yr survival was dose-related with a hazard ratio of 1.377 per unit of platelets (P = 0.01) and 1.057 per unit of RBC (P = 0.001). The negative impact of platelet transfusion on survival was confirmed by propensity-adjusted analysis.CONCLUSION: This retrospective study indicates that, in addition to RBC, platelet transfusions are an independent risk factor for survival after OLT. These findings have important implications for transfusion practice in liver transplant recipients.

Background. Hypertension (HT) is common in patients on continuous ambulatory peritoneal dialysis (CAPD) and is responsible for increased cardiovascular morbidity and mortality. In this study, we aimed to determine the prevalence of 'uncontrolled HT' during background therapy in CAPD patients by using office measurements and ambulatory blood pressure monitoring (ABPM). We further determined whether intravascular volume status, assessed by inferior vena cava diameter (IVCD) index, contributes to higher blood pressure (BP) and increased left ventricular mass index (LVMI). Methods. Seventy-four CAPD patients were included in the final analysis. All patients underwent echo-cardiographic examination and received ABPM. Patients undergoing CAPD were categorized into two groups: 'uncontrolled HT' (Group A) and 'normotensive and controlled HT' (Group 13). Intravascular volume status was determined using the IVCD index and collapsibility index (CI) on the same day as ABPM. Results. The prevalence of HT was 84% when using office measurements and 82% when using daytime ABPM. Daytime BP was 147/92 mm Hg by office measurements and 145/91 mm Hg by ABPM (P>0.05). The prevalence of 'uncontrolled HT' measured by ABPM was 73% (n = 54). Patients with uncontrolled HT (Group A) were taking more antihypertensive medications than patients with 'normotension and controlled HT' (Group B, n = 20; 1.0+/-0.8 vs 0.5+/-0.7, P=0.008). The IVCD index was higher in Group A 2 than in Group B (9.2+/-2.1 vs 7.7+/-1.9 mm/m(2), P=0.007). There was no correlation between IVCD index and office BP, ABPM measurements or LVMI. The LVMI was also higher in Group A than in Group B (145+/-39 vs 118+/-34g/m(2), P

Background/Aims: It is unclear whether treatment of patients with Budd-Chiari syndrome (BCS) should be based on liver histology, as large histopathological studies have not been performed. We investigated the relationship between the histopathological findings and survival. Methods: We studied the clinical features and findings on biopsy specimens in 45 patients with BCS who were admitted to four tertiary referral medical centers. Histological findings, i.e. congestion, necrosis, inflammation and fibrosis, were graded. Survival was assessed in relation to histological findings and clinical features at the time of diagnosis as well as in relation to subsequent treatment with or without portosystemic shunting. Results: Centrilobular congestion, centrilobular necrosis, lobular inflammation and portal inflammation were not significantly related to survival. In addition, there was no association between either pericentral or periportal fibrosis and survival. Univariate analysis revealed that the prothrombin time and Child-Pugh score were significantly related to survival (P = 0.005 and P-trend = 0.02, respectively). Multivariate analysis yielded the Child-Pugh score, serum alanine aminotransferase (ALT) and treatment with portosystemic shunting as independent prognostic indicators. Conclusions: We found no evidence for a relationship between early liver pathology and survival. Child-Pugh score, serum ALT and portosystemic shunting appeared to be prognostic indicators for patients with BCS. (C) 2001 European Association for the Study of the Liver. Published by Elsevier Science B.V. All rights reserved.

Background: Fluid therapy is the first important step in patients with signs of shock but assessment of the volume status is difficult and invasive measurements are not readily available in the emergency department. We have investigated whether the respiratory variation in diameter of the inferior vena cava is a reliable parameter to predict fluid responsiveness in spontaneous breathing emergency department patients with signs of shock.Methods: All patients admitted to the emergency department during a 15 week period were screened for signs of shock. If the attending physician planned to give a fluid challenge, the caval index was determined by transabdominal ultrasonography in supine position. Immediately afterwards 500 ml NaCl 0.9% was administered in 15 minutes and the clinical response was observed. An adequate response was defined as an increase in systolic blood pressure of at least 10 mm Hg. Based on this definition patients were divided into responders and non-responders.Results: After selection a total number of 45 patients was included. A low caval index (Conclusions: In spontaneously breathing patients with signs of shock in the emergency department, a high caval index (>36.5%) does not reliably predict fluid responsiveness in our study, while a low caval index (