Catheter-directed thrombolysis for lower extremity deep venous thrombosis: report of a national multicenter registry

PURPOSE

To evaluate catheter-directed thrombolysis for treatment of symptomatic lower extremity deep venous thrombosis (DVT).

MATERIALS AND METHODS

From a registry of patients (n = 473) with symptomatic lower limb DVT, results of 312 urokinase infusions in 303 limbs of 287 patients (137 male and 150 female patients; mean age, 47.5 years) were analyzed. DVT symptoms were acute (< or = 10 days) in 188 (66%) patients, chronic (> 10 days) in 45 (16%), and acute and chronic in 54 (19%). A history of DVT existed in 90 (31%). Lysis grades were calculated by using venographic results.

RESULTS

Iliofemoral DVT (n = 221 [71%]) and femoral-popliteal DVT (n = 79 [25%]) were treated with urokinase infusions (mean, 7.8 million i.u.) for a mean of 53.4 hours. After thrombolysis, 99 iliac and five femoral vein lesions were treated with stents. Grade III (complete) lysis was achieved in 96 (31%) infusions; grade II (50%-99% lysis), in 162 (52%); and grade I (< 50% lysis), in 54 (17%). For acute thrombosis, grade III lysis occurred in 34% of cases of acute and in 19% of cases of chronic DVT (P < .01). Major bleeding complications occurred in 54 (11%) patients, most often at the puncture site. Six patients (1%) developed pulmonary emboli. Two deaths (< 1%) were attributed to pulmonary embolism and intracranial hemorrhage. At 1 year, the primary patency rate was 60%. Lysis grade was predictive of 1-year patency rate (grade III, 79%; grade II, 58%; grade I, 32%; P < .001).

CONCLUSION

Catheter-directed thrombolysis is safe and effective. These data can guide patient selection for this therapeutic technique.

Characterization of symptomatic and asymptomatic carotid plaques using high-resolution real-time ultrasonography

High-resolution ultrasonography was used to classify carotid plaques into five different types in 72 patients with symptoms and in 49 without, and with stenosis of the origin of the internal carotid artery > 70 per cent. There were 72 plaques in the symptomatic group and 75 in the asymptomatic group. Type 1 plaques were uniformly echolucent, type 2 predominantly echolucent, type 3 predominantly echogenic, type 4 uniformly echogenic and type 5 consisted of plaques that could not be classified owing to heavy calcification and acoustic shadows. Type 1 plaque was found in 90 per cent of patients with symptoms and in 10 per cent of those without, type 2 plaque was found in 53 and 47 per cent, type 3 in 34 and 66 per cent, and type 4 in 5 and 95 per cent, respectively. The preponderance of echolucent plaques in symptomatic patients with stenosis > 70 per cent supports the hypothesis that this type of plaque is unstable and tends to embolize. In contrast, in patients without symptoms there is preponderance of echogenic plaques.

Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms

PURPOSE

We previously reported preliminary data on a new procedure that we developed for the treatment of femoral pseudoaneurysms after catheterization. This study presents our current results of percutaneous ultrasound-guided thrombin injection for treating pseudoaneurysms that arise from various locations and causes.

METHODS

Between February 1996 and May 1999, we performed thrombin injection of 83 pseudoaneurysms in 82 patients. There were 74 femoral pseudoaneurysms: 60 from cardiac catheterization (36 interventional), seven from peripheral arteriography (four interventional), five from intra-aortic balloon pumps, and two from dialysis catheters. There were nine other pseudoaneurysms: five brachial (two cardiac catheterization, two gunshot wounds, one after removal of an infected arteriovenous graft), one subclavian (central venous catheter insertion), one radial (arterial line), and one distal superficial femoral and one posterior tibial (both after blunt trauma). Twenty-nine pseudo-aneurysms were injected while on therapeutic anticoagulation. Patients underwent repeat ultrasound examination within 5 days and after 4 weeks.

