Intermittent edema of the upper and lower extremities and the abdominal wall caused by membranous stenosis of the superior vena cava and membranous obstruction of the inferior vena cava

We report on a 38-year-old patient with intermittent edema of the lower legs, arms and abdominal wall. The cause for his tendency to develop edema was a membranous obstruction of the inferior vena cava and a membranous stenosis of the superior vena cava. The etiology of these anomalies of the vena cava suggests a congenital malformation. In consideration of the cases of inferior and/or superior vena cava-anomalies published to date the patient received an anticoagulant therapy (coumarin) and treatment with graduated compression stockings. He now complains from time to time of a sensation tension in the lower legs after prolonged standing or sitting. Edema of the upper and lower extremities and the abdominal wall have disappeared.

Valvular function of peripheral veins after hyperemic dilation

PURPOSE

We wanted to answer the question of whether physiological dilation of normal extremity veins can induce temporary valvular leakage and reflux.

METHODS

Directional flow was recorded in 22 forearm and popliteal veins by Doppler duplex scanning after distal compression. Reflux was assessed by valve closure time and calculation of a "reflux index," the ratio of backward to forward flow areas.

RESULTS

Hyperemia and enhanced flow did not increase but lowered reflux. During control conditions the mean reflux ratio (backward/forward flow area) of 21 veins was 0.058 and decrease to 0.028 (p < 0.05). Reflux was slightly longer in patients in the erect position in the popliteal vein, compared to forearm veins (with the patients in the sitting position). Significantly increased reflux occurred during hyperemia in only one deep forearm vein (valve closure time 0.92 seconds).

CONCLUSIONS

Most veins of the upper (forearm) and lower extremity (popliteal vein) were competent even after a maneuver that induced venodilation and an increase in blood flow (exercise hyperemia or postocclusion reactive hyperemia). Veins with an inherent valvular weakness can be identified by a hyperemia test with duplex flow analysis.

Diagnosis of chronic venous disease of the lower extremities: the "CEAP" classification

OBJECTIVE

To test a new classification of chronic venous disease (CVD)--based on clinical, etiologic, anatomic, and pathophysiologic data (the CEAP system)--in a series of patients by using objective tests to establish all diagnoses.

MATERIAL AND METHODS

The CEAP classification was applied to 102 extremities in 70 consecutive patients with CVD. Diagnoses were based on objective testing with continuous-wave Doppler studies, duplex scanning, plethysmography, venous pressure, and phlebography, which were applied selectively (the more invasive methods were reserved for cases of greater severity).

RESULTS

Use of this classification provided an organized categorization of the key elements of the venous abnormalities in each case and clarified the interrelationships among the clinical manifestations, cause of the process, and anatomic distribution of involvement. For example, in this series of 102 extremities, 79% had primary venous disease, 18% had secondary disease, and 3% had congenital abnormalities. Ulcers were found in 7% of extremities with primary CVD and 44% with secondary CVD. Of the cases with ulceration, 43% were due to primary incompetence and 57% to postthrombotic disease. Reflux was the pathophysiologic problem in 86% of the total series and in 80% of ulcer cases. Similar relationships can be delineated for cases with varicose veins, edema, or skin changes. Study of the specific facets of the CEAP classification provided precise information about the cause and the effect of venous abnormalities that could be compared with cases in other series.

CONCLUSION

Use of the CEAP classification with diagnoses determined by objective testing accurately identifies categories of CVD. The objective date provide a clear description of the abnormalities in each case and may be used for analyses of meaningful relationships between categories of CVD. Adoption of this objective method of classifying CVD will facilitate interinstitutional studies.

[The role of heparin sulfate in the treatment of pregnant women with circulatory deficiency syndrome]

The syndrome from circulatory maternal, precocious and belated deficit could influence the appearance of a vast range of obstetric incluted pathology: recurrent abortions, delays of increase, pre-eclampsia, fetal and neonatal dead. The principal biochemical implicated mechanism has represented from alteration of equilibrium trombossano prostaciclina with adjunct vasoconstriction and uterum-placental hypoperfusion. In this study the authors have estimated the efficacy and the compliance of the heparan sulfate in 30 pregnant patients to risk for vascular pathology. In all these cases, the rational to the use the heparan sulfate had represented from the necessity to associate a therapy anteplatelet with associate an fibrinolitic activity. The percent of pregnancies with alive and vital fetuses was of the 90%; the collateral effects have been inconsiderable. The authors retain useful effect randomize checked studies to evaluate further the real results this therapy.

