B P5 C44 Treatment of Noncoronary Obstructive Vascular Disease Flashcards
_____ is a general term that includes pathologic processes affecting arteries, veins, and lymphatics
Peripheral vascular disease
_____ PAD may be asymptomatic or may manifest as claudication, critical limb ischemia (CLI), or embolic infarction of a distal organ
(e.g., stroke)
Chronic
Asymptomatic disease is common. In the lower extremities, asymptomatic disease occurs in at least half and in as many as 80% of patients with abnormal functional test results indicative of obstructive arterial disease (e.g., abnormal ABI).
Even asymptomatic disease indicates elevated CV risk. These considerations warrant _____ risk factors as a prime goal of therapy to reduce the risk for myocardial infarction (MI) and stroke, the most common causes of death in patients with PAD.
Intensive modification of atherosclerosis
_____ classically refers to leg discomfort, weakness, or pain related to exercise and relieved by rest, but it also describes discomfort in the upper limbs caused by effort-related ischemia.
Claudication
Supervised exercise training consisting of _____ is particularly useful at improving walking, with or without endovascular intervention
1-hour sessions two to three times a week for 12 weeks
_____ strategies aim to improve arterial blood flow in obstructed large- and medium-sized arteries when noninvasive therapies fail.
Revascularization
_____, also referred to as critical limb-threatening ischemia, refers to PAD with ischemic pain at rest or tissue loss (e.g., ulcer or gangrene).
This scenario has clinical urgency because of near- term risk for limb jeopardy requiring major amputation
Critical limb ischemia
_____ amputation in the lower limbs refers to amputation at or above the level of the ankle and requires a prosthesis for the patient to walk.11 Amputation is disfiguring and at higher levels (above versus below knee amputation) has greater impact on functional independence of the patient
Major
_____ amputations (e.g., toe or transmetatarsal) usually have little impact on the patient’s ability to walk. Catheter-based therapies for CLI are used to improve blood flow and heal ischemic tissue, to salvage the limb (prevent major amputation), or to enable a lower level of amputation that might have less impact on the patient’s ability to walk
Minor
The risk for major stroke is high shortly after a symptomatic event but declines to the level of asymptomatic disease after approximately _____ months.
3 months
_____ remains the mainstay of endovascular intervention for PAD and venous disease
Balloon angioplasty
Angioplasty remodels the artery by expansion and accommodates the atherosclerotic plaque to expand the vessel lumen.
This procedure usually causes _____ of the plaque that may or may not impair blood flow.
Dissection
Angioplasty is limited in the short term by acute recoil of the artery and flow-limiting dissections, which may cause abrupt closure of the artery.
Angioplasty is limited in the short term by acute recoil of the artery and flow-limiting dissections, which may cause abrupt closure of the artery. In the intermediate time frame, _____ may lead to symptomatic restenosis
Overexuberant neointimal hyperplasia and negative remodeling of the artery
Most operators use prolonged inflations (at least ____ minute or more)
1 min or more
Bare-metal stents (BMSs) come in two types:
Balloon-expandable stents
Self-expanding stents
______ stents have greater radial strength and are less likely to move on deployment, which is important for ostial placement.
Balloon-expandable stents
Such stents can be crushed by external compression and are therefore avoided outside the torso.
They are sometimes used to treat tibial dis- ease, but only for CLI, for which long-term patency may be less of an issue once tissue healing has occurred.
_____ stents were originally made of stainless steel but are now usually made of nitinol. Nitinol stents reexpand on compression and are therefore used outside the torso, where external compression is more likely to occur.
Self-expanding stents
They may also be used in tortuous arteries, where they probably conform better than balloon-expandable stents. Their lower radial strength, however, increases the risk for recoil. Con- temporary self-expanding stent designs are more durable and less likely to fracture than older designs.
______ stents using a polymer or polymer-free coating of paclitaxel offer lower rates of restenosis than bare-metal self-expanding stents.
