[Short-stay surgery of inguino-crural hernia]

BACKGROUND

To evaluate the hospital stay, morbidity, and patients' compliance for short stay inguinal hernia repair.

METHODS

Retrospective analysis of 669 patients (594 men and 75 women) who underwent short stay inguinal hernia repair (706 inguinal and 45 femoral repairs) at the Institute of General Surgery, University of Ferrara. Mean age was 60.7 years (range, 18-84 years). The anesthesia was: loco-regional in 495 patients (74%) and general or epidural in 174 (26%).

RESULTS

Mean hospital stay was 1.2 days. Postoperative complications were: three scrotal hematomas, two ischemic orchitis, three prosthetic infections, one local anesthetic intolerance, and three high fever. Eighty-five percent of patients were satisfied of the surgical procedure in short hospital stay. Mean follow-up was 36 months.

CONCLUSIONS

Short hospital stay in inguinal hernia repair is safe, effective, and widely accepted by patients.

Genetic vaccination with "self" tyrosinase-related protein 2 causes melanoma eradication but not vitiligo

"Self" melanocyte differentiation antigens are potential targets for specific melanoma immunotherapy. Vaccination against murine tyrosinase-related protein (TRP)-1/gp75 was shown recently to cause melanoma rejection, which was accompanied by autoimmune skin depigmentation (vitiligo). To further explore the linkage between immunotherapy and autoimmunity, we studied the response to vaccination with a related antigen, TRP-2. i.m. inoculation of plasmid DNA encoding murine trp-2 elicited antigen-specific CTLs that recognized the B16 mouse melanoma and protected the mice from challenge with tumor cells. Furthermore, mice bearing established s.c. B16 melanomas rejected the tumor upon vaccination with a recombinant vaccinia virus encoding trp-2. Depletion experiments showed that CD8+ lymphocytes and natural killer cells were crucial for the antitumor activity of the trp-2-encoding vaccines. Mice that rejected the tumor did not develop generalized vitiligo, indicating that protective immunity can be achieved in the absence of widespread autoimmune aggression.

Surgical management of ascending saphenous thrombophlebitis

BACKGROUND

Acute saphenous vein ascending thrombophlebitis is recognised to be a dangerous condition due to the reported high incidence of deep vein thrombus involvement and possibly fatal pulmonary embolism. We assessed the accuracy of duplex scanning in determining the extent of thrombosis as well as the effectiveness of surgical treatment.

METHODS

We retrospectively reviewed 146 patients referred to our Vascular Laboratory for acute superficial thrombophlebitis from 1987 to 1997. Duplex scanning identified 85 cases of superficial thrombophlebitis involving at least a segment of the saphenous vein localised below the knee (58.2%); 37 of thrombophlebitis extending into both the superficial and deep venous systems (25.3%), and 24 of saphenous thrombosis extending to within 5 cm of the saphenofemoral junction (16.4%). The latter group underwent saphenofemoral disconnection. We compared the preoperative duplex with the surgical reports and evaluated the surgical results.

RESULTS

We did not observe any complication. Return to work and normal activity occurred within 3-5 days. When varicose vein thrombectomy was performed concurrently, the patients had better postoperative pain control.

CONCLUSIONS

Duplex scanning showed 100% accuracy both in determining the presence of thrombosis and its extent. Saphenofemoral disconnection for thrombosis involving the saphenofemoral junction is a safe procedure and can be performed on an outpatient basis.

The Relationship between Ultrasonic Ambulatory Venous Pressure and Residual Volume Fraction in Primary Venous Insufficiency

Objective:

To study the relationship between two non-invasive methods for determining ambulatory venous pressure (AVP) in primary chronic venous insufficiency of the lower limbs.

Design:

Comparison between ultrasonic AVP (US-AVP) and residual volume fraction (RVF) determined by means of air plethysmography (APG).

Setting:

Department of Surgery and Vascular Laboratory, University of Ferrara, Italy.

Patients:

Twenty-one subjects affected by primary chronic venous insufficiency (CVI).