Schistosomiasis as a predisposing factor to veno-occlusive disease of the liver following allogeneic bone marrow transplantation

Among 89 allogeneic bone marrow transplant recipients, veno-occlusive disease of the liver (VOD) was diagnosed in 10 patients (11.2%). All cases (n = 5) with schistosomal hepatic periportal fibrosis detected by pretransplant ultrasonography, developed severe fatal VOD in spite of normal initial liver functions and absence of portal hypertension. The incidence of VOD among patients without previous schistosomal contact was 5.95% (5/84). The relative risk to develop VOD was calculated to be 16.8-fold higher in patients with previous schistosomiasis. Schistosomal hepatic periportal fibrosis may thus be added to the known risk factors predisposing to the development of VOD in allogeneic transplant recipients.

Treatment of veno-occlusive disease of the liver with bolus tissue plasminogen activator and continuous infusion antithrombin III concentrate

Veno-occlusive disease (VOD) of the liver is a common complication of BMT and is accompanied by reduced levels of natural anticoagulants and by multi-organ dysfunction. We describe two cases of clinical VOD developing after autologous BMT and accompanied by ultrasonographic features of reversed portal venous flow. In both cases the patients had decreased levels of antithrombin (AT). Once the diagnosis of VOD was made, these patients were treated with tissue plasminogen activator (tPA) and continuous infusion AT. Each patient had radiographic and clinical resolution of VOD with the therapy. This novel treatment appears to have reversed the course of VOD without the increased risk of bleeding seen in the use of heparin therapy.

The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency

PURPOSE

The purpose of this study was to identify the distribution of venous reflux in patients with different patterns of reflux with each class.

METHODS

Color-flow duplex imaging was used to evaluate the entire venous system from groin to ankle in 465 patients (594 limbs) belonging to different clinical CVI classes (0, 1, 2, and 3). A history of previous superficial thrombophlebitis was present in five limbs and past deep vein thrombosis in 70.

RESULTS

One hundred seventy eight (30%) limbs were normal and the remaining 416 (70%) had venous incompetence. Deep reflux was present exclusively in 19 limbs (3.2%), and the perforation system alone was involved in only three limbs (0.5%). However, isolated superficial incompetence was seen in 186 limbs (31.3%) and a combination of superficial with perforating alone was involved in 45 (7.6%). Incompetence in all three systems was seen in 99 extremities (16.7%). In addition, the superficial system was involved in 390 limbs, the perforators in 151, and the deep system in 178 limbs. Only a small percentage of those in class 0 had reflux, and most of them had a single site of incompetence. In class 1 the majority of the limbs had superficial reflux (90.3%), 10.3% of the limbs had deep venous reflux, and 6.9% were competent. Reflux in the superficial system was only seen in 80.7% of the limbs in class 1 and in one fifth of the limbs in classes 2 and 3. Isolated deep or perforated incompetence was rare in all classes. Variable combined patterns of reflux were seen more often in classes 2 and 3 (p < 0.0001). In classes 2 and 3 there were no differences in the number of incompetent sites in the superficial and deep venous systems or the patterns of reflux (p > 0.1). The number of incompetent perforators in class 3 tended to be higher than that in class 2, especially in the below-knee segment, but no significant differences were seen. Distal reflux was present in the majority of the limbs in all symptomatic classes (1, 2, and 3).

CONCLUSIONS

The distribution and extent of reflux is strongly associated with clinical severity of CVI through class 2. Distal venous reflux is present in at least 80% of the symptomatic limbs. Deep venous thrombosis may not be a prerequisite for the development of skin changes or ulceration in about 75% of the limbs. Superficial venous surgery could be beneficial to at least one third of patients with skin changes or ulceration.