RESULTS

Eighty-two of 83 pseudoaneurysms had initial successful treatment by this technique, including 28 of 29 in patients who were undergoing anticoagulation therapy. The only complication was thrombosis of a distal brachial artery, which resolved spontaneously. There were early recurrences in seven patients: four patients underwent successful reinjection; reinjection failed in two patients, who underwent surgical repair; and one patient had spontaneous thrombosis on follow-up. After 4 weeks, ultrasound examinations were completely normal or showed some residual hematoma, and there were no recurrent pseudoaneurysms.

CONCLUSION

Ultrasound-guided thrombin injection of pseudoaneurysms has excellent results, which support its widespread use as the primary treatment for this common problem.

Superficial venous insufficiency: correlation of anatomic extent of reflux with clinical symptoms and signs

PURPOSE

The aim of this study was to assess the distribution and extent of valvular incompetence in patients with reflux confined to the superficial venous system and correlate the extent of such reflux with clinical symptoms and signs.

METHODS

Two hundred fifty-five limbs of 217 patients with superficial venous insufficiency and normal perforating and deep veins were examined with color-flow duplex imaging. One hundred twenty-three limbs (48.2%) of 102 patients had reflux confined to the long saphenous system, 83 limbs (32.6%) of 72 patients had reflux confined to the the short saphenous system, and 49 limbs (19.2%) of 43 patients had reflux in both long and short saphenous systems.

RESULTS

In the long saphenous system the commonest pattern of reflux was that which extended throughout the length of long saphenous vein (LSV) (47%). Ache, swelling, and skin changes were common in the presence of below knee reflux irrespective whether the thigh segment was involved. Ulceration (8%) was found only in limbs with reflux extending throughout the length of LSV. In the short saphenous system the most common pattern of reflux extended throughout the length of short saphenous vein (SSV) (57%) without involvement of Giacomini or gastrocnemial veins. Ache and swelling were present in 62% and 72% of the limbs, but this incidence was not related to the extent of reflux. Swelling, skin changes, and ulceration occurred only when the whole of the SSV was involved. In the limbs with reflux in both the long and short saphenous systems, the most common pattern of reflux extended throughout the length of both systems (45%). In these limbs the incidence of swelling was 80%. The incidence of skin changes went from 44% when the below-knee segment of the LSV was involved to 73% when reflux occurred throughout the LSV and SSV. Ulceration (14%) was found only in the latter situation. Variable patterns of saphenogastrocnemial termination were seen. In 57.8% of the limbs SSV joined the popliteal vein just above the popliteal crease, whereas the SSV terminated in the thigh in 26.6%.

CONCLUSIONS

We conclude that ache, ankle edema, and skin changes in limbs with reflux confined to the superficial venous system are predominantly associated with reflux in the below-knee veins. Ulceration is found only when the whole of the LSV is involved (8%) or when reflux is extensive in both LSV and SSV (14%).

Percutaneous ultrasound guided thrombin injection: a new method for treating postcatheterization femoral pseudoaneurysms

PURPOSE

Since its introduction in 1991, ultrasound guided compression repair of postcatheterization femoral artery pseudoaneurysms has been shown to be effective. Disadvantages of ultrasound guided compression repair include patient discomfort during compression, inability to treat noncompressible pseudoaneurysms, prolonged use of ultrasound equipment and personnel, limited success with patients being treated with anticoagulants, and some early recurrences. We conducted a prospective study to evaluate a new method of treating femoral pseudoaneurysms, percutaneous ultrasound guided thrombin injection.

METHODS

Under duplex ultrasound guidance, a 22- or 25-gauge needle was percutaneously positioned within the pseudoaneurysm. Without compressing the pseudoaneurysm, 0.5 to 1 ml thrombin solution (1000 U/ml) was injected to induce thrombosis. Early in the study, the procedure was modified to allow more than one injection. After successful thrombosis, the patients were kept at rest in bed for at least 1 hour. Duplex ultrasound examination was repeated in 1 to 4 days. Distal pulses and ankle-brachial indexes were measured before and after the procedure.

