Rheolytic thrombectomy with distal filter embolic protection as adjunctive therapies to high-risk saphenous vein graft intervention

Percutaneous intervention of saphenous vein graft (SVG), especially those with heavy atherothrombotic load, presents high risk for distal embolization and no-reflow. Using the distal filters alone may occasionally be disadvantageous because of the large debris burden and the inability to assess the underlying culprit lesions and vessel size accurately. We present a case of intervention of an occluded SVG using a combination of rheolytic thrombectomy and distal filter embolic protection as a pretreatment before stenting. This strategy has the potential to reduce further the risk of no-reflow and to provide visualization for proper assessment of the underlying anatomy especially in clot-laden vessels.

[Endovascular therapy of truncal varicose veins of the lower extremities with a diode laser]

The authors present their experiences with new miniinvasive treatment of varicose veins--endovenous diode laser system. The results of 60 procedures treating truncal varices are reported with special concern to percutaneous access technique under ultrasound guidance. This new concept based on haemodynamic ultrasound findings is compared to the traditional surgical technique of cross-sectomy and stripping.

The StethoDop: a Doppler stethoscope attachment for investigation of arterial and venous insufficiency of the lower extremities

BACKGROUND

The aim of the current study was to investigate whether the StethoDop can serve as a valid and reproducible instrument for measuring the ankle-brachial index (ABI) and assessing venous reflux, even when used by inexperienced investigators, in comparison with the classic Doppler.

METHODS

I) During four weeks, four ankle-brachial index (ABI) measurements were performed on 44 patients: one measurement with the classic Doppler by an experienced investigator, one with the classic Doppler by an inexperienced investigator and two measurements with the StethoDop by the inexperienced investigator. II) 36 patients were screened for venous insufficiency by detecting venous reflux with the StethoDop and classic Doppler at the saphenofemoral and saphenopoplitial junctions by an inexperienced investigator. The results were compared with the results of the duplex as gold standard and with the results of the examination by an experienced dermatologist with the classic Doppler.

RESULTS

I) The confidence interval of ABI measurement for both the classic Doppler and the StethoDop by the inexperienced investigator was within an acceptable +/- 0.21 interval of significant change. II) For venous reflux determination, the overall sensitivity and specificity of the StethoDop were comparable with the sensitivity and specificity of the classic Doppler: sensitivity 76.0 and 75.0%, specificity 94.8 and 94.2%, respectively. The positive predictive value of the StethoDop, compared with the duplex, was 87.5%; the negative predictive value was 90.0%.

CONCLUSION

I) For ABI measurement, the StethoDop is a valid instrument with reproducible results, even when used by inexperienced investigators. II) For venous reflux determination, the StethoDop is a valid screening instrument for venous insufficiency. However, as with determination with the classic Doppler, the reflux assessment by StethoDop gives no information about the deep veins and may miss up to 24% of apparent reflux.

The lateral accessory saphenous vein - a common cause of recurrent varicose veins

BACKGROUND

Varicose veins commonly recur after surgery and present a large burden to the NHS. The aim of this study was to demonstrate that the lateral accessory saphenous vein is the commonest cause of groin recurrence of varicose veins and we discuss a possible anatomical reason for this.

PATIENTS AND METHODS

The case notes of all patients presenting to two vascular surgeons with recurrent varicose veins over a 3-year period were studied. All limbs were assessed by duplex ultrasound scanning. These scans were reviewed to identify the site of recurrence. When recurrence occurred in the groin, the scans were further evaluated to identify the cause of groin recurrence.

RESULTS

A total of 216 limbs in 186 patients were evaluated over a 36-month period. Of these, 141 (65%) demonstrated a recurrence in the groin: 56 (26%) recurrences were due to either incompetent thigh or calf perforators and there were 19 (9%) cases of saphenopopliteal or short saphenous vein incompetence. Out of 141 groin recurrences, 61 (43%) were due to a persistent lateral accessory saphenous vein.

CONCLUSIONS

The lateral accessory saphenous vein is the commonest cause of recurrence in the groin of varicose veins. It should be looked for specifically during pre-operative assessment duplex scanning and at primary surgery. If identified at operation, we believe it should be either stripped or avulsed to reduce the risk of recurrence.

Factors affecting saphenous vein graft patency: clinical and angiographic study in 1402 symptomatic patients operated on between 1977 and 1999

BACKGROUND

The purpose of this study was to find the preoperative and intraoperative factors that affect vein graft patency.

