A Novel Endoluminal Technique for Varicose Vein Management: The VNUS Closure

In an attempt to reduce the morbidity of high tie and strip of the long saphenous vein various extraluminal and intraluminal electrosurgical devices have been employed in the past using monopolar energy to ablate varicose veins. As result of this full-thickness skin burns and saphenous nerve injuries were observed by surgeons using these techniques. This report describes the VNUS Closure, a novel endovascular computer-feedback-controlled application of bipolar electrothermal energy which ensures transmural heating of the vein wall while minimising thermal spread to neighbouring tissues.

Lymphoma masquerading as a recurrent brachial artery aneurysm

Malignant lymphoma infiltrating the brachial artery in a renal transplant patient has not been documented previously. We report an angiodestructive B-cell lymphoma in a 64-year-old post-renal transplant recipient. Improved longevity post-transplantation has been associated with an increased incidence of cancer which means that we will be seeing such patients more frequently in the future.

Day-case angioplasty in diabetic patients with critical ischemia

AIM

Recent studies have shown that percutaneous transluminal angioplasty (PTA) can be safely performed as a day-case procedure. Many centers consider diabetes mellitus as a contraindication to day-case PTA. In this study, the safety and efficacy of 95 day-case PTA in 66 diabetic patients with critical leg ischemia (CLI) were evaluated.

METHODS

Diabetic patients with CLI were assessed in a one-stop multidisciplinary outpatient clinic. Sixty-six outpatients with CLI deemed suitable for radiological intervention by non-invasive imaging (ultrasound angiology or magnetic resonance angiography) were scheduled for day-case PTA.

RESULTS

PTA was initially successful in 63 out of 66 patients (95%). In 3 patients (5%), PTA was not possible because the lesion could not be balloon dilated or crossed with a guide wire. Clinically suspected first, second and third re-stenosis confirmed by non-invasive studies occurred in 20 out of 63 (31%), 7 out of 20 (35%) and 2 out of 7 (28%) patients, respectively. Following PTA, debridement was performed in 11 patients (17%), minor amputation in 8 (13%) and major amputation in 3 (5%). Relief of the primary symptom of rest pain or healing of ulcers was achieved in 23 out of 32 (72%) and 25 out of 27 (92.5%) patients, respectively. No peri-interventional morbidity or mortality was encountered.

CONCLUSION

PTA is feasible and safe as a day-case procedure in diabetic patients with CLI. Re-stenosis can be managed by repeat day-case PTA.

Invos Cerebral Oximeter compared with the transcranial Doppler for monitoring adequacy of cerebral perfusion in patients undergoing carotid endarterectomy

AIM

The aim of this prospective study was to assess the correlation between signals obtained during carotid endarterectomy (CEA) under local (LA) or general anesthesia from the Somanetics Invos cerebral oximeter (CO) and transcranial Doppler (TCD).

METHODS

Forty patients were enrolled in the study. The percentages fall in TCD mean flow velocity (FVm) and CO regional oxygen saturation (rSO2) on the ipsilateral side following clamping were recorded and the correlation coefficient and Spearman's coefficient of rank correlation were calculated.

RESULTS

Fourteen patients were not included in the statistical analysis because either no TCD window or reliable TCD signal was obtained. The remaining 26 patients had a fall in either FVm, rSO2 or both during carotid clamping. There was a highly statistically significant correlation between the percentage fall in FVm and rSO2 with a correlation coefficient of 0.73, P<0.0001, with a 95% confidence interval (CI) for r=0.48 to 0.87; Spearman's coefficient of rank correlation (rho) =0.67, P=0.0008, with a 95% CI for rho=0.384 to 0.84. A significant decline in both TCD and rSO2 was noted in 3 patients under LA out of which 2 required shunts for alteration in conscious level. In 2 LA patients there was a significant decline in TCD but not in rSO2 and the endarterectomy was completed without a shunt.

CONCLUSIONS

Regional oxygen saturation correlates well with FVm during carotid clamping. However, the inability to obtain reliable TCD FVm readings in 35% of patients is a serious disadvantage for this monitor. It appears that CO is a satisfactory and possibly superior device for monitoring adequacy of cerebral perfusion and oxygenation during CEA in comparison with the TCD.

