Results of a New Human Recombinant Thrombin for the Treatment of Arterial Pseudoaneurysm

Objective: To evaluate the results of a new thrombin sealant (Recothrom) for the treatment of arterial pseudoaneurysms (PDAs). Methods: We reviewed 47 consecutive patients prospectively entered in a dedicated data set who underwent ultrasound-guided percutaneous thrombin injection to treat PDA. End points were PDA recurrence, need for reintervention, and related complications such as limb ischemia or allergic reactions. Results: Twenty-six patients were females (55%) and the median age of the entire group was 71 years (range, 45-87). The mean size of the PDA was 2.3 ± 0.9 cm. The mean injected volume was 2.4 ± 1.4 mL containing 500 ± 320 units. Recurrence of the PDA occurred in 4 (8.5%) patients and was not related to anticoagulation status, body habitus, platelets levels, or use of antiplatelets. All recurred PDAs were successfully sealed with a second (n = 3) and a third injection (n = 1). There was no distal embolization or allergic reactions and no surgical intervention was required. Conclusion: The new human recombinant thrombin (Recothrom) is a safer nonimmunogenic option with similar success rates of other fibrin glue sealants.

Review of indications and practices of vena caval filters at a large university hospital

BACKGROUND

Vena caval filter (VCF) use has been increasing in recent years. Prophylactic VCF placement has been applied liberally in high-risk patients.

METHODS

Consecutive patients with VCF placement over a 2-year period at a university hospital were reviewed.

RESULTS

A total of 244 patients underwent VCF placement in 2 years. Of all, 54% of the patients had the VCF placed for an absolute indication, 14% for a relative indication, and 32% for prophylaxis. Only 14 (9%) of the retrievable filters were removed. Eight patients had a complication of VCF placement; there were no complications of filter retrieval. Vena caval filter placement for prophylaxis alone was 57% from the division of trauma and surgical critical care, 18.3% from interventional radiology department, and 5.2% from the division of vascular surgery.

CONCLUSIONS

This study indicates that many VCFs are placed for prophylaxis. A low percentage of VCFs was retrieved. This may be the practice at many other large university-based hospitals, necessitating strategies for reducing their placement.

How to diagnose giant cell arteritis

AIM

Current debate on how to diagnose giant cell arteritis (GCA) has strayed from the traditional approach of temporal artery biopsy and has instead explored the effectiveness of alternative imaging modalities.

METHODS

We have reviewed the literature and pooled published results for temporal artery imaging including magnetic resonance imaging (MRI), Duplex ultrasound, positron emission tomography-computed tomography (PET-CT) scan.

RESULTS

The results of this review show that ultrasound and MRI both represent viable options for evaluation of GCA; however utilizing ultrasound first may be the best first option in diagnostic tools. In 1990 the American College of Rheumatology offered criteria for positive pathology in GCA.

CONCLUSION

In this study, we propose a risk stratification criteria as well as an algorithm for the best diagnostic approach when GCA is suspected.

Splenic Vein Turndown Repair in Superior Mesenteric Vein Trauma: A Reasonable Alternative

Objective: To determine previous experience and results of autologous splenic vein graft repairs in traumatic superior mesenteric vein (SMV) avulsions. Design of Study: Systemic review was conducted for SMV trauma and methods of repair between 1897 and 2010. Articles were further analyzed for use of the splenic vein as an alternative conduit and were included in this study. Results: Of the 56 articles identified during our search, 4 included use of the splenic vein as an autologous vein graft. A total of 5 cases using the splenic vein turndown repair were identified in addition to our case. Of the 6 patients, 4 survived. Only one other case exists regarding the successful use of the splenic vein turndown technique in blunt abdominal trauma. Conclusion: There is little information regarding the feasibility and success of this technique in traumatic SMV disruption. Future studies are required to assess its role in abdominal vascular trauma.

Secondary chronic venous disease progresses faster than primary

PURPOSE

To compare the progression rate of primary with secondary chronic venous disease (CVD).

