Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3742_Библиотеки_им_академика_М_И_Перельмана
.pdf
280 Section 13: Venous Disease
Correct Answer D Multiple traumas, intracranial bleeding, and in pregnancy
Reference
Hartung, O., Benmiloud, F., Barthelemy, P., et al. (2008). Late results of surgical venous thrombectomy
with iliocaval stenting. J Vasc Surg, 47(2), 381–387. PMID: 18241761
34. RATIONALE
The aim of open iliofemoral venous thrombectomy is to remove all thrombus, restore
patency to the operated veins, and maintain unobstructed flow from the iliofemoral
venous segment into the vena cava and is best achieved by opening the thrombosed
infrainguinal venous segments, correcting any underlying venous lesions or compression,
and preventing deep thrombosis by constructing an arteriovenous fistula and providing
adequate anticoagulation, often by catheter-directed techniques, into the thrombectomized veins. The long-term patency of the iliac vein in 80% of patients has been reported
following iliofemoral venous thrombectomy with arteriovenous fistula. Routine use of IVC
filters is not necessary except in patients with a free-floating thrombus in the inferior vena
cava. After completion of iliofemoral venous thrombectomy, intraoperative venography
and intravascular ultrasound are performed to detect any iliac vein stenosis and should be
corrected by iliac vein angioplasty and stenting. An end-to-side AV fistula is constructed
by anastomosing the amputated end of the proximal greater saphenous vein or a large
proximal branch of the greater saphenous vein to the side of the superficial femoral artery
with an anastomotic diameter of 3.5–4 mm. The purpose of AVF is to increase venous
velocity but not the venous pressure.
Correct Answer C 80% of patients
Reference
Comerota, A., & Ruiz-Gamboa, R., (2018). Operative venous thrombectomy. In S. Hans, Shepard, A.,
Weaver, M., et al. (Ed.), Endovascular and open vascular reconstruction: a practical approach
(pp. 383–388). Boca Raton, FL: Taylor & Francis/CRC Press.
35. RATIONALE
Oral anticoagulation is started when the patient resumes oral intake after open thrombectomy.
Heparin infusion followed by direct-acting oral anticoagulants and, in some cases, warfarin
is continued for an extended period, generally for 1 year or longer. Intermittent pneumatic
compression garments are used on both legs postoperatively when the patient is not ambulating. Before discharge, the patient is fitted with a 30–40 mmHg ankle gradient below the knee
compression stockings for walking in the morning until bedtime. Randomized trials have
demonstrated at least a 50% reduction in post-thrombotic morbidity with the use of
30–40 mmHg ankle gradient compression stockings.
Correct Answer D 50%
Reference
Prandoni, P., Lensing, A. W., Prins, M. H., et al. (2004). Below-knee elastic compression stockings to
prevent the post-thrombotic syndrome: a randomized, controlled trial. Ann Intern Med, 141(4),
249–256. PMID: 15313740
36. RATIONALE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Section 13: Venous Disease 281
Saphenopopliteal bypass (SPB) involves transplantation of the ipsilateral greater saphenous
vein to bypass a femoral vein occlusion. It can be used to treat unilateral occlusion of the
femoral vein, especially if the profunda femoris vein (PFV) is an inadequate collateral conduit.
Preoperative venogram and imaging with duplex ultrasound, including superficial vein mapping, are obtained. Usually, profunda femoris vein flow compensates for femoral vein occlusion.
Saphenopopliteal bypass may be indicated if there is evidence of unilateral occlusion of the
femoral vein with a patent iliac venous system and occlusion of the profunda femoris vein or the
profunda femoris is small in caliber. Appropriate candidates for this procedure must have preserved inflow and outflow, including a popliteal vein, greater saphenous vein, saphenofemoral
junction, and patent proximal iliocaval venous outflow. The decision to include a distal arteriovenous fistula to augment inflow is made intraoperatively by assessment of the flow through
the bypass and is performed between the popliteal artery and vein distal to the anastomosis
or an interposition graft using a 1- to 2-cm segment from a side branch, or a distal segment of
the greater saphenous vein is harvested. A side-biting clamp is applied to the popliteal artery
distal to the saphenopopliteal anastomosis. An arteriotomy is created and then extended with
an arterial anastomosis and then completed in an end-to-end manner with 6-0 polypropylene
suture. A side-biting clamp vascular clamp is then applied, and an end-to-side anastomosis is
performed. Arteriovenous fistula should be assessed for a thrill. Primary patency of saphenopopliteal bypass is 53%; primary assisted patency rates of 69% and 75% have been reported.