METHODS

A total of 3715 graft angiograms in 1607 patients were studied for recurrence of angina. The preoperative patient characteristics and intraoperative variables were prospectively collected from patients who had primary coronary artery bypass grafting during the period from 1977 to 1999. A total of 1339 (83%) patients were male, with a mean age of 59 years. The mean period from operation to reangiogram was 99 months. The saphenous vein was grafted to the left anterior descending artery in 557 (15%), to the diagonal artery in 669 (18%), to the obtuse marginal artery in 1300 (35%), to the right coronary artery in 409 (11%), and to the posterior descending artery in 780 (21%) cases. Graft failure was defined as >or=80% stenosis.

RESULTS

During the course of the study, 2266 (61%) grafts were patent, and 1449 (39%) had failed. The patient variables that significantly reduced graft patency were a younger age (P <.001) and an ejection fraction <30% (P =.047). Operative variables associated with reduced graft patency were small coronary artery diameter (P <.001), large conduit diameter (P =.001), and the coronary artery grafted (lowest patency in the right coronary artery and maximum patency in the left anterior descending artery territory; P =.002). The interval from operation to repeat angiogram (P <.001, with 78% patent at 1 year, 78% at 5 years, 60% at 10 years, and 50% at 15 years) and the year in which the operation was performed (more recent operations had better patency; P <.001) significantly affected graft patency.

CONCLUSIONS

Saphenous vein graft patency improved over the course of the study. The best results were obtained in older patients with good left ventricular function. Large-caliber arteries on the left system, when grafted with a small-diameter vein, were associated with the best outcome.

[Diagnosis and treatment of postoperative recurrences of varicosity]

The aim of the present work was to study the causes of post-operative recurrences of varicosity and to define approaches to their optimal correction. Duplex scanning (DS) with Color Doppler Imaging of the blood flow was used to examine 126 patients (136 extremities) with recurrences of varicosity. The patients were distributed according to the CEAP clinical classification. Altogether 76 patients (78) extremities with recurrences of varicosity were operated on. 27 persons received different variants of sclerotherapy including echoscleroobliteration. According to the DS data, the most frequently obtained finding in patients with recurrences of varicosity was identification of the perforating veins with valvular insufficiency, namely in 120 (or in 88.2%) extremities. The long stump of the greater saphenous vein (CSV) was discovered in 86 (63.2%) extremities, the long stump of the lesser saphenous vein (LSV) in 6 (4.4%), ectasia of LSV trunk was recognised in 20 (14.5%), incompetence of the valves of the sural veins in 12 (8.8%) extremities. Incompetence of the valves of the deep veins was present in 73 (53.6%) patients. No sources of pathological veno-venous runoff were identified in 12 (8.1%) cases. A good agreement was established between the incidence of valvular incompetence of the deep veins and the disease severity. The indications for surgical correction of valvular insufficiency were worked out. It has been demonstrated that sclero-obliteration is the method of choice in the treatment of the recurrences of varices. The long-term results of operations for recurrences of varicosity were followed up in 62 patients over the period of one to 15 years. Good and satisfactory results were obtained in 60 (96.8%) cases. The authors believe that the majority of varicosity recurrences arise from an inadequate assessment of the status of lower extremity venous bed as well as from technical and methodological faults of the operating surgeon. DS in an indispensable component of preoperative examination of patients with varicosity recurrences.

Early Experience with Radiofrequency Ablation of the Greater Saphenous Vein

Radiofrequency ablation of the greater saphenous vein (GSV) has been proposed as an alternative to conventional ligation and stripping in the treatment of varicose veins. We have reviewed our initial experience with this new technology in 28 procedures on 24 patients. Preoperative duplex scans confirmed venous valvular incompetence of the GSV in all patients. Intraoperative ultrasound was used to measure the depth of the GSV, to precisely place the radiofrequency catheter adjacent to the saphenofemoral junction, and to confirm the results of the ablative procedure. Occlusion of the GSV was seen on 96% of completion scans and in all patients within 1 week of the procedure. Duplex scans were available for 21 limbs at 3 months and for 3 at 1 year. Persistent occlusion was documented in all cases. No patient had paresthesias or thermal skin injury. Two patients had transient superficial thrombophlebitis around the knee in a treated segment of the GSV. One patient was found to have extension of an asymptomatic, nonocclusive thrombus into the common femoral vein on a routine scan 3 days after surgery. Postoperative patient questionnaires showed that 96% of respondents were very satisfied with the procedure. Radiofrequency ablation of the GSV appears to be a safe alternative to conventional stripping and ligation. Subjective assessment by the surgeons suggests an earlier return to work and active lifestyle compared to traditional extirpative techniques. Longer follow-up is required to establish the durability of the procedure.

