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PurposeTo assess safety and patency of the Venovo venous stent for the treatment of iliofemoral vein obstruction.Materials and MethodsTwenty-two international centers enrolled 170 patients in the VERNACULAR study (93 post-thrombotic syndrome; 77 non-thrombotic iliac vein lesions). Primary outcome measures were major adverse events at 30 days and 12-month primary patency (freedom from target vessel revascularization, thrombotic occlusion, or stenosis > 50%). Secondary outcomes included the Venous Clinical Severity Score Pain Assessment and Chronic Venous Quality-of-Life Questionnaire assessments (hypothesis tested). Secondary observations included primary patency, target vessel and lesion revascularization (TVR/TLR), and assessment of stent integrity through 36 months.ResultsFreedom from major adverse events through 30 days was 93.5%, statistically higher than a pre-specified performance goal of 89% (p = 0.032) while primary patency at 12 months was 88.6%, also statistically higher than a performance goal of 74% (p < 0.0001). Mean quality-of-life measures were statistically improved compared to baseline values at 12 months (p < 0.0001). Primary patency at 36 months was 84% (Kaplan–Meier analysis) while freedom from TVR/TLR was 88.1%. There was no stent embolization/migration, and no core laboratory assessed stent fractures reported through 36 months. Six deaths were reported; none adjudicated as device or procedure related.ConclusionThe Venovo venous stent was successfully deployed in obstructive iliofemoral vein lesions and met the pre-specified primary outcome measures through 12 months. At 3 years, primary patency was 84%, reintervention rates were low, standardized quality-of-life and pain measures improved from baseline, and there was no stent migration or fractures.Level of EvidenceLevel 2—prospective, multicenter, controlled clinical study without a concurrent control or randomization. Pre-specified endpoints were hypothesis-tested to performance goals derived from peer-reviewed clinical literature.Registration clinicaltrials.govUnique Identifier NCT02655887.

This trial of varicose-vein treatments showed no substantial differences in quality of life 6 months after ultrasound-guided foam sclerotherapy, endovenous laser ablation, or surgery, but disease-specific quality of life was slightly worse after foam treatment than after surgery. Ultrasound-guided foam sclerotherapy and thermal ablation techniques such as endovenous laser ablation have become widely used alternatives to surgery for the treatment of varicose veins. Previous randomized trials and meta-analyses have shown these treatments to be effective in terms of short-term technical success and clinician-reported outcomes. 1 – 19 Clinical practice guidelines recommend the use of patient-reported quality of life to assess the outcomes of treatment of varicose veins. 20 Quality of life was a primary outcome measure in two small randomized trials that compared surgery and endovenous laser ablation, 5 , 9 but to our knowledge, it has not been assessed as a primary . . .

Splanchnic vein thrombosis (SVT) including portal, mesenteric, splenic vein thrombosis and the Budd-Chiari syndrome, is a manifestation of unusual site venous thromboembolism. SVT presents with a lower incidence than deep vein thrombosis of the lower limbs and pulmonary embolism, with portal vein thrombosis and Budd-Chiari syndrome being respectively the most and the least common presentations of SVT. SVT is classified as provoked if secondary to a local or systemic risk factor, or unprovoked if the causative trigger cannot be identified. Diagnostic evaluation is often affected by the lack of specificity of clinical manifestations: the presence of one or more risk factors in a patient with a high clinical suspicion may suggest the execution of diagnostic tests. Doppler ultrasonography represents the first line diagnostic tool because of its accuracy and wide availability. Further investigations, such as computed tomography and magnetic resonance angiography, should be executed in case of suspected thrombosis of the mesenteric veins, suspicion of SVT-related complications, or to complete information after Doppler ultrasonography. Once SVT diagnosis is established, a careful patient evaluation should be performed in order to assess the risks and benefits of the anticoagulant therapy and to drive the optimal treatment intensity. Due to the low quality and large heterogeneity of published data, guidance documents and expert opinion could direct therapeutic decision, suggesting which patients to treat, which anticoagulant to use and the duration of treatment.

