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.

Living related liver transplantation in children

We reviewed 37 living related liver transplantations (LRLT) performed by our department during the last 27 months on children with end-stage liver disease. The patients were 15 boys and 22 girls aged 7 months to 15 years with biliary atresia (27), cryptogenic cirrhosis (3), Budd-Chiari syndrome (2), progressive intrahepatic cholestasis (2), protoporphyria (1), Wilson's disease (1), and fulminant hepatitis (1). The donors were 14 fathers and 23 mothers. Grafts were made from the left lateral segment (19), left lateral segment with partial S4 (11), left lobe (6), and right lobe (1). After graft harvesting all donors resumed normal liver function and normal life. The recipient underwent total hepatectomy with preservation of the inferior vena cava. FK506 and low-dose steroids were used for immunosuppression. The survival rate was 90% (27/30) in elective cases and 57% (4/7) in emergency cases. Six recipients had functioning grafts but died of extrahepatic complications. Hepatic vein stenosis occurred in 3 cases at 3 months after LRLT and was successfully treated by balloon dilatation. Portal vein stenosis occurred in 1 case at 8 months after LRLT and was also safely dilated. We incurred no hepatic artery thrombosis after introducing microsurgery techniques. Among 12 viral, 5 bacterial, and 3 fungal postoperative infections, 1 Candida pneumonia and 1 EBV-associated lymphoma were lethal. Three patients with ABO-blood group compatible grafts and one with an incompatible graft developed acute rejection, which was controlled in evey case by steroid bolus and/or increasing the dose of FK506. There were no definite episodes of rejection in ABO-identical cases. Children with moderate growth retardation (> or = -1.5 SD of normal growth) caught up in growth soon after LRLT, but those with severe retardation (<-1.5 SD) were slow to attain age-normal height. Appropriate timing, meticulous surgical procedures, and comprehensive management of complications are crucial for successful outcome with LRLT. LRLT is a promising option for alleviating the shortage of livers for pediatric transplantation and may be regarded as an independent modality to supplement cadaver donation.

[Penile vein surgery. A follow-up study of erectile dysfunction of presumed venous origin]

Forty patients who underwent penile venous surgery (PVS) because of suspected veno-occlusive dysfunction, were evaluated approximately 15 months (median) postoperatively as to their sexual capability. Although 47.5% were able to obtain penile rigidity, this was sufficient for intercourse in only 35%. Short-term subjective improvement was noted in 55% as opposed to long-term improvement in 35%. Analysis for predictive factors was negative. In conclusion, the indication for PVS should be reconsidered, as an insufficient theoretical concept might explain the low long-term success rate.

The development of valvular incompetence after deep vein thrombosis: a follow-up study with duplex scanning

PURPOSE

Duplex ultrasonography with distal cuff deflation was used to establish the physiologic reflux duration in different segments of the deep venous system in healthy individuals, and to document the occurrence of deep vein valve incompetence in patients after deep vein thrombosis (DVT).

METHODS

Two hundred fifty-two vein segments in 42 legs of 21 healthy individuals and 160 deep vein segments in 27 patients with phlebographically documented DVT were examined with duplex scanning.

RESULTS

The duration of reflux in healthy subjects was significantly shorter in distal deep vein segments. Ninety-five percent of the values were less than 0.88, 0.8, 0.8, 0.28, 0.2, and 0.12 seconds, respectively, for the common femoral, superficial femoral, deep femoral, popliteal, and posterior tibial vein (at midcalf and ankle level). The 95 percentile for reflux duration in the superficial venous system was 0.5 seconds for all vein segments, regardless of the location. No significant correlation was found between the reflux peak flow velocity and reflux duration (R = 0.6). The reflux peak flow velocity is therefore not useful as a parameter of the degree of reflux. The patient group was examined with an interval of 18 to 51 months (mean 34 months) after DVT. Forty-five percent of the initially affected segments showed valve incompetence at follow-up (n = 54); only three of 40 segments initially free from thrombus showed pathologic reflux at follow-up (p < 0.01). Reflux durations in most of the incompetent vein segments were two or more times the normal value of reflux duration. The highest prevalence of valve incompetence was found in the superficial femoral and popliteal vein segment (p < 0.01). None of the patients showed valve incompetence at all levels of the deep venous system. A significant (p = 0.04) relation was found between the extent of the initial thrombosis and the number of refluxing vein segments at follow-up, but no correlation was found between the extent of initial thrombosis and the late clinical symptoms (p = 0.16); clinical symptoms could not be related to the number of incompetent vein segments.