Early drop in protein C and antithrombin III is a predictor for the development of venoocclusive disease in patients undergoing hematopoietic stem cell transplantation

Venoocclusive disease (VOD) of the liver remains one of the major obstacles for patients undergoing high-dose chemotherapy and hematopoietic stem cell transplantation (HSCT). Many factors have been associated with the development of VOD, including a hypercoagulable state secondary to a drop in protein C and antithrombin III (AT III). We conducted a prospective nonrandomized trial to try to determine whether the development of clinical VOD was associated with a drop in protein C, protein S, and AT III. A total of 42 patients undergoing high-dose chemotherapy and HSCT were enrolled in this study. Eleven patients underwent allogeneic bone marrow transplantation (BMT) following high-dose cyclophosphamide and fractionated total body irradiation (TBI). Thirty-one patients received autologous stem cell rescue following different preparative regimens. Measurements of protein C, protein S, and AT III levels were obtained prior to conditioning therapy and weekly thereafter for 2-3 weeks. A significant difference was noted in the mean levels of protein C on day 7 between those who developed VOD and those who did not (57.5 versus 72.1, p = 0.009). Similarly, there was a significant difference in the mean levels of AT III on days 7 and 14 between the two groups (day 7, 95.5 versus 80.6, p = 0.002; day 14, 99.6 versus 85.2, p = 0.01). The drop in protein S levels on days 7 and 14 was not statistically significant between the two groups. In conclusion, the degree of drop in protein C and AT III levels on day 7 was predictive for the development and severity of VOD.

[Chronic venous insufficiency 7 to 10 years after partial vena cava interruption with a clip]

In order to test the responsibility of inferior vena cava clips in post thrombotic venous disease, we performed a comparative retrospective study 7 to 10 years after vena cava interruption by clip. Patients were compared with patients matched for sex, age, and prior deep vein thrombosis (same period and same localisation) but without inferior vena cava partial interruption. The results show that 1) functional complaints were significantly higher in the vena cava clip group; 2) valvular incompetency, in the initially thrombosed leg, (tested by scanning duplex) was not different in the two groups: 3) inversely, on the other leg, valvular incompetency was greater in the vena cava clip group. Furthermore this valvular incompetency was principally located at a femoral level, suggesting that the vena cava clip may induce backward thrombosis; 4) complications were independent of vena cava thrombosis.

Changes of atrial natriuretic peptide level in patients with nephrotic syndrome after supine bicycle exercise

OBJECTIVES

The exact role of atrial natriutetic peptide (ANP) in the pathogenesis of edema in nephrotic syndrome (NS) has not been fully elucidated. We aimed to investigate the possible contribution of ANP to edema formation in NS.

METHODS

We subjected 18 nephrotic subjects and 20 healthy volunteers to supine bicycle exercise (SBE), a maneuver that seemed to increase venous return and to enhance the release of ANP. Plasma concentrations of immunoreactive-ANP were measured before and after SBE by radioimmunoassay.

RESULTS

There was a significant rise in the plasma concentration of ANP in the controls after SBE (from 31.1 +/- 6.16 to 42.0 +/- 6.01 pg/ml: p < 0.05). Meanwhile, there was no change in plasma concentration of ANP in the patients with NS (from 35.4 +/- 6.04 to 35.1 +/- 5.31 pg/ml). The change in plasma concentration of ANP in controls was significantly different from that in those with NS (p < 0.05). The mean baseline value of ANP in controls was the same as in NS.

CONCLUSIONS

These results show that SBE was a simple maneuver to stimulate the release of ANP in healthy controls. In contrast, it failed to stimulate the release of ANP in subjects with NS.