Duplex ultrasound scan findings two years after great saphenous vein radiofrequency endovenous obliteration

OBJECTIVE

To assess the clinical and duplex ultrasound scan findings in the groin and thigh 2 years after great saphenous vein (GSV) radiofrequency endovenous obliteration (RFO).

METHODS

Sixty-three limbs in 56 patients with symptomatic varicose veins and GSV incompetence were treated with RFO, usually with adjunctive stab-avulsion phlebectomies, and examined at a median follow-up of 25 months, by using a color-coded, duplex sonography protocol that mandated views in at least two planes of the saphenofemoral junction (SFJ) and its tributaries and at three GSV levels in the thigh.

RESULTS

The commonest duplex finding in the groin was an open, competent, SFJ with a < or =5-cm patent terminal GSV segment conducting prograde tributary flow through the SFJ (82%). Despite the presence of a total of 104 patent junctional tributaries, SFJ reflux was uncommon, affecting only five limbs. GSV truncal occlusion was observed in 90% of treated GSVs. Limited segmental treatment was successful in three limbs with a midthigh reflux source well below competent terminal and subterminal valves. Six GSV trunks had partial or no occlusion, but only one refluxed. These were anatomical RFO failures (9.5%) but were clinically improved, including the refluxing limb. Neovascularity was not identified in any groin. Thigh varicosities were observed in 12 limbs, including telangiectasias and isolated small tributary branches. New varicosities, linked to refluxing thigh perforators (two), or patent SFJ tributaries (three), were present in five limbs.

CONCLUSION

RFO is the ideological opposite of high ligation without GSV stripping. It leaves physiologic tributary flow relatively undisturbed, does not incite groin neovascularity, eliminates the GSV as a refluxing conduit in >90% of limbs and has a 2-year, postadjunctive phlebectomy varicosity prevalence of 7.9%, with symptom score improvement in 95% of limbs with an initial score higher than zero.

Early ostial saphenous vein graft stenosis associated with the use of Symmetry sutureless aortic proximal anastomosis device: Successful percutaneous revascularization

A recent advance in technology permits the creation of sutureless proximal aortic anastomosis during coronary artery bypass graft surgery. This new tool has significant potential benefit by minimizing aortic manipulation with subsequent reduction in neuroembolization. Implantation of a nitinol-based proximal aortic connector (Symmetry) has a potential to elicit intimal hyperplastic reaction analogous to restenosis after coronary stent placement. We report cases of early vein graft stenosis in association with the use of the Symmetry device. Three patients suffered from severe ostial stenosis within 6 months of bypass surgery with symptomatic presentation. Of these three patients, two underwent successful percutaneous revascularization. Fluoroscopic star-shaped appearance of the metallic Symmetry allows device recognition during angiography. We review current data regarding graft patency with the use of Symmetry device and discuss technical issues to address specific problems during percutaneous revascularization.

Factors predictive of venous thrombotic complications in patients with isolated superficial vein thrombosis

OBJECTIVE

Superficial vein thrombosis may be complicated with venous thromboembolism. We examined factors predictive of venous thromboembolism in superficial vein thrombosis, which, to our knowledge, had not been prospectively studied before.

DESIGN AND METHODS

We performed post hoc analysis of the STENOX trial, a prospective randomized controlled trial that investigated various antithrombotic therapies in 427 hospitalized patients with objectively confirmed symptomatic isolated superficial vein thrombosis. The value of various baseline characteristics as predictive factors of venous thrombotic complications at 3 months was studied with logistic regression. Venous thrombotic complications were defined as deep vein thrombosis or pulmonary embolism, or recurrence or proximal extension of superficial vein thrombosis.