RESULTS

Twenty of 21 consecutive pseudoaneurysms were successfully treated with thrombin injection. Fifteen pseudoaneurysms thrombosed immediately (<20 seconds) after one injection. The other five had partial thrombosis after one injection and complete thrombosis immediately after a second injection. The one failure occurred in a patient who had only one injection and then underwent subsequent ultrasound guided compression repair, which failed. No patient required sedation or analgesia during thrombin injection. There were no procedure-related complications and no recurrences.

CONCLUSIONS

Percutaneous ultrasound guided thrombin injection appears to be a safe and expeditious method for treating postcatheterization femoral pseudoaneurysms. It has significant advantages with respect to ultrasound guided compression repair or surgical repair.

Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs--UIP consensus document. Part I. Basic principles

OBJECTIVES

Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP). The aim was to obtain a consensus of international experts on the methodology to be used for assessment of veins in the lower limb by ultrasound imaging.

DESIGN

Consensus conference leading to a consensus document.

METHODS

The authors invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the experts were made available to all participants via the UIP website. The authors prepared a draft document for discussion at a UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually all participants agreed the final version of the paper.

RESULTS

The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document suggests a methodology for complete assessment of the superficial and perforating veins of the lower limbs, including recommendations on reporting results and training of personnel involved in these investigations.

CONCLUSIONS

The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonographpy.

Where does venous reflux start?

PURPOSE

This study was designed to identify the origin of lower limb primary venous reflux in asymptomatic young individuals and to compare patterns of reflux with age-matched subjects with prominent or clinically apparent varicose veins.

METHODS

Forty age- and sex-matched subjects with no symptoms (age, 15 to 35 years; 80 limbs; group A), 20 subjects (age, 19 to 32 years; 40 limbs) with prominent but nonvaricose veins (n = 26 limbs; group B), and 50 patients (age, 17 to 34 years; 100 limbs) with varicose veins (n = 64; group C) were examined with color flow duplex imaging. All proximal veins (above popliteal skin crease), superficial, perforator, and deep, in the lower limb were examined in the standing position, and all the distal veins in the sitting position. Patients who had a documented episode of superficial or deep vein thrombosis, previous venous surgery, or injection sclerotherapy were excluded from the study.

RESULTS

The prevalence of reflux in group A was 14% (11 of 80), in group B 77% (31 of 40), and in group C 87% (87 of 100). In more than 80% of limbs in the three groups, reflux was confined to the superficial veins alone. Deep venous reflux or combined patterns of reflux were uncommon even in group C. Reflux was detected in all segments of the saphenous veins and their tributaries. In the 125 limbs that had superficial venous incompetence, the below-knee segment of the greater saphenous vein was the most common site of reflux (85, 68%), followed by the above-knee segment of greater saphenous vein (69, 55%) and the saphenofemoral junction (41, 32%). Nonsaphenous reflux was rare (3, 2.4%). Reflux in the lesser saphenous vein (21, 17%) was seen in all groups, whereas involvement of both greater and lesser saphenous veins (8, 6.4%) was seen in group C alone. The incidence of multisegmental reflux was significantly higher in group C (61 of 64, 95%) than in group A (two of 11, 18%) or group B (14 of 26, 54%). The prevalence of distal reflux was comparable in all groups.

CONCLUSIONS

Primary venous reflux can occur in any superficial or deep vein of the lower limbs. The below-knee veins are often involved in asymptomatic individuals and in those who have prominent or varicose veins. These data suggest that reflux appears to be a local or multifocal process in addition to or separate from a retrograde process.

The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency

PURPOSE

The purpose of this study was to identify the distribution of venous reflux in patients with different patterns of reflux with each class.

METHODS

Color-flow duplex imaging was used to evaluate the entire venous system from groin to ankle in 465 patients (594 limbs) belonging to different clinical CVI classes (0, 1, 2, and 3). A history of previous superficial thrombophlebitis was present in five limbs and past deep vein thrombosis in 70.