METHODS

Patients with a first episode of proximal deep vein thrombosis (DVT), diagnosed by duplex ultrasound (DU) were included in group A - secondary CVD (41 patients, 46 limbs). DU was performed at least once, 1 year after the diagnosis, and repeated at 5 years. Group B - primary CVD (41 patients, 50 limbs) included age- and sex-matched patients with primary CVD and duration of 5 to 10 years to be comparable with that of group A. They had no history of DVT and were referred for reflux evaluation. All their veins were free of postthrombotic signs upon DU examination. Group C (15 patients, 30 limbs) had no signs and symptoms of CVD and were examined at baseline and 5 years later. This group of patients was also matched for age and sex. Clinic examinations were performed at 3, 6, and 12 months and yearly thereafter. The CEAP system was used to grade disease severity. The proximal veins were divided in the CFV, FV, and POPV segments for analysis. Thrombosed veins were subsequently graded as complete, partial, and fully recanalized. Recurrent DVT cases were also recorded.

RESULTS

At 5-year follow-up, the prevalence of skin damage was significantly higher in group A (11/46 vs group B 3/50, P = .019 and vs group C 0/30, P < .01). The progression to skin damage in group A was faster as it changed from 4% (2/46) at 1 year (P = 0.014) compared with the two other groups. In group A, 22 limbs had reflux, three had obstruction, 19 had combine reflux and obstruction, and two were normal. In group B, superficial, deep, and perforator vein reflux were seen in 50, 4, and 15 limbs, respectively. In group C, five limbs in four patients developed superficial reflux in which only two had symptoms. The CEAP class in this group was C0N = 25, C1 = 3, and C2 = 2. In group A, skin damage was significantly higher in limbs with combined proximal and distal obstruction as well as in limbs with combined reflux and obstruction (P = .012 and P = 0.013, respectively). DVT was found in 108 segments (25 CFV, 40 FV, and in 43 POPV), 82 at the first episode and 26 as an ipsilateral recurrence. Ipsilateral and contralateral recurrences were seen in 21.9% and 9.8% of patients, respectively. Complete recanalization occurred in 43 segments, partial in 55, and none in 10. Reflux occurred in 85.5% and 60.5% of the partially and completely recanalized segments, respectively (P = .006).

CONCLUSIONS

The progression of CVD is more rapid in postthrombotic limbs when compared with those with primary CVD. The incidence of CVD in normal individuals is small and its progression is slow. Poor prognostic factors for progression to advanced CVD include the combination of reflux and obstruction, ipsilateral recurrent DVT, and multi-segmental involvement.

Venous Outflow Obstruction With Retroperitoneal Kaposi's Sarcoma and Treatment With Inferior Vena Cava Stenting

A 26-year-old man presented with acute renal insufficiency, and severe lower extremity swelling. Computed tomographic scan revealed retroperitoneal lymphadenopathy encasing both ureters and the inferior vena cava. He underwent placement of ureteral stents to relieve the obstruction and afterward underwent lymph node biopsy, which revealed Kaposi's sarcoma. He subsequently was diagnosed with acquired immunodeficiency syndrome. Abdominal and lower extremity venous duplex ultrasound did not show any evidence of deep vein thrombosis. The inferior vena cava measured 3.5 mm in diameter and was encased by retroperitoneal lymphadenopathy. Bilateral transfemoral venography and intravascular ultrasound demonstrated significant compression of the inferior vena cava below the renal veins. Endovascular treatment was followed with primary stenting under intravascular ultrasound guidance. His symptoms improved with reduction in swelling. At 1-year follow-up, the patient was ambulatory with mild symptoms, and on venography the iliac vein and inferior vena cava stents were widely patent.

Midterm Follow-up After Pharmacomechanical Thrombolysis for Lower Extremity Deep Venous Thrombosis

Objective: To provide follow-up in patients treated with pharmacomechanical thrombolysis (PhMT) for lower extremity deep venous thrombosis (DVT). Methods: Retrospective analysis of prospectively collected data. Patients underwent clinical evaluation, duplex ultrasound, venous clinical severity scoring, venous segmental disease scoring, and venous disability scoring. Results: Fourteen patients were available for evaluation. Median age was 40 years (19—58). Median follow-up was 24 months (13—69 months). Thirteen of 14 patients (93%) had a venous disability score < 1 and 13 of 14 patients (93%) had a venous clinical severity scoring < 5. In all but 1 patient the venous segmental disease scoring score was < 5. All iliac segments were patent, all but 3 patients had partial infrainguinal obstruction and 5 of 14 (36%) had reflux. Conclusions: Our data demonstrate that the good early clinical results after PhMT can be sustained on longer follow-up and may prevent the development of advanced postthrombotic syndrome.