RESULTS

Venous thrombotic complications occurred in 78 patients. Independent predictive factors for complications were superficial vein thrombosis of recent onset (odds ratio [OR], 3.01; 95% confidence interval [CI], 1.44-6.27), severe chronic venous insufficiency (OR, 2.75; CI, 1.10-6.89), male gender (OR, 2.17; CI, 1.28-3.68), and history of venous thromboembolism (OR, 2.07; CI 1.06-4.04). Deep vein thrombosis or pulmonary embolism occurred in 19 patients. Only severe chronic venous insufficiency was an independent predictor of this complication (OR, 4.50; CI, 1.30-15.61).

CONCLUSIONS

After symptomatic isolated superficial vein thrombosis, venous thrombotic complications are relatively frequent, and are more likely to occur in men, in patients with a history of venous thromboembolism or with severe chronic venous insufficiency, or in whom superficial vein thrombosis is recent. Knowledge of such predictive factors may be useful for determining appropriate treatment in patients with superficial vein thrombosis and for designing future phase III clinical trials.

Endovenous Laser Surgery of the Incompetent Greater Saphenous Vein With a 980-nm Diode Laser

BACKGROUND

In recent years, the minimal endoluminal invasive alternatives against surgical ligation and stripping for the treatment of incompetent greater saphenous vein (GSV) have been explored. Endovenous laser surgery is one of these endoluminal alternatives, and its clinical results are being reported at up to 3 years.

OBJECTIVE

To evaluate the safety and efficacy of a 980-nm diode laser for the elimination of the incompetent GSV.

METHOD

Fifteen limbs in 12 patients with incompetent GSV were treated via an endovenous route with a 980-nm laser under local anesthesia in an outpatient setting. The effects were evaluated clinically along with duplex ultrasound at 1, 4, and 12 weeks after the treatment to determine efficacy and possible complications.

RESULTS

Complete occlusion and retraction of treated GSV in all patients were observed during the 12 weeks of the postoperative period. There have been no significant complications to be concerned.

CONCLUSION

The endovenous 980-nm diode laser surgery is a relatively simple, safe, office-based procedure that is expected to promise favorable results while a long-term follow-up is awaited.

[Varicose vein recurrence after surgery of the sapheno-femoral junction: color Doppler ultrasonography study]

The aim of this study was to evaluate the accuracy and sensitivity of colour Doppler ultrasonography for the diagnosis of postoperative recurrent varicose veins in patients submitted to surgical ligation of the saphenofemoral junction with a view to classifying the recurrences according to the causes. We studied 401 lower limbs in the orthostatic position with colour Doppler ultrasonography in 318 patients (64 M and 254 F) presenting postoperative varicose vein recurrence during the follow-up (12-60 months). We evaluated the type of reflux at the inguinal level under the Valsalva manoeuvre and divided them into 5 types. We observed an incomplete crossectomy (type 1) in 23.2% of the cases; an incontinent saphenofemoral junction, intact and in an anatomical site in 12.5% (type 2); a major tributary (double saphena) originating from the common femoral vein near to the crossectomy site in 10.2% (type 3); neovascularization in 9.7% (type 4) and the presence of a number of major tributaries from the veins of the perineal and pudendal region or from the abdominal parietal veins in 44.4% (type 5). In all cases it was possible to note and classify the type of recurrence. Colour Doppler ultrasonography is an accurate, reliable tool for the diagnosis and classification of postoperative varicose vein recurrences in patients submitted to surgical obliteration of the saphenofemoral junction. It is decisive in the preoperative evaluation and follow-up of patients. In our experience, more than one half of the cases of recurrence were not due to an error of surgical technique.

Combined distal embolization protection and rheolytic thrombectomy to facilitate percutaneous revascularization of totally occluded saphenous vein grafts

Totally occluded saphenous vein grafts are difficult to treat percutaneously with a higher likelihood of distal embolization and slow-flow or no-reflow during percutaneous interventions. The PercuSurge system, which utilizes a distal balloon occlusive device, has been shown to improve clinical outcomes during saphenous vein graft (SVG) interventions. This device may not be optimal in the setting of heavy thrombus or debris burden, a situation frequently encountered in totally occluded SVGs. Rheolytic thrombectomy facilitates percutaneous interventions by effectively removing intraluminal thrombus and debris but lacks distal embolization protection. We report our experience with the synergistic use of balloon-based distal embolization protection (PercuSurge) and rheolytic thrombectomy (AngioJet) to optimize percutaneous revascularization of totally occluded SVGs.