RESULTS

One hundred seventy eight (30%) limbs were normal and the remaining 416 (70%) had venous incompetence. Deep reflux was present exclusively in 19 limbs (3.2%), and the perforation system alone was involved in only three limbs (0.5%). However, isolated superficial incompetence was seen in 186 limbs (31.3%) and a combination of superficial with perforating alone was involved in 45 (7.6%). Incompetence in all three systems was seen in 99 extremities (16.7%). In addition, the superficial system was involved in 390 limbs, the perforators in 151, and the deep system in 178 limbs. Only a small percentage of those in class 0 had reflux, and most of them had a single site of incompetence. In class 1 the majority of the limbs had superficial reflux (90.3%), 10.3% of the limbs had deep venous reflux, and 6.9% were competent. Reflux in the superficial system was only seen in 80.7% of the limbs in class 1 and in one fifth of the limbs in classes 2 and 3. Isolated deep or perforated incompetence was rare in all classes. Variable combined patterns of reflux were seen more often in classes 2 and 3 (p < 0.0001). In classes 2 and 3 there were no differences in the number of incompetent sites in the superficial and deep venous systems or the patterns of reflux (p > 0.1). The number of incompetent perforators in class 3 tended to be higher than that in class 2, especially in the below-knee segment, but no significant differences were seen. Distal reflux was present in the majority of the limbs in all symptomatic classes (1, 2, and 3).

CONCLUSIONS

The distribution and extent of reflux is strongly associated with clinical severity of CVI through class 2. Distal venous reflux is present in at least 80% of the symptomatic limbs. Deep venous thrombosis may not be a prerequisite for the development of skin changes or ulceration in about 75% of the limbs. Superficial venous surgery could be beneficial to at least one third of patients with skin changes or ulceration.

Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs—UIP Consensus Document. Part II. Anatomy

OBJECTIVES

Duplex ultrasound investigation has become the reference standard in assessing the morphology and haemodynamics of the lower limb veins. The project described in this paper was an initiative of the Union Internationale de Phlébologie (UIP), The aim was to obtain a consensus of international experts on the methodology to be used for assessment of anatomy of superficial and perforating veins in the lower limb by ultrasound imaging.

DESIGN

Consensus conference leading to a consensus document.

METHODS

The authors performed a systematic review of the published literature on duplex anatomy of the superficial and perforating veins of the lower limbs; afterwards they invited a group of experts from a wide range of countries to participate in this project. Electronic submissions from the authors and the experts (text and images) were made available to all participants via the UIP website. The authors prepared a draft document for discussion at the UIP Chapter meeting held in San Diego, USA in August 2003. Following this meeting a revised manuscript was circulated to all participants and further comments were received by the authors and included in subsequent versions of the manuscript. Eventually, all participants agreed the final version of the paper.

RESULTS

The experts have made detailed recommendations concerning the methods to be used for duplex ultrasound examination as well as the interpretation of images and measurements obtained. This document provides a detailed methodology for complete ultrasound assessment of the anatomy of the superficial and perforating veins in the lower limbs.

CONCLUSIONS

The authors and a large group of experts have agreed a methodology for the investigation of the lower limbs venous system by duplex ultrasonography, with specific reference to the anatomy of the main superficial veins and perforators of the lower limbs in healthy and varicose subjects.

Venous hemodynamic abnormalities in patients with leg ulceration

PURPOSE

Venous ulceration in the leg has been predominantly associated with deep venous insufficiency, although a few reports have implicated the superficial veins. The aim of this study was to identify the distribution of valvular incompetence in patients with active leg ulceration.

PATIENTS AND METHODS

Color flow duplex imaging (CFDI) ultrasonography was used to evaluate the entire venous system--superficial, perforator and deep--from groin to ankle in 112 limbs of 94 patients with venous leg ulcers.

RESULTS

Seventy two limbs (64%) had multisystem incompetence and 36 (32%) had one system involved only, whereas in 4 limbs (4%) there was no venous incompetence. Deep venous reflux exclusively was present in 7 limbs (6%) and the perforator system alone was involved only in 3 limbs (3%). However, isolated superficial incompetence was seen in 26 extremities (23%) and combination of superficial with perforator system alone in 23 (21%). In addition, reflux overall in the superficial system (alone and in combination with perforator and deep systems) was seen in 94 limbs (84%). The most common pattern (28%) of abnormality was reflux in all systems, superficial, perforator, and deep.