Drug coated self-expanding stents
In the _____ study, a polymer-coated paclitaxel stent had similar 12 months of efficacy and safety outcomes to a polymer-free paclitaxel stent, and a single-arm cohort study suggested no “catch-up” target vessel revascularization over 3 years with this device.
IMPERIAL
The duration of DAPT required for these stents (Drug coated self-expanding stents) is uncertain, but recent randomized trials have generally used _____ months of treatment with an adenosine receptor antagonist.
2-6 months
Compared with plain balloon angioplasty, drug- coated balloons have less _____ and repeat in the femoral- popliteal arteries, and similar patency to drug-coated self-expanding stents
Less restenosis and repeat revascularization
Drug-coated balloons also offer a lower risk of restenosis at 1 year compared with plain balloon angioplasty for treating in- stent restenosis lesions
The duration of DAPT with drug-coated balloons in the femoral-popliteal arteries is uncertain but varies between _____ months in most randomized trials.
1-6 months
However, in 2018 a group-level meta-analysis of randomized trials suggested that patients treated with paclitaxel drug-coated balloons or stents for femoral-popliteal disease had _____ rates of mortality 2 to 5 years after their procedure compared with non-paclitaxel balloons and stents
Higher
_____ is a key determinant of restenosis, and a meta-analysis suggests that long lesions have less restenosis and need for target revascularization with paclitaxel drug-coated balloons and stents
Lesion length
_____ are very useful for treating perforations related to endovascular treatment or excluding aneurysms
Stents covered with or sandwiching a polymer such as polytetrafluooethylene (PTFE)
Potential disadvantages of covered stents include _____.
(1) Unintentional occlusion of important branch vessels
(2) Concerns about the risk for late stent thrombosis
(3) Whether restenosis was merely delayed rather than prevented
_____ is an important adjunctive therapy for arterial thrombosis, stent thrombosis, and occlusive thrombotic venous disease.
Catheter-directed thrombolysis
Catheter-directed thrombolysis is more effective than intravenous thrombolysis only if an infusion catheter (with multiple infusion holes) is inserted into the thrombosed vessel.
It is also less effective if given more than _____ days after thrombosis.
Typically, the infusion continues for 12 to 24 hours, because treatment over 48 hours is associated with depletion of circulating fibrinogen and a higher risk for major bleeding
> 14 days: Less effective
Catheter-based thrombolysis with or without angioplasty or stenting also reduces the incidence of _____ in patients with proximal (iliac) deep venous thrombosis (DVT), and it is used as adjunctive therapy for massive pulmonary emboli
Post-thrombotic syndrome
Any thrombolysis regimen increases risk for fatal or major bleeding. Absolute contraindications to thrombolysis include:
(1) a cerebrovascular event less than 2 months previously
(2) active bleeding
(3) gastrointestinal bleeding less than 10 days previously
(4) neurosurgery (intracranial or spinal surgery) or trauma less than 3 months previously.
Relative contraindications include:
(1) cardiopulmonary resuscitation less than 10 days previously
(2) nonvascular surgery or trauma less than 10 days previously
(3) uncontrolled hyper- tension (sustained systolic blood pressure [BP] >180 mm Hg or dia- stolic BP >110 mm Hg)
(4) puncture of a noncompressible vessel
(5) intracranial tumor
(6) recent eye surgery
The _____ flow retriever system (Inari Medical, Irvine, CA) uses a much larger catheter (up to 24F) and is designed mainly for venous thromboembolism, but case reports show large thrombi extracted with this system.
Inari flow retriever system
The _____ aspiration system uses a mechanical aspirator and a range of 3 to 8F catheters to gen- erate a greater suction than manual aspiration catheters
Penumbra Indigo (Penumbra, Almeda, CA)
The _____ is primarily a rotational atherectomy device but also aspirates debris and is used for atherectomy and aspiration of a thrombus. M
Jetstream (Boston Scientific, Marlborough, MA)
_____ thrombectomy is a more rapid treatment than catheter-directed thrombolysis; embolization can occlude the distal arterial bed and lead to infarction and tissue loss, although combination with an embolic protection device might theoretically reduce this risk.
