Clinical application of sonographic elasticity imaging for aging of deep venous thrombosis: preliminary findings

OBJECTIVE

Aging of deep venous thrombosis is an important and difficult clinical problem. Because it is known that thrombi harden as they mature, we have preliminarily tested sonographic elasticity imaging, a technique that estimates tissue hardness, to age venous thrombi.

METHODS

Two adult patients with lower extremity thrombi were studied. One had a clinically chronic thrombus (at least 3 years old), whereas the other patient's thrombus was clinically subacute (25 days old). We performed freehand compression sonographic scans using a 5-MHz linear array transducer. Phase-sensitive B-scan frames were processed offline by a two-dimensional complex correlation-based adaptive speckle-tracking technique. The distribution of internal strains in the wall of the vein, thrombus, and surrounding tissue was analyzed. Clot hardness was normalized to the venous wall.

RESULTS

The chronic clot was homogeneous, and the strain in the chronic clot was at least 10 times smaller than that in the vessel wall. The subacute clot was much more heterogeneous, and, on average, the strain magnitude in the clot was 3 to 4 times greater than that in the vessel wall.

CONCLUSIONS

In this preliminary work, the 2 thrombi appeared very different, and these results suggest that elasticity imaging may be able to age deep venous thrombosis.

Clinical and angiographic efficacy of a self-expanding nitinol stent in saphenous vein graft atherosclerotic disease: the Stent Comparative Restenosis (SCORES) Saphenous Vein Graft Registry

BACKGROUND

The Stent Comparative Restenosis (SCORES) Saphenous Vein Graft (SVG) Registry was a multicenter, prospective registry designed to evaluate the safety and efficacy of a self-expanding, nickel-titanium (nitinol) stent for de novo SVG lesions.

METHODS

In all, 159 patients with de novo vein graft lesions > or =2.75 and < or =4.25 mm in diameter and <30 mm in length underwent stenting with the Radius self-expanding stent. The primary end point was target vessel failure (TVF) at 9 months, which was defined as a composite of procedural failure, death, myocardial infarction, or target vessel revascularization.

RESULTS

Procedural success was achieved in 96.8% of patients, and the 30-day incidence of major adverse cardiac events was 2.5%. The binary rate of restenosis at 6 months was 28.6%. By 9 months, the rate of TVF was 24.5%, and the rate of major adverse cardiac events was 23.1%. The 9-month Kaplan-Meier survival rates for freedom from TVF and target lesion revascularization were 76.0% and 87.9%, respectively. No clinical or angiographic characteristic was predictive of restenosis.

CONCLUSIONS

In de novo atherosclerotic SVG disease, the use of a self-expanding, nitinol stent was associated with high initial procedural success and favorable early and intermediate outcomes. Because few studies have examined the influence of stent composition and design in SVG disease, these findings not only show the safety and efficacy of this self-expanding stent in de novo SVG disease, but also merit further comparison with balloon-expandable stents.

Quantified duplex augmentation in healthy subjects and patients with venous disease: San Diego population study

OBJECTIVE

This study was undertaken to determine the quantitative augmentation response in several veins examined in a cohort assembled to permit comparisons by sex, age, and ethnicity, under normal conditions and in the presence of obstruction, with and without trophic changes.

METHOD

The common femoral vein, superficial femoral vein, sapheno-femoral junction, popliteal vein, sapheno-popliteal junction, and posterior tibial vein were studied with duplex ultrasonographic scanning. Augmentation response was elicited with use of an automated cuff inflator. Mean level of each response was analyzed according to patient sex, age, and ethnicity, each adjusted for the other two. Normal values were compared with those obtained from legs with venous obstructive disease, with or without signs of trophic changes.

RESULTS

Decreased augmentation response was noted only in the sapheno-femoral junction and sapheno-popliteal junction, and was smaller in women. Augmentation response was slightly increased in the oldest age group (>70 years) in the common femoral vein, superficial femoral vein, popliteal vein, and posterior tibial vein. The highest augmentation response was found in Asian subjects, in the common and superficial femoral veins and the sapheno-femoral and sapheno-popliteal junctions; and the smallest augmentation response was found in African American subjects, in these same veins and junctions. Differences in vein diameters may explain these findings, ie, smaller diameters in Asians and larger diameters in African Americans. Most important, compared with normal values, augmentation response was decreased in legs with venous obstructive disease only when trophic changes were present.