Endovascular covered stenting for visceral artery pseudoaneurysm rupture: report of 2 cases and a summary of the disease process and treatment options

We present 2 cases of hemorrhage from a visceral artery pseudoaneurysm, managed successfully with endovascular covered stent placement. The first case was a 59-year-old man, 3 months after a laparoscopic distal pancreatectomy for adenoma, presenting with diffuse abdominal pain. The patient was evaluated with a computed tomography scan revealing a splenic artery pseudoaneurysm (PA) bleeding into a pancreatic pseudocyst. He was emergently taken to the angiography suite where a covered stent was deployed at the level of splenic artery PA. The second case was a 52-year-old woman with recurrent left retroperitoneal mass 5 years after distal pancreatectomy and splenectomy for a nonfunctional neuroendocrine tumor. She underwent resection of the mass in the left upper quadrant. Postoperative course was complicated by hematoma, abscess formation, reexploration, and repair of the duodenotomy and the portal vein. Subsequently, she was noted to have intermittent gastrointestinal hemorrhage, which prompted an angiogram revealing a hepatic artery PA that was repaired with a covered balloon-expandable stent. A completion angiogram was obtained in each case demonstrating exclusion of the PA. Our experience with these 2 cases supports the notion that endovascular covered stenting is a safe and effective therapy for exclusion of visceral artery aneurysm.

Endovascular repair of a symptomatic subclavian artery aneurysm in a patient with Marfan syndrome: a case report

Endovascular techniques are being employed with increasing frequency in the management of peripheral arterial aneurysms. A 57-year-old patient with Marfan syndrome presented with a symptomatic 5 cm left subclavian artery aneurysm. He underwent successful endovascular exclusion of the aneurysm with immediate improvement of his symptoms. Duplex ultrasound 3 months after the procedure confirmed a patent graft and complete exclusion of the aneurysm.

Heparin-independent mitogenicity in an endothelial and smooth muscle cell chimeric growth factor (S130K-HBGAM)

BACKGROUND

Through site-directed mutagenesis we have created a favorable fibroblast growth factor-1 (FGF-1) mutant (S130K) and linked it to a heparin-binding growth-associated molecule (HBGAM) to form the chimera S130K-HBGAM creating a heparin-independent, endothelial cell (EC)-specific mitogen.

METHODS

The proliferative responses of primary canine carotid artery smooth muscle cells (SMC) and jugular vein EC to FGF-1, S130K, or S130K-HBGAM, with and without heparin (5 U/mL), was quantitated by measuring tritiated thymidine uptake over 24 hours and expressing the results as percent of positive control (20% fetal bovine serum [FBS]) for group comparison.

RESULTS

Unlike FGF-1, both S130K and S130K-HBGAM are heparin-independent mitogens for EC and SMC. S130K-HBGAM was equivalent to FGF-1 with heparin at 6 nmol/L. S130K-HBGAM did not demonstrate relative EC specificity in this assay.

CONCLUSIONS

At higher concentrations, S130K-HBGAM is a potent, heparin-independent EC and SMC mitogen. Co-culture assays and in vivo delivery models may demonstrate EC specificity not identified in this single cell type proliferation assay.