Mechanical
The _____ is generally too small for the larger peripheral arteries, and it is uncertain how a large amount of plaque ablated from a long peripheral lesion would affect the downstream microcirculation. However, for the smaller popliteal artery rotational atherectomy may allow balloon dilation without stenting
Rotablator (Boston Scientific, Marlborough, MA)
The _____ (Cardiovascular Systems, Inc., St. Paul, MN) is an orbital atherectomy device.
Diamondback360
Directional atherectomy devices include the _____ device
SilverHawk
_____ atherectomy uses high-energy monochromatic ultraviolet light to vaporize tissue in contact with the catheter tip and debulk de novo and restenotic lesions in peripheral arteries.
Excimer laser atherectomy
_____ involves the use of proprietary balloon and inflation technology to inflate the balloon with nitrous oxide, which chills on expansion to −10°C.
Cryoplasty
Network meta-analyses comparing multiple different therapies suggest cryoplasty is inferior to other technologies with a higher rate of restenosis
_____ (Shockwave Medical, Santa Clara, CA) uses a balloon with up to five pressure-emitting nodes along the balloon shaft to generate waves of pressure into the artery wall during a low-pressure balloon inflation
Intravascular lithotripsy
_____ is a proven treatment for walking function in patients with claudication. Supervised exercise training after endovascular interventions may also improve maximum walking distance over endovascular interventions alone and should be considered as an adjunctive therapy.
Supervised exercise training
_____ is a phosphodiesterase inhibitor that improves walking function in some patients with intermittent claudication
Cilostazol
Small meta-analyses suggest cilostazol used after endovascular therapy may improve walking function and decrease the risk for restenosis, repeat revascularization, and major amputation.
In the ______ trial, antithrombotic therapy with low- dose rivaroxaban 2.5 mg twice a day with aspirin decreased the risk of a combined endpoint of vascular, cardiac, and cerebrovascular ischemic events with an increase in major bleeding.54 This regimen may be considered in patients with a favorable balance of bleeding and ischemic risk
VOYAGER
_____ is the first stage of planning an endovascular intervention
Vascular imaging
_____ angiography images remove bone and soft tissue from the image while leaving the contrast-enhanced image of the artery for more clarity, provided that the limb remains still during acquisition
Digital subtraction
_____ using iodinated contrast material provides more rapid imaging, but heavy calcification can mask stenoses and make interpretation of lesion severity more difficult. Iodinated contrast agents can cause adverse reactions or impair renal function.
Computed tomographic angiography (CTA)
_____ uses gadolinium or other contrast agents or time-of-flight techniques.
Time of flight relies on laminar blood flow to image arteries and has the advantage of not requiring contrast material, which can rarely cause serious adverse effects in patients with renal insufficiency (e.g., nephrogenic scleros- ing fibrosis)
Magnetic resonance imaging (MRI)
MRI cannot be used in patients who have retained ferric metals (e.g., some pacemakers, shrapnel). Most contemporary stents are compatible with MRI but leave a flow void that does not allow interpretation of obstructive disease. _____ offers advantages for assessing stent patency.
High-resolution contrast-enhanced CT scans
Typical symptoms of PAD with a normal resting ABI should raise suspicion for iliac or aortic disease, in which case an _____ is generally abnormal
Exercise ABI
Aortoiliac disease is approached from the _____.
Ipsilateral femoral artery
Contralateral femoral artery
Radial artery
Brachial artery.
In aortoiliac disease, many operators will often use a second arterial access (e.g., contralateral femoral) to provide quick access to the aorta or proximal iliac artery for temporary balloon occlusion in the event of _____.