CONCLUSION

Like quantification of reflux, quantitative evaluation of the augmentation response may help in diagnosis of venous obstructive disease when trophic changes are present.

Endovenous laser treatment of the lesser saphenous vein with a 940-nm diode laser: early results

BACKGROUND

Until now, endovenous laser treatment (ELT) of the lesser saphenous vein (LSV) has not been reported.

OBJECTIVE

To evaluate efficacy and side effects for ELT of the LSV.

METHOD

Otherwise unselected patients with an incompetent LSV were included. After perivenous infiltration of tumescent local anesthesia, laser energy (940 nm) was administered endovenously, either in a pulsed fashion or continuously during constant backpull of the laser fiber. Patients were scheduled for duplex follow-up at Day 1 and also at 1, 3, 6 and 12 months, postoperatively.

RESULTS

Forty-one LSVs were targeted in 33 patients with a median age of 66 years (range, 35 to 93). Seventy-three percent of patients had skin changes (C4). Thirty-six percent had an open or healed venous ulcer (C5,6) and 15% a postthrombotic syndrome (ES AS,D PR). Thirty-nine LSVs (95%) completed ELT successfully. During a median follow-up interval of 6 months (range, 3 to 12 months), no recanalization event could be observed. Apart from one thrombosis of the popliteal vein in a patient with polycythemia vera, only minor side effects, particularly no permanent paresthesia, could be observed.

CONCLUSION

ELT of the LSV under tumescent local anesthesia is feasible and effective. Caution is warranted with ELT of thrombophilic patients.

External reinforcement of varicose veins with PTFE prosthesis in infrainguinal bypass surgery -- clinical results

OBJECTIVE

Segmental varicose degeneration of the autogenous greater saphenous vein may limit its use in infrainguinal bypass surgery. Wrapping a PTFE prosthesis around dilated veins has emerged as an option to create externally reinforced vein bypasses. Results regarding graft patency and limb salvage were analyzed.

METHODS

Between September 1995 and January 2001, 35 infrainguinal bypass operations in 33 patients were performed with greater saphenous veins exhibiting segmental varicose dilatation. Grafts were followed by duplex scan and retrospective analysis of graft patency and limb salvage was performed.

RESULTS

One bypass prompted successful revision for early occlusion. Four bypasses required additional reintervention during follow-up. 48 months primary, primary assisted and secondary patency rates were 66%, 82% and 82%, respectively, with a limb salvage rate of 97%. Duplex scan failed to demonstrate stenosis of the reinforced vein segments or aneurysmal degeneration of the residual vein.

CONCLUSION

External reinforcement with a PTFE prosthesis allows the use of autogenous greater saphenous veins with varicose dilatation and enables the construction of all autogenous bypasses with promising graft patency and limb salvage.

Whole-leg duplex mapping for varicose veins: observations on patterns of reflux in recurrent and primary legs, with clinical correlation

BACKGROUND

the variability of venous reflux patterns complicate the management of venous disease. Our study investigates specific variations in venous anatomy and patterns of reflux in varying clinical situations.

METHODS

prospective analysis of 464 legs in 355 patients was performed by complete duplex venous mapping of both primary and recurrent varicose veins. Hand Held Doppler (HHD) and Duplex Ultrasonography (Duplex US) observations in the popliteal fossa were compared in a subgroup of 89 patients with primary varicose veins. Distribution of venous system disease was correlated with clinical severity in a subgroup of 117 affected legs which was representative of the overall study group.

RESULTS

sapheno-femoral junction (SFJ) incompetence predominated in both primary and recurrent varicose veins. Only 21% of primary legs and 25% of recurrent legs had sapheno-popliteal junction (SPJ) incompetence. SPJ incompetence was present in only 42% of cases where reflux in the popliteal region on HHD had been demonstrated. A proportion of both primary and recurrent varicose veins had evidence of deep venous incompetence (DVI). Sixty-four percent of primary leg ulcer patients had superficial incompetence alone. In patients with recurrent varicosities and ulceration, 57% had SPJ incompetence, 64% multiple sites and 50% DVI.