[Short saphenous vein incompetence as a cause of recurrent varicose veins]

The aim of the study was the retrospective ultrasound Doppler evaluation the patients with recurrent varicose veins after surgery of the short saphenous vein incompetence. This study was performed in 35 patients (42 limbs). Mean interval between the time of operation and ultrasound Doppler evaluation was 4.9 years. The causes of the recurrence were divided due to F. Vin and F. Chleir classification. Recurrences were classified in five categories. The main causes of recurrence were: the remains of the short saphenous vein in primary operation (52.3%) and junctional stump with incontinent collaterals (26.1%).

CONCLUSIONS

The recurrence of varicose veins is mostly associated with incompetence of short saphenous vein. The colour-coded duplex sonography is a modern tool in preoperative diagnostics of anatomical variety of short saphenous vein and in establishing the cause of the recurrence. USG evaluation could make precise operation easier and in a case of recurrence helps to eliminate the origin of reflux.

Assessment of sapheno-femoral junction continence in patients with primary adolescent varicocoele

BACKGROUND

Although there is much evidence supporting a relationship between primary varicocoele and venous incompetence of the saphenofemoral junction in adults, there is no evidence for such a relationship during adolescence. Because of the effect of age and future occupation (standing upright for long periods) on the aetiology, pathogenesis and frequency of varicose veins of the lower extremity and incompetence of saphenofemoral junctions in adulthood, a comparison during adolescence is appropriate.

OBJECTIVE

On the basis of a close physiopathological and haemodynamic relationship between primary varicose veins and primary varicocoele, we decided to evaluate the competence of the saphenofemoral junctions in a selected group of adolescents affected by primary varicocoele and compare these results with age-matched healthy adolescents.

MATERIALS AND METHODS

Twenty-five adolescents with primary varicocoele and 23 age-matched healthy controls were included in the study. In all cases physical examination and colour Doppler US was used to diagnose or exclude the presence of primary varicocoele and to evaluate the continence of the saphenofemoral junction.

RESULTS

On the right side, 10 of 25 varicocoele patients and on the left side 11 of 25 varicocoele patients had incompetence of the saphenofemoral junction. For the control patients the incidence was 2/23 on the right side and 4/23 on the left side. The difference is statistically significant.

CONCLUSIONS

We demonstrated high concurrence of varicocoele and valvular incompetence of the saphenofemoral junction in a particular adolescent group. We suggest clinical examination and US assessment of the saphenofemoral junctions of adolescents affected by varicocoele in order to detect the early diagnosis of venous insufficiency of the lower limbs among these patients.

Effect of direct stenting on clinical outcome in patients treated with percutaneous coronary intervention on saphenous vein graft

BACKGROUND

Percutaneous coronary intervention (PCI) of saphenous vein graft (SVG) is associated with frequent postprocedural enzyme elevation and late cardiac events. New strategies are proposed to minimize distal embolization and to improve the outcome of patients treated with stenting for SVG lesions. The objectives of the current study were to examine direct stenting (DS) strategy of PCI in SVG lesions and its effects on creatine-kinase (CK) release, major adverse cardiac events (MACE), and late outcome when compared to conventional stenting (CS).

METHODS

A consecutive series of 527 patients treated with stent implantation for SVG stenosis was analyzed. In this cohort, 170 patients with 229 lesions were treated with DS and 357 patients with 443 lesions were treated with CS. The inhospital and 12-month follow-up events were recorded and reported.

RESULTS

Baseline clinical and postprocedural angiographic characteristics were similar between the 2 groups except for higher preprocedural prevalence of thrombus-containing lesions in the DS group. Patients in the DS group had less CK-MB release (P <.001), and less non-Q-wave myocardial infarction (P =.024). Multivariate analysis detected unstable angina (odds ratio [OR] = 1.8, P =.03) as a correlate for non-Q-wave MI; DS was inversely associated with non-Q-wave myocardial infarction (OR = 0.65, P =.04). At 1 year, the target lesion revascularization-MACE was significantly lower in the DS group (P =.021). Multivariate analysis showed that DS (OR = 0.47, P =.007) was associated with reduction of the target lesion revascularization-MACE.

CONCLUSIONS

When feasible, DS may be the best approach for treating SVG stenosis.

Distal filter protection during percutaneous coronary intervention in native coronary arteries and saphenous vein grafts in patients with acute coronary syndromes

BACKGROUND

Percutaneous coronary interventions on saphenous vein grafts (SVG) and in patients with acute coronary syndromes (ACS) have been associated with the distal embolization of the thrombus and plaque and to the no-reflow phenomenon. We report on the safety and feasibility of a new distal emboli protection filter.