Main outcome measure:

A comparison of the AVP values extrapolated from the change in ultrasonic diameter of the saphenous vein after exercise and from RVF values. Ultrasonographic extrapolation was also made by the means of the software Venometer and compared with manual assessment.

Results:

Linear regression analysis demonstrated that US-AVP values were significantly correlated with RVF values ( r = 0.86 and p<0.0001). Assessment by Venometer as compared with manual calculation showed a high degree of correlation ( r = 0.98), p<0.0001).

Conclusions:

The two methods for non-invasive assessment of AVP appear to be closely and significantly correlated. The Venometer allows reliable and rapid extrapolation of AVP values.

Seasonal variation in the occurrence of nontraumatic rupture of thoracic aorta

Research has identified circadian and seasonal patterns for several acute cardiovascular diseases. In order to investigate the possible existence of a seasonal variation in the onset of acute nontraumatic ruptures of thoracic aorta, this study considered all patients referred to the emergency department of St Anna Hospital of Ferrara, Italy, from January 1985 to December 1996. In the considered period, 85 patients (52 males, 33 females) of nontraumatic ruptures of thoracic aorta were observed. Cosinor analysis and partial Fourier series with up to 4 harmonics were applied to monthly data, and the best-fitting curves for circannual rhythmicity were calculated. A higher winter occurrence with a significant peak in January was found for the total population and the male subgroup. Although the underlying factors are not fully known, such patterns strictly resemble that of arterial blood pressure. Emergency doctors can put to practical use the recognition of a clearly identified chronorisk for aortic rupture, increasing alertness, and providing the most effective antihypertensive protection at the specific vulnerable periods.

Circadian variation in the onset of acute critical limb ischemia

Research has identified a circadian rhythm for several acute thrombotic cardiovascular and cerebrovascular diseases. We investigated the possible existence of a circadian variation in the onset of acute critical limb ischemia. Out of a consecutive series of 198 cases, precise determination (within 30 minutes) of the time of symptom onset was possible in 156 (78.8%). Partial Fourier series were applied to hourly data and the best-fitting curves for circadian rhythmicity were calculated. Both in the total population and in subgroups by gender and location of ischemia, a highly significant circadian pattern of occurrence was demonstrated with peak in the morning (approximately 0800) and nocturnal minimum around midnight. This study is the first demonstration of the circadian pattern of acute arterial occlusion of the limbs, in agreement with several studies showing a circadian pattern to the time of onset of acute myocardial infarction and other unfavorable acute events related to thrombosis. This opens up the potential for therapeutic implications, suggesting the need to adjust the dose of drugs based on the time of day. Further studies dealing with circadian variation in the efficacy of thrombolytic agents are so needed.

Effects of vasoactive agents in healthy and diseased human saphenous veins

PURPOSE

Smooth muscle reactivity is one of the factors involved in the pathogenesis of varicose veins. We investigated the myotropic effects of the 3 main vasoconstrictor agents norepinephrine (NE), angiotensin II (Ang II), and endothelin-1 (ET-1) in isolated human saphenous veins.

METHODS

Human saphenous veins were collected from 23 patients with primary chronic venous insufficiency who underwent elective varicose vein resections and who were stratified into the following 3 groups: group 1, 7 patients in clinical class 2; group 2, 9 patients in clinical classes 3 and 4; and group 3, 7 patients in clinical classes 5 and 6. Moreover, 6 patients who underwent arterial bypass grafting procedures represented the control group. The tissues were suspended in organ baths that contained Krebs solution, and their mechanical responses were measured isometrically. The cumulative concentration-response curves to Ang II, NE, and ET-1 were performed at 90-minute intervals in each tissue.

RESULTS

In the control tissues, NE, Ang II, and ET-1 induced concentration-dependent contractions with apparent affinities (pEC50, the negative logarithm to base 10 of the molar concentration of the agonist, which produces the 50% of the maximal effect) and maximal effects (maximum effect, g of contraction) that were equal to 7.06 +/- 0.23, 8.53 +/- 0.34, 7.63 +/- 0.10, and 2.21 +/- 0.33, 1.65 +/- 0.31, 2.60 +/- 0.77, respectively. Two main findings were evident in comparison of varicose veins with control tissues. First, the maximum effect that was evoked by all of the stimulants was reduced progressively with the increasing severity of the disease, which raised the third group to statistical significance for both NE and Ang II (P <.05). Second, a marked reduction of Ang II apparent affinity was already evident in tissues that were taken from patients in an early stage of the disease (P <.05).

