A 25-year-old man presents to the clinic with complaints of pain in his feet with walking. He reports this has been going on for several months and has progressively worsened in the past few weeks. He is beginning to develop symptoms in his right calf and earlier this week noticed a black area on his great toe. He has no medical problems, takes no medications, and is in good health overall. He is a smoker and works as a computer salesman. He reports a family history of VTE; his mother had a pulmonary embolism at the age of 50 and was diagnosed with the antiphospholipid antibody syndrome.
What is the most important aspect of therapy for this patient?
Cessation of exposure to all forms of tobacco. The strong link between tobacco abuse and TAO is well recognized. There have been suggestions that some patients may demonstrate an abnormal sensitivity to a component of tobacco, which leads to small vessel occlusive disease. It has been shown that patients with TAO have higher tobacco consumption as well as higher carboxyhemoglobin levels than do patients with atherosclerosis.
Reference:
Creager MA, Dzau VJ, Loscalzo J, eds. Vascular Medicine: A Companion to Brunwald’s Heart Disease. Philadelphia, PA: Saunders; 2006:641–654.
A 24-year-old woman presents with complaints of a swollen, painful left leg. She has a history of two episodes of deep vein thrombosis in the past. She recalls that they were both on the left side, but is unsure of which veins were involved. She was on warfarin in the past but discontinued it when she began attempting to conceive. Venous duplex demonstrates an acute deep vein thrombosis of the left femoral vein. You initiate treatment with LMWH.
What is the most likely diagnosis?
May-Thurner syndrome. Also known as iliac vein compression syndrome, Cockett syndrome, or iliocaval compression syndrome, May-Thurner syndrome is caused by compression of the left common iliac vein by the right common iliac artery and the underlying vertebral body. A history of chronic left lower extremity edema with or without the presence of DVT is suggestive of May-Thurner syndrome, especially in a female population. This phenomenon causes a partial obstruction caused by physical entrapment of the vein under the artery as well as by repetitive pulsatile force resulting in intimal hyperplasia of the vein. It has been estimated that this condition occurs in 2% to 5% of patients who are evaluated for lower extremity venous problems.
Cil BE, Akpinar E, Karcaaltincaba M, et al. Case 76: May-Thurner syndrome. Radiology. 2004;233:361–365.
Which of the following is the best management option?
Venography for thrombus removal and stent placement. May-Thurner syndrome is an anatomical anomaly that results in repeated venous trauma and often subsequent thrombus formation. Removal of thrombus followed by angioplasty, if needed, and placement of a stent is a potentially definitive treatment that could avoid the need for indefinite anticoagulant therapy in the young woman presented in this case.
A 68-year-old gentleman underwent coronary artery bypass surgery using the saphenous vein harvested from his left leg. He has done well postoperatively except for failure of the left leg incision to heal completely. Four months after surgery, his leg is still not fully healed and a peri-incisional ulcer is now present. He has significant edema in his leg, which was present prior to surgery. There are no symptoms or physical findings suggestive of infection. His ABI is 0.94 on the right and 0.89 on the left. You order an ultrasound, which is negative for acute thrombus but does reveal significant venous valvular incompetence in the deep veins.
Which of the following is most likely to improve this patient’s wound healing?
Compression stockings. The importance of edema control is often underestimated for wound healing. This patient has deep system venous reflux. He has no signs of infection complicating the healing of his incision, so antibiotics are unlikely to be helpful. Topical steroids offer no benefit in this case. His ABIs suggest adequate arterial inflow for wound healing. Whirlpool therapy is helpful in select cases, most often when multiple small wounds are present, which need cleansing and gentle debridement. Although the size of the wound is not clearly stated, these wounds are most often small and referral for skin grafting is not indicated.
Takahaski PY, Kiemele LJ, Jones JP. Wound care for elderly patients: advances and clinical applications for practicing physicians. Mayo Clin Proc. 2004;79:260–267.
You are providing postoperative care for a patient who is in the cardiovascular surgery postoperative ICU, status post coronary artery bypass surgery. A venous duplex ultrasound was performed to evaluate for newonset bilateral leg swelling. Results are reported as negative for DVT, but with monophasic flow noted within the bilateral common femoral veins.
Which of the following is the next best step?
CT venogram of the abdomen and pelvis. Monophasic (loss of respiratory phasicity) flow is suggestive of proximal venous obstruction, especially in a patient with swollen limbs and under high-risk circumstances for VTE. Monophasicity is not specific to thrombosis. Other potential causes include obesity, pregnancy, and a pelvic mass. Respiratory or cardiac dysfunction may also produce an abnormal venous flow pattern.
Reference: Dewald CL, Jensen CC, Park YH, et al. Vena cavography with CO2 versus iodinated contrast material for IVC filter placement: a prospective evaluation. Radiology. 2000;216:752–756.
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