CONCLUSION

the complex variations of varicose vein anatomy and functional pathology in the lower limb are currently best assessed by complete whole-leg venous duplex mapping.

The thigh extension of the lesser saphenous vein: from Giacomini's observations to ultrasound scan imaging

BACKGROUND

Giacomini described a vein that now bears his name almost 130 years ago. Subsequent anatomic studies detail his findings but receive inadequate attention in clinical and surgical textbooks. The purpose of this study was to present a summary of the original observations by Giacomini, present our ultrasound scan findings, and review later anatomic, venographic, and ultrasound scan studies.

METHODS

The study was a literature review and experience with duplex ultrasound scanning from units in Italy and Australia.

RESULTS

Giacomini described a thigh extension from the lesser saphenous vein that passed to join with the greater saphenous vein, which since then bears his name, and described also the other destinations of the thigh extention to deep veins through perforators or an end as multiple tributaries in the superficial tissues or muscles. Duplex ultrasound scanning shows that the vein can be affected by varicose disease with reflux either upwards or downwards in the thigh to the greater or lesser saphenous veins respectively.

CONCLUSION

Ultrasound scan imaging has brought the vein of Giacomini from the realm of anatomic dissection to an important structure to be considered in the clinical management of chronic venous disease.

Angiographic changes in saphenous vein grafts are predictors of clinical outcomes

BACKGROUND

Previous studies have suggested that angiographic evidence of disease progression in coronary arteries increases the risk of subsequent coronary clinical events. This study ascertained whether patients enrolled in the Post Coronary Artery Bypass Graft Clinical Trial (POST CABG) who had substantial progression of atherosclerosis in >or=1 saphenous vein grafts (on the basis of assessment of baseline and follow-up angiograms obtained 4-5 years after study entry), but who had not reported clinical symptoms before follow-up angiography, were at a higher risk of subsequent events than patients who did not have substantial progression of atherosclerosis (decrease >or=0.6 mm in lumen diameter at site of greatest change from baseline).

METHODS

All 1351 patients enrolled in the trial underwent baseline angiography; only the 961 patients who had follow-up angiography and no coronary events before the follow-up study were included in this analysis. The clinical center staff contacted patients to ascertain the events that had occurred after follow-up angiography (approximately 3.4 years later).

RESULTS

Sixty-nine patients had died; 870 patients or relatives were interviewed, and 22 patients could not be contacted. Univariable estimates of relative risk associated with substantial progression ranged from 2.2 (P <.001) for cardiovascular death or nonfatal myocardial infarction to 3.3 (P <.001) for revascularization. Multivariable and univariable estimates of risk were similar.

CONCLUSIONS

The findings provide evidence that patients who had substantial progression of atherosclerosis in vein grafts are at an increased risk for subsequent coronary events and suggest that angiographic changes in vein grafts are appropriate surrogate measures for clinical outcomes.

Complete compression ultrasonography of the leg veins as a single test for the diagnosis of deep vein thrombosis

Noninvasive diagnosis of deep vein thrombosis (DVT) is based on ultrasound examination of the leg veins, usually restricted to only compression of the proximal veins (CUS). Patients with negative CUS findings require a second examination or a combination with other tests, which impairs clinical efficiency. In this prospective outcome study, 1646 consecutive patients with clinically suspected DVT were examined once by a standardized protocol of complete compression ultrasound comprising all proximal and distal veins (CCUS) as the only diagnostic test. The examination was equivocal in 15 patients (1% technical failure rate). Another 366 patients (22%) were tested positive for proximal DVT, distal DVT, muscle vein thrombosis, or phlebitis. Of 1265 patients in whom CCUS findings were negative, 242 met exclusion criteria for follow-up (age <18, life expectancy <3 months, other reasons for anticoagulation, postthrombotic lesions of the leg veins, or lack of informed consent). During the 3 months of follow-up, three of 1023 patients with negative CCUS findings experienced a symptomatic venous thromboembolic event (0.3% [95% CI 0.1%-0.8%]). We conclude that the CCUS protocol has a low technical failure rate and is safe with respect to excluding DVT, thereby reducing the diagnostic workup of patients with suspected DVT to a single ultrasound examination.