Perforation and rapid hemorrhage
_____stents are useful for treating aneurysms and potentially life-saving for treating vessel rupture or perforation
Covered stents
Occlusions involving the _____ aorta often undergo surgical treatment, although percutaneous transluminal angioplasty and stenting offer an option to patients with prohibitive surgical risk.
Distal
Obstructive atherosclerosis is more common in the SFA than the popliteal artery or the CFA. Usually, the _____ serves as an important source of collateral blood flow to the leg in patients with obstructive SFA disease
Profunda femoris
Even though balloon angioplasty can successfully treat obstructive CFA disease secondary to atherosclerosis or complications of CFA access for other procedures, surgical repair with patch angioplasty is the standard of care for most patients with acceptable surgical risk.
_____ should not be used in this location because of repetitive compression during movement of the hip.
Balloon-expandable stents
In patients with a prohibitive surgical risk, _____ is used for CFA lesions, along with bail-out self-expanding stents for flow-limiting dissections.
Balloon angioplasty with or without atherectomy
Most percutaneous femoral interventions involve the SFA and popliteal artery, and interventional techniques are similar with both arteries.
The _____ and particularly the ____ are subject to torsion, stretch, and kinking with movement of the leg
Distal SFA
Popliteal artery
For this reason, stents are generally avoided below the level of the top of the patella and above the tibial metaphyseal plate when viewed with the leg straight.
Stenting between this region subjects stents to extreme flexion, compression, and torsion and is associated with stent fracture, restenosis, and poor long-term durability, although specific helical mesh stents may be more durable than other self-expanding stents in this location
Acute procedural success rates with catheter-based interventions in femoro-popliteal disease now approach _____%, in part because of a wide variety of wires, crossing catheters, reentry catheters, and combined antegrade and retrograde approaches for difficult total occlusions
90%
Restenosis rates are higher than in the _____ artery and may require repeated intervention
Iliac
Balloon angioplasty in femoro-popliteal disease alone has durability similar to that of primary stenting for short lesions (<50 to 100 mm in length), and in this setting, provisional stenting for _____ is an acceptable strategy
Abrupt closure,
Fow-limiting dissection
Poor expansion (residual stenosis >50%)
For longer femoral-popliteal lesions (>100 mm), _____ stents offer better durability and walking function than balloon angioplasty with provisional stenting
Primary stenting with self-expanding nitinol stents
The popliteal artery divides into three tibial arteries:
(1) Anterior tibial, which becomes the dorsalis pedis in the foot
(2) Posterior tibial, which forms the pedal arcade with the anterior tibial artery
(3) Peroneal artery, which usually ends just above the ankle but can be an important collateral to the foot.
In general, claudication is rare with loss of even two of the three tibial arteries
Treating severe tibial disease in patients with CLI can promote _____.
Wound healing
Resolve pain at rest
Prevent major amputation
A _____ access site for tibial disease may become a nonhealing ulcer if the intervention is unsuccessful
Pedal
_____ revascularization refers to revascularization of a tibial artery that supplies the area of a nonhealing ulcer or gangrene
Angiosome-directed
The value of angiosome-directed revascularization versus restoring any straight flow to the foot is debated. In observa- tional studies, wound healing was better and amputation lower with angiosome-directed rather than indirect (nonangiosome) tibial revascularization.
Tibial disease is most often treated by _____ balloon inflation, but stents are used as bail-out treatment of flow-limiting dissection
Prolonged
Managing CLI with ulceration or gangrene requires close follow-up to _____ in ulcerated areas and aid healing.
Débride dead tissue
Gangrenous toes can be left dry until they mummify and autoamputate or can be surgically amputated once viable and devitalized tissue are clearly demarcated.
Infected gangrene does require surgical amputation to avoid _____.
Osteomyelitis
_____ are the most important factor related to the risk for disabling stroke and the indication for revascularization.
Symptoms
“Symptomatic disease” refers to patients with a minor stroke or TIA.
n the carotid circulation, symptoms are typically dysphasia, contralateral hemipa- resis or hemiparesthesia, or ipsilateral transient monocular blindness (_____)
Amaurosis fugax
Symptoms lasting less than ___ hours and without infarction noted on imaging are classified as TIAs.