CONCLUSIONS

The results of this study show that variable combined patterns account for over two thirds of patients with ulceration. No comprehensive surgical policy for alleviating ulceration can be justified; we suggest that a complete evaluation of all venous systems from groin to ankle with CFDI ultrasonography in patients with venous ulceration is practical on a routine basis and will be particularly valuable before surgery in order to target intervention at specific incompetent sites.

New insights into perforator vein incompetence

BACKGROUND

there has been much controversy on the role of perforator veins in the development of chronic venous disease (CVD). This study was designed to determine the duration and direction of flow of lower limb perforator veins (PVs) in relation to their location, diameter and competency status of superficial and deep veins, in healthy volunteers and patients with different grades of CVD.

PATIENTS AND METHODS

thirty limbs in 15 symptom-free volunteers and 103 limbs in 75 patients with signs and symptoms of CVD were examined with colour-flow duplex scanning. Superficial, perforator and deep veins were studied in the standing and sitting positions. Flow-velocity characteristics, the number and maximum PV diameter at the deep fascia and subfascially were determined. A PV was considered incompetent when the outward flow lasted >0.5 s.

RESULTS

581 PVs were found in the patients and 106 in the volunteers. 163 PVs (28%) were incompetent in the first group and none in the latter. The total number of PVs and the number of incompetent PVs per limb increased significantly with the severity of CVD. The mid-calf area had more competent and incompetent PVs in patients (p <0.01). Mean diameter of incompetent PVs in all the CVD classes was significantly larger than that of competent PVs. Competent PVs tended to be larger with increasing severity of CVD and they were significantly larger in the CVD classes 4 to 6 compared to controls (p <0.01). Subfascial PV diameter was markedly larger than that at the fascial level (p <0.001) regardless of the CVD class. A subfascial PV diameter of >3.9 mm (95% CI 3.4 to 4.4 mm) indicated incompetence. However, the reverse was not true, because about a third of incompetent PVs had a subfascial diameter of <3.9 mm. Both competent and incompetent PVs were smaller when located at the lower thigh, knee, ankle and anterior aspect of the calf than those found in the rest of the calf and mid-thigh (p =0. 03). Both inward and outward flow was found more often in patients than in controls (70/418 vs. 9/106, p =0.048). Most incompetent PVs had outward flow alone (126, 77%). PV incompetence was most frequently associated with reflux in superficial veins (120, 74% (p <0.0001), followed by reflux in both the superficial and deep veins (34, 21%) and reflux in the deep veins alone (9, 5%). The mean duration of outward flow was markedly longer in the presence of both superficial and deep vein reflux compared to superficial (p <0.001) or deep vein reflux alone (p <0.0001).

CONCLUSIONS

the number of incompetent PVs and the diameter of both competent and incompetent PV increases with the severity of CVD. Bidirectional PV flow is more common in patients than in normal volunteers, while 77% of the incompetent PVs have outward flow alone. PV incompetence is most often associated with reflux in the superficial veins, indicating that deep venous reflux is rarely the primary cause of PV insufficiency.

Clinical Significance of Superficial Vein Thrombosis

OBJECTIVE

To evaluate the clinical implications of superficial thrombophlebitis (STP) including its demographic characteristics, distribution, risk factors, relationship with deep vein thrombosis (DVT), pulmonary embolism (PE), diagnosis and management.

METHODS

Data were collected from relevant papers using a MEDLINE search and an extensive bibliography review. Studies were considered only when they contained pertinent material to STP. Thirty-seven papers were analysed.