An integrated care pathway to save the critically ischaemic diabetic foot

This prospective study describes and evaluates the efficacy of an integrated care pathway for the management of the critically ischaemic diabetic foot patients by a multidisciplinary team. A weekly joint diabetes/vascular/podiatry ward round and outpatient clinic was established where patients were assessed within 7 days of referral by clinical examination, ankle-brachial-index-pressures, duplex angiogram and transcutaneous oxygen pressures. An angiogram +/- angioplasty or alternatively a magnetic resonance angiography prior to surgical revascularisation was performed in patients deemed not suitable for angioplasty based on the above vascular assessment. Between January 2002 and June 2003(18 months), 128 diabetic patients with lower limb ischaemia were seen. Thirty-four (26.6%) patients received medical treatment alone, and 18 (14.1%) were deemed 'palliative' due to their significant co-morbidities. The remaining 76 (59.4%) patients underwent either angioplasty (n = 56), surgical reconstruction (n = 18), primary major amputation (n = 2) or secondary amputation after surgical revascularisation (n = 1). Minor toe amputations were required in 35 patients. The mortality in the intervention group was 14% (11/76). This integrated multidisciplinary approach offers a consistent and equitable service to diabetic patients with critically ischaemic feet and appears to have a beneficial major/minor amputation ratio.

Randomized clinical trial of vertical or transverse laparotomy for abdominal aortic aneurysm repair

BACKGROUND

The objective of this randomized trial was to evaluate the incidence of incisional hernia after transverse or vertical incisions for open aortic aneurysm repair.

METHODS

The study group comprised 69 patients who underwent elective aneurysm repair between November 1998 and November 2000 (60 men, nine women; mean age 72.8 (range 56-95) years). Patients were randomized to a transverse (n = 32) or vertical (n = 37) incision for the procedure. Of the 42 patients who were still alive in February 2004, 37 (15 transverse, 22 vertical incisions) attended for review. Laparotomy scars were assessed both clinically and ultrasonographically by the same examiner, to look for incisional hernia.

RESULTS

Mean follow-up was 4.4 years. A multivariable logistic regression analysis revealed that the type of incision was the only parameter that significantly influenced the rate of incisional hernia: six of 15 patients with a transverse laparotomy versus 20 of 22 with a vertical laparotomy (P = 0.010).

CONCLUSION

The incidence of incisional hernia was high after aortic aneurysm repair, but was lower in patients who had a transverse incision.

Are we managing primary upper limb deep venous thrombosis aggressively enough in the district?

AIM

The objective of this retrospective study was to analyse risk factors, management and outcome of primary upper limb deep venous thrombosis (ULDVT, Paget von Schroetter syndrome) in 4 district hospitals.

METHODS

The study group audited between May 1995 and January 2004 comprised of 24 patients with primary ULDVTs (8 male, 16 female; age range 21-80 years, mean 46 years).

RESULTS

Common risk factors included smoking (n=8, 33.3%) and hormonal therapy for women (n=4, 25%). Diagnosis was established by duplex ultrasound alone in 13 patients (54.2%), by venogram alone in 9 patients (37.5%) and by both investigations in 2 patients (8.3%). A thrombophilia screen was performed in 19 patients (79.2%) of which 5 patients (20.8%) were identified with a hypercoagulable state. Twenty-three patients were anticoagulated (95.8%). One patient (4.2%) was initially thrombolysed and subsequently anticoagulated. Overall symptoms resolved or improved in 14 patients (58.3%), symptoms persisted in 8 patients (33.3%) and in 2 patients (8.3%) the outcome was not documented. Only one patient was further evaluated and identified as having thoracic outlet compression. Most patients were managed by physicians (n=19 versus surgeons n=5).

CONCLUSIONS

This study reveals that most patients with primary ULDVT are treated with anticoagulation alone probably based on protocols for lower limb deep vein thromboses which results in an unacceptable high number of patients (33.3%) with persisting disability. Therefore, we suggest a more proactive approach in such patients with evaluation for thoracic outlet compression.

Is screening of abdominal aortic aneurysm effective in a general practice setting?

AIM

This prospective study was conducted to assess feasibility, patients' acceptability and impact of ultrasound screening on rupture rate of abdominal aortic aneurysms (AAAs).

METHODS

A population based sample of men (n=2709), aged over 60 years, covering 11 general practices was offered ultrasound screening between January 1996 and December 2003. The presence of risk factors for arteriosclerosis and annual rupture rates for AAAs were analyzed.