Congenitally absent inferior vena cava presenting in adulthood with venous stasis and ulceration: a surgically treated case

Absence of the inferior vena cava (IVC) is an uncommon congenital abnormality. Symptoms of lower extremity venous insufficiency resulting from this anatomic abnormality have been reported only once in the English literature, and no experience with surgical treatment of this condition has been published. We report the case of an otherwise healthy 41-year-old man with an 18-month history of severe venous insufficiency involving the right leg manifested by extensive ulceration that did not respond to aggressive conservative treatment. Duplex findings were not suggestive of venous obstruction or reflux, but venography documented no filling of the common iliac vein or inferior vena cava, and outflow was via collaterals to the azygous and hemiazygous systems. Computed tomography demonstrated complete absence of the inferior vena cava with azygous continuation. A prosthetic bypass from the external iliac to the intrathoracic azygous vein was performed with complete symptomatic relief after a 30-month follow-up period. Venous bypass surgery may play a role in treatment of this rare cause of venous insufficiency.

Is veno-occlusive disease incidence influenced by the total-body irradiation technique?

BACKGROUND

In order to assess the influence of total-body irradiation technique on veno-occlusive disease (VOD) incidence, we retrospectively analyzed our leukemia patients treated with bone-marrow transplantation conditioned using total-body irradiation and high-dose chemotherapy.

PATIENTS AND METHODS

Between 1980 and 1992, 305 patients with acute non-lymphoblastic leukemia (ANLL; n = 170) and acute lymphoblastic leukemia (ALL; n = 135) were treated with bone-marrow transplantation in their first complete remission (CR; n = 223) or in second CR (n = 82). All patients underwent total-body irradiation either in single dose (n = 176; 10 Gy to L4, 8 Gy to the lungs) or in 6 fractions (n = 129; 12 Gy in 3 consecutive days to L4, 9 Gy to the lungs) before bone-marrow transplantation. Patients were analyzed in 2 instantaneous dose rate groups: 104 (34%) patients received an instantaneous dose rate < or = 4.80 cGy/min (mean: 3.07 +/- 0.60 cGy/min), and 201 (66%) > 4.80 cGy/min (mean: 6.60 cGy/min +/- 0.30). Conditioning chemotherapy consisted of cyclophosphamide alone in 231 patients, cyclophosphamide and etoposide or melphalan in 53 patients, and 21 patients were conditioned with cytosine arabinoside and melphalan. Bone-marrow transplantation was autologous in 197 patients, and allogeneic in 108 patients.

RESULTS

Thirty (10%) of the 305 patients experienced VOD. In univariate analyses, its incidence was not influenced by instantaneous dose rate (9.6% [10/104] in < or = 4.80 cGy/min group vs. 10% [20/201] in > 4.80 cGy/min group; p = 0.91), fractionation (11% [19/176] in single-dose total-body irradiation vs. 8.5% [11/129] in fractionated total-body irradiation, p = 0.64), age (9% [21/241] in < or = 40-year old-patients vs. 14% [9/64] in > 40-year-old patients, p = 0.29), sex (6% [7/113] in male patients vs. 12% [23/192] in female patients, p = 0.15), type of VOD prevention (16% [16/101] in patients using heparin vs. 10% [14/142] in those receiving dinoprostone and pentoxifylline combination, p = 0.23), type of bone-marrow transplantation (9% [10/108] in allogeneic bone-marrow transplantation group vs. 10% [20/197] in autologous bone-marrow transplantation group, p = 0.96), or type of acute leukemia (9.6% [13/135] in ALL vs. 10% [17/170] in ANLL, p = 0.93). However, VOD incidence was significantly lower in patients whose conditioning chemotherapy consisted of cyclophosphamide alone (6.5% [15/231] vs. 20% [15/74] by other drugs +/- cyclophosphamide, p < 0.0001), and in patients treated after 1985 (7% [16/226] vs. 18% [14/79] in those treated before 1985, p = 0.01). Multivariate logistic regression analysis revealed that the best independent factors influencing the occurrence of VOD were the male sex (p = 0.03), conditioning chemotherapy consisting of cyclophosphamide alone (p = 0.01), and bone-marrow transplantation after 1985 (p = 0.008).

CONCLUSION

In our series of 305 acute leukemia patients treated with allogenic or autologous bone-marrow transplantation, total-body irradiation technique (fractionation or instantaneous dose rate) did not seem to influence the incidence of VOD.

Peripherally inserted central catheters in children

PURPOSE

To assess the feasibility and complications of peripherally inserted central catheters (PICCs) in pediatric patients.

