[Relation between changes in the microcirculation in the capillaries supplying the toenails and the degree of chronic venous insufficiency]

Chronic venous insufficiency (CVI) is characterised by stasis which may lead to an imbalance in the cutaneous microcirculation resulting in a wide spectrum of complications. The use of capillaroscopy on the toenail folds of patients with CVI allows the morphological and microhemorrheological aspects of microcirculatory disorders to be studied. The aim of this study was to clarify the correlation between the extent of abnormalities of the nutritional capillary and the degree of severity of CVI according to Widmer's classification. Capillaroscopy of the toenail fold was used to study 100 patients suffering from essential varicose disease (EVD) and post-thrombotic syndrome (PTS) with CVI of various degrees, giving a total of 110 limbs grouped as follows: 30 limbs at stage 0; 49 at stage 1; 20 at stage 2 and 12 at stage 3. In addition, a further 30 limbs of normal subject without a family history of varicose disease were included in the study. All patients and control subjects were examined clinically and using ultrasound c.w. Doppler and eco-color-Doppler of the lower limbs. The results highlighted a progressive deterioration of the capillaroscopic conditions in relation to the severity of CVI. In particular, during stage 1 microcirculatory alterations found in patients with primary varicose syndromes appeared to be more severe than those with PTS. This apparent contradiction may be attributed to the unique topography of this hemodynamic disorders since the subpapillary circulation in EVD is topographically in direct continuity with the site of venous hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and risk factors of varicose veins in an elderly population

The prevalence of and risk factors for varicose veins (VV) were studied in elderly persons over 60 years of age who had visited the Tonya and Farabi Hospitals in Trabzon, a city in northeastern Turkey. VV were defined as dilated, tortuous and elongated veins of the lower extremities and were classified into four types. The total prevalence of VV was 36.7% (14.6% in males and 22.1% in females). Segment type varices were observed in 16.5%, saphenous type in 5.6%, reticular type in 4.7%, web type in 2.3%, and combined types in 7.5%. The prevalence of VV increased with age and was greater among those with a family history of the condition in 154 of 312 patients with VV (49.4%). Other factors, such as congestive heart failure, angina pectoris, hypertension, cigarette smoking, diabetes mellitus, height, weight, obesity, or hyperlipidemia, were not found to be associated with the prevalence of VV. However, the factors of age, work posture and childbirth did show an association with prevalence, as reported by others.

Risk factors for varicose disease before and during pregnancy

Risk factors for varicose disease before and during pregnancy have been analyzed by use of data from a survey on venous disease in pregnancy conducted in 611 women (mean age thirty years, range fifteen to forty-seven) who consecutively delivered at the Obstetric-Gynecologic Clinic "L. Mangiagalli" of Milan between January and April, 1989. In total, 137 women (22%) reported varicose disease before the index pregnancy. The relative risk (RR) of varicose disease before the index pregnancy increased with age, being, as compared with women aged twenty-nine years or less, 1.6 in those aged thirty to thirty-four and 4.1 in those aged thirty-five years or more (chi 2(1) trend 25.28, p < 0.001). Compared with nulliparae, women reporting a full-term pregnancy before the index pregnancy had an RR of venous disease of 1.2, and the risk increased to 3.8 in women reporting two or more births (chi 2(1) trend 25.28, p < 0.001). A family history of varicose disease was associated with an RR of venous disease of 6.2 (95% confidence interval, CI, from 4.1 to 9.6). No relationship emerged between varicose disease and overweight. Of the 474 women who did not report venous disease before the index pregnancy, 132 (28%) developed venous disease during the index pregnancy. The risk of developing venous disease in pregnancy increased with age, being, as compared with women aged twenty-four years or less, 4.0 in those aged thirty-five years or more, and the trend in risk was statistically significant (chi 2(1) trend 16.25, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Two vascular complications of the Ehlers-Danlos syndrome

Patients with Ehlers-Danlos syndrome type IV have thin walled, friable arteries and veins and are prone to spontaneous arterial rupture. We present a patient who suffered severe damage to the common femoral vein during surgery for varicose veins and who subsequently suffered a spontaneous rupture of the right external carotid artery, treated by ligation and oversewing. Intraarterial radiology and surgery in such patients are hazardous and should be avoided if possible. Where operation is essential, the simplest available procedure should be performed. Patients should be counselled to inform every doctor they consult that they have the Ehlers-Danlos syndrome.

Familial varices of the colon and small bowel

We describe two patients, brother and sister, with identical pathology, whose only clinical presentation was recurrent massive lower digestive tract bleeding. Haemorrhage was due to a complex form of familial venous vascular malformation in the digestive tract, represented by the existence of varices of colon, small intestine and, to a lesser extent, oesophagus and gastric funcus. We have been able to study, examine and treat both patients for 9 and 3 years respectively.