CONCLUSIONS

Duplex scanning allows a good discrimination between physiologic and abnormal reflux duration and is an important tool in the evaluation of the postthrombotic limb. Early assessment after DVT may have prognostic value in individual patients.

[Treatment of Cockett syndrome by percutaneous insertion of a vascular endoprosthesis (Gianturco)]

The authors report the use of endovascular stents in the treatment of one Cockett's syndrome. The compression above left iliac vein ranged on 5 cm. The number of stents placed in the patient was as follow: two stents. An ipsilateral femoral approach was used. The stents were placed immediately after dilatation.

Negative extrathoracic pressure ventilation--evaluation of the neck seal

The effect of the neck seal used in the application of negative extra-thoracic pressure ventilation was studied using near infrared spectroscopy. Changes in cerebral blood volume (CBV) were monitored during discontinuation of negative pressure and during removal of the neck seal. CBV increased by 0.17 ml 100 ml brain-1 (95% CI +0.0875 to +0.481) when negative pressure was discontinued. Removal of the neck seal had no significant effect on CBV. It is concluded that the neck seal does not cause significant jugular venous occlusion.

Venous stasis during laparoscopic cholecystectomy

The objectives of this research were (a) to determine the effect of insufflation at laparoscopic cholecystectomy to 12 mm Hg on femoral venous blood flow; and (b) to assess the function of intermittent pneumatic compressors (IPC) and intermittent electric calf stimulators (IECS) in the presence of a pneumoperitoneum. Measures of baseline venous blood flow velocity, femoral vein diameter, and maximum blood flow velocity achieved by IPC or IECS were made in the presence or absence of a pneumoperitoneum of 12 mm Hg. The ICP and IECS were randomly allocated to either leg. All measures were made by an experienced sonologist. Insufflation to 12 mm Hg caused a statically significant decrease in femoral blood flow velocity and was accompanied by a significant increase in femoral vein diameter. The IPC and IECS were able to achieve pulsatile venous blood flow despite the presence of a pneumoperitoneum, but they had no effect on the depressed baseline blood flow velocity. We concluded that insufflation to 12 mm Hg causes significant venous stasis in the lower limb and that IPC and IECS cannot completely eliminate this stasis. Further research needs to be done to clarify the optimal methods of prophylaxis in view of the implications for deep venous thrombosis.

Variability of venous-hemodynamics with daily activity

PURPOSE

This study was designed to evaluate changes in venous hemodynamics that occur in normal, symptom-free male and female volunteers, as a consequence of daily activity.

METHODS

Each leg of 25 symptom-free volunteers was prospectively studied twice in the early morning and twice in the late afternoon on 2 days. Air plethysmography was used to evaluate venous volumes, venous valvular function, calf muscle pump function, and the noninvasive equivalent of ambulatory venous pressure.

RESULTS

There was significant change in venous valvular function (venous filling index) indicating progressive insufficiency in the late afternoon compared with the results of the morning studies (p = 0.039). This was demonstrated by a shortened venous filling time (p = 0.033) but not a change in venous volume (p = 0.794). Calf muscle pump function and ambulatory venous pressures remained constant. Although there were significant leg volume and ejection volume differences at baseline in male volunteers compared with female volunteers, no gender differences were evident as a result of daily activity. Five of 25 (20%) volunteers and seven of 50 (14%) extremities had normal venous refill times and venous function index in the morning, which became abnormal in the afternoon, indicating deterioration of venous valve function.