Recurrent varices after internal saphenectomy. Physiopathological hypothesis and clinical approach

BACKGROUND

This paper analyses the causes and describes the best care of recurrent varicose veins after internal saphenectomy.

METHODS

A series of 19 patients who had previously undergone internal saphenectomy were selected for surgery due to recurrent varices in the lower limbs. Clinical examination and colour duplex sonography were used as the preoperative diagnostic tools in all patients. No patients underwent phlebography. In 17 cases the main source of reflux was an incontinent saphenous stump at the level of the saphenofemoral junction with varicose cross-groin collaterals. In 2 cases recurrence was caused by incontinence of the upper thigh perforating vein. In 1 of these patients the recurrence also involved the district of the small saphenous vein. Groin neovascularisation was detected in 1 patient.

RESULTS

All patients underwent groin re-dissections using transversal incisions: in 9 cases, access to the saphenofemoral junction was obtained under or at the same level as the inguinal fold, and in 10 cases using a suprainguinal route. The vertical inguinal incision was never employed. Incompetent perforating veins (thigh or leg) were ligated or sectioned in 11 patients. Ligations and exeresis of communicating veins were executed in all patients. Müller's phlebectomies were performed intra- or postoperatively on collateral varices in practically all cases. Postoperative ambulatory sclerotherapy was necessary in 6 cases.

CONCLUSIONS

A correct surgical approach is only assured by diagnostic accuracy coupled with a precise hemodynamic evaluation. Correct management of the postoperative follow-up of varicose vein surgery is also important.

Distal embolization at the site of a stenotic distal anastomosis of a saphenous vein graft, leading to dye entrapment

This case report describes the entrapment of contrast media after recanalization of a recently occluded saphenous vein graft with balloon predilation, thrombectomy and stent implantation. Recanalization of the respective coronary artery was performed, and the entrapped contrast media within the saphenous vein graft progressed to the left circumflex artery.

[Surgery of the saphenous-popliteal junction: a delicate procedures with potential risks]

The authors evaluate the results achieved in two groups of patients operated on for varicose veins in small saphenous vein (SSV) territory in 3 year interval. In the first group gathered from January to December 1998 (114 patients--36 men and 78 women, 123 procedures--118 primary and 5 re-do) the operative indication was based on the clinical examination and continual doppler evaluation. These patients were operated on in general, spinal or local and flash general anaesthesia. In the second group gathered in the same period of the year 2001 (72 patients--21 men and 51 women) 75 procedures were performed (3 patients with bilateral operation). In this group, 49 patients with 50 procedures were selected. The diagnosis was based not only on clinical and continuous doppler examination, but mainly on colour flow duplex mapping. The operation was performed on strictly ambulatory basis using pure local anaesthesia completed with small dose of sedation. Any patient needed complementary sclerotherapy one month after procedure. In mid-term follow-up complementary conservative treatment was necessary in 51 p.c. of the whole series.

CONCLUSION

Use of colour coded duplex ultrasound in preoperative evaluation of varicose veins patients enabled us to precise preoperative diagnosis, to diminish the number of aggressive surgical procedures in favour of less traumatic operations and to perform this surgery on ambulatory basis. Nevertheless, small sahenous vein surgery still remains delicate and sometimes also hazardous.

Primary varicose veins: the sapheno-femoral junction, distribution of varicosities and patterns of incompetence

OBJECTIVE

to determine the patterns of long saphenous vein (LSV) disease in primary varicose veins (VVs).

DESIGN

a retrospective analysis of venous duplex scans performed on patients referred for treatment of primary VVs.

METHODS

analysis was made of sapheno-femoral junction (SFJ) incompetence, non-SFJ incompetence, segmental and perforating vein incompetence, distribution of varicosities, deep venous insufficiency, and short saphenous incompetence.

RESULTS

four hundred and eighty-one patients were assessed (median age 50 (range 12-98) years; male:female ratio 1:1.95), comprising 706 limbs. Forty-six per cent of limbs had a competent SFJ, 64% of which had no incompetent perforating vessels associated. Disease was more widespread when the SFJ was incompetent. Varicosities were most common in the calf, occurring at or below the level of incompetence within the LSV. Incompetent segments occurred most commonly above-knee. There was no obvious correlation between incompetent perforators and distribution of varicosities, or incompetent segments. Short saphenous incompetence and non-SFJ groin recurrence were associated more with a competent SFJ, the converse being true for the Giacomini vein.

