[Causes of need for reoperation following surgery for varicose veins in Denmark]

In a surgical varicose vein practice 509 patients who had suffered recurrent varicose veins following surgery in other institutions were traced. The causes of recurrences were identified in a retrospective analysis and related to the source of primary treatment: in hospital treatment (n = 290), surgical practice (n = 56) or another varicose vein specialist (n = 104). A significant difference was noted between the three institutions in the use of saphenofemoral resection (78%, 63% and 97%) as well as greater saphenous vein stripping (44%, 14% and 0%). Lack of or insufficiently performed saphenofemoral surgery were identified as contributing to saphenofemoral insufficiency in 40% and 43% of patients primarily treated in hospital and in surgical practice, respectively, but only in 14% of those treated by a varicose vein specialist (p < 0.001). Primary sapheno-popliteal resection had been used equally infrequently (11%, 13% and 16%, respectively) and was equally frequently insufficiently performed (66%, 57% and 41%). This retrospective investigation concludes that insufficient varicose vein surgery is a major contributor to recurrences, particularly when primary surgery is performed in hospital or in surgical practice, as opposed to in a varicose vein practice. These results warrant a reorganisation of varicose vein surgery in Denmark.

[125 reinterventions for recurrent popliteal varicose veins after excision of the short saphenous vein. Anatomical and physiological hypotheses of the mechanism of recurrence]

Recurrence of popliteal varicose veins has long been attributed to insufficient excision of an incompetent short saphenous vein. Indeed, recurrence is still frequent after surgery of the short saphenous. In order to assess the risk of insufficient excision and study the mechanism of recurrence, we reviewed 125 popliteal procedures for recurrence after excision of an incompetent short saphenous vein. Among this series, 48 were personal procedures and among these, 43 had been performed without preoperative ultrasound explorations prior to 1991. Recurrences were classified into five categories (table I) according to the anatomic presentation at reoperation. Type 1) 17 patients had an intact short saphenous (13.6%) with either an inadequate incision or a simple recanalized suture. Type 2) 53 patients had a long stump (42.4%) with new superficial varicose communications. Type 3) 4 patients had a small residual and incompetent short saphenous trunk (3.2%), 20 patients had both a long stump and an incompetent residual trunk (16%). Type 4) 29 patients had incompetent popliteal perforating veins (23.2%). Type 5) 2 patients developed recurrence on a new varicose communication which followed the posterior nerves of the thigh. Among our personal series, 43 reoperations for recurrence were performed without preoperative duplex Doppler exploration. Among them, excision was insufficient in 38 (table II). The 5 patients reoperated after preoperative ultrasound exploration had a popliteal perforating vein. Recurrence with a popliteal perforator was significantly more frequent in men than in women (table III). The delay to reoperation for popliteal recurrence after surgery of the short saphenous (50% at 6 years) was significantly shorter than the delay to reoperation for inguinal recurrence after surgery of the greater saphenous (50% at 12 years) (table V). Insufficient excision was observed in 75.2% of the cases, but 23.2% of the recurrences were due to the development of an incompetent popliteal perforating veins. These perforating veins were residual stumps of the short saphenous with complex pathways, unrecognized perforating veins associated with the short saphenous at the first operation, or a new popliteal incompetence. Ces perforantes de la fosse poplitée pourraient être des moignons résiduels de petites saphènes à trajet complexe, des perforantes méconnues associées à la petite saphène developing in several perforating vessels described in the popliteal fossa. The lack of preoperative ultrasound data made it difficult to interpret these recurrences. The development of perforating veins in the popliteal fossa is a type of recurrence which is probably the expression of particular hemodynamic phenomena in the popliteal venous circulation. These phenomena probably involve the flexion of the popliteal vein, the contraction of the calf muscles, and also popliteal valvular incompetence frequently demonstrated in patients who develop short saphenous vein insufficiency.