CONCLUSIONS

Venous hemodynamic changes occur normally as a consequence of daily activity and seem to result from valvular dysfunction. This occurs in men and women and can alter diagnostic conclusions in 20% of otherwise normal patients. These findings have important implications for venous testing and accurate patient evaluation. However, extrapolation of these data to patients with established venous disease should not be made.

Arteriovenous shunt as a method of restoring venous drainage in rabbit ear replantation

An arteriovenous (AV) shunt as a method of restoring venous drainage during replantation was examined by use of the rabbit ear model. The results were compared to ears replanted using one vein (1:1) or two veins (2:1) for venous drainage. The success rate for AV shunt replantations was found similar to that of replantations with a 1:1 ratio, but lower than that of ears with a 2:1 ratio. Postoperatively, ears replanted using an AV shunt or a 1:1 ratio revealed more swelling and lower tissue oxygenation than ears with a 2:1 ratio. After 10-14 days, all ears that survived were similar in appearance, regardless of method of replantation. Microscopic venules crossing the replanted interface appeared at seven days following surgery in all groups. The authors conclude that the AV shunt method offers an alternative to venous anastomosis when vein-to-vein reconstruction cannot be established.

Successful treatment of venous congestion in free skin flaps using medical leeches

Of 74 patients with extensive skin loss of the upper and lower extremities who were treated with free skin flaps, 20 patients presented with venous insufficiency within the immediate 6 to 12 hours following surgery. In 17 of these patients, the venous congestion after free tissue transfer was successfully treated with medical leeches. The remaining three skin flaps did not survive, despite leeching, as well as exploration and revision of the venous anastomoses. The results from this small number of patients with free skin tissue transfer are encouraging, suggesting that in the presence of venous congestion, the use of medicinal leeches is a desirable modality of treatment.

Venous ulceration of the hand secondary to a cimino fistula

Cimino fistula is an anastomosis created for chronic hemodialysis, between the radial artery and cephalic vein near the wrist. Its complications include thrombosis (most frequent), infection, congestive heart failure, arterial insufficiency, venous hypertension, vascular access neuropathy, and aneurysms. Of these, venous hypertension appears to occur rarely. We report here a case where it resulted in pigmentation, swelling, and ulceration of the middle finger. It was surgically treated, without ligating the arteriovenous fistula, by selective ligation of tributaries from the affected fingers.

Popliteal vein entrapment presenting as deep venous thrombosis and chronic venous insufficiency

PURPOSE

This report describes popliteal vein entrapment in three patients and demonstrates that it may present with manifestations of typical venous disease.

METHODS

This report was compiled from a review of inpatient and outpatient records.

RESULTS

In the first case, a 28-year-old woman was seen with left leg popliteal and calf deep vein thrombosis without obvious cause. She described long-standing calf discomfort, and passive dorsiflexion of the left foot caused disappearance of arterial pulsations at the pedal level. She was given the anticoagulants heparin and sodium warfarin (Coumadin) followed by surgical exploration. The popliteal vein and artery were entrapped by a fibrous extension of the medial head of the gastrocnemius muscle attaching to the lateral femoral condyle. After band lysis, the patient has been symptom free for 6 years. The second patient, a 37-year-old man, was seen with bilateral chronic venous insufficiency (CVI). Passive dorsiflexion and active plantar flexion of the feet did not diminish the pedal pulses; impedance plethysmography suggested mild outflow obstruction. Ascending venography demonstrated entrapment at the midportion of duplicated popliteal veins with no postthrombotic changes. He was treated with compression stockings and has done well during an 18-month follow-up. The third patient, a 17-year-old male, was seen with severe symptoms of right leg CVI and venous obstruction since 3 years of age. Air plethysmography revealed ambulatory venous hypertension, whereas venography demonstrated reflux down to the knee with an extrinsic narrowing at the midpopliteal vein. During operation, an abnormal origin of the lesser saphenous vein (LSV) from the popliteal vein was found; the LSV took a medial route, compressed the tibial nerve, and caused severe distortion and narrowing of the popliteal vein. Division of the LSV resulted in release of popliteal venous compression and immediate relief of symptoms.