MATERIALS AND METHODS

The authors attempted to place PICCs in 122 patients aged 9 days to 19 years (mean, 6.82 years; median, 5 years). Catheters were placed to allow prolonged administration of antibiotics or chemotherapeutic agents (n = 50), provide total parenteral nutrition (n = 41), and establish prolonged intravenous access for blood draws and fluid administration (n = 31). Silicone catheters measuring 3, 4, and 5 F were inserted in either basilic or cephalic veins and positioned at the junction of the superior vena cava and right atrium under fluoroscopic guidance. Patients were monitored for complications until devices were removed.

RESULTS

Fluoroscopically guided PICC placement was successful in 137 of 148 attempts. Postinsertion complications included mechanical defects of the catheter, PICC-related infection, occlusion of the PICC, and venous stasis. Complications occurred at a rate comparable to those seen with blind insertion.

CONCLUSION

Fluoroscopically guided PICC placement is feasible and safe in pediatric patients.

Venous valvular reflux in veins not involved at the time of acute deep vein thrombosis

PURPOSE

The aim of this study was to determine whether, in lower extremities with documented episodes of acute deep venous thrombosis (DVT), incompetence develops in veins that were not the site of thrombosis.

METHODS

Patients were monitored with serial duplex ultrasonography at 1 day, 1 week, 1, 3, 6, 9, and 12 months, and then annually after detection of acute DVT. The following venous segments were analyzed: common femoral, greater saphenous, proximal superficial femoral, deep femoral, popliteal, and posterior tibial. The incidence of reflux development in both thrombosed and uninvolved segments was determined. Reflux was categorized as either transient or permanent.

RESULTS

A total of 227 limbs in 188 patients were serially studied. Mean follow-up was 19.9 months (range 1 to 88 months). Overall, 403 of the 1423 segments (28.3% +/- 2.3%) developed reflux during the study, of which 118 (29.3% +/- 4.4%) had no prior or concurrent history of thrombosis. Considering only the segments that developed incompetence, the percent without prior thrombosis at each level was as follows: common femoral vein (40.0%), greater saphenous vein (53.1%), deep femoral vein (20.6%), proximal superficial femoral vein (23.9%), popliteal vein (8.9%), and posterior tibial vein (31.9%). Valvular insufficiency developing in segments uninvolved with thrombus was more likely to be transient (40.2%) than was the reflux in thrombosed segments (22.6%). This difference was statistically significant (p < 0.05).

CONCLUSIONS

Permanent venous valvular damage can occur in the absence of thrombosis after DVT. Reflux in uninvolved venous segments has a different anatomic distribution and is more likely to be transient than the incompetence associated with thrombosis.

[Late results of the Palma operation]

Since 1981, 54 femoro-femoral crossover saphenous bypass (Palma-operation) were performed for chronic venous insufficiency caused by unilateral iliac vein occlusion. Long-term patiency rate and clinical results were evaluated by radioisotope venography and venous occlusion plethysmography. Plethysmography demonstrated significant improvement of maximal venous outflow after operation. Radioisotope venography showed remarkable long-term patency rate of Palma-bypass (of 42 operation, 29 patent graft). Long-term clinical results appeared to be excellent after operation of isolated iliac vein occlusion, whereas the results after operations performed with postthrombotic changes in more distal deep veins were not acceptable, therefore a more critical preoperative selection seems to be necessary.

Lower-extremity venous stasis during laparoscopic cholecystectomy as assessed using color Doppler ultrasound

Lower-extremity venous stasis during laparoscopic cholecystectomy was evaluated in 16 patients by monitoring the blood velocity in the femoral vein and the femoral vein size (cross-sectional area) using color Doppler ultrasonography. The blood velocity in the femoral vein decreased significantly after the start of 10-mmHg abdominal insufflation in the supine position. When the patients were placed in a reverse Trendelenburg position during 10-mmHg insufflation, blood velocity in the femoral vein further decreased. However, velocity returned to the baseline after deflation. The cross-sectional area of the femoral vein was significantly elevated after the start of 10 mm Hg insufflation in the supine position. When patients were placed in the reverse Trendelenburg position during 10-mmHg insufflation, this parameter was further elevated, but returned to the baseline soon after deflation. These results indicate that femoral vein stasis during laparoscopic cholecystectomy can be minimized by reducing the pressure of abdominal insufflation and avoiding elevation of the patient's head as much as possible.