Surgical intervention in venous ulceration

The purpose of this article is to review surgical management for dermal ulceration that results from chronic venous insufficiency. Efficacy is gauged by freedom from recurrent ulceration, an objective clinical monitor. Accurate preoperative diagnosis and postoperative assessment of the venous circulation is enhanced by reliable non-invasive examinations. A recently developed clinical classification unifies reporting criteria and has been widely subscribed. Standard surgical ablation of incompetent saphenous and other superficial veins significantly improves clinical and hemodynamic outcome. Perforator incompetence alone is rarely the cause of ulcerative disease, but adjunctive ligation of communicating veins is considered important to the effective elimination of chronic venous insufficiency. New endoscopic techniques reduce morbidity associated with long incisions from the open subfascial procedure. In a more advanced role, deep venous reconstruction is infrequently performed, but is quite durable. Free-tissue transfer appears to be effective after 2 years of observation. Post-thrombotic chronic venous insufficiency continues to confer a more severe prognosis, which emphasizes the importance of accurate and precise diagnosis. Investigation of patients with ulcerative chronic venous insufficiency should be actively pursued, since individualized surgical management will effectively reduce recurrence of ulceration.

Increased hindlimb leukocyte concentration in a chronic rodent model of venous hypertension

BACKGROUND

The pathophysiologic mechanism for tissue damage in chronic venous insufficiency (CVI) is venous hypertension (VH), the primary mediator behind leukocyte trapping in tissues. We developed a new rodent model of chronic hindlimb VH to allow testing of the microvascular dysfunction that occurs in clinical CVI.

MATERIALS AND METHODS

Hindlimb VH was created in adult rats ( approximately 350 g, male, Wistar) by ligation of the inferior vena cava, bilateral common iliac veins, and bilateral common femoral veins. In a sham group, a loose tie was placed around the same vessels. One week later, pressure catheters were placed in the right common carotid artery, right internal jugular vein (forelimb), and right superficial epigastric vein (hindlimb). Measurements were taken 15 min later, to allow for stabilization. Bilateral forelimb and hindlimb skin specimens were harvested. The myeloperoxidase (MPO) assay, an indicator of tissue leukocyte trapping, was performed using a well-described, standard technique.

RESULTS

In the chronic rats (n = 8), the hindlimb pressures (12.6 +/- 3.2 mm Hg) were significantly elevated (P < 0.05) when compared to forelimb pressures (1.75 +/- 0.71) and to chronic sham rat (n = 6) hindlimb (3.3 +/- 1.2) pressures. There was a significant (P < 0.05) elevation of MPO activity in hindlimbs of the chronic group (32.9 +/- 13.9 units) when compared to forelimbs (17 +/- 11.3) and sham hindlimbs (18 +/- 10.2).

CONCLUSIONS

In our chronic model, as in clinical studies and previous acute investigations, we have demonstrated, using an MPO assay, an increase in the amount of cutaneous leukocytes in the hindlimbs with chronic VH but not in experimental forelimbs or sham hindlimbs or forelimbs.

Alveolar echinococcosis of the liver: sequelae of chronic inferior vena cava obstructions in the hepatic segment

BACKGROUND

The clinical pattern and long-term course of chronic inferior vena cava (IVC) obstructions are variable and depend on the underlying cause, the segment involved, and the extension of secondary thrombosis. Pertinent data on IVC obstructions in well-defined series of patients are lacking. We report the sequelae of chronic IVC obstructions in the hepatic segment in 11 consecutive patients derived from a cohort of 104 patients with alveolar echinococcosis of the liver.

METHODS

Based on the results of computed tomography scans, 11 patients (7 men, 4 women; mean age, 53.4 years) with IVC obstructions were selected from an ongoing prospective long-term chemotherapy trial comprising 104 patients with alveolar echinococcosis studied at yearly intervals according to a protocol. Obstruction of the IVC in the 11 patients existed for a mean duration of 8.6 years. In these patients, magnetic resonance imaging was performed to assess the morphologic features and extension of the IVC obstruction, as well as the collateral venous pathways. Patency and valvular function of the femoropopliteal veins were analyzed by color-coded duplex ultrasonography.

RESULTS

Total occlusions of the IVC were evident in 8 patients (73%) and subtotal stenoses in 3 patients (27%). Only 4 patients (36%) exhibited signs and symptoms of chronic venous insufficiency of the lower extremities; 2 (18%) of the 4 had a history of swelling in the lower extremity. Seven patients (64%) had no lower extremity symptoms. One patient had a history of pulmonary embolism. Abdominal collateral veins were documented in 5 patients (45%) by using magnetic resonance imaging; however, they were clinically evident in only 3 patients (27%). In the 8 patients with IVC occlusion, thrombosis ended at the confluence of the hepatic veins. Obstruction of the IVC was limited to the hepatic segment in 2 patients (18%) and extended to the distal IVC or the iliofemoral veins in 6 patients (54%). Chronic venous insufficiency was present only if the femoropopliteal veins had been involved in the thrombotic process, showing residual venous obstruction, valvular incompetence, or both. Bilateral renal vein thrombosis with moderate proteinuria was observed in 2 patients (18%). The main collateral drainage was achieved through the ascending lumbar, azygos, and hemiazygos veins.