Correct Answer C Unilateral occlusion of the femoral vein with a patent iliac venous system
and occlusion of the profunda femoris vein
Reference
Coleman, D. M., Rectenwald, J. E., Vandy, F. C., & Wakefield, T. W. (2013). Contemporary results after
sapheno-popl iteal bypass for chronic femoral v ein occlusion. J Vasc Surg Venous Lymphat Disord ,
1(1), 45–51. PMID: 26993893
282 Section 13: Venous Disease
37. RATIONALE
Inferior venocavogram through a 9 Fr, 30-cm sheath from the right internal jugular vein
access with the tip of the sheath placed in the suprarenal inferior vena cava. Antegrade
right common femoral digital subtraction venogram through a 6 Fr, 30 cm greater saphenous vein sheath, which is upsized to 10 Fr. Only retroperitoneal and pelvic collateral veins
are visible in patients with no visualization of the external iliac vein or common iliac vein.
Using the greater saphenous vein as access with the wire advanced into the inferior vena
cava using access from the contralateral side. Final placement of two kissing wall stents
(12 mm) and an 18-mm wall stent in the suprarenal inferior vena cava with a short 5-cm
(approximately) segment of inferior vena cava at renal veins was not intentionally stented to
preserve renal vein outflow. The patient was discharged on low molecular weight heparin,
clopidogrel, and aspirin. Staged procedures for a complex case with acute thrombosis below
the groin and chronic occlusive lesions of external iliac veins, common iliac veins, and inferior vena cava are more appropriate.
Correct Answer B Venography with thrombolysis, balloon angioplasty, suction thrombectomy from above the knee popliteal veins to external iliac veins followed by bilateral iliofemoral
recanalization with bilateral overlapping wall stents from the common iliac vein, external iliac
vein, and rostral femoral vein 6 months later
Reference
Williams D. M. (2014). Iliocaval reconstruction in chronic deep vein thrombosis. Tech Vasc Interv
Radiol, 17(2), 109–113. PMID: 24840966.
38. RATIONALE
Creation of arteriovenous fistula is an important adjunct if there is concern for poor inflow.
Postoperatively patients are started on low molecular weight heparin followed by oral anticoagulation, and in some cases antiplatelet medications are added. These medications alone are
Section 13: Venous Disease 283
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
not sufficient to prevent thrombosis in a crossover femoro-femoral venous bypass. Therefore,
creation of an arteriovenous fistula is a necessary adjunct. The 5-year primary patency of
femoro-femoral venous bypass is 70%, and a secondary patency rate of 78% has been reported.
Complications of crossover femoro-femoral venous bypass includes surgical site infection,
hematoma, and early graft occlusion.
Correct Answer D Creation of arteriovenous fistula
Reference
Garg, N., Gloviczki, P., Karimi, K. M., et al. (2011). Factors affecting outcome of open and hybrid recon-
structions for nonmalignant obstruction of iliofemoral veins and inferior vena cava. J Vasc Surg,
53(2), 383–393. PMID: 21146346
39. RATIONALE
Popliteal vein aneurysms are a rare entity that necessitate repair because of the associated
high risk of pulmonary embolism. Up to 71% of patients with venous aneurysms develop
venous thromboembolism. Several methods of repair have been described. If there is a
redundant length of the vein associated with the aneurysm, resection and end-to-end anastomosis to the proximal and distal segments of the vein can be performed.
1,2
If additional
length of the vein is required for tension-free anastomosis, resection with an interposition
graft of the greater saphenous vein or femoral vein should be performed. Alternatively, surgical aneurysmectomy and lateral venorrhaphy can be considered. In the presence of thrombosis, open thrombectomy before plication should be performed. Preoperative evaluation
includes duplex ultrasound and MRV. Posterior approach for popliteal vein aneurysm is
preferable than medial approach.
Correct Answer C To prevent pulmonary embolism
References
1. Sessa, C., Nicolini, P., Perrin, M., et al. (2000). Management of symptomatic and asymptomatic
popliteal venous aneurysms: a retrospective analysis of 25 patients and review of the literature.
J Vasc Surg, 32(5), 902–912. PMID: 11054222
2. Teter, K. A., Maldonado, T. M., & Adelman, M. A. (2018). A systematic review of venous
aneurysms by anatomic location. J Vasc Surg Venous Lymphat Disord, 6(3), 408–413.