CONCLUSION

The demonstration of a significant reduction in Ang II and NE contractile activities and the important reduction of that of ET-1 in the diseased veins as compared with the control tissues extends the previous observations regarding the impairment of smooth muscle contractility in primary chronic venous insufficiency. Moreover, the dramatic reduction of Ang II affinity, which appears in an early stage of the disease, supports the hypothesis that such abnormality within the venous wall could play a role in the pathogenesis of primary varicose vein disease.

In vitro versus in vivo assessment of vein wall properties

Venous compliance reflects the mechanical properties of the vein wall. Clinical methods of measurement have not been validated by comparison with the accepted in vitro measurement. Despite this, clinical assessment of vein compliance may have a series of useful applications: (1) to assess the progression of chronic venous insufficiency and the related hemodynamic forces acting on the saphenous vein wall; (2) to determine the suitability of the saphenous vein for replacement of an arterial conduit by testing its mechanical properties; and (3) to select the saphenous vein with preferable mechanical performance for coronary artery bypass. The aim of this study is to assess the relationship between in vitro and two in vivo methods of compliance measurement. Compliance of the saphenous vein was determined in 20 patients, using both an invasive and a noninvasive (A and B, respectively) method. Duplex scanning was used for diameter measurement. Venous pressure was derived either intravenously with a needle transducer, or noninvasively with limb length measurement. Patients underwent saphenous excision with further in vitro compliance measurement of the same vein segment (method C). The compliance values obtained with the three methods showed different degrees of correlation (r= 0.516, p = 0.0001 for method A versus method C; r = 0.658, p = 0.0001 for method B versus method C; r = 0.993, p = 0.0001 for method A versus method B). The relationships with the in vitro measurements that were determined validate both in vivo methods for assessment of saphenous vein compliance. Due to its completely noninvasive design, method B appears to have potential use for clinical assessment of saphenous vein wall properties.

Saphenous vein sparing surgery: principles, techniques and results

OBJECTIVE

Evaluation of saphenous vein sparing surgical procedures alternative to high ligation and distal stab avulsion, in terms of effectiveness and suitability for eventual bypass surgery.

EXPERIMENTAL DESIGN

Prospective evaluation of 421 operations for primary varicose veins, 64 external valve-plasties of the sapheno-femoral junction (EV-SFJ), (42 performed using the hand sewing technique and 22 using the Veno-cuff device), mean follow-up 52 months, and 357 hemodynamic correction of varicose veins (French acronymis CHIVA), mean follow-up 49 months. Moreover, a subgroup of 27 patients was operated on using the CHIVA technique in two steps, mean follow-up 18 months.

SETTING

Institute of General Surgery, University of Ferrara. Institutional practice, one-day surgery.

PATIENTS

Patients were selected using clinical and duplex scanning evaluations, and classified according to CEAP criteria. Patients with varicose veins due to sapheno-femoral reflux with duplex scanning evidence of mobile valve leaflets underwent EV-SFJ. The other patients were operated on using the hemodynamic correction technique.

INTERVENTIONS

EV-SFJ restores valve function correcting vein wall dilatation by applying an external prosthesis. CHIVA consists of selected ligatures of the superficial veins that allow superficial blood aspiration in the deep veins through the perforators as well as the preservation of saphenous drainage.

MEASURES

The outcome was evaluated with independent clinical and ultrasonographic examinations; pre and postoperative AVP and LRR-RT measurements were assessed in 125 cases. Data from self-assessment of the functional and cosmetic result of the patients of the CHIVA group were also obtained using a scoring system. Moreover, scanning the preserved long saphenous vein the rate of long saphenous vein suitable as arterial conduit following sparing surgery was also evaluated.

RESULTS

Overall long saphenous vein patency registered after EV-SFJ and CHIVA was 94%. Varicose veins recurrence rate was 12% and 11%, respectively. Postoperative AVP and LRR-RT improvement was statistically significant (p<0.001).