CONCLUSIONS

In patients with alveolar echinococcosis, obstruction of the IVC in the hepatic segment often develops asymptomatically and rarely leads to the impairment of renal function. The collateral circulation fully compensates for obstruction of the IVC. Thrombotic involvement and valvular incompetence of the femoropopliteal veins seems to determine the development of chronic venous insufficiency of the lower extremities.

The relevance of large-vessel vascular disease and restricted ankle movement to the aetiology of leg ulceration in rheumatoid arthritis

Leg ulceration in rheumatoid arthritis (RA) without systemic vasculitis is a difficult clinical problem and a common cause of morbidity. We have assessed venous function, arterial pressures and range of ankle movement in 23 RA patients with a leg ulcer and compared the results with those in the non-ulcerated contralateral limb and in 25 RA patients matched for age and duration of arthritis. We found evidence of venous insufficiency in RA ulcer patients compared to disease controls. Ankle movement was more restricted in the ulcerated limb compared to the non-ulcerated contralateral leg. There was no difference in large-vessel arterial function between groups. These findings have implications for therapy and rates of healing.

Fasciotomy, chronic venous insufficiency, and the calf muscle pump

OBJECTIVE

To test the hypothesis that fasciotomy may impair the function of the calf muscle pump, which in turn could result in the development of chronic venous insufficiency.

DESIGN

A cohort study of patients with a history of lower extremity fasciotomy.

SETTING

An urban trauma center.

PATIENTS

Seventeen of the 83 patients identified through trauma, vascular, and/or orthopedic registries consented to participation in this study.

INTERVENTIONS

Participating patients completed a study questionnaire, and then underwent a complete vascular examination, including air plethysmographic (APG) assessment. Patients with a history of venous injuries were also studied with color flow duplex venous imaging.

MAIN OUTCOME MEASURES

Function of the calf muscle pump as measured by APG, and evidence of chronic venous insufficiency as measured by APG, findings on clinical examination, and by venous ultrasonography.

RESULTS

Seventeen patients completed the study, including 8 with a history of vascular injuries, 6 with old fractures, and 3 who had undergone fasciotomy for soft tissue infections. The time from injury to examination ranged from 5 months to 20 years. Eight patients had signs or symptoms of venous insufficiency, the severity of which appeared to be time dependent. The APG data showed significant mean differences between fasciotomy and control extremities in ejection fraction (P<.001) and residual volume fraction (P<.001), both measures of calf muscle pump function. There were no significant changes in venous filling index, a measure of venous reflux, or in outflow fraction, which correlates with venous obstruction. There were no differences in APG variables between patients with vascular injuries vs those with orthopedic or soft tissue injuries.

CONCLUSIONS

Lower extremity fasciotomy impairs long-term calf muscle pump function, as measured by APG, in patients with and without vascular injuries. These patients are at risk for the long-term development of chronic venous insufficiency following lower extremity trauma.

The 4 rights of compression therapy for patients with chronic venous insufficiency and venous ulceration

Compression therapy has become an ever increasing component in the care of patients with Chronic Venous Insufficiency (CVI) and venous ulcerations. Although compression therapy is of great benefit to many of these patients, this treatment option does not come without risks. The increased use of compression therapy has coincided with an increase in its improper application. This article simplifies the principles of compression and highlights the common pitfalls of its use, with an emphasis on the home healthcare setting.