PMID:29661366
40. RATIONALE
The largest single-institution series of popliteal venous aneurysm consists of 25 patients
who underwent surgical repair (n19). The reported complications were 8% hematoma,
8% transient peroneal nerve palsy, 4% local infection, and 12% early thrombosis. A recent
meta-analysis summarizes the complications reported in the literature and reveals that
20% (5/25) had early thrombosis from the procedure, 4% had late thrombosis, and 12% had
aneurysm recurrence. The varying rates of early thrombosis likely reflect differing practice
patterns in anticoagulation, ranging from the use of low molecular weight heparin for a
limited time to varying treatment lengths of oral anticoagulation ranging from 3 months to
lifelong. In the setting of thrombus and recurrence of pulmonary embolism, open thrombectomy with an adjunct procedure to correct the cause of the nidus for thrombus formation should be considered.
284 Section 13: Venous Disease
Correct Answer C 20%
Reference
Maldonado-Fernandez, N., Lopez-Espada, C., Martinez-Gamez, F. J., et al. (2013). Popliteal venous
aneurysms: results of surgical treatment. Ann Vasc Surg, 27(4), 501–509. PMID: 23522443
41. RATIONALE
Nutcracker syndrome describes a phenomenon that occurs when the left renal vein is compressed
between the aorta and the superior mesenteric artery. Posterior nutcracker syndrome is another
variant of this condition, which occurs when a retroaortic left renal vein is compressed between
the aorta and vertebral body. Many patients are symptomatic. The most common symptom is
hematuria followed by abdominal or flank pain. Hematuria is secondary to left renal vein compression. Increased intraluminal pressure within the left renal vein results in the development of hilar
varices around the renal pelvis and the ureter, and rupture of thin-walled veins within the collecting system may result in both macroscopic and microscopic hematuria. Other symptoms include
orthostatic proteinuria, pain in the left flank or left upper quadrant of the abdomen, left-sided varicocele, and fatigue. Conservative treatment of nutcracker syndrome is successful in up to 30% of
patients. For patients with more severe symptoms, distal transposition of the left renal vein directly
into the inferior vena cava should be considered. Other open surgical options include gonadal vein
reimplantation, ectopic kidney transplantation, and even nephrectomy. Endovascular stenting is
being increasingly utilized, but long-term outcome data is lacking. The preferred open technique
for treating nutcracker syndrome is left renal vein transposition 3–5 cm below the formal opening
of the left renal vein. Adjunct procedures using greater saphenous vein interposition should be considered in select cases to avoid narrowing of the left renal vein and to decrease the tension between
the left renal vein and inferior vena cava when the length of the left renal vein is too short to reach
the inferior vena cava comfortably. Primary patency of 74% has been reported at 2 years. A reintervention rate of 10% within 30 days after open venous procedure has been reported, most often due
to left renal vein stenosis as detected by intravascular ultrasound.
Correct Answer A Hematuria
Reference
Velasquez, C. A., Saeyeld in, A., Zafar, M. A., Brownstein, A. J., & Erben, Y. (2018). A systemat ic review on
management of nutcracker syndrome. J Vasc Surg Venous Lymphat Disord, 6(2), 271–278. PMID:
29292117
42. RATIONALE
Pelvic congestion syndrome occurs in premenopausal women secondary to venous drainage obstruction causing multiple varicose veins and painful venous congestion in the pelvis, perineum, and vulva. Pain becomes worse on standing, walking, and factors increasing
intraabdominal pressures such as lifting and pregnancy. The pain is relieved on lying down.
Vessel diameter alone is only accurate in 56% for ref lux identification. Venous reflux can be
divided into three grades:
• Grade I – When the retrograde flow is limited to ovarian vein
• Grade II – When the retrograde flow is present in the parauterine veins
• Grade III – Retrograde flow crossing the midline passing to the parauterine plexus of the
contralateral side
Section 13: Venous Disease 285
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CT and MRI provide accurate anatomical visualization. Venography remains the gold standard
for diagnosis of pelvic congestion syndrome. It should be reserved for patients who had prior
noninvasive imaging while the interventional therapy is being planned. Minimally invasive
intervention in the form of ovarian vein embolization and embolization of the branches of the
internal iliac vein should be considered. All venous outlets should be closed, and when multiplication of ovarian veins is present, embolization of each branch should be performed.