Predictors of Early Discharge following Open Abdominal Aortic Aneurysm Repair

Patients undergoing endovascular abdominal aortic aneurysm (AAA) repair have lower perioperative morbidity and leave the hospital earlier than patients undergoing open repair. However, potential complications require continuous surveillance of endografts and there are few data regarding their long-term fate. If an open operation were well tolerated, this might be a preferable alternative. The purpose of this study was to identify patients with lower morbidity and shorter hospital stay following open AAA repair and to analyze factors that might point to open repair as the preferred approach. We performed a retrospective review of all patients who underwent AAA repair between 1995 and 2000 at our institution. All patients with ruptured aneurysms and those that required renal, celiac, or superior mesenteric reconstructions during the AAA repair were excluded. Patient demographics, preoperative comorbid conditions, intraoperative data, and postoperative complications were analyzed in detail. A total of 115 patients fulfilled the inclusion criteria. There was only one perioperative death (0.9%). The mean hospital stay was 8.1 days. A history of chronic obstructive pulmonary disease (COPD) and longer operative time were independent factors associated with prolonged hospital stay. Forty-one patients (35.6%) left the hospital in 5 or less days. Compared to the group with hospital stay >5 days, these patients had a lower incidence of COPD (7.3% vs. 25.7%, p < 0.05) and smaller-size AAAs (5.6 vs. 6.4 cm, p < 0.0001), and were more often operated on via a retroperitoneal approach (61% vs. 40.5%, p < 0.05). Their time in the operating room was less (3.5 vs. 4.5 hr, p < 0.0001), and they had less estimated blood loss (750 vs. 1500 cc, p < 0.001) and fewer transfusions (0.95 vs. 2.45 units, p < 0.0001). Patients without COPD and smaller AAAs that can be repaired via a retroperitoneal approach have a lower incidence of perioperative complications and a shorter hospital stay following open AAA repair. Until long-term results for endografts are available, our data suggest that these patients are well served with an open repair.

Definition of venous reflux in lower-extremity veins

PURPOSE

This prospective study was designed to determine the upper limits of normal for duration and maximum velocity of retrograde flow (RF) in lower extremity veins.

METHODS

Eighty limbs in 40 healthy subjects and 60 limbs in 45 patients with chronic venous disease were examined with duplex scanning in the standing and supine positions. Each limb was assessed for reflux at 16 venous sites, including the common femoral, deep femoral, and proximal and distal femoral veins; proximal and distal popliteal veins; gastrocnemial vein; anterior and posterior tibial veins; peroneal vein; greater saphenous vein, at the saphenofemoral junction, thigh, upper calf, and lower calf; and lesser saphenous vein, at the saphenopopliteal junction and mid-calf. Perforator veins along the course of these veins were also assessed. In the healthy volunteers, 1553 vein segments were assessed, including 480 superficial vein segments, 800 deep vein segments, and 273 perforator vein segments; and in the patients, 1272 vein segments were assessed, including 360 superficial vein segments, 600 deep vein segments, and 312 perforator vein segments. Detection and measurement of reflux were performed at duplex scanning. Standard pneumatic cuff compression pressure was used to elicit reflux. Duration of RF and peak vein velocity were measured immediately after release of compression.

RESULTS

Duration of RF in the superficial veins ranged from 0 to 2400 ms (mean, 210 ms), and was less than 500 ms in 96.7% of these veins. In the perforator veins, regardless of location, outward flow ranged from 0 to 760 ms (mean, 170 ms), and was less than 350 ms in 97% of these veins. In the deep veins, RF ranged from 0 to 2600 ms. Mean RF in the deep femoral veins and calf veins was 190 ms, and was less than 500 ms in 97.6% of these veins. In the femoropopliteal veins, mean RF was 390 ms, and ranged from 510 to 2600 ms in 21 of 400 segments; however, RF was less than 990 ms in 99% of these veins. Duration of RF was significantly longer in all three veins systems in patients (P <.0001 for all comparisons). With a cutoff value of more than 1000 ms rather than more than 500 ms, prevalence of abnormal RF in the femoropopliteal veins was significantly reduced, from 29% to 18% (P =.002). Thirty-seven vein segments (2.4%) had RF greater than 500 ms in the supine position, compared with less than 500 ms in 22 of these vein segments (59%) in the standing position. Of the 48 vein segments (3.1%) with RF greater than 500 ms in the standing position, RF was less than 500 ms in 6 of these vein segments (13%) in the supine position. Similar observations were noted in patient veins. There was no association between RF and peak vein velocity. Peak vein velocity had no significance in determining reflux.

CONCLUSIONS

The cutoff value for reflux in the superficial and deep calf veins is greater than 500 ms. However, the reflux cutoff value for the femoropopliteal veins should be greater than 1000 ms. Outward flow in the perforating veins should be considered abnormal at greater than 350 ms. Reflux testing should be performed with the patient standing.

Distal venous arterialization for limb salvage--a case report

The reperfusion of an ischemic limb in the absence of suitable target artery remains a formidable task. The authors report a case of an ischemic limb in patient whose distal arteries were identified intraoperatively as unsuitable for conventional revascularization. A distal arteriovenous fistula was created between the already arterialized in situ greater saphenous vein conduit and the inframalleolar superficial venous system of the foot. The flow through the superficial venous system salvaged the limb and continues to perfuse the foot 4 years post-operatively with resolution of rest pain.