METHODS

Angioplasty using distal filter protection (Angioguard, Cordis, Warren, NJ, USA) was attempted in 38 patients (mean age 65 +/- 11 years, 79% males) affected by ACS. A percutaneous coronary intervention was performed in 27 native coronary arteries, in 10 SVG and in one arterial graft (mean diameter stenosis 88 +/- 9%). Patients with vessels presenting severe proximal tortuosity, more than mild calcification, a diameter < 3.0 mm and a lesion length > 15 mm were excluded.

RESULTS

It was possible to position the device in all patients (100%); in 7 patients (18%) the lesion could be crossed with the filter only after balloon predilation. Procedural success with final TIMI flow 3 was obtained in all patients and the mean residual diameter stenosis after stent implantation was 5 +/- 8%. Transient procedural complications without clinical sequelae included the no-reflow phenomenon (2 patients, 5%) and vessel perforation (1 patient, 2.5%). In no case was distal embolization observed. As regards the device-related complications, one occlusive dissection (2.5%) occurred and was successfully treated with stent implantation. In-hospital and 30-day major adverse cardiac events consisted of two non-Q wave myocardial infarctions (5%), both occurring during SVG interventions.

CONCLUSIONS

The use of the Angioguard filter for preselected lesions in patients with ACS had a high technical success and carried a low rate of device-related complications. The clinical efficacy of the device needs further evaluation.

Superior vena cava syndrome secondary to saphenous venous graft aneurysm with right atrial fistula

Mega-aneurysms of saphenous vein grafts (SVGs) to coronary arteries are rare complications of bypass surgery. We report the development of superior vena cava syndrome secondary to an SVG mega-aneurysm with concomitant fistulous communication to the right atrium. Successful treatment was achieved by coil embolization and chronic anticoagulation.

Beta brachytherapy of an old degenerated saphenous vein graft with occlusive in-stent restenosis

We report a case of obstructive in-stent restenosis in a diffusely diseased saphenous vein graft complicated by a non-ST-elevation myocardial infarction. With tirofiban infusion, the extensively occluded saphenous bypass was reperfused, establishing a TIMI flow 3, and then entirely irradiated with a beta source (32P) without any complication. At 7 months the patient was asymptomatic and the control angiogram did not reveal any restenosis. In conclusion, 32P beta brachytherapy may be extremely effective not only in case of native vessel in-stent restenosis but also in cases of high-risk vein graft in-stent restenosis.

[Noninvasive diagnosis of the main forms of venous hypertension in patients with varicosity]

The mechanisms of the development of venous hypertension were studied in 212 patients with varicosity. The clinical and instrumental research methods (rheovasography, photoplethysmography, duplex scanning) were employed. Two groups of patients suffering from superficial (simple) and deep (complicated) forms of venous hypertension were distinguished. The superficial form (85.3%) largely occurs under the action of the hydrostatic force of gravitation nature. The axial reflux via the sapheno-femoral and sapheno-popliteal anastomoses, which occurs when the patient is in the vertical position produces insufficiency of the superficial venous valves. The musculovenous pump maintains its function. That is why the hydrody-namic effects via the insufficient perforating veins play a less important part in the development of venous stasis. Trophic disorders emerge 20-30 years after the disease onset and are associated with the development of fairly intensive blood refluxes in the superficial and perforating veins. Dysfunction of the musculovenous pump of the lower extremities underlies the formation of deep hypertension (14.7%). Primary valvular insufficiency of the deep veins induces the formation of hemo-dynamically significant refluxes in the deep, superficial and perforating veins. The work of the musculovenous pump is far from promoting venous return. On the contrary, the movement is associated with an increase in blood volume in all elements of the pump. At first this leads to phlebostasis and then to capillary stasis, provoking the development of trophic disorders at the early stages of disease.