Correct Answer B 71.2% at 5 mm, 83.3% at 6 mm, 81.1% at 7 mm, and 75.8% at 8 mm
Reference
Bałabuszek, K., Toborek, M., & Pietura, R. (2022). Comprehensive overview of the venous disorder
known as pelvic congestion syndrome. Ann Med, 54(1), 22–36. PMID: 34935563
43. RATIONALE
Post-embolization syndrome occurs in 20% of patients characterized by increased pelvic pain,
hyperthermia, and tenderness over the embolized vein. The use of nonsteroidal antiinflammatory
drugs helps in resolution of symptoms. A potentially dangerous complication is coil or vascular plug
migration to central veins and its eventual migration to the pulmonary artery. The endovascular
approach is usually successful in the retrieval of coils or vascular plug if not in a desirable location.
Correct Answer B 20%
Reference
Bałabuszek, K., Toborek, M., & Pietura, R. (2022). Comprehensive overview of the venous disorder
known as pelvic congestion syndrome. Ann Med, 54(1), 22–36. PMID: 34935563
44. RATIONALE
A systemic literature search including 1197 studies (45 trials) showed that compared with the
low molecular weight heparin (LMWH)–vitamin K antagonist combination, a treatment strategy using ultra-fractionated heparin UFH–vitamin K antagonist combination was associated
with an increased risk of recurrent venous thromboembolism (hazard ratio 1.42). The reported
incidences of patients experiencing recurrent thromboembolism during 3 months of treatment
were 1.84% for the UFH–vitamin K antagonist combination and 1.30% for the LMWH–vitamin K
antagonist combination. Apixaban and rivaroxaban were associated with a lower risk of bleeding than the LMWH–vitamin K antagonist combination, with a lower proportion of patients
experiencing a major bleeding event during 3 months of anticoagulation. The conclusion of
this analysis was that there were no statistically significant differences for efficacy and safety
associated with most treatment strategies used to treat acute venous thromboembolism compared with the LMWH–vitamin K antagonist combination. However, findings suggest that the
UFH–vitamin K antagonist combination is the least effective strategy and that rivaroxaban and
apixaban may be associated with the lowest risk for bleeding.
Correct Answer A Oral apixaban
Reference
Castellucci, L. A., Cameron, C., Le Gal, G., et al. (2014). Clinical and safety outcomes associated with
treatment of acute venous thromboembolism: a systematic review and meta-analysis. JAMA,
312(11), 1122–1135. PMID: 25226478
286 Section 13: Venous Disease
45. RATIONALE
Lef t, CT coronal v iew, Right, CT ax ial view of 18. 6 cm × 15.5 cm × 9.9 cm pelvic ma ss causing a n effect on pelvic st ructu res.
Top left, imaging after tPA prior to mechanical thrombectomy. Top right, Imaging after mechanical thrombectomy.
Bottom, thrombus ext racted using Inari device.
Section 13: Venous Disease 287
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Left common iliac vein stent.
Left lower extremity on hospital discharge.
Phlegmasia cerulea dolens is a precursor of venous gangrene and is a limb life-threatening
condition with a mortality of 20%–40%, and in approximately 30% of these, death is caused by
pulmonary embolism. This is slightly more prevalent in men, with a male-to-female ratio of
1.5 to 1. The patients present with pain followed by significant swelling and cyanosis second-
ary to thrombosis in the main axial and collateral veins causing a massive fluid shift into the
interstitium, obstructing arterial f low and causing venous gangrene. The patient described in
this question developed compression of the left common iliac vein from a large uterine fibroid
measuring 18 × 18 cm. The management of this serious condition is by elevation of the extremity, anticoagulation, catheter-directed mechanico-pharmacological thrombolysis, and left
common iliac vein angioplasty/stenting in selected cases. In addition, removal of the cause –
hysterectomy in this patient for a large uterine fibroid – will result in a satisfactory outcome in
most instances.
Correct Answer
C Phlegmasia cerulea dolens
Reference
Ekkel, E., Chandran, T., Trpkovski, M., & Hans, S. (2022). Management of phlegmasia cerulea dolens
caused by a giant leiomyoma. J Vasc Surg Cases Innov Tech, 8(2), 240–243. PMID: 35493345
46. RATIONALE
May–Thurner syndrome results from the compression of the proximal segment of the left common vein by the crossing of the right common iliac artery. Autopsy studies have shown the
prevalence of May–Thurner syndrome is 14%–32% in the general population, and some have
288 Section 13: Venous Disease
suggested that iliac vein compression could be a normal anatomical pattern. The compression
caused by the artery against the lumbar spine results in deposition of the collagen and venous
spur formation with thrombosis, resulting from overlapping risk factors for DVT such as oral
contraceptive use, postpartum status, scoliosis, and thrombophilia. Duplex venous imaging
and CT venography are diagnostic, although duplex venous study can visualize the left common iliac vein in only 47% of instances. May–Thurner syndrome accounts for only 2%–5% of all
patients presenting with DVT. In symptomatic patients, mechanico-pharmacological thrombectomy for associated iliofemoral venous thrombosis followed by venous angioplasty and
stenting is recommended. Anticoagulation should be continued for at least 6–12 months following intervention for May–Thurner syndrome.