24 hours
Minor strokes are classified as “mild clinical deficits” or “no clinical residual deficits” with evidence of _____ on imaging
Infarction
In older trials of endarterectomy versus medical therapy, patients with recent symptoms and a stenosis of ____% had higher risk of stroke and a greater benefit from endarterectomy within the first week after symptoms.
50% to 99%
The risk of stroke declines rapidly after this time, with a smaller net benefit from revascularization especially more than 3 months after symptoms.
Compared with carotid endarterectomy, _____ in symptomatic patients is associated with a higher risk of death or stroke over the following 30 days in patients over 70 years of age, but patients younger than 70 years of age had similar outcomes, and the risk of MI and cranial nerve injury was lower with stenting in all age groups.
Carotid stenting
Carotid stenting for patients with a 50% to 99% stenosis and recent TIA or minor stroke symptoms may be considered in patients with _____.
Good anatomy for stenting
With high risk of MI or poor surgical outcomes with endarterectomy
In asymptomatic patients, the severity of stenosis determines risk, with stenoses greater than ____% increasing the risk of stroke.The reduction in risk with revascularization accrues slowly over the long term and needs to offset the small but important periprocedural/operative risk.
> 80%
Factors Associated with Increased Risk for Complications with Carotid Artery Stent Placement
Tortuous aortic arch
Platelet or clotting disorder Difficult vascular access
Lesion or heavy vessel calcification Visible thrombus
Advanced age (>75-80 years)*
- The risk for a cerebrovascular accident (stroke) with carotid artery stent placement is increased, and the risk for myocardial infarction with carotid endarterectomy is increased.
Factors Associated with Increased Risk from Carotid Artery Surgery
ANATOMIC CRITERIA
High cervical or intrathoracic lesion
Previous neck surgery or radiation therapy
Contralateral carotid artery occlusion
Previous ipsilateral carotid endarterectomy
Contralateral laryngeal nerve palsy Tracheostomy
MEDICAL COMORBIDITIES
Age >80years*
Class III or IV congestive heart failure
Class III or IV angina pectoris
Left main coronary disease
Two- or three-vessel coronary artery disease Need for open heart surgery
Ejection fraction 30%
Recent myocardial infarction
Severe chronic obstructive lung disease
For asymptomatic patients with carotid disease, indications for carotid stenting include _____% stenosis in those with a periprocedural risk for stroke or death of less than 3%
80% to 99%
Carotid stenting starts with access to the common carotid artery with a diagnostic catheter and then a delivery sheath.
Embolic protection consists of distal protection using _____ deployed distal to the carotid stenosis or proximal occlusion devices deployed proximal to the stenosis.
Filters allow blood flow to the brain to continue and theoretically lead to less brain ischemia if the circle of Willis is incomplete.
Filters or obstructive balloons
Diagnosis of vertebrobasilar insufficiency is clinical with symptoms affecting the brainstem and cerebellum, including _____.
Dizziness
Ataxia
Diplopia
Syncope
Atherosclerosis usually affects the _____ vertebral arteries, but more extensive proximal disease in the subclavian or brachiocephalic arteries can cause vertebrobasilar insufficiency
Proximal
Medical treatment of vertebral artery disease includes _____.
Antiplatelet agents and statins
BP control to reduce ischemic stroke requires careful titration to avoid hypotension and hypoperfusion, which can precipitate symptoms.
Surgical therapy consisting of vertebral and subclavian disease - ______ entails considerable morbidity, including Horner syndrome, lymphocele, and thrombosis.
Transection and reimplantation into an adjacent subclavian artery
_____ percutaneous treatment, particularly with stenting, has much lower morbidity and short-term mortality.
Extracranial
Two randomized trials of intracranial or extracranial vertebral artery stenting for symptomatic vertebral artery disease showed no significant reduction in stroke compared with medical therapy; however, both trials were stopped early.