CONCLUSIONS

These two alternative procedures seem to be effective in varices treatment following the proposed indications and techniques. In addition, they appear able to preserve a more significant rate of saphenous veins suitable for eventual bypass surgery than high ligation and multiple cosmetic avulsion.

Ultrasonographic assessment of ambulatory venous pressure in superficial venous incompetence

PURPOSE

In spite of its invasiveness, measurement of ambulatory venous pressure (AVP) is widely considered the gold standard measurement of venous function. We studied a technique for noninvasive ultrasonographic AVP determination in superficial venous incompetence.

METHODS

A linear relationship between venous pressure (measured by echo-guided venous puncture) and diameter (measured by transverse axis duplex imaging) was preliminarily demonstrated with multiple measurements in different conditions (supine, sitting, standing, and Trendelenburg positions, after exercise with and without cuff occlusion) in a saphenous tract at the thigh of 82 limbs in which reflux had been previously demonstrated. Then AVP was measured in another group of 44 patients who had demonstrated superficial venous incompetence, both with and without proximal occlusion, using again the same invasive method and a new noninvasive technique. The latter technique consisted in the construction of a linear diameter/pressure curve obtained after saphenous diameter (by high-resolution sonography) and noninvasive pressure (using hydrostatic values) determinations in the sitting and standing positions. Further measurement of saphenous diameter after standardized exercise permits extrapolation of the AVP values from the curve.

RESULTS

Linear regression analysis demonstrates that (1) beginning from 20 mm Hg, the pressure/diameter relationship of the incompetent greater saphenous vein is linear; and (2) AVP values derived invasively and noninvasively are significantly correlated (r = 0.7347 and p < 0.0001 for AVP derived without occlusion; r = 0.7270 and p < 0.0001 for values recorded with occlusion).

CONCLUSIONS

The proposed technique appears able to reliably assess noninvasively AVP values in superficial venous incompetence. In addition, it can be performed with equipment that is widely used for vascular investigations.

Reparative surgery of valves in the treatment of superficial venous insufficiency. External banding valvuloplasty versus high ligation or disconnection. A prospective multicentric trial

OBJECTIVE

A prospective study was performed in order to compare results obtained in the treatment of early and/or limited primary varicose veins of the lower limbs using two different procedures: external valvuloplasty and high ligation or disconnection of the sapheno-femoral junction.

MATERIALS AND METHODS

116 limbs (113 patients) were selected. 57 with normal cusps in dilated valves were subjected to external valvuloplasty with Silicone prosthesis under Doppler control (intraoperative angioscopy in 16 cases); 59 limbs were subjected to high ligation or disconnection of the junction; 57 limbs out of 116 were subjected to complementary procedures. Duplex and photoplethysmographic examinations were performed before and after the surgical procedures in all patients. Doppler venous pressures were measured in 36 limbs and invasive pressures in 40 limbs. Patients were postoperatively followed up every 4 months until the 12th month.

RESULTS

Indications for valvuloplasty were found in 8.2% of cases and in 66.3% of the early varices. Clinical results were slightly superior in the reparative surgery group. Thrombotic occlusion of the proximal long saphenous vein was significantly higher in the ligation-disconnection group. Results from photoplethysmography and venous pressure measurements indicated that both operations are equally effective in the elimination of reflux in the junction.

How not to miss a somatic needle in the haystack of chronic pain

Interviews with 18 male patients with predominantly psychogenic pain (DSM-III and DSM-III-R) and with 18 male patients with pain of mainly physical origin, consecutively admitted to a medical department, were rated by blinded and independent raters with respect to "symptom description," "manner of speech," "personality characteristics," "interviewer reactions," "interpersonal relationships," and "relationships at work." Patients with predominantly organic pain significantly more often described a clear localization of the pain symptom, used more sensory words for the description of pain quality; more often described discrete changes of pain intensity and periodicity; more often showed pain-intensifying factors dependent on movement and pain-decreasing factors; more often believed pain to be a symptom versus as a disease itself, and tended to have fewer difficulties in their interpersonal relationships than those with predominantly psychogenic pain (p < 0.05 for all factors, two-tailed Fisher's Exact test).