Changes in extracellular matrix proteins may contribute significantly to the adaptation of vein grafts to the arterial circulation. We examined the production and distribution of versican and hyaluronan in intact human vein rings cultured ex vivo, veins perfused ex vivo, and cultured venous adventitial and smooth muscle cells. Immunohistochemistry revealed higher levels of versican in the intima/media compared to the adventitia, and no differences in hyaluronan. In the vasa vasorum, versican and hyaluronan associated with CD34+ progenitor cells. Culturing the vein rings for 14 days revealed increased versican immunostaining of 30-40% in all layers, with no changes in hyaluronan. Changes in versican accumulation appear to result from increased synthesis in the intima/media and decreased degradation in the adventitia as versican transcripts were increased in the intima/media, but unchanged in the adventitia, and versikine (the ADAMTS-mediated cleavage product of versican) was increased in the intima/media, but decreased in the adventitia. In perfused human veins, versican was specifically increased in the intima/media in the presence of venous pressure, but not with arterial pressure. Unexpectedly, cultured adventitial cells express and accumulate more versican and hyaluronan than smooth muscle cells. These data demonstrate a differential regulation of versican and hyaluronan in human venous adventitia vs. intima/media and suggest distinct functions for these extracellular matrix macromolecules in these venous wall compartments during the adaptive response of vein grafts to the arterial circulation.

Varicose veins are characterized by disturbed hemodynamics due to blood reflux. We previously identified altered flow-driven endothelial-to-mesenchymal transition (EndMT) in varicose veins. Mechanosensors such as Piezo1 provide a molecular bridge between hemodynamic forces and cellular mechanoregulation in vasculature. We hence hypothesized that depletion of blood flow-sensing Piezo1 channels induces EndMT process during venous remodeling. Here, we analyzed 20 human varicose veins and 22 healthy saphenous veins for a comprehensive view of Piezo1 expression using qRT-PCR, western blot and immunohistostaining techniques. Our study reveals a significant loss of Piezo1 expression in varicose veins at both mRNA and protein levels. Our in vitro experiments using microfluidic flow channels showed that Piezo1 expression and calcium influx function are drastically affected in endothelial cells (ECs) exposed to oscillatory venous shear stress. Piezo1 depletion reduces KLF2, which triggers the EndMT program in venous ECs. Kinase inhibitor assays indicated that Piezo1-based calcium influx promotes CAMKII autophosphorylation and induces KLF2 expression via both MEK5/ERK5 and PI3K-AKT-FOXO pathways in venous flow. Piezo1 agonist Yoda1, at low doses mimicking venous flow, augmented KLF2 expression and prevented aberrant molecular EndMT reprogramming in cells exposed to oscillatory shear stress. Yoda1 was also effective in restoring calcium influx and stimulating angiogenesis by promoting endothelial tube formation hindered by Piezo1 depletion. Taken together, the endothelial-protective role of Piezo1 ion channels due to uniform hemodynamic flow is coupled to KLF2, a downstream mediator in the venous circulation. The Piezo1-KLF2 pathway can be utilized for identifying targeted therapeutic options in patients with varicose veins. Graphical abstract

This randomized controlled trial was aimed to compare 1-year morphologic changes of the no-touch saphenous vein graft as Y-composite (Composite group) versus aortocoronary (Aorta group) configurations in coronary artery bypass grafting. The primary endpoint was intima-media thickness of the saphenous vein graft as measured by intravascular ultrasound (IVUS) at the 1-year angiographic evaluation. Recruitment of 25 patients in each group was necessary based on a superiority design. Among the 50 patients, IVUS data were obtained in 22 and 24 patients from the Composite and Aorta groups, respectively. Mean age was 64.8 ± 9.2 years, and the proportion of females was 20.0%. The numbers of distal anastomoses per saphenous vein graft were 2.7 ± 1.1 and 2.6 ± 0.8 in the Composite and Aorta groups, respectively. The intima-media thickness of the saphenous vein graft 1 year after surgery were 0.25 ± 0.04 mm and 0.24 ± 0.06 mm in the Composite and Aorta groups, respectively (P for superiority = .99). Other IVUS parameters of saphenous vein grafts, including vessel diameter, luminal diameter, and the ratio of intima-media thickness to vessel diameter, also demonstrated no differences between the groups. No neointimal hyperplasia or plaque formation was detected using IVUS. All study patients underwent 1-year angiographic evaluation, and the patency rates were 94.7%(89 out of 94 anastomoses) and 100.0%(90 out of 90 anastomoses) in the Composite and Aorta groups, respectively. The intima-media thickness of the saphenous vein graft 1 year after surgery demonstrated no significant difference between the Y-composite and aortocoronary configurations (NCT04782492). Trial Registration: ClinicalTrials.gov NCT04782492.