CONCLUSION

primary VVs develop in isolated segments of the superficial venous system (without connection to the deep system) at, or distal to, the underlying main trunk incompetence, suggesting a process of "spreading incompetence" from one focal point, producing varicosities (mainly in tributaries).

Saphenous vein graft aneurysm: case report and review

The authors present a case of a large, saphenous vein graft aneurysm, and present a detailed review of the disease.

Duplex saphenous vein mapping: venous occlusion and dependent position facilitate imaging

The purpose of this study was to develop an optimal technique for greater saphenous vein distention during preoperative duplex assessment. An Acuson 128 scanner with a 7.5-MHz sector probe was used to assess the effects of venous occlusion and dependent position on the diameter of the greater saphenous vein in 20 male volunteers. The greater saphenous vein was imaged 10 cm above and 10 cm below the knee with the subject lying horizontal, horizontal with a thigh tourniquet inflated to 40 mm Hg, inclined at 15 degrees of reversed Trendelenburg, and inclined at 15 degrees of reversed Trendelenburg combined with the tourniquet inflated to 40 mm Hg. Maximal vein diameters and circumferences were measured by a sonographer blinded to the conditions of vein measurement to avoid interpretation bias. Using a t test assuming equal variances, the increases in vein circumferences and diameters achieved by dependency and tourniquet combined were significantly greater than those achieved by dependency alone (p=0.004). The technique of dependency combined with tourniquet inflation to 40 mm Hg facilitates greater saphenous vein imaging and provides an optimal method of venous distention.

Duplex imaging analysis of the long saphenous vein reflux: basis for strategy of endovenous obliteration treatment

BACKGROUND

The purpose of this study was to characterize greater saphenous vein (GSV) reflux in order to better define indications for appropriate endovascular obliteration treatment.

METHODS

Color-flow duplex imaging was used prospectively to categorize 133 lower limbs of 102 consecutive outpatients, presenting with chronic superficial vein disease associated with GSV incompetence. Sapheno-femoral junction (SFJ) and tributaries morphology and hemodynamics, and GSV main trunk reflux extent were assessed.

RESULTS

GSV reflux was related to terminal valve incompetence in 70 (52.3%) limbs, to sub-terminal valve incompetence in 37 (27.8%), and to segmental incompetence of the GSV trunk in 26 (19.6%). Reflux originated from common femoral vein (CFV) and/or SFJ tributaries and/or GSV collaterals, including multiple origins combinations. CFV was the reflux origin in 77 (57.9%). GSV reflux arose from SFJ or trunk tributaries in 69 (51.9%) and 32 (24%), limbs respectively. Circumflex and superficial epigastric veins were involved in 65.2% and 50.7% respectively of the SFJ tributaries. GSV reflux extended down to the mid-third of the calf or below in only 45 cases (33.7%). The age of the patients was not correlated with reflux origin.

CONCLUSIONS

Preliminary analysis suggests that in 2/3 of the cases, endovenous obliteration treatment should extent from the thigh to just below the knee. Furthermore, in order to preserve GSV competent valves and collateral veins drainage, treatment should start just below the main SFJ tributary when the terminal valve is still competent, and just below the main branches connection when only the GSV trunk is incompetent.

Postoperative changes in angiographically normal saphenous vein coronary bypass grafts using intravascular ultrasound

We examined the process of vessel wall thickening in angiographically normal saphenous vein grafts (SVGs) using intravascular ultrasound. Fifteen SVGs were studied in the early stage (within 1 month postoperatively) and 14 SVGs in the late stage (over 6 months postoperatively). Lumen cross-sectional area (CSA) and vessel CSA were measured. Vessel wall area (VWA) was calculated and %VWA was defined as VWA / vessel CSA. Vessel CSA, VWA, and %VWA were significantly larger in the late stage than in the early stage (28.8 vs 21.6 mm(2), 15.8 vs 5.3 mm(2), 55.7% vs 24.9%, respectively) and lumen CSA was smaller in the late stage (12.8 vs 16.2 mm(2)). VWA correlated with vessel CSA, but not with lumen CSA. The time course of %VWA showed that %VWA in the late stage was a plateau state. From these findings, we concluded that the wall thickening process in SVGs begins within 6 months postoperatively and is accompanied by compensatory vessel enlargement.