[An epidemiologic study of the pathogenesis of varices. The Bochum study I-III]

A longitudinal study was carried out at 11 secondary schools (Gymnasium) of the city of Bochum to investigate the early and preclinical stages of developing varicose veins. The same pupils were examined when being in the 5th, 9th, and 13th classes (Bochum Study I, II and III). A significant correlation between familial predisposition and the occurrence of varicose veins could not be found until the Bochum Study III. The girls dominated with respect to reticular varices and telangiectasias, the boys with respect to trunk varices, branch varices and incompetent perforators. Photoplethysmography showed shorter refilling times for children and adolescents than for adults, but was not suitable to distinguish between pathological and normal findings. Large varices appeared later than small varices and were preceded by refluxes of the long and short saphenous veins. We thus have for the first time a preclinical sign, which clearly identifies individuals at risk.

Predisposing factors of varicose and telangiectatic leg veins

Presented is an epidemiologic study on predisposing factors in telangiectatic and varicose leg veins on 500 female patients. Genetic predisposition, hyperestrogenemic states, standing vocations, and obesity were found to be the major predisposing factors. Recognition of these factors may help to prevent further progression of proliferative venous disease after sclerotherapy in susceptible individuals.

Genetic aspects of the Klippel-Trenaunay syndrome

An extensive search for a genetic pattern in Klippel-Trenaunay syndrome (KTS) revealed two other cases of KTS in the families of two of the 86 patients with this vascular syndrome who were questioned. Patients with KTS also had family members with other malformations: e.g. hemihypertrophy in one family, and a prevalence of 7/400 of naevi flammei in first-degree relatives of KTS patients was observed. We suggest that KTS can be inherited in a multifactorial way and a range of vascular malformations can be observed in the family members of patients with this syndrome.

[Etiopathogenesis of varicosities of the lower extremities]

This study was performed to validate the importance of heredity in the development of varicosities of lower extremities and to establish the correlation between the sclerotherapy and the pathological changes on the perforating and deep veins. The aim was also to determine the share of trauma in the development of insufficiency of the perforating veins of the lower leg. The author studied 484 hospitalized patients. By application of modern diagnostic procedures, pathological changes in the system of veins were discovered and located and varicose veins were classified into five groups. A positive family history was found in 64.5% of the treated patients. The relationship between the heredity and the pathological changes in the venous system has been given in tables. Of all the treated patients, 12.2% underwent sclerotherapy earlier. Among these patients, 50.8% showed pathological changes on the perforating veins; in 22% pathological changes, however, were found on the deep veins as well. One hundred and thirty-five patients were operated on due to insufficiency of the communicating veins. Of those patients, 21.4% stated a positive trauma in their past history, while 14.1% showed some degenerative changes in the fatty-connective tissue of the deep fascia of leg. In conclusion these results tissue of the deep fascia of leg. In conclusion these results confirm the hypothesis that trauma of lower extremities may lead to insufficiency of the communicating veins.

Polymorphisms of serum proteins in Japanese patients with vascular diseases. I. Factor XIIIB, plasminogen and complement types in primary varicose veins

The polymorphisms of the B subunit of coagulation factor XIII (F13B), plasminogen (PLG), complement C6, C7, factor B (BF) and factor I (IF) were studied among 21 unrelated Japanese patients with primary varicose veins (PVV) by isoelectric focusing followed by immunoblotting. The allele frequencies for F13B*2 and IF*A in PVV patients were significantly higher (F13B*2, p = 0.0047; IF*A, p = 0.0006) than those in healthy controls (n = 60). Significant associations of F13B 2 allotype [p = 0.0220, relative risk (RR) = 13.9] and IF A allotype (p = 0.0006, RR = 10.0) with PVV were observed; however, no significant association of PLG, C6, C7 or BF allotype with the disease was found.

[The clinical existence of isolated non-thrombotic insufficiency of the conductive veins of the leg]

Attention is paid to the set of problems connected with the nonthrombotic insufficiency of the conducting veins of the leg. Phlebographic and X-ray morphometric investigations of the last years were able to prove that the primary varicosis does not exclusively represent a disease of the superficial and perforating fasciae venous system, but that the subfascial venous system (system of conductive veins) is without doubt also included in the pathogenetic reactive process. Two casuistic descriptions of cases with phlebographically and Doppler-sonographically ascertained insufficiency of the conductive veins of the leg are demonstrated. It is referred to the diagnostic, clinical and therapeutic problems of the isolated nonthrombotic insufficiency of the conductive veins. Leading diagnostic criteria of the isolated ectatic (varicose) insufficiency of the conducting veins of the leg are: symptomatology of subjective complaints, such as sensation of tension, feeling of heaviness of the legs, inclination to swelling, pains, epifascial freedom from varices, phlebographic evidence of the ectasia of conductive veins and sonographic confirmation of reflux.