Subclavian stenosis more often affects the _____ subclavian origin than the brachiocephalic or right subclavian arteries
Left
This predilection may result from more disturbed blood flow at the origin of the left subclavian artery
Subclavian stenosis usually causes a _____ mm Hg or greater difference in noninvasive brachial BP between the two arms, in the absence of significant bilateral disease
> 15 mm Hg
Symptoms from subclavian stenosis include:
(1) Arm claudication with activity
(2) Angina in patients with a left internal mammary/thoracic artery graft from previous coronary artery bypass surgery
(3) VBI with arm activity because of vertebral steal
(4) Ischemic (hand) steal syndrome in patients with a dialysis fistula
Because most subclavian disease is proximal or ostial, surgical revascularization usually involves _____ bypass.
Subclavian-to-common carotid
More commonly, symptomatic subclavian artery disease is treated with the less morbid procedure of subclavian artery _____. Both treatments have low periprocedural risks of stroke (1% to 2%)
_____ stents are generally used because they allow more precise placement to cover the ostium of the artery and avoid the vertebral and left internal mammary artery origins.
Stenting
Balloon-expandable
Embolic stroke is rare in the treatment of subclavian/vertebral artery disease ,possibly because of _____ flow down the vertebral artery during balloon dilation and stenting.
Reverse flow
Thus, embolic protection is infrequently used for vertebral and subclavian artery stenting.
The long-term results of stenting subclavian and brachiocephalic disease are excellent (>80% overall patency).
Three arteries supply the mesenteric viscera:
Celiac
Superior mesenteric
Inferior mesenteric.
Although advanced atherosclerosis of the aorta is common, mesenteric angina or infarction is very uncommon, probably because of the multiple collateral networks in the mesentery.
Acute mesenteric ischemia with infarction is a surgical emergency because it is usually associated with infarction of the _____.
Small and large intestine
An embolus (e.g., from thrombus in the heart associated with atrial fibrillation) is a common cause and typically lodges in the _____ mesenteric artery (usually the superior mesenteric artery)
Proximal
Although some cases can be treated by endovascular techniques, ____ indicate bowel necrosis and need for open surgery
(1) Clinical signs of peritonitis or CT findings of pneumatosis
(2) Free intra-abdominal air
(3) Portal venous gas
Chronic mesenteric ischemia is a more insidious syndrome that causes abdominal discomfort or pain _____ minutes after eating, early satiety, and substantial weight loss because of food fear or avoidance.
30-60 mins
Classically, more than two mesenteric arteries are stenosed or occluded. The disease is usually adjacent and involves advanced atherosclerosis of the aorta and origins of the mesenteric arteries. Asymptomatic disease of the mesenteric arteries does not require revascularization.
_____ revascularization with reimplantation of the arteries (in mesenteric artery disease) has high mortality and morbidity (10% to 15%) because of the advanced age and other vascular comorbid conditions.
Surgical
____ in mesenteric artery disease has lower mortality (<5%) and morbidity and achieves good resolution of symptoms in about 70% to 80% of patients over several years.
Percutaneous angioplasty with stenting
Restenosis may require further intervention and can be identified by duplex ultrasound and CTA.
Renal artery stenosis can cause secondary hypertension or rapidly deteriorating renal function.
Clinical clues to the diagnosis of renal artery stenosis include _____.
(1) Onset of hypertension before 55 years of age
(2) Resistant or malignant hypertension (particularly in a previously well-controlled patient)
(3) Rapidly increasing creatinine level over a several-month period or earlier
(4) Sudden pulmonary edema without a clear cardiac cause (e.g., because of sudden hypertension with or without acute mitral regurgitation)
In the _____ study, even the subgroup of participants with a renal artery stenosis of at least 80% did not benefit from renal artery stenting.