Initial experiences in endovenous treatment of saphenous vein reflux

INTRODUCTION

The most common site of venous reflux is the long saphenous vein (LSV). The preferred treatment for reflux in the LSV is surgical stripping of the LSV. However, the complications of surgical stripping are well documented and undesirable. The constant search for treatment options with less morbidity, which are also cosmetically more acceptable, has resulted in the endovenous treatment for primary varicose veins, developed by VNUS Medical Technologies, Inc (Sunnyvale, Calif). We hereby present our first treatment experiences and propose refinements to the procedure.

METHODS

Two types of heat-generating endovenous catheters were used to treat incompetence of the LSV with a diameter of up to 12 mm. The procedure was performed on a blood-empty limb.

RESULTS

Twenty-six limbs, in 26 patients, were treated, and the follow-up period was 1 year. The mean preoperative CEAP score was 4, and the postoperative score was 1.26, which was statistically significantly less (P <.0001, with Wilcoxon nonparametric matched pair test). Five patients had postoperative paresthesia of the saphenous nerve, and one patient had a burn from the procedure. The overall complication rate was 23%. All complications occurred in the first half of the studied population (P =.015, with Fisher exact test), indicating the learning curve effect. In one patient (3.8%), was total recanalization of the treated segment occurred, one patient (3.8%) could not be treated at all (technical failure), and one patient (3.8%) had partial recanalization of the LSV. Eight patients (30.8%) had closure of the entire LSV but with persisting reflux in the saphenofemoral junction (SFJ). Two patients had a competent SFJ with occlusion of the LSV. In 13 patients (50%), closure of both the LSV and the SFJ was seen. The LSV was successfully occluded in 88% of the patients.

CONCLUSION

The endovenous catheter should not be used more than 5 to 10 cm below the knee to prevent saphenous nerve damage. Performance of the procedure with bloodlessness is preferable. A result of 88% of successfully treated LSV segments indicates a promising alternative for surgical stripping of the LSV.

Assessment of coronary artery bypass graft disease using cardiovascular magnetic resonance determination of flow reserve

OBJECTIVES

The purpose of this study was to assess the value of cardiovascular magnetic resonance (CMR)-determined graft flow and flow reserve in differentiating significant from non-significant vein graft disease.

BACKGROUND

In patients after coronary artery bypass grafting (CABG), non-invasive testing may be helpful in the detection of recurrent graft disease.

METHODS

Randomly selected patients (n = 21) scheduled for X-ray angiography because of recurrent chest complaints after CABG were included for evaluation of vein grafts (n = 40) by CMR. Three-dimensional contrast-enhanced CMR angiography was performed and followed by flow measurements at rest and during hyperemia in patent grafts only. Flow reserve was calculated when resting flow exceeded 20 ml/min. Analysis was based on four categories defined by X-ray angiography: occluded grafts (n = 3), grafts with stenosis >50% (n = 19), grafts with stenosis <50% with diseased graft run-off (n = 8), and grafts with stenosis <50% and normal run-off (n = 10).

RESULTS

The CMR angiography demonstrated occlusion of three grafts. In nine of the 37 patent grafts, basal blood flow was <20 ml/min, all demonstrating significant stenosis at X-ray angiography. In grafts with resting flow >20 ml/min (n = 28), flow reserve significantly differed between grafts without stenosis and grafts with significant stenosis or with diseased run-off (2.5 +/- 0.7 vs. 1.8 +/- 0.9, p = 0.04). An algorithm combining basal volume flow <20 ml/min and graft flow reserve <2 had a sensitivity and specificity of 78% and 80% respectively for detecting grafts with significant stenosis or diseased run-off.

CONCLUSIONS

This feasibility study showed that quantification of flow and flow reserve by CMR may serve as a non-invasive adjunct to differentiate between vein grafts without stenosis and grafts with significant stenosis or diseased run-off.