Relationship between changes in the deep venous system and the development of the postthrombotic syndrome after an acute episode of lower limb deep vein thrombosis: a one- to six-year follow-up

PURPOSE

This study investigated changes in the deep venous system and the development of the postthrombotic syndrome (PTS) after an episode of acute deep vein thrombosis (DVT).

METHODS

Seventy-eight patients (41 male patients, 37 female patients) with acute DVT in 83 legs (31 right, 42 left, five bilateral) underwent annual follow-up examinations for 1 to 6 years (median, 3 years) for symptoms and signs of the PTS. A venous duplex scan was performed at each visit to detect obstruction and reflux in the veins, both of which may contribute to the development of the PTS. DVT was primary in 69 limbs and recurrent in 14 limbs.

RESULTS

When last examined 49 limbs were free of symptoms, and 34 had the PTS (23 edema only, 11 hyperpigmentation). Only two patients had ulcers during the follow-up period; both patients had the ulcers in areas of hyperpigmentation in limbs with recurrent DVT. The extent of disease was similar in limbs with the PTS (79% multisegment, 18% single segment) and those without the PTS (69% multisegment, 12% single segment). In limbs with the PTS the deep veins were normal in only one (3%), six (18%) showed reflux only, five (15%) obstruction only, and 22 had features of both obstruction and reflux (65%). In limbs without the PTS the deep veins showed no abnormality in nine (18%), reflux only in 17 (35%), obstruction only in six (12%), and reflux with obstruction in 17 (35%). In the 11 limbs with hyperpigmentation nine had obstruction and reflux noted, one had obstruction only, and one had reflux alone.

CONCLUSIONS

After an episode of acute DVT 12% of the limbs returned to normal by duplex criteria. Although only 13% developed skin complications, 41% had features of the PTS. Limbs with the PTS had more than three times the odds of having combined reflux and obstruction than did limbs without the PTS (odds ratio = 3.5, 0.95 confidence intervals = 1.4, 8.6). Continued study of these patients will determine the course of those limbs with venous abnormalities that have not yet developed symptoms and signs of the PTS.

Venous haemodynamics and the occurrence of leg oedema in patients with popliteal aneurysm

OBJECTIVES

To see whether popliteal aneurysms cause venous obstruction and to investigate leg oedema and DVT following repair.

DESIGN

Prospective open clinical study.

SETTING

University Department of Surgery.

MATERIALS

8 patients undergoing popliteal aneurysm repair in 9 legs (1 bilateral repair).

CHIEF OUTCOME MEASURES

CT and plethysmographic evidence of vein compression, the occurrence of postoperative leg oedema and phlebographic evidence of deep venous thrombosis (DVT).

MAIN RESULTS

Preoperative CT investigation showed that the aneurysm compressed the popliteal vein in 6/9 limbs where surgery was planned and in 9/10 limbs with popliteal aneurysms (patent or occluded) of > 2 cm diameter (p < 0.01). However, on the CT image, increased collateral network could be observed and most patients had normal venous drainage prior to operation as assessed by air plethysmography. Postoperatively, leg volume was measured by the formula of a truncated cone. Following vascular reconstruction, leg volume increased by 23%. Except for one patient with a confirmed DVT preoperatively, postoperative venous congestion and DVT was not observed in the operated leg as assessed by phlebography and plethysmography.

CONCLUSIONS

Popliteal artery aneurysms "2 cm diameter usually compress and dislocate the popliteal vein prior to operation. However, sufficient venous drainage is maintained, possibly because of an increased collateral venous network. Disruption of lymph channels with secondary lymphoedema is probably the most important mechanism behind the leg swelling observed in patients following popliteal aneurysm repair.

