Optimal management of upper extremity deep vein thrombosis: Is venous thoracic outlet syndrome underrecognized?

Background: Upper extremity deep vein thrombosis (UEDVT) accounts for ~10% of all cases of DVT. In the most widely referenced general review of DVT, the American Academy of Chest Physicians essentially recommended that UEDVT be treated identically to that of lower extremity DVT, with anticoagulation the default therapy. However, the medical literature has not differentiated well between DVT in the arm vs DVT in the leg and has not emphasized the effects of the costoclavicular junction and the lack of the effect of gravity to the point at which UEDVT due to extrinsic bony compression at the costoclavicular junction is classified as "primary.

Results of first stage brachiobasilic and brachiobrachial fistula creation: Implications for staged versus single procedure decision making.

Introduction: Transposed brachiobasilic AV fistulas (BVT) have increasingly been performed in two stages. Published reports give conflicting results, perhaps in part as many reports of staged procedures eliminate those patients who "fail" the first stage (i.e.

Safe and effective HeRO graft placement: Technique and results.

Objectives: Hemodialysis Reliable Outflow (HeRO) grafts are used when venous outflow is inadequate to support conventional access. These have been perceived as complex to implant and being associated with high risk. We have evolved a defined protocol for insertion that minimizes morbidity and maximizes efficiency.

Surgical management of post-thrombotic syndrome in chronic venous thoracic outlet syndrome.

Objective: Venous thoracic outlet syndrome (VTOS) is considered chronic when symptoms and venous stenosis or occlusion are present for >3 months after the initial primary upper extremity deep vein thrombosis event. Many of patients with chronic VTOS receive conservative treatment. However, a subset of these patients will have persistent post-thrombotic syndrome symptoms because of underlying causative anatomy.

How Common Is Thoracic Outlet Syndrome?

The incidence of neurogenic thoracic outlet syndrome is completely unknown, and has been wildly overestimated in the past. Based on a prospectively maintained database at our academic Thoracic Outlet Center, we estimate the yearly incidence of neurogenic and venous thoracic outlet syndrome to be approximately 3 and 1 per 100,000 population, respectively. The ratio of neurogenic to venous thoracic outlet syndrome seems to be approximately 80:20 based on presentation, and 75:25 based on operative correction.

The role of surgery for assisted maturation after endovascular and percutaneous arteriovenous fistula creation.

Even in the best of circumstances, a significant number of patients will require adjunctive endovascular and/or surgical revision prior to achieving functional patency after endovascular or percutaneous AVF creation, at least within the United States. This rate appears to be higher after percutaneous AVF than after endovascular AVF, although because published reports of the former are mostly derived from American experience and those of the latter derived from experience outside the United States, it is unclear whether these differences are due to the technique itself or cultural and/or anatomic differences in dialysis access practices and patient populations. If arterial inflow is poor, this should be corrected first.

Single Center Outcomes of Carotid Artery Stenting in Veterans with Prior Head and Neck Cancer.

Background: Patients meeting criteria for intervention of carotid stenosis with a history of prior cervical radiation or neck dissection are considered "high risk" for carotid endarterectomy. This is a well-established indication for carotid artery stenting (CAS). The long-term outcomes of CAS in this population are less frequently published in the literature but are poor.

The Incidence of Thoracic Outlet Syndrome.

Background: Thoracic outlet syndrome (TOS) refers to a constellation of compressive problems that occur at the thoracic outlet. TOS has been recognized since the 19th century, and the "modern" era of treatment, especially for neurogenic TOS, dates from at least the 1970s. Despite this, however, the incidence and prevalence of these syndromes are almost completely unknown.

Evaluation and treatment of thoracic outlet syndrome during the global pandemic due to SARS-CoV-2 and COVID-19.

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources).

Arteriovenous Access superficialization: A New Technique and Review of Options.

Background: Up to 30% of autogenous cephalic vein arteriovenous fistulas (AVFs) are too deep for reliable cannulation. Techniques to superficialize these AVFs have been described previously. This study describes a new surgical technique for AVF superficialization and provides a review of the alternative techniques.

Use of a novel immediate access dialysis graft designed to prevent needle-related complications: A first-in-man case report.

Currently, there is no vascular access that possesses all ideal qualities for hemodialysis access, but attributes particularly lacking include: ease of identification (cannulation zone), ease of access, resistance to stenosis, durable to repetitive cannulation, resistance to infection, resistance to acute needle-related injuries, and instant hemostasis. The overall value of these attributes could be appreciated in the reduction of complications (patient burden and suffering, which can also result in increased healthcare costs), and improved safety and durability. In this case report, we present a novel hemodialysis access graft that has the potential to provide the following benefits: it is designed to be self-sealing and immediately usable post implant, easy to identify, easy to access, has more durable cannulation zones, and protects from needle-related injuries.

Hemodynamic events during carotid stenting are associated with significant periprocedural stroke and adverse events.