[New directions in the surgical treatment of gastroesophageal reflux. Review of the literature]

The pathophysiology of gastroesophageal reflux disease (GERD) is often multifactorial, as abnormal function of the lower esophageal sphincter (LES) may be associated to abnormalities of the esophageal peristalsis, the esophageal clearance, and the gastric reservoir. The preoperative evaluation of patients with GERD must include esophageal function tests (esophageal manometry and ambulatory pH monitoring) and evaluation of the gastric emptying in addition to UGI series and endoscopy. The information provided by these tests is essential to identify the pathophysiology of the disease in the individual patient, and tailor the operative treatment accordingly. For patients with an incompetent LES but normal esophageal peristalsis, the Nissen fundoplication is the procedure of choice. When abnormal peristalsis and delayed clearance are identified by preoperative esophageal function tests, a partial fundoplication must be chosen in order to avoid postoperative dysphagia and gas bloat syndrome. Too many eponyms have been used to describe antireflux surgery (Nissen, Rossetti, Toupet, Lind, Hill, Guarner). It is time to go beyond these eponyms, and focus on the technical details which contribute to the stability of the wrap, as this is the main determinant of long term outcome.

Seasonal variations in the rupture of abdominal aortic aneurysms

From 1982 to 1994, 54 patients (47 men; mean age 72 years) were referred to the Hospital of Ferrara, Italy for spontaneous rupture of abdominal aortic aneurysm. Sixteen died in the emergency department and 38 underwent urgent surgery. Day and month of onset of acute symptoms leading to urgent surgery were recorded. A seasonal variation with significant peaks in spring and autumn was found. These findings are likely influenced by local environmental, social and epidemiological factors, but may be relevant for the appropriate timing of the follow-up and therapeutic strategies for abdominal aortic aneurysms.

Membranous obstruction of the inferior vena cava and Budd-Chiari syndrome. Report of a case

Membranous obstruction of the inferior vena cava (MOIVC) is a rare, congenital or acquired, cause of Budd-Chiari syndrome leading to hepatocellular carcinoma in 20 to 40% of the patients. It has a very poor prognosis when treated medically and balloon angioplasty (PTA) represents, nowadays, the treatment of choice, having no mortality or significant morbidity with follow-up as long as 5 years; transatrial membranotomy, direct reconstruction of IVC and bypass surgery are alternative techniques when PTA is not feasible. One case of Budd-Chiari syndrome due to an incomplete membranous obstruction of the suprahepatic portion of the inferior vena cava is reported. A PTA was not feasible as it was not possible to pierce the membranous obstruction. A successful inferior vena cava-right atrium PTFE bypass, with a 3.5-year follow-up, was performed. This surgical approach is a valuable alternative to transatrial membranotomy and direct reconstruction of the IVC.

The relationship between in vitro and in vivo venous compliance measurement

OBJECTIVE

To assess the relationship between in vitro and in vivo venous compliance measurement.

DESIGN

Prospective, blind study.

MATERIALS AND METHODS

Patients affected by primary varicose veins and classified in accord with the new CEAP criteria (C2-6/S, Ep, AS1-4/p17-18, PR) underwent blind venous compliance measurements using two different methods. 1) In vivo assessment of the compliance of the greater saphenous vein by duplex scanning, for diameter, and a needle transducer, for venous pressure measurements. 2) In vitro standard compliance assessment of the same vein segment after its excision.

RESULTS

The compliance values obtained with the two methods showed a significant degree of correlation, which improved with increasing intravenous pressures.

CONCLUSIONS

In vivo compliance assessment of the saphenous vein was validated by the relationship with the standard in vitro measurement.

Alternative saphenous vein sparing surgery for future grafting

OBJECTIVE

Evaluation of long saphenous vein sparing surgical procedures alternative to high ligation and distal stab avulsion, in terms of effectiveness and suitability for eventual by-pass surgery.