Hypotension during septic shock does not correlate with exhaled nitric oxide in anesthetized rat

Sepsis is characterized by hypotension, acidosis, and increased nitric oxide (NO) production. The role of NO in the development of sepsis-related hypotension is still unclear. The relationship among exhaled nitric oxide (ENO), arterial blood pressure (BP), and pH after administration of lipopolysaccharide (LPS) and tumor necrosis factor alpha (TNFalpha) was investigated in anesthetized rats. Forty-three adult male Sprague-Dawley rats were randomized into five groups: group 1 (C, n = 8) received normal saline; group 2 (LPS-I, n = 8) received Escherichia coli (LPS) 10 mg/kg intravenously (i.v.); group 3 (LPS-h, n = 10) received 100 mg/kg LPS i.v.; group 4 (n = 9) was treated with 100 mg/kg i.v. aminoguanidine (AG) 1 h after receiving 100 mg/kg i.v. LPS; group 5 (TNFalpha, n = 8) received 1 microg recombinant rat TNFalpha i.v.. ENO, BP, and pH were measured every 30 min for 4 h whereas arterial blood gases and pH were measured every hour. LPS administration induced a dose-related increase in ENO and a dose-related decrease in BP and pH. AG blocked the increase in ENO after LPS but had minimal effect on BP and pH. TNFalpha administration increased ENO without changing BP and pH. In LPS-treated rats, no significant correlation was found between ENO and BP (r2 = 0.13, P= ns). However, there was a significant correlation between pH and BP (r2 = 0.7, P < 0.01). Our results suggest that, in this animal model, ENO may not be a key mediator in the development of systemic hypotension during sepsis, while acidosis may significantly contribute to it.

Nonsaphenous superficial vein reflux

BACKGROUND

Information on nonsaphenous superficial venous reflux is lacking. This study was designed to determine the prevalence of reflux in nonsaphenous veins, their association and correlation with risk factors, and signs and symptoms of chronic venous disease (CVD).

METHODS

Information on 835 limbs in patients with signs and symptoms of CVD were prospectively entered into a customized database. These patients had been referred from the venous clinic to the vascular laboratory for color-flow duplex scanning evaluation of the lower-limb veins. All patients were examined for reflux in the standing and sitting positions. Nonsaphenous reflux was defined as that in superficial veins that are not part of the greater or lesser saphenous systems. Particular attention was paid to the patterns of reflux and anatomy of the nonsaphenous veins from the proximal to the distal ends, including their connections with the saphenous and deep veins.

RESULTS

Nonsaphenous venous reflux was found in 84 limbs (10%) of 72 patients, 67 of whom were women. The mean number of pregnancies in these patients was higher than that of 100 randomly selected women with saphenous reflux (3.2 vs 2.2). According to CEAP classification, 90% of the limbs were in CVD classes 1 through 3 and only 10% had skin damage (classes 4-6). Symptoms were present in 67 limbs (80%). Forty-two limbs (50%) had reflux in tributaries of lateral, posterior, and medial thigh. These veins were connected with perforators uniting with the deep femoral, femoral, and muscular veins of the thigh in 36 limbs. Reflux in these perforators was detected in 19 limbs. Reflux arising from the pelvic veins was found in 29 limbs (34%), 18 of which were from vulvar veins medial to saphenofemoral junction and 11 of which were from veins in the gluteal area. Incompetent veins from the sciatic nerve were found in nine limbs (10%). Reflux in the vein of the popliteal fossa was found in seven limbs (8%). Reflux in knee tributaries was detected in three limbs (4%), two of which were connected with posterolateral knee perforators and one with the posterior tibial nerve veins.

CONCLUSIONS

The prevalence of nonsaphenous reflux in our practice was 10%. The vast majority of these patients (93%) were women with a mean of 3.2 pregnancies. Ninety percent of these limbs have signs and symptoms assigned to CVD classes 1 to 3. These data may simply reflect the referral pattern, but also a possible association with female sex and number of pregnancies. The unusual anatomy of these veins stresses the importance of color-flow duplex scanning before surgery.