RESULTS

Of the 2709 patients approached, 2561 (95%) accepted and 161 (6%) did not attend. A total number of 81 (3.4%) patients (average age: 71 years) were identified with an AAA, of which 59 were small (<5 cm) and 22 large AAAs (>5 cm). The most common risk factors identified in patients with AAA were smoking/ex-smoking (n=68, 84%) and hypertension (n=32, 40%). The overall annual rupture rate was reduced from 47% in 1996 to 14% in 2003.

CONCLUSIONS

Ultrasound screening for AAA is feasible, acceptable by elderly male patients in a primary care setting and reduces the incidence of ruptured AAAs.

Are we managing deep venous thrombosis of the upper limb appropriately?

Objective: The objective of this retrospective study was to analyse risk factors, management and outcome of upper limb deep venous thrombosis (ULDVT) in two London district hospitals.

Methods: The study group audited between May 1995 and July 2002 comprised 33 patients with ULDVTs, of which 12 were primary and 21 were secondary.

Results: Common risk factors included malignant disease ( n=17, 51.5%), smoking ( n=16, 48.5%), central venous access ( n=9, 27.3%), cardiac disease ( n =6, 18.2%) and hormonal therapy ( n=4, 12.1%). None of the patients were evaluated for thoracic outlet compression. A thrombophilia screen was performed in eight patients with primary ULDVT and in seven patients with secondary ULDVT. Thrombophilic states were identified only in the primary group, in two patients. Twenty-eight patients were anticoagulated (84.8%) and overall symptoms resolved in 20 patients (60.6%). All 13 deaths occurred within the secondary group.

Conclusions: The present study reveals that there is no consensus in investigating and managing patients with ULDVT, which is probably due to the variety of aetiological factors of this condition.

Preventing Venous Ulcer Recurrence: The Impact of the Well Leg Clinic

Background:

The aim of this prospective study was to evaluate the effectiveness of a nursing-led clinic within a District Hospital setting in detecting early skin break-down in healed venous ulcers.

Patients and Methods:

A total of 76 patients (45 women, 31 men; age range 24-91 years, mean 74 years) with healed venous ulcers were included in the study between July 1999 and April 2001. Patients were counselled about managemant of ulcers at their initial visit and followed up at 3 and 6 months.

Results:

We received 79 referrals and of those 76 (96%) accepted our invitation. Fifty-six patients did attend the first clinic appointment, 39 (67%) attended their second clinic visit at 3 months and 38 (68%) were followed up by a telephone call at 6 months. During this period 9 recurrent leg ulcers were noted which were referred for further intervention.

Conclusion:

It is important to provide follow-up for patients with healed ulcers in order to minimise the recurrence rate and to re-institute treatment soon, as recurrence can occur early following healing.

Venous thromboembolism. Prophylaxis on a Saturday morning in a district hospital

BACKGROUND

Implementation of guidelines to prevent venous thromboembolism (VTE) is essential to help guide junior medical staff but adherence to such protocols is insufficient. This study aims to audit the use of VTE prophylaxis (Tinzaparin 3500 units and/or thromboembolic deterrent stockings (TED) in general surgical inpatients in a district hospital on a random day at the beginning (Group A) and at the end of the junior house officer's 6 monthly term (Group B).

METHODS

Patients were analyzed within the subgroups elective and emergency admissions and assessed regarding the appropriate prescription of tinzaparin and TED-stockings. The presence of a significant time lag between patients arriving on the ward and VTE-prophylaxis being prescribed was documented.

RESULTS

Tinzaparin was appropriately prescribed or not prescribed if contraindicated in 86% of elective admissions in Group A (versus 91% in Group B) and in 58% of emergency admissions in Group A (versus 85% in Group B). The subcutaneous injection of tinzaparin was commenced on the day of admission in 67% in Group A and in 75% of patients in Group B. CONCLUSIONS. Despite the institution of local guidelines adherence to such recommendations appears to be sub-optimal even at the end of the junior house officer's 6 monthly term when one would expect a higher vigilance.

Ultrasound changes at the saphenofemoral junction and in the long saphenous vein during the first year after VNUS closure

BACKGROUND

The VNUS Closure is an endoluminal, percutaneous catheter-based device using a radiofrequency current to cause permanent closure of the long saphenous vein (LSV) as an alternative to high tie and stripping. This study describes our postoperative ultrasound scan surveillance results of VNUS Closure cases over a one year period.