Resistance to venous outflow during laparoscopic cholecystectomy and laparoscopic herniorrhaphy

The effects of pneumoperitoneum on peak venous flow velocity in the common femoral vein and the vena cava have already been studied. The results suggested that venous stasis occurs during surgical pneumoperitoneum. This study determines the effects of pneumoperitoneum on the overall venous outflow resistance of the lower limbs. Venous outflow resistance was measured during surgical procedures by impedance plethysmography in 12 patients undergoing laparoscopic cholecystectomy, 4 patients undergoing laparoscopic herniorrhaphy, 4 patients undergoing conventional cholecystectomy, and 2 patients undergoing conventional herniorrhaphy. Venous outflow resistance did not change significantly during laparoscopic cholecystectomy or herniorrhaphy. No difference in venous outflow resistance between laparoscopic cholecystectomy and herniorrhaphy was found. During pneumoperitoneum, no obstruction to total lower limb venous outflow could be demonstrated, indicating that venous stasis in the limbs did not occur, and consequently, flow in the iliac and inferior caval veins was not compromised. Hypothetically, active vasodilatation resulting from mild compression may explain this. In our view, no special measures to prevent deep venous thrombosis have to be taken during laparoscopic procedures.

Foot venous pressure measurement for evaluation of lower limb venous insufficiency

PURPOSE

Foot venous pressure measurement is considered to be useful for assessing lower limb venous insufficiency, because venous hypertension is the main factor predisposing to venous insufficiency. In this study, we investigated the utility of foot venous pressure measurement in the evaluation of venous insufficiency.

METHODS

A total of 148 limbs of 101 patients with venous insufficiency associated with varicose veins and treated over 5 years were studied. The measurements assessed were percentage decrease in foot venous pressure with manual calf compression (%drop), rate of increase in foot venous pressure during a 4-second period after release of compression (4SR%), and time to 50% recovery of foot venous pressure (RT50).

RESULTS

A higher incidence of skin changes (clinical, etiologic, anatomic, and pathophysiologic classification classes 4 to 6) caused by venous insufficiency was associated with %drop, 4SR%, and RT50 values. Skin changes were found in more than 50% of the limbs with a %drop less than 50%, 4SR% more than 50%, or RT50 less than 4 seconds. After tourniquets were applied to occlude the superficial veins, limbs with severe below-knee deep venous reflux (%drop 60.3 +/- 14.6, 4SR% 36.7 +/- 30.2, RT50 13.9 +/- 14.7) showed significantly worse values than those with no reflux (%drop 79.9 +/- 3.2, 4SR% 8.1 +/- 3.1, RT50 48.9 +/- 17.9) or with mild above-knee reflux (%drop 77.0 +/- 5.0, 4SR% 7.1 +/- 3.2, RT50 46.9 +/- 26.7). After sclerotherapy or surgical treatment, including deep venous reconstruction for severe below-knee reflux, all limbs showed significant improvement in clinical manifestations and foot venous pressure values (%drop 68.1 +/- 7.5 to 76.5 +/- 5.8, 4SR% 33.1 +/- 12.9 to 12.7 +/- 7.6, RT50 7.5 +/- 4.2 to 20.1 +/- 6.5).

CONCLUSION

Foot venous pressure measurements showed a good correlation with clinical severity and degree of venous reflux and were very useful for evaluating the outcome of therapy for venous insufficiency.

The valvular apparatus in venous insufficiency: a problem of quantity?

Abnormal venous valvular function may produce venous reflux and venous insufficiency. While valvular agenesis is a known, but rare cause of venous insufficiency. While valvular agenesis is a known, but rare cause of venous insufficiency, little work has been done on the relative number of greater saphenous vein (GSV) valves in patients with venous insufficiency. This study investigates whether the GSV in patients with symptomatic venous insufficiency has fewer valves than the GSV of patients without venous insufficiency. The number of GSV valves in patients (n = 51) with symptomatic venous insufficiency undergoing saphenectomy (VI) were compared with the number of GSV valves in patients (n = 26) without venous insufficiency undergoing in situ GSV bypass under angioscopic surveillance who served as a control group. The two groups differed, as expected, in age and sex distribution. The VI group had a mean of 25.7 +/- 11.0 centimeters of GSV between valves, while the control group had 19.0 +/- 9.7 centimeters of GSV between valves (F = 6.99; p = 0.01). The mean number of valves in the saphenous veins of the two groups also differed significantly: VI = 2.3 +/- 0.83 versus control (CTRL) = 4.8 +/- 2.01 (F = 61.86; p < 0.0001). That properly functioning valve leaflets help maintain physiologic antegrade venous flow is indisputable. This study, however, suggests that the relative lack of valves may be related to the development of venous insufficiency. This report documents that patients with symptomatic reflux in the GSV have significantly fewer valves than patients with apparently normal functioning saphenous veins.