EXPERIMENTAL DESIGN

Prospective evaluation of 125 operations for primary varicose veins, 52 external valve-plasties of the sapheno-femoral junction (EV-SFJ) (42 performed using the hand sewing technique and 10 using the Veno-cuff device), mean follow-up 45 months, and 73 hemodynamic correction of varicose veins (French acronyms: CHIVA), mean follow-up 30 months.

SETTING

Department of General Surgery, University of Ferrara. Institutional practice, one-day surgery.

PATIENTS

Patients were selected using clinical, Doppler cw, and duplex scanning evaluations. Patients with early varices due to sapheno-femoral reflux with duplex scanning evidence of mobile valve leaflets underwent EV-SFJ. The other patients were operated on using the hemodynamic correction technique. Both groups underwent preoperative ambulatory venous pressure (AVP) and light reflection rheography-refilling time (LRR-RT) measurements.

INTERVENTIONS

EV-SFJ restores valve function correcting vein wall dilitation by applying an external prosthesis. CHIVA consists of selected ligatures of the superficial veins that allow superficial blood aspiration in the deep veins through the perforators.

MEASURES

The outcome was evaluated with clinical and ultrasonographic examinations, AVP and LRR-RT measurements.

RESULTS

Long saphenous vein patency registered after EV-SFJ and CHIVA was 94.2% and 90.4%, respectively. Both treatments preserve the drainage function in the saphenous system. Varicose veins recurrence percentage rate was 9.6% and 10.9%, respectively.

CONCLUSIONS

Following the proposed selection criteria, these two alternative procedures seem to be more effective in varices treatment than high ligation and have the advantage of preserving saphenous veins suitable for eventual by-pass surgery.

When CHIVA treatment could be video guided

BACKGROUND

Hemodynamic correction (CHIVA) is a conservative, ambulatory, and controversial varicose vein treatment. It consists of selected ligatures of the superficial venous system decided by means of preoperative duplex mapping.

OBJECTIVE

Prospective evaluation of 80 patients, operated on according to the CHIVA technique described by Claude Franceschi. Mean follow-up length was 30 months.

METHODS

Fifty-five consecutive patients were operated on after clinical, ultrasonographic, ambulatory venous pressure and light reflection rheography evaluations. After a 3-year follow-up, another 25 consecutive patients were selected applying some exclusion criteria that emerged in the first part of the study. This second series was operated on by means of intraoperative angioscopy. The same preoperative evaluations have been used to study the outcome in all patients.

RESULTS

CHIVA failed in the short saphenous vein territory varices and when the long saphenous vein and the insufficient perforating veins had a preoperative diameter greater than 10 and 4 mm, respectively. The procedure showed a long saphenous vein patency of 90.4% and registered a total recurrence rate of 18.7%.

CONCLUSIONS

CHIVA seems to be a more effective varicose vein treatment than high ligation and distal stab avulsion. It also preserves a higher rate of long saphenous veins, suitable for bypass surgery.

[Laparoscopic treatment of Mirizzi's syndrome]

The Mirizzi syndrome is an unusual benign obstructive jaundice due to extrinsic mechanical compression of the common hepatic duct by gallstone impacted within the neck or cystic duct of the gallbladder. This syndrome is described either as an acute form due only to extrinsic compression of the common bile duct (type I) or as a chronic form resulting in an erosive cholecysto-choledochal fistula (type II). Up to date, the syndrome remains a clinically and surgically challenging problem. The anatomic basic of the syndrome (an anomalous relationship between the cystic duct and the common hepatic duct) when associated with inflammation and interbiliary fistula predisposes to a critical situation to be clearly detected and contributes to technical difficulties when surgical management is performed. The operative diagnosis of Mirizzi syndrome remains elusive and requires careful scrutiny of the biliary tract imaging to recognize the diseased duct system and to facilitate the following operative procedures. The surgical treatment requires a skill and careful operative dissection of the duct system, cholecystectomy and a safe biliary exploration and stone clearance, avoiding any iatrogenic damage to common hepatic duct. Laparotomy is commonly advocated as the safer approach to the diseased biliary tract and it is still employed by most authors. The laparoscopic surgery has not yet entered as the first-choice procedure for this syndrome due to jaundice and acute inflammation considered by some as contraindication to mini-invasive treatment. This paper describes successful surgical management by laparoscopic techniques in two patients affected by Mirizzi type I and type II syndrome treated by cholecystectomy alone and cholecystectomy with choledochal fistula flap repair, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiovideo-assisted hemodynamic correction of varicose veins

OBJECTIVE

Evaluation of the feasibility and utility of angioscopy in the hemodynamic correction (French acronyms is CHIVA) of primary varicose veins disease.