CONCLUSIONS

The three cases presented demonstrate that popliteal venous entrapment may begin with symptoms of deep vein thrombosis and CVI. Popliteal venous entrapment must be considered in the differential diagnosis of venous disease in younger patients in whom common predisposing factors are absent.

[Female gonadal venous insufficiency]

The varicocele is a disease recognized and studied in the man. Dilatation of the ovarian veins and the pelvic varicosities secondaries to a varicocele in the woman is a rarely described disease but, if it were researched, it could be more frequent. Diverse syndromes of chronic abdominal pain in the woman with unrecognized etiology and associated with urologic and/or gynecologic symptomatology could be caused by this pathology, but the absence of a clinical description difficult the diagnosis of the most part of cases. The practice of gonadal selective venographies shows a high percentage of dilatation of the gonadal veins associated to a dilatation of the pelvic veins and of the lower limbs veins. The study of the anatomy of the gonadal veins shows diverse anomalies respect to the classical descriptions. Furthermore, the varicocele could be the cause of a high part of the "essential" varicosities presents during the pregnancy. We present a case that instead of being treated by Services of Urology or Gynecology, it was treated by the Vascular Surgery Service. So, the literature about the respect was reviewed. We think that, some entities, like the feminine varicocele, ovarian vein syndrome, pelvic congestion syndrome chronic pelvic pain, pelvic varicosities, vulvar varicosities and some "essential" pregnant varicosities at the lower limbs could be enclosed into the same clinical entity (with a common etiology, physiopathology, clinical presentation and treatment). It should be intending to unify criteria (etiologic, diagnostic and therapeutics criteria) by the different Specialized Unities in such type of pathology.

Etiology of venous ulceration

The etiology of venous ulceration is far more complex than Homans' theory of stagnation and hypo-oxygenation. Indeed, studies have shown that flow in lipodermatosclerotic limbs is actually faster than normal. We suggest, therefore, that the terms "stasis dermatitis" and "stasis ulcer" be dropped from medical parlance. The term "lipodermatosclerosis with ulceration" as used by the British, or simply "venous ulcer," would seem more appropriate. Venous hypertension, produced by incompetence of deep and communicating vein valves and thrombosis of segments of the deep system, is closely correlated with the development of venous ulcers. Precisely how this venous hypertension translates into ulceration is unclear. Burnand et al showed that fibrin cuffs are deposited around the capillaries in lipodermatosclerotic limbs. These cuffs may serve as barriers to the diffusion of oxygen, leading to local ischemia and epidermal necrosis. Others suggest that trapped leukocytes in the microcirculation alter capillary permeability by releasing various inflammatory mediators that hasten the flow of fibrinogen across the capillary membrane and promote the formation of fibrin cuffs. Proof of this hypothesis is still lacking, but may eventually come from using radioactive WBC tagging procedures. A synthesis of these two theories may in fact explain the etiology of venous ulceration.