Nutritional support in the patient with HIV infection

Weight loss and malnutrition are the most common symptoms associated with active infection with human immunodeficiency virus. The origin of the malnutrition is considered multifactorial and broadly includes decreased nutrient intake, nutrient malabsorption, and metabolic alterations. Steady advances have been made in understanding the mechanisms underlying weight loss in these patients. The utility and optimal modes of nutrition support have not yet been fully established.

Angiogenic mechanisms of endothelialization of cardiovascular implants: a review of recent investigative strategies

Both cardiovascular implants and therapeutic interventions on native arteries fail due to biologic responses occurring at the blood/prosthesis/arterial wall and tissue/prosthesis/arterial wall interfaces, resulting in the failure modes of thrombosis and myointimal hyperplasia. Systemic pharmacologic approaches including use of anti-coagulant and anti-platelet agents have significant untoward side effects and have not resulted in a dramatic impact on failure modes in many applications, including small diameter vascular grafts. Local delivery of therapeutic agents via surface attachment with defined release kinetics may alter thrombogenicity and/or myointimal hyperplasia. Therapeutic agents may include a spectrum of biologic agents from peptides to endothelial cells. Efficient attachment and release of these agents in biologically active form is dependent upon improved methods of surface modification. The intended action of the biologic agent may similarly be impacted by the surface and bulk characteristics of the underlying biomaterial. It is often assumed, without concrete data. that surface re-endothelialization may have a beneficial impact on both thrombogenicity and myointimal hyperplasia. New clinical data on endothelial cell seeding has been supportive. Spontaneous re-endothelialization may be stimulated via an induced directed angiogenesis resulting in trans-interstitial capillarization and surface endothelialization. Recent advances in therapeutic angiogenesis have suggested the power of angiogenic factors to induce neovascularization of ischemic tissue beds. These concepts have been used to surface modify prosthetic devices with either VEGF or FGF and both in vitro and animal data suggest a potent stimulation of surface re-endothelialization. Neither of these growth factors is likely to be ideal. VEGF is relatively endothelial cell specific but is a relatively weak endothelial cell mitogen. FGF-1 and FGF-2 are more potent mitogens but are less cell specific. Recent work has led to the generation of mutant growth factors via site-induced mutagenesis and results of several such FGF mutants on endothelial cell and smooth muscle cell proliferative response have been studied. The use of 'designer growth factors' on cardiovascular implants and on manipulated native vessels may have a significant positive impact on re-endothelialization and thereby on the failure modes of thrombosis and myointimal hyperplasia.

Construction and biological characterization of an HB-GAM/FGF-1 chimera for vascular tissue engineering

OBJECTIVE

Cardiovascular tissue engineering approaches to vessel wall restoration have focused on the potent but relatively nonspecific and heparin-dependent mesenchymal cell mitogen fibroblast growth factor 1 (FGF-1). We hypothesized that linking FGF-1 to a sequence likely to bind to cell surface receptors relatively more abundant on endothelial cells (ECs) might induce a relative greater EC bioavailability of the FGF-1. We constructed a heparin-binding growth-associated molecule (HB-GAM)/FGF-1 chimera by linking full-length human HB-GAM to the amino-terminus of human FGF-1beta (21-154) and tested its activities on smooth muscle cells (SMCs) and ECs.

METHODS

Primary canine carotid SMCs and jugular vein ECs were plated in 96-well plates in media containing 10% fetal bovine serum and grown to approximately 80% confluence. After being growth arrested in serum-free media for 24 hours, the cells were exposed to concentration ranges of cytokines and heparin, and proliferation was measured with tritiated-thymidine incorporation. Twenty percent fetal bovine serum was used as positive control, and phosphate-buffered saline was used as negative control.

RESULTS

In the presence of heparin the HB-GAM/FGF-1 chimera stimulated less SMC proliferation than did the wild-type FGF-1 with a median effective dose of approximately 0.3 nmol versus approximately 0.1 nmol (P <.001). By contrast, the chimera retained full stimulating activity on EC proliferation with a median effective dose of 0.06 nmol for both cytokines. Unlike the wild-type protein, the chimera possessed heparin-independent activity. In the absence of heparin, the chimera induced dose-dependent EC and SMC proliferation at 0.06 nmol or more compared with the wild-type FGF-1, which stimulated minimal DNA synthesis at 6.0-nmol concentrations.