[Therapeutic effectiveness of flavonoids illustrated by daflon 500 mg]

Besides the standard therapy of chronic venous insufficiency with compression drug treatment with effective substances considerably improves the prognosis. Among these substances Daflon 500 mg, consisting of a micronized fraction of flavonoids, is one of the best investigated drugs. It shows a very good tolerability: in none of the toxicological studies substance-related alterations were found. This statement refers as well to questions of acute, subacute and chronic toxicity as also to mutagenicity, fertility, embryotoxicity, respectively. Pharmacokinetic studies showed that it is well absorbed from the gastrointestinal tract, although is is not clear whether this concerns the unchanged drug or only metabolites. Pharmacodynamically an improvement of the velocity of lymphstream was shown and clinically the effects on chronic venous insufficiency, venous leg ulcers and hemorrhoids were statistically highly significant. The micronized flavonoids in Daflon 500 mg allow an exact dose regimen (2 tablets a 500 mg/day, once daily given), shows an excellent tolerability and therefore a high acceptance by the patient.

Vascular injuries in total knee arthroplasty. A review of the problem with special reference to the possible effects of the tourniquet

Considering the proximity of the major vascular structures to the back of the knee, vascular complications of total knee arthroplasty are relatively rare. A patient who developed acute vascular insufficiency immediately following a total knee arthroplasty is reported. This stimulated a survey of arterial complications encountered by members of the British Association for the Surgery of the Knee. The majority of surgeons still use a tourniquet but will modify their practice if there is anxiety about vascular status. The mechanism of injury to the vascular system is either direct trauma or thrombosis. The outcome following treatment after direct injury is extremely good. The outcome after thrombosis is extremely poor. There is no recorded case of thrombosis occurring when a tourniquet was not used. Whether all knee arthroplasties should be done without a tourniquet is discussed. Early intervention is vital if a vascular injury is suspected.

Elevated cutaneous leukocyte concentration in a rodent model of acute venous hypertension

BACKGROUND

The pathophysiologic mechanism of the skin pathology in chronic venous insufficiency is venous hypertension (VHTN). Microvascular dysfunction involving leukocytes has recently been proposed as the primary mediator of tissue damage from VHTN. We developed a rodent model allowing the investigation of the effects of acute VHTN on tissue leukocyte concentration.

MATERIALS AND METHODS

Under general anesthesia, adult male rats underwent transperitoneal isolation of the inferior vena cava and the common iliac veins and arteries. Bilateral thigh incisions allowed isolation of the common femoral veins and superficial epigastric veins (SEV: distal branch of the femoral vein in the thigh). Pressure in the SEV and flow in the iliac artery were measured before (T-Pre), immediately after (T-0), and for 135 min (T-1) after ligation of the cava, iliac, and femoral veins. Sham rats were identical except no venous ligation was performed. After the T-1 pressures were obtained, the distal hindlimb and forelimb skin was harvested and processed to measure myeloperoxidase (MPO) activity, an index of the number of tissue leukocytes. To evaluate the effect of arterial flow reduction known to occur with acute venous ligation, the above measurements were made in an Aortic group of rats in which the aorta was manually stenosed.

RESULTS

This venous ligation technique resulted in a significant (P < 0.05) and sustained rise in venous pressure (T-Pre, 9.91 +/- 0.94 and T-1, 26.22 +/- 2.15). Hypertensive rats had significantly elevated hindlimb MPO activity (4.77 +/- 0.36) vs forelimb (0.60 +/- 0.39), Sham (hindlimb, 0.77 +/- 0.41; forelimb, 0.10 +/- 0.05), and Aortic (hindlimb, 0.96 +/- 0.38; forelimb, 0.58 +/- 0.11) controls.

CONCLUSIONS

Acute VHTN was successfully created by venous ligation in this newly developed rat model. VHTN, but not arterial flow reduction, was associated with significantly elevated hindlimb skin MPO activity, suggesting that leukocytes may indeed be mediators of skin pathology in VHTN. This model will allow further investigation into the mechanisms of microvascular dysfunction in VHTN.