RESULTS

The diversity of patients and methods used in the different studies made the comparison among them difficult. STP is a common condition with an underestimated prevalence. There are many risk factors associated with STP but the strongest relation was seen with hypercoagulable states. Malignancy may be another important factor but the strength of this association remains unknown. Coexistence with DVT was found in 6-53%. PE occurred in 0-33.3%. Propagation to DVT ranged from 2.6 to 15%. Treatment has not been standardised and may include elastic compression, anti-inflammatory drugs, anticoagulation and surgery.

CONCLUSION

The limited number of prospective randomised studies on STP does not allow strong recommendations to be given. Although STP most often is perceived as benign, it can coexist with or progress to DVT, and even give rise to PE. It is also associated with hypercoagulability and malignancy.

Patterns and distribution of isolated calf deep vein thrombosis

PURPOSE

In the search for calf deep vein thrombosis (DVT) with color-flow duplex scanning (CFDS), most vascular laboratories investigate only the posterior tibial and peroneal veins. Few laboratories assess the soleal and gastrocnemial veins. This study was designed to determine the patterns and distribution of isolated calf DVT, including the soleal and gastrocnemial veins.

METHODS

In the last 3 years, 5250 patients (mean age, 66 +/- 15 years; range, 22 to 93 years) were referred to the vascular laboratory for clinical suspicion of DVT and underwent examination with CFDS. All superficial and deep named veins, excluding the anterior tibial from groin to ankle, were imaged. Of the deep veins in the calf, the peroneal, the posterior tibial, the gastrocnemial, and the soleal veins were examined throughout their length.

RESULTS

DVT was detected in 14% of the patients. Isolated calf DVT was detected in 282 limbs of 251 patients (4.8%). No significant difference was noted for the sex (114 men vs 137 women; P =.15) or the limb preference (145 left vs 137 right; P =.5). The peroneal veins were most frequently involved, with 115 limbs (41%) affected. The soleal veins were involved in 109 limbs (39%), followed by the posterior tibial in 105 limbs (37%) and the gastrocnemial in 79 limbs (29%). Thrombus in the soleal vein alone was found in 57 limbs (20%), in the gastrocnemial in 48 limbs (17%), in the peroneal in 41 limbs (15%), and in the posterior tibial vein in 35 limbs (12%). Thrombus confined to a single or paired vein was found in 181 limbs (64%). Thrombus involving two different veins (27%) was the second most frequent pattern, and thrombus in three (7%) or four (1.4%) different veins was less prevalent. Isolated thrombosis in veins not routinely investigated was found in 113 limbs (40%; soleal, n = 57; gastrocnemial, n = 48; soleal + gastrocnemial, n = 8). Multifocal origin of thrombosis, defined as thrombi in two different veins that do not anatomically communicate, was identified in 63 limbs (22%).

CONCLUSION

Forty percent of the patients with acute isolated calf DVT would be judged to have normal CFDS examination results if the muscular veins in the calf were not imaged. Multifocal origin of thrombosis was found in 22% of the involved limbs. The prevalence of thrombosis in any calf vein either alone or in combination is comparable. Accordingly, the soleal and gastrocnemial veins should be examined routinely.

A prospective study of the effects of irradiation on the carotid artery

OBJECTIVES/HYPOTHESIS

To prospectively assess the effects of irradiation on the carotid artery in patients with head and neck cancer, as a possibly relevant factor in cancer treatment planning.

STUDY DESIGN

Prospective study from a tertiary care academic setting on university (22 patients) and Veterans Affairs (14 patients) hospital patients; 1-year follow-up, including comparison of study data with age-matched and sex-matched control subjects from epidemiological studies.

METHODS

Thirty-six patients with head and neck cancer who underwent therapeutic neck irradiation were examined by high-resolution ultrasound before and 1 year after treatment. Twelve patients were also studied at 2 years. Measurements included the intima-media thickness (IMT) of the carotid artery wall, the degree of stenosis as estimated from velocity measurements, and the presence and size of plaque.