The use of ultrasound (US) has been proposed to reduce the number of complications and to increase the safety and quality of central venous catheter (CVC) placement. In this review, we describe the rationale for the use of US during CVC placement, the basic principles of this technique, and the current evidence and existing guidelines for its use. In addition, we recommend a structured approach for US-guided central venous access for clinical practice. Static and real-time US can be used to visualize the anatomy and patency of the target vein in a short-axis and a long-axis view. US-guided needle advancement can be performed in an \"out-of-plane\" and an \"in-plane\" technique. There is clear evidence that US offers gains in safety and quality during CVC placement in the internal jugular vein. For the subclavian and femoral veins, US offers small gains in safety and quality. Based on the available evidence from clinical studies, several guidelines from medical societies strongly recommend the use of US for CVC placement in the internal jugular vein. Data from survey studies show that there is still a gap between the existing evidence and guidelines and the use of US in clinical practice. For clinical practice, we recommend a six-step systematic approach for US-guided central venous access that includes assessing the target vein (anatomy and vessel localization, vessel patency), using real-time US guidance for puncture of the vein, and confirming the correct needle, wire, and catheter position in the vein. To achieve the best skill level for CVC placement the knowledge from anatomic landmark techniques and the knowledge from US-guided CVC placement need to be combined and integrated.

Background Single centre studies support No Touch (NT) saphenous vein graft (SVG) harvesting technique. The primary objective of the SUPERIOR SVG study was to determine whether NT versus conventional (CON) SVG harvesting was associated with improved SVG patency 1 year after coronary artery bypass grafting surgery (CABG). Methods Adults undergoing isolated CABG with at least 1 SVG were eligible. CT angiography was performed 1-year post CABG. Leg adverse events were assessed with a questionnaire. A systematic review was performed for published NT graft patency studies and results aggregated including the SUPERIOR study results. Results Two hundred and-fifty patients were randomized across 12-centres (NT 127 versus CON 123 patients). The primary outcome (study SVG occlusion or cardiovascular (CV) death) was not significantly different in NT versus CON (NT: 7/127 (5.5%), CON 13/123 (10.6%), p  = 0.15). Similarly, the proportion of study SVGs with significant stenosis or total occlusion was not significantly different between groups (NT: 8/102 (7.8%), CON: 16/107 (15.0%), p  = 0.11). Vein harvest site infection was more common in the NT patients 1 month postoperatively (23.3% vs 9.5%, p  < 0.01). Including this study’s results, in a meta-analysis, NT was associated with a significant reduction in SVG occlusion, Odds Ratio 0.49, 95% Confidence Interval 0.29–0.82, p  = 0.007 in 3 randomized and 1 observational study at 1 year postoperatively. Conclusions The NT technique was not associated with improved patency of SVGs at 1-year following CABG while early vein harvest infection was increased. The aggregated data is supportive of an important reduction of SVG occlusion at 1 year with NT harvesting. Trial registration NCT01047449 .

We report an interesting incidental liver finding during ECG-gated cardiac computed tomography (CT) in a newborn with infracardiac total anomalous pulmonary venous connection to the portal vein. This case shows a unique abnormality in hepatic perfusion that was initially mistaken for hepatic vein thrombosis. We review the altered hepatic blood flow distribution in this pathologic anatomy to help explain the observed hepatic perfusion abnormality on CT. This understanding will enable an imager to anticipate hepatic perfusion patterns in similar patients, potentially avoiding misdiagnosis and unnecessary further testing.

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing liver regeneration therapies prior to major hepatectomies, including portal vein embolization, double vein embolization and liver venous deprivation. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It encompasses all clinical and technical details required to perform liver regeneration therapies, revising the indications, contra-indications, outcome measures assessed, technique and expected outcomes.