Long-term follow-up of a superficial femoral vein injury: a case report from the Vietnam Vascular Registry

We report a 29-year follow-up of a high-velocity superficial femoral vein injury sustained during the Vietnam War that was treated by emergent ligation. After years of suffering recurrent ulceration from chronic venous insufficiency, this patient underwent axillary vein valve transfer with improvement in his venous hypertension. Long-term follow-up of patients with deep venous injuries is necessary to avoid complications from chronic venous insufficiency.

The venous thrombectomy: obsolete or forgotten?

This report describes the surgical management of three patients with an extended ilio-femoral deep venous thrombosis. In the first patient a residual occlusion of the common iliac vein was treated conservatively and this patient developed severe chronic venous insufficiency. In the second patient a residual (sub)occlusion of the common iliac vein was treated with a stent and this patient remained asymptomatic with two years follow-up. In the third patient no residual or underlying anatomical abnormality was found with a good result at one year. Venous thrombectomy still has a place in the treatment of deep venous thrombosis and the long term results may be improved by application of endovascular techniques.

Characteristics of chronic venous insufficiency in 895 patients followed in general practice

BACKGROUND

This study was designed to describe the main semiological and etiological characteristics of chronic venous insufficiency (CVI) and to determine if there was a relationship between the extent of objective signs, severity of symptoms and aetiology.

MATERIALS AND METHODS

895 outpatients presenting CVI of the lower limbs over a period of at least one year, irrespective of grade of severity or aetiology, were included in this retrospective study. They were treated with 2 different pharmaceutical forms of the same venoactive medication (1000 mg of micronised flavonoid fraction) for 2 months. Organic CVI (OCVI) was classified, in stages of increasing severity, according to the Widmer and Porter classification. In the absence of anatomical lesions of the main veins or their valvular system, CVI was termed functional (FCVI).

RESULTS

Analysis indicated that CVI was more frequent in women than in men (sex ratio 10:1). 26% were FCVI and 91% of OCVI were of varicose origin. The mean progression time of the disease was 13+/-11 years. Disease began earlier in women than in men (34+/-14 vs 41+/-14 years). Oedema was the first objective sign in 68% of patients and the only one in 20% of FCVI. Heaviness was more frequent in FCVI and its intensity was not related to the severity of CVI. Trophic complications were more frequent in the advanced stages.

CONCLUSIONS

In order to avoid progression to more severe forms which are disabling or expensive to treat, a rational approach to the management of early CVI is essential.

Clinical scrutiny of the de facto superiority of proximally versus distally based fasciocutaneous flaps

Just as the dogma that skin flap survival depends on rigid length-to-width ratios has been refuted as a consequence of advances in understanding the anatomical basis of the cutaneous circulation, the generalization that distally based flaps are inherently inferior to proximally based flaps also deserves to be challenged. All else being equal, the truly critical factor for flap viability in either case is the nature of their intrinsic blood supply rather than any arbitrary configuration or orientation. Previous laboratory evidence has proved this fact and is now further validated by a clinical experience with 194 local fascia flaps in 174 patients. There was a 22.2 percent overall incidence of complications, but no statistically significant difference in this rate was observed whether the flap was distally based (18.8 percent of 16 flaps) or proximally based (23.5 percent of 162 flaps) (p = 0.669). Major complications, usually a failure of the intended coverage, actually were more common for proximally based flaps (12.9 percent) than those distally based (6.3 percent), although not statistically different (p = 0.436). Bipedicled fasciocutaneous flaps, which should have had augmented perfusion from their dual sources of inflow, sustained complications in 12.5 percent of 16 flaps. Although none was classified as a major problem, again no difference was apparent when compared with proximally based (Pprox = 0.316) or distally based (pdis = 0.626) flaps. Some caution is prudent in interpreting these retrospective data, not because of an admitted bias for more frequent selection of proximally based flaps, but because the choice for any of these local fasciocutaneous flap always followed a careful assessment of the status of the fascial plexus adjacent to any defect. Audible or color Doppler ultrasound localization of available cutaneous perforators can predetermine the feasibility of any option, thereby ensuring a reasonable success rate regardless of pedicle orientation.

[Chronic venous pathology: presentation of a new international classification]

The Authors present a new classification of chronic venous pathology. The first presentation was in Maui during the Congress of the North American Society of Phlebology and the second in London, during the last World Congress of International Union of Phlebology. The aim is to standardize the clinical and instrumental data to propose a common classification to all physicians. Etiological, anatomical, physiopathological and clinical findings were considered.