Superficial venous insufficiency: correlation of anatomic extent of reflux with clinical symptoms and signs

PURPOSE

The aim of this study was to assess the distribution and extent of valvular incompetence in patients with reflux confined to the superficial venous system and correlate the extent of such reflux with clinical symptoms and signs.

METHODS

Two hundred fifty-five limbs of 217 patients with superficial venous insufficiency and normal perforating and deep veins were examined with color-flow duplex imaging. One hundred twenty-three limbs (48.2%) of 102 patients had reflux confined to the long saphenous system, 83 limbs (32.6%) of 72 patients had reflux confined to the the short saphenous system, and 49 limbs (19.2%) of 43 patients had reflux in both long and short saphenous systems.

RESULTS

In the long saphenous system the commonest pattern of reflux was that which extended throughout the length of long saphenous vein (LSV) (47%). Ache, swelling, and skin changes were common in the presence of below knee reflux irrespective whether the thigh segment was involved. Ulceration (8%) was found only in limbs with reflux extending throughout the length of LSV. In the short saphenous system the most common pattern of reflux extended throughout the length of short saphenous vein (SSV) (57%) without involvement of Giacomini or gastrocnemial veins. Ache and swelling were present in 62% and 72% of the limbs, but this incidence was not related to the extent of reflux. Swelling, skin changes, and ulceration occurred only when the whole of the SSV was involved. In the limbs with reflux in both the long and short saphenous systems, the most common pattern of reflux extended throughout the length of both systems (45%). In these limbs the incidence of swelling was 80%. The incidence of skin changes went from 44% when the below-knee segment of the LSV was involved to 73% when reflux occurred throughout the LSV and SSV. Ulceration (14%) was found only in the latter situation. Variable patterns of saphenogastrocnemial termination were seen. In 57.8% of the limbs SSV joined the popliteal vein just above the popliteal crease, whereas the SSV terminated in the thigh in 26.6%.

CONCLUSIONS

We conclude that ache, ankle edema, and skin changes in limbs with reflux confined to the superficial venous system are predominantly associated with reflux in the below-knee veins. Ulceration is found only when the whole of the LSV is involved (8%) or when reflux is extensive in both LSV and SSV (14%).

Vascular involvement in Behçet's disease: 8-year audit

Behçet's disease is a multisystemic disorder characterized by recurrent ulcers of the mouth and genitalia and relapsing iritis. Four types of vascular lesion are recognized in Behçet's disease: arterial occlusions, aneurysms, venous occlusions, and variceal development. The incidence of vascular involvement reported in the literature ranges from 7% to 29%. The aim of this study was to determine the rate of vascular involvement in Behçet's disease at our hospital between 1983 and 1992. Of 1200 patients with Behçet's disease, 173 (14.4%) had venous manifestations and 19 (1.6%) had arterial manifestations (in some patients more than one organ was involved). In the group of patients with venous manifestations, there were 154 (12.8%) with venous thrombosis, 17 (1.4%) with vena cava superior syndrome, 5 (0.4%) with inferior vena cava syndrome, 5 (0.4%) with varices, 2 with upper extremity venous thrombosis, 1 with internal jugular vein thrombosis, 1 with cavernous sinus thrombosis, and 1 with hepatic vein thrombosis. In the arterial manifestation group there were 7 femoral, 3 abdominal, 3 popliteal, 2 iliac, 2 pulmonary, 1 axillary, and 1 carotid artery aneurysm as well as 3 arterial occlusions. We concluded that vascular surgeons dealing with young adults should bear Behçet's disease, an uncommon clinical entity, in mind.

Postlaminectomy arteriovenous fistula masked by stenosis of the inferior vena cava

Discovery of a postlumbosacral discectomy fistula between the right iliac artery and vein was obscured by an associated severe stricture of the infrarenal inferior vena cava in a 49-year-old man. During venous stenting for treatment of peripheral edema, the fistula was suspected because of faint pulsatile right iliac vein flow and increased O2 saturation of the venous blood. The suspicion was confirmed on subsequent iliac arteriography. Surgical closure of the fistula with arterial interposition grafting was then performed. The patient improved substantially.