CONCLUSIONS

The HB-GAM/FGF-1 chimera displays significantly greater and uniquely heparin-independent mitogenic activity for both cell types, and in the presence of heparin it displays a significantly greater EC specificity.

Prevalence of deep venous reflux in patients with primary superficial vein incompetence

PURPOSE

This prospective study was designed to determine the prevalence of deep reflux and the conditions under which it may occur in patients with primary superficial venous reflux and absence of deep venous thrombosis (DVT).

METHODS

We studied 152 limbs in 120 consecutive patients in the standing position who had superficial venous reflux with color flow duplex scanning. Limbs with documented evidence of DVT or post-thrombotic vein wall changes during the examination were studied but not included in the analysis. Limbs were divided into those that had at least reflux in the saphenofemoral, the saphenopopliteal, or the gastropopliteal junction and into those with nonjunctional reflux in the superficial and gastrocnemial veins. Peak velocity and duration of reflux were measured. To examine the recirculation theory, we tested the deep veins by occluding and refluxing saphenous veins 10 cm below the sampling site.

RESULTS

Thirteen limbs in 11 patients (9%) were excluded because of previous DVT. Of the remaining 139 limbs, 106 (76%) had junctional reflux. Saphenofemoral junction was involved in 89 limbs (84%), saphenopopliteal junction in 18 (17%), and gastropopliteal junction in 7 (4%). In 33 limbs (24%), reflux was detected in the main trunk or tributaries of the saphenous veins alone with no junctional incompetence. Femoral or popliteal reflux was present in 31 limbs (22%). This reflux was segmental in 27 limbs, and it was limited in the junction in 24 limbs. The mean duration of deep venous reflux was 0.9 seconds, it ranged from 0.6 to 3.7 seconds, and it was significantly shorter than that in the superficial veins (2.6 seconds; P <.0001). In the absence of junctional reflux, the prevalence of deep venous insufficiency (DVI) was significantly lower compared with that in limbs with junctional involvement (2 of 33 vs 29 of 106; P =.038). The mean duration of deep venous reflux in these groups was comparable (0.85 seconds vs 0. 91 seconds; P =.44). Occlusion of the incompetent superficial veins reduced somewhat the duration of the deep venous reflux but did not abolish it (0.88 seconds vs 0.82 seconds; P =.072). The presence of DVI was associated with junctional reflux of high peak velocity and long duration.

CONCLUSIONS

The prevalence of DVI in patients with primary superficial venous reflux and without history of DVT is 22%. However, this reflux is segmental, mainly in the common femoral vein, and is of short duration. It is associated with the presence of junctional incompetence that has a high peak velocity and long duration. These findings may explain why surgical correction of superficial reflux abolishes DVI.

Current concepts in chronic venous ulceration

OBJECTIVES

despite numerous reports on the distribution of reflux in patients with venous ulceration, there is no consensus on the contribution of each venous system. This study was performed to evaluate the distribution of reflux in this group of patients.

METHODS

a literature search from 1980 to 1998 was performed. Because duplex scanning is the best method for detecting venous reflux, we only included reports that used this diagnostic modality. All studies with less than 30 ulcerated limbs were excluded. Since most reports did not give detailed data on perforator veins, reflux in these veins was combined with the superficial and deep veins. Documented episodes of superficial or deep vein thrombosis were noted.

RESULTS

thirteen studies that included 1249 ulcerated limbs fulfilled the inclusion criteria. The mean age of patients was 59 years (95% CI: 54-63, range: 14-93). Reflux was detected in 1153 (92%) of limbs. Reflux confined to the superficial veins alone was seen in 45% of limbs, in the deep veins alone in 12% and in both the superficial and deep veins in 43% of limbs. The overall involvement of the superficial veins was 88% and of the deep veins 56% (p <0. 0001). A documented episode of deep vein thrombosis was reported in only six of the 13 studies and the incidence was found to be 32%.

CONCLUSIONS

reflux in the superficial veins is seen in 88% of limbs with venous ulcers (CEAP classes 5 and 6). Isolated superficial vein incompetence is detected in 45%, while reflux in the deep venous system alone is seen in only 12%. These data have significant clinical implications, since reflux in the superficial system can be easily eliminated by excision of the affected veins.