METHODS

Between March and August 2000, 79 patients had 127 legs treated. Postoperative ultrasound scans were performed in order to evaluate persistence of a patent superficial inferior epigastric vein at the saphenofemoral junction (SFJ), stump length of the remaining SFJ and changes in morphology and diameter of the ablated LSV. Ten legs were chosen randomly for this evaluation at each follow-up appointment.

RESULTS

Fifty-seven per cent of the patients' legs had a patent SFJ-stump with a remaining patent superficial epigastric vein but none of the patients showed neovascularisation at the SFJ or recanalisation of the LSV. The stump length at the SFJ appeared to be getting smaller as our experience grew greater.

CONCLUSIONS

This new technique of radiofrequency ablation provides a minimal access alternative to the classical high tie and stripping. Our results to date show that this procedure leaves a small patent stump at the SFJ with no evidence of neovascularisation and a completely atrophied closed LSV.

A novel approach to the treatment of recurrent varicose veins

BACKGROUND

A variety of approaches has been described for the treatment of recurrence at the saphenofemoral junction (SFJ) after primary varicose vein surgery most, of them based on dissection through virgin tissue. This observational study describes our clinical experience with the VNUS Closure, a percutaneous catheter-based procedure in which the long saphenous vein (LSV) is ablated from within by resistive heating.

METHODS

Twelve patients who had undergone previous high tie and stripping procedures had 18 legs treated with the VNUS Closure between March 1999 and April 2000. In one patient VNUS Closure was performed also in an anterior thigh branch. Postoperative ultrasound scans were performed at regular intervals in order to assess successful closure of the LSV.

RESULTS

None of the patients showed recanalisation of the LSV during the duplex ultrasound scan surveillance and the only complication related to the VNUS Closure noted were sensory disturbances at the inner thigh in 6 legs.

CONCLUSION

This new endovascular technique is the authors' preferred method of treating recurrent varicose veins where an incompetent LSV persists either due to neovascularisation at the saphenofemoral junction or to a persisting midthigh perforator.

Unilateral Congenital Foot Lymphoedema with Hypoplastic Toes

Congenital lymphoedema causes limb swelling from impaired lymph drainage and it can predispose patients to infection and rarely to cancer. We report a case of unilateral primary congenital lymphoedema of the foot associated with hypoplastic toes, which has not been documented in the literature before.

Etiology of leg ulcers, healing and recurrence rates in octo- and nonagenarians

BACKGROUND

A high proportion of leg ulcers refractory to ambulatory compression therapy have a mixed etiology. This study evaluates this mixed etiology and the healing and recurrence rate in octo- and nonagenarians.

METHODS

The study group comprised 101 patients with 119 legs affected by ulcers. Concomitant diseases, ulcer size, healing time and time for the ulcer to recur were documented.

RESULTS

Sixty-four ulcers were of venous origin [healing rate (HR): 45.3%, recurrence rate [(RR): 10.3%], 23 ulcers were complicated by 1 additional disease process (HR: 47.8%, RR: 45.5%), 13 ulcers were complicated by 2 or more concomitant diseases (HR: 46.2%, RR: 16.6%) and 19 ulcers (HR: 26.3%, RR: 20%) were of non-venous origin.

CONCLUSIONS

This study showed that venous reflux in combination with local or systemic disease in our elderly patient group increases the chance of recurrence. Non-venous ulcers appear to have a reduced healing rate possibly due to the underlying pathology.

The Saphenofemoral Valve: Gate Keeper Turned into Rear Guard

Objective:

Trendelenburg's theory was based on the concept of a descending valvular incompetence com mencing at the saphenofemoral junction (SFJ) with subsequent distal progression of reflux. The aim of this study was to evaluate the distribution of reflux in patients with superficial venous incompetence in order to assess validity of the above hypothesis.

Procedures:

The superficial and deep venous system of a consecutive series of 443 patients presenting with primary varicose veins was examined by one vascular technologist using colour flow ultrasonography.

Results:

Six hundred and eleven lower limbs in 443 patients were examined. The distribution of long saphenous vein (LSV) reflux was the following: Of the 611 limbs 454 showed LSV reflux, with 240 legs exhibiting total reflux (SFJ and LSV) and 214 legs exhibiting reflux in evolution (LSV reflux with competent saphenofemoral valve, isolated posterior arch reflux and lateral anterior thigh vein reflux with SFJ reflux).

Conclusion:

These results suggest that reflux starts distally and progresses proximally, thus throwing the Trendelenburg theory into dispute.