Morbidity in superficial thrombophlebitis and its potential surgical prevention

Thrombophlebitis is a common condition which can lead to deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE). Thrombophlebitis can reach the deep venous system via the long or short saphenous vein or via perforating veins. Between the 1st of January 1999 and the 31st of December 2000 a total of 17 cases of superficial (or ascending) thrombophlebitis closer than 5 cm to the deep venous system were surgically treated in our clinic. 14 times the long saphenous vein was affected and 3 times the short-saphenous vein. The age of the nine females and seven males ranged from 31 to 77 (mean of 54.6) years. Duplex ultrasound was performed in all patients. In the case of a deep venous thrombosis (four cases) a computer tomography scan (CT) of the pelvis and abdomen was performed to define the extension of DVT. In all 17 (100%) cases a high ligation (crossectomy) and in four (23.5%) cases a venous thrombectomy was performed. In all of these four cases the DVT was limited to the common femoral vein. In all seventeen procedures including venous thrombectomy there was no mortality and no relevant morbidity. Mean hospitalization time was 3.1 days for crossectomy with thrombectomy, and 1.8 days for crossectomy alone. Follow-up has been so far uneventful (mean follow-up time being 12 months in the case of a DVT). In the literature there is no clear concept of how to treat, conservatively or operatively, ascending thrombophlebitis. The surgical procedure can be performed under local anesthesia, and it is safe and efficient.

Use of multiple stents to seal off an epicardial pseudoaneurysm

A 69-year-old male patient had triple-vessel coronary artery bypass graft (CABG) surgery. Three months later, an echocardiogram revealed a 6 x 6 cm cardiac mass. A computed tomography scan of the chest showed a 6 cm mass with contrast enhancement. Cardiac catheterization revealed a pseudoaneurysm of the saphenous vein graft to a circumflex marginal branch at the distal anastomosis site. The aneurysm neck was completely sealed off using 3 stents, leaving a patent saphenous vein graft and good distal run-off.

Sequential bypass using the right gastroepiploic artery for coronary artery bypass grafting

OBJECTIVE

Since 1989, we have applied the right gastroepiploic artery (RGEA) as a third arterial conduit for coronary artery bypass grafting (CABG) and started to use sequential RGEA in 1992. We evaluated the feasibility and efficacy of sequential RGEA grafting in CABG.

METHODS

From December 1990 to January 2000, 46 patients underwent CABG with sequential RGEA. There were 42 male and 4 female patients with a mean age of 59 +/- 8.1 years. Mean postoperative follow-up period was 70 months.

RESULTS

The mean number of anastomoses was 3.7 per patient. Mean luminal diameter of the RGEA was 2.2 +/- 0.4 mm by preoperative angiography and 2.3 +/- 0.6 mm by intraoperative measurement. Patency of the sequential RGEA was 92%; proximal anastomosis 100%, distal anastomosis 86% (p = 0.01). The 5-year actuarial survival and cardiac event-free rate were 91% and 93%, respectively.

CONCLUSIONS

Sequential bypass using the RGEA is feasible, with excellent early and long-term results. The indication for sequential RGEA, however, needs careful anatomical consideration of both the luminal diameter of the RGEA and proximal stenosis of the target coronary arteries.

Global venous function correlates better than duplex derived reflux to clinical class in the evaluation of chronic venous disease

AIM

To compare the symptoms and signs of patients with chronic venous disease with the objective results of duplex ultrasound and plethysmography (foot volumetry).

METHODS

One hundred and one patients with symptomatic chronic venous disease were investigated with duplex ultrasound and foot volumetry. Patients were classified according to the CEAP classification and the symptoms of pain, heaviness, tiredness, ankle swelling and night cramps were graded. The severity of the disease was judged objectively by the reflux time (sum of reflux time at 6 levels) and the venous function was measured globally with expelled volume (ml) and refilling rate (Q) (ml/100 mlxmin) after exercise, and expelled volume related to foot volume (EVrel), (ml/100 ml). The ratio Q/EVrel)was calculated. Correlation was calculated between clinical class, symptoms and objective parameters.

RESULTS

The correlation analyses showed a clear constant relationship between the CEAP clinical classification and the foot volumetry measures (Q/EVrel), r=0.48; p<0.01) There was no such relationship between clinical class and the sum of duplex calculated reflux time (r=-0.05), or between foot volumetry and reflux time. There was no correlation between the clinical class and the total score of symptoms (r=0.044).

CONCLUSION

The clinical class of CEAP classification correlates significantly with foot volumetry parameters. There is no correlation between clinical class and reflux time. The severity of the venous disorder and subsequently the need for treatment is more accurately judged by foot volumetry as a global measure. Clinical classification has a realistic meaning concerning the functional evaluation of venous disease.