[The contribution of Doppler echography in the diagnostic and therapeutic plan in chronic venous insufficiency surgery]

Indications for duplex scan in venous surgery. Vascular surgeons are led to request Duplex Scan examination of patients with chronic venous insufficiency in a number of circumstances: A) To obtain information supporting the diagnosis and treatment plan: Chronic venous insufficiency may be due to isolated superficial venous insufficiency or (and) deep venous insufficiency (post-thrombotic syndrome, primary deep valvular insufficiency, congenital malformation). In practice, Duplex Scan examination of the deep venous system is indicated whenever the patient's history is suggestive of deep venous thrombosis or the clinical status is stage 2 or 3 (Ad Hoc Committee classification). In patients with reflux in the popliteal fossa, Duplex Scan is helpful because physical examination and Doppler cannot correctly differentiate short saphenous insufficiency, gastrocnemius insufficiency and reflux in the popliteal-tibial axis, especially as these physiopathologic mechanisms may be associated. In patients with atypical varices, Duplex Scan can demonstrate: Absence of reflux in the greater saphenous vein-femoral vein termination or the short saphenous vein-popliteal vein termination. Varices in the lateral or posterior thigh. In patients with varicose vein thrombosis, Duplex Scan can reveal: The extent of any association with deep venous system. The extent of superficial venous thrombosis. When the results of varicose vein surgery are unsatisfactory, Duplex Scan can determine whether a redo surgery is justified: Persistence of a major leak between the deep and superficial venous system usually prompts redo surgery. Less often, recurrence is due to primary deep valvular insufficiency, in which case valvuloplasty may be indicated.(ABSTRACT TRUNCATED AT 250 WORDS)

Deep venous insufficiency: the relationship between lysis and subsequent reflux

PURPOSE

Although venous valvular insufficiency is well recognized as the most important etiologic mechanism in the development of the postthrombotic syndrome, the factors contributing to valve incompetence after deep venous thrombosis remain obscure.

METHODS

To establish the relationship between recanalization and valve competence, 113 patients with acute deep venous thrombosis were studied with serial duplex ultrasonography.

RESULTS

Median lysis times for segments developing reflux (214 to 474 days) were 2.3 to 7.3 times longer than for corresponding segments not developing reflux (65 to 130 days) for all except the posterior tibial vein. In the posterior tibial vein, median lysis times for those with and without reflux were nearly identical (72 vs 80 days). The median time to onset of reflux was significantly less than the median lysis time in the mid and distal superficial femoral veins and was simultaneous with recanalization in all other segments.

CONCLUSIONS

Early recanalization is important in preserving valve integrity for all but the posterior tibial segment. However, the small number of patients with reflux despite early lysis (< 1 month) or without reflux despite relatively late lysis (> 9 to 12 months) suggests that other factors may also contribute to the development of valvular incompetence. These factors may be particularly important in the posterior tibial vein, in which lysis time has little relationship to the ultimate development of reflux.

Venous insufficiency: a late sequelae of four-compartment fasciotomy in the lower extremity?

Four-compartment fasciotomies used to relieve abnormally high compartment pressures necessitate interruption of the ensheathing fascial membrane. In the calf, this is considered an important component in maintaining a viable musculovenous pump and preventing venous hypertension, a leading cause of venous insufficiency. Through postoperative physical examination and photoplethysmography evaluation of 47 patients who underwent this procedure, no indication exists that division of the fascial component leads to calf pump dysfunction and chronic venous insufficiency. Of the patients studied, 92 per cent had unchanged musculovenous pump function upon photoplethysmography reevaluation at 19 weeks compared with the initial values recorded 6 weeks postoperatively; 6 per cent had improved venous flow, while only one of the 47 (2%) had venous recovery measurements consistent with diminished venous flow.

Supracondylar femoral extension osteotomy: its complications

Between 1979 and 1989, 105 supracondylar extension osteotomies of the femur were performed to correct knee flexion contractures. Disturbed by serious neurovascular complications, we reviewed our experience. Besides other complications, nine patients developed serious neurovascular complications; seven had permanent residua. There was no correlation between neurovascular complications and degree of preoperative contracture, patients' ages, or scarring from previous operation. We conclude that this osteotomy, although it appears to be technically simple, is potentially dangerous. We propose that the osteotomy be internally fixed and that the knee be flexed to relax the posterior neurovascular structures.