Familial varices of the colon

Two patients from the same family with varices throughout the entire colon and no apparent portal hypertension, are described. One patient experienced profuse bleeding after polypectomy, the other had recurrent rectal blood loss.

Familial aortic dissection in absence of ascending aortic aneurysms: a lethal syndrome associated with precocious systemic hypertension

The interaction of elevated blood pressure and aortic metabolism in the genesis of aortic dissection is uncharacterized. A kindred with fatal familial aortic dissection in association with precocious systemic hypertension and in absence of a definable connective tissue syndrome has undergone genealogical, clinical, pathological, and biochemical evaluation. Six family members spanning three generations have died of acute dissection. Five men died at a mean age of 28 years (range 22-34), while the proband's paternal grandmother died at 62 years of age. All were hypertensive. A constellation of subtle clinical features points toward deficient integrity of connective tissues; however, major hallmarks of known connective tissue syndromes including aortic root ectasia or aneurysms are absent. Studies of cultured dermal and aortae fibroblasts of two of the proband's brothers mitigate against Ehlers-Danlos IV syndrome. This family's susceptibility to aortic dissection reflects the synergistic liability of coexistent elevated blood pressure and metabolic abnormalities in the genesis of aortic degeneration.

[Sclerotherapy of varices and protein C deficiency]

The appearance of relapsing venous thrombosis after sclerosis of varices in a woman aged 30 led us to discover a quantitative protein C deficiency, found in her father and 4 of her brothers and sisters. The transmission mode is autosomal and dominant. Within this family, 6 subjects are affected, 4 showing symptoms, clearly showing the heterogeneity of the clinical manifestation of the deficiency. Dealing with the special problem of pregnancy in women with the biological disorder, one ought to consider the literature on the subject, showing the large occurrence of ante- and post-natal accidents. The treatments of thromboembolic complications is based on the use of heparin administered appropriately through antivitamins K for a period which is till to be defined. In asymptomatic subjects, a preventive anticoagulant treatment is recommended in all circumstances likely to encourage the relapse of thrombosis.

[Individual variability in the structure of the walls of the principal trunks of the subcutaneous veins of the lower extremities of the human fetus]

Certain regional peculiarities are noted in the development process of the human principle trunks of the subcutaneous veins during antenatal period. In the fetuses of all ages the wall thickness of the subcutaneous veins is the greatest in the femur, and the middle tunic is better developed in the shin. The vein structure depends on the type of architectonics: at the magistral type (86%) the walls in the large and minor subcutaneous veins are thick with well developed smooth myocytes and connective tissue fibers; at the reticulate type (14%) the walls are thin, their elements are poorly developed. When there is mentioned varicosity of the lower extremity veins in the parents' anamnesis, in fetuses (57%) all the tunics in the venous wall develop more poorly, there is retardation in formation of smooth myocytes and in maturation of collagen fibers. This results in less amount of contractile structures in the middle tunic and optic density of collagen is less manifected.

Distichiasis, congenital heart defects and mixed peripheral vascular anomalies

We report on a previously apparently unreported syndrome of distichiasis with congenital heart defects and with mixed peripheral vascular anomalies in a mother and her four children. The mother had a ventricular septal defect; both daughters had surgery for patent ductus arteriosus. Sinus bradycardia alone (elder son), with stress induced asystole (younger son), and with wandering atrial pacemaker (both daughters) are documented electrocardiographically. Three of the five have edema, two have visible varicosities, three have symptoms consistent with chronic venous disease of the legs, and the older daughter has complaints consistent with arterial disease in the legs. Doppler flow studies demonstrated post-phlebitic syndrome in all but the younger daughter, and vasospastic disease in the mother, older daughter, and second son.

[The importance of nutrition among the risk factors in varicose veins]

The author reminds us that varicose veins involve a large social and financial cost. He states the the etiopathogenic hypotheses commonly suggested have not been confronted with geographic pathological data and that consequently they are of little value. A thorough study of the epidemiological data and clinical characteristics of the disease was made. The different factors which are considered or which are likely to be considered in the onset of varicose veins are investigated in light of these data. From this comparison, it appears that the Western diet is the fundamental cause of varicose inducement and that it leaves the other factors (predisposing, triggering or aggravating) as risk factors. The part it plays is probably due to a slight vitamin E deficiency which, once aggravated (during pregnancy for instance), would act upon venous walls, coagulation and fibrinolysis. Thus, the veins would become sensitive to blood stasis and to venous hypertension effects due in particular to constipation.