Correct Answer B 2%–5% of cases
Reference
Birn, J., & Vedantham, S. (2015). May–Thurner syndrome and other obstructive iliac vein lesions:
meaning, myth, and mystery. Vasc Med, 20(1), 74–83. PMID: 25502563
47. RATIONALE
Vascular malformations, though uncommon (0.8%–1.1% of the general population), are often
associated with significant morbidity. Vascular anomalies can be divided into two groups:
Vascular tumors or vascular malformations. The most common vascular tumor is hemangioma,
which is present at birth, is a proliferative lesion, and usually resolve spontaneously during
childhood. Vascular malformations are also present at birth, with growth rates parallel with
the patient, although they may not become clinically evident until later in life. Vascular malformations have normal endothelial cells and clinically do not regress, but rather continue to
progress over the lifetime of the patient. Vascular malformations can be trivial to life threatening, from focal to extensive. They are classified based on the territory of vascular involvement,
vascular structure (arterial, venous, lymphatic, or combined), and flow dynamics. The crucial
distinction between high-flow and low-flow lesions should be ascertained because prognosis
and treatment are dependent on the flow dynamics of the lesion. The utility of dynamic contrast-enhanced magnetic resonance imaging (DCE MRI) to distinguish between high-flow and
low-flow vascular malformation was successful in 83.8% of patients, minimizing the need for
invasive catheter-based arteriography.
Correct Answer C Dynamic contrast-enhanced MRI
Reference
Lidsky, M. E., Spritzer, C. E., & Shortell, C. K. (2012). The role of dynamic contrast-enhanced magnetic
resonance imaging in the diagnosis and management of patients with vascular malformations.
J Vasc Surg, 56(3), 757–764.e751. PMID: 22840741
48. RATIONALE
A reported 136 vascular malformations in 135 patients were classified as low-flow lesions in 105
and high-flow lesions in 31. Of 105 low-flow vascular malformations (77.2%), 23 (21.9%) were
managed conservatively, 30 (36.2%) were treated with sclerotherapy (sodium tetradecyl sulfate,
polidocanol, doxycycline, and/or ethanol), 19 (17.1%) were surgically resected, and 8 (7.6%)
were managed with a combination of all three modalities. Of the 31 (22.8%) high-flow vascular
malformations, 8 (25.8%) were managed conservatively, 8 (25.8) were treated with transcatheter
Section 13: Venous Disease 289
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
embolization, 6 (19.4%) required embolization followed by sclerotherapy, and 5 (16.1%) underwent primary resection. Patients requiring sclerotherapy underwent a median of three sessions.
Primary resection was performed in 23 (low- and high-flow lesions combined), of which 12
lesions (52.2%) were venous, 5 (21.7%) were lymphatic, and 1 (4.3%) was venolymphatic and 5
had an arterial component. Infection, ulceration, deep venous thrombosis, pulmonary embolism, and minor hemorrhage are reported complications.
Correct Answer D All of the above
Reference
Lidsky, M. E., Spritzer, C. E., & Shortell, C. K. (2012). The role of dynamic contrast-enhanced magnetic
resonance imaging in the diagnosis and management of patients with vascular malformations.
J Vasc Surg, 56(3), 757–764.e751. PMID: 22840741
49. RATIONALE
Left external iliac interposition 10-mm PTFE graft.
The patient underwent emergent bedside duplex venous ultrasound in the recovery room,
which confirmed the absence of flow in the left common femoral and external iliac vein and
minimal flow in the left femoral and popliteal vein. The patient was reexplored using midline
infraumbilical incision extending from the symphysis pubis to 2 cm above the umbilicus. The
left external iliac vein was found to be occluded, and a 10-mm PTFE graft was interposed from
the external iliac vein just above the groin to the common iliac vein bifurcation, with complete
relief of symptoms of swelling and discoloration. The left lower extremity regained its normal
appearance. Follow-up duplex vein imaging 2 years following reconstruction showed a patent interposition graft. Patients with iatrogenic iliac vein injury diagnosed during the index
Соседние файлы в папке Библиотека им академика М.И. Перельмана