EXPERIMENTAL DESIGN

Prospective evaluation of 25 patients, undergoing hemodynamic correction of primary varicose disease with intraoperative videoangioscopic guide. Patients have been selected according to criteria emerged from a prospective study that we had previously conducted. Follow-up lasted 1 year (range 8-18 months).

SETTING

Department of Surgery, University of Ferrara, Italy. Institutional practice. One-day surgery.

PATIENTS

Their selection has been carried out in our Vascular Laboratory. The adopted clinical criteria of selection were: Primary varicose disease of the long saphenous vein territory, no previous thrombophlebitis and/or sclerotherapy. Doppler cw and Duplex criteria followed were: competent deep venous system, long saphenous vein diameter minor than 10 mm and incompetent perforating veins diameter minor than 4 mm.

INTERVENTIONS

25 hemodynamic corrections according to the CHIVA method described by Franceschi. An angioscope, introduced through a distal collateral of the long saphenous vein, permitted the precise interruption of the venous-venous shunts and of the superficial venous system, just below the perforators chosen as re-entry points in the deep venous system.

MEASURES

Clinical: varices and symptomatology reduction. Duplex and Doppler cw: detection of the superficial blood flow re-entry, in the deep venous system, through the perforators and identification of recurrences or new refluxes. Pre and postoperative Ambulatory Venous Pressure and Refilling Time have also been measured.

RESULTS

In 20 patients symptoms and varices relief were recorded (80%), in 5 patients varices reduction was observed only during walking (20%). In 2 of these latter patients there was no re-entry through the perforators, with a recurrent sapheno-femoral reflux in 1 of them. Early complications recorded were: 2 long saphenous vein thrombosis (8%); 7 ecchimosis (28%) when heparine/saline solution had been used for angioscopic clearance.

CONCLUSIONS

Intraoperative angioscopy is feasible and useful when the hemodynamic situation is complex and the Duplex map is difficult to be interpreted by the surgeon. In this series the second look percentage rate has been minor compared to the percentage rates published so far by other authors.

[Clinical and hemodynamic effects of external valvuloplasty of the sapheno-femoral junction]

Selected patients with primary varicose vein disease and sapheno-femoral reflux as the only point of regurgitation in the affected lower limb and duplex evidence of mobile valve leaflets underwent external valvuloplasty of the sapheno-femoral junction. Operations were performed under local anesthesia in one day-surgery. One PTFE sleeve 0.4 mm thick, in average 1.2 cm long and able to uncircle a circumference in average of 1.7 cm was put around the terminal Long Saphenous vein valve, located in the last centimeter of this vein. If also the subterminal Long Saphenous Vein valve site, located 5 cm below is dilated a second valvuloplasty was performed. In 15 case we used intra-operatory video-angioscopy guide. This examination allowed us to exclude two patients with valve damages not duplex demonstrable. Furthermore angioscopy permitted immediate demonstration of restored valvular function. Follow-up lasted on average 48 months: two early postoperative long saphenous vein thrombosis, and two late sapheno-femoral reflux recurrences were the main complications. We never observed graft infection. AVP was reduced and RT, measured by the means of LRR, had a prolongation after surgery. Both measurements had an highly significant difference from a statistical point of view, comparing pre and postoperative values. 95% of the operated patients have stable varices reduction. Long Saphenous Vein patency was recorded in 37 cases (92.5%). On the contrary, after high ligation, the fate of the saphenous vein in 21% of case is the occlusion. Symptoms of venous insufficiency disappeared completely in 80% of cases and improved in 95% of the operated patients.(ABSTRACT TRUNCATED AT 250 WORDS)