Background: There are limited data on the impact of carotid angioplasty and stenting (CAS)-related changes in blood pressure, heart rate, and preprocedural medications on periprocedural stroke in contemporary, real-world practice. This study evaluates the risk attributable to the CAS-related hemodynamic events and the impact preprocedural medications have on mitigating this risk in a large, population-based cohort.

Methods: We studied all patients in the Vascular Quality Initiative who underwent CAS between January 2006 and December 2016.

Technical note: An alternative method for AV access superficialization.

Introduction: An arteriovenous fistulae for dialysis access is only functional if superficial enough for reliable cannulation. We describe a previously unreported technique to superficialize arteriovenous fistulae too deep for reliable cannulation.

Method: The path of the fistula is marked using ultrasound, and three to four transverse incisions are made along this path.

One- versus two-stage transposed brachiobasilic arteriovenous fistulae: A review of the current state of the art.

In the absence of suitable cephalic vein, the brachiobasilic vein complex represents the best option for arteriovenous access. However, the basilic vein is too deep to cannulate and requires transposition to be accessible. Transposition can be performed during fistula creation (single-stage BBTx) or at a second operation after initial fistula creation (two-stage brachiobasilic transposition (BBTx)).

Outcomes of venous bypass combined with thoracic outlet decompression for treatment of upper extremity central venous occlusion.

Background: Upper extremity central venous stenosis results from a variety of environmental and anatomic conditions, including venous thoracic outlet syndrome, the presence of device leads or catheters, and the turbulence created by the presence of arteriovenous fistulas or grafts. In cases of total occlusion, especially at the bony costoclavicular junction, options for endovascular treatment and open venous reconstruction are limited and bypass grafting may be needed. We describe our experience with venous bypass combined with thoracic outlet decompression in a cohort of symptomatic patients with subclavian vein occlusion.

Surgical and endovascular central venous reconstruction combined with thoracic outlet decompression in highly symptomatic patients.

Background: Subclavian vein stenosis or occlusion at the thoracic outlet is a problem associated with certain anatomic and environmental stresses (venous thoracic outlet syndrome [VTOS]), the presence of central venous catheters, and the high flows associated with arteriovenous (AV) access in the limb. We describe our experience with open and endovascular techniques for restoring patency in highly symptomatic patients.

Methods: A prospectively collected database of patients was queried for patients treated for central venous obstructive disease in the setting of highly symptomatic VTOS and ipsilateral AV access from October 2011 to August 2016.

REHEARSAL Using Patient-Specific Simulation to Improve Endovascular Efficiency.

Objective: To determine whether rehearsal using patient-specific information loaded onto an endovascular simulator prior to carotid stenting improves procedural efficiency and outcomes.

Methods: Patients scheduled for carotid artery stenting who had adequate preoperative computed tomography (CT) imaging were considered for enrollment. After obtaining informed consent, patients were randomized to control versus rehearsal groups.

Positive Impact of an Aortic Center Designation.

Background: In January 2015, we created a multidisciplinary Aortic Center with the collaboration of Vascular Surgery, Cardiac Surgery, Interventional Radiology, Anesthesia and Hospital Administration. We report the initial success of creating a Comprehensive Aortic Center.

Methods: All aortic procedures performed from January 1, 2015 until December 31, 2016 were entered into a prospectively collected database and compared with available data for 2014.

Postoperative Pain Management following Thoracic Outlet Decompression.

Background: Thoracic outlet decompression (TOD) is associated with significant postoperative pain often leading to hospital length of stay out of proportion to the risk profile of the operation. We seek to describe the improvement in hospital length of stay and patient pain control with an improved multiagent pain management regimen.

Methods: We retrospectively reviewed the hospital length of stay, medication regimen/usage, operative details, and operative indications for all patients undergoing TOD from January 2012 through June 2015.

Overview of aortic aneurysm management in the endovascular era.

Management of aortic aneurysm disease has changed in the endovascular era, with the majority of patients opting for stent-graft repair of abdominal and thoracic aneurysms. An understanding of this vascular condition is important for primary care, emergency medicine, medicine specialists, and vascular surgeons alike. Awareness of the patient risk factors for aneurysmal degeneration, sac rupture, and medical management allows physicians to screen appropriate patient populations, which decreases aneurysm-related mortality due to rupture.

Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome.

Thoracic outlet syndrome (TOS) is a group of disorders all having in common compression at the thoracic outlet. Three structures are at risk: the brachial plexus, the subclavian vein, and the subclavian artery, producing neurogenic (NTOS), venous (VTOS), and arterial (ATOS) thoracic outlet syndromes, respectively. Each of these three are separate entities, though they can coexist and possibly overlap.

Reporting standards of the Society for Vascular Surgery for thoracic outlet syndrome: Executive summary.

Thoracic outlet syndrome (TOS) is a group of disorders all having in common compression at the thoracic outlet. Three structures are at risk: the brachial plexus, the subclavian vein, and the subclavian artery, producing neurogenic (NTOS), venous (VTOS), and arterial (ATOS) thoracic outlet syndromes, respectively. Each of these three are separate entities, though they can coexist and possibly overlap.