As a result, the enthusiasm for renal artery stenting has waned considerably, although there is still some support for stenting renal artery steno- sis in the presence of “flash” pulmonary edema without cardiac causes, rapidly decreasing renal function, and some cases of accelerating or resistant hypertension, based mainly on case reports and case series
CORAL
_____ is a rarer cause of renal artery stenosis and hypertension more often seen in younger patients, with a higher prevalence in women. Although defined histologically in the past, this is now superseded by a classification based on imaging (multifocal “beading” versus focal disease)
Fibromuscular dysplasia (FMD
FMD typically involves the _____ renal artery, whereas atherosclerosis usually involves the ostium or proximal renal artery.
Middle or distal
Lower extremity DVT is treated primarily medically with anticoagulation, but _____ treatment is an option for patients with proximal venous thrombosis defined as being at the level of the common femoral vein or higher
Endovascular
Recognition that the rich plexus of sympathetic nerves in the adventitia of renal arteries may contribute to resistant hypertension led to a number of catheter-based technologies to ablate the sympathetic nerves to lower BP and CV risk
Several randomized sham-controlled trials show on average a modest effect on systolic BP after catheter-based renal sympathetic denervation.
In early studies, this procedure decreased systolic BP by an average _____ mm Hg, with second-generation devices lowering systolic BP by an average of _____ mm Hg
Earlier: 2 mm Hg
2nd Gen: 6 mm Hg
Proximal DVT occurs more frequently in the _____ leg as a result of compression of the left iliac vein by the overlying right iliac artery
Left leg
“May-Thurner syndrome”
Acute severe proximal deep venous occlusion, characterized by a blue limb, pain, and limb ischemia (_____) is often associated with malignancy.
Phlegmasia cerulea dolens
_____ syndrome occurs over several years in about half the patients with iliofemoral DVT and involves limb swelling, heaviness, and pain.
Chronic post-thrombotic
Medical treatmen of DVT includes compression stockings and anticoagulation.
Endovascular treatment of proximal DVT by catheter-directed thrombolysis with or without balloon angioplasty and self-expanding stents reduces the incidence of post-thrombotic syndrome by about _____%
30%
Upper extremity DVT is related to _____.
- Effort-related proximal vein thrombosis in athletes (Paget-Schroetter syndrome)
- Venous thoracic outlet syndrome
- Catheter-related thrombosis
- Malignancy
_____ syndrome is related to compression of the subclavian vein as it exits the thoracic cage between the clavicle, first rib, costoclavicular ligament, and subclavian and anterior scalene muscles.
Venous thoracic outlet
______ is the most common treatment of upper extremity DVT, but endovascular therapy can provide relief from post-thrombotic syndrome.
Anticoagulation
Endovascular therapy includes catheter-directed thrombolysis and treatment of any precipitating cause.
For example, thoracic outlet syndrome generally requires_____ soon after thrombolysis because stents usually crush or fracture in this location
Surgical decompression (resection of the first rib or other structures) and venoplasty
_____ syndrome results from obstruction of the superior vena cava with impairment of venous return from the head and upper limbs
Superior vena cava syndromer
Typical causes of SVCS include _____.
(1) External compression
(2) Invasion from a tumor
(3) Thrombosis related to an indwelling central catheter (e.g., for chemotherapy) or leads from pacemakers or defibrillators
In SVCS, thrombosis often accompanies stenosis and requires _____ therapy before balloon and stent therapy.
The stent should be oversized and extended well above and partly below the lesion so that it has an _____ shape to help keep it anchored and less likely to embolize
Catheter-directed thrombolytic
Hourglass shaped
Anticoagulation is generally prescribed in SVCs, often indefinitely for superior vena cava obstruction or thrombosis associated with malignancy.
Symptoms usually respond rapidly within _____ hours.
24 hours
Long-term out- comes depend more on the cause of the superior vena cava obstruction, but in nonmalignant cases, resolution of symptoms occurs in more than _____% of cases.
70%