RESULTS

The pretreatment carotid IMT at baseline was 0.68 mm and was comparable to age-matched and sex-matched control subjects. Significant increase in the IMT was observed on both the left (0.67 vs. 0.84 mm) and the right (0.7 vs. 0.87 mm) sides (P < .001) 1 year after irradiation. In 12 patients who completed 24 months of follow-up the carotid IMT continued to significantly increase statistically compared with that at the first year after treatment (left side, 0.79 vs. 0.85 mm, P = .037; right side, 0.79 vs. 0.95 mm, P = .014). Statistically significant thickening of the carotid wall developed in all 36 patients by 1 year. Two patients experienced post-treatment neurological events and an area of stenosis greater than 75%.

CONCLUSIONS

Neck irradiation significantly increases the thickness of the carotid wall during the first year after treatment--on average, 21 times more than in epidemiologically matched control volunteers. This phenomenon should be taken into consideration when planning treatment for the node-negative (NO) neck.

Carotid endarterectomy for recurrent stenosis

PURPOSE

The purpose of this study was to report our results in the surgical management of recurrent carotid stenosis (RCS) after carotid endarterectomy (CEA).

METHODS

In a 20-year period, we performed 1209 CEAs; 82 operations (6.8%) were for RCS. There were 33 men and 36 women, with an average age of 66.3 years. Nine patients underwent two redo CEAs and two patients underwent three redo CEAs for either bilateral recurrence or a second recurrence on the same side. Overall, 10 patients were identified with a second recurrence.

RESULTS

The average time to presentation with RCS was 65 months (range, 3 to 361 months). The majority of patients (66%) were symptomatic, 34% had transient ischemic attacks, 17% had amaurosis fugax, 9% had strokes, and 6% had nonhemispheric symptoms. Before repair, angiograms were obtained. Patch repair was performed in 61 procedures (74%), 41 with vein, 11 with Dacron, and nine with polytetrafluoroethylene. Autogenous or synthetic bypass grafts were used in 20 procedures (24%), vein in eight, Dacron in two, and polytetrafluoroethylene in 10. In one patient, an occluded internal carotid artery was ligated and an endarterectomy of the external carotid artery was performed without a patch. The operative stroke rate was 4.8%. Minor complications included transient or permanent cranial nerve deficits in 7.3% and wound hematomas in 2.4%.

CONCLUSION

Although repeat endarterectomy to treat RCS is technically more demanding, it can be performed safely. Long-term follow-up examination shows that a second recurrence may develop, and we recommend serial noninvasive testing.

The role of venous outflow obstruction in patients with chronic venous dysfunction

OBJECTIVE

To quantify the functional venous outflow obstruction with different location and extent of obstruction attributed to previous deep vein thrombosis.

DESIGN

Case-control study.

SETTING

Vascular Laboratory, St Mary's Hospital Medical School, London, England.

PATIENTS

Two groups: group 1, 25 case patients and 9 control subjects, and group 2, 45 case patients and 30 control subjects.

INTERVENTIONS

Ascending venography, duplex scanning, air plethysmography, and venous pressure measurements in the foot and the arm via a 21-gauge butterfly needle.

MAIN OUTCOME MEASURES

Venous outflow fraction (VOF), venous outflow resistance (VOR), and arm-foot pressure differential (A-F PD) at rest and after reactive hyperemia.

RESULTS

Venous outflow resistance was evaluated in group 1. Twenty-two case patients underwent VOF testing, and 16 had A-F PD measurement performed. Case patients in group 2 underwent VOF testing. Signs and symptoms of chronic venous dysfunction were associated with the anatomical extent of obstruction. Limb swelling and ache were present in most of the patients; skin changes were noted in about 30% and ulceration in 10% of patients. The results of all tests showed no evidence of obstruction in control subjects. In most case patients with popliteal vein obstruction, test results were similar to those in control subjects: the more proximal the veins involved, the more severe the obstruction. In 16 case patients, all 3 tests were performed and agreement between A-F PD and VOR test results was found in 14 of them. The VOF test results agreed with the results of A-F PD and VOR tests in 9 case patients. In group 2, 50% of the limbs with obstruction proximal to the popliteal vein had a reduced VOF, which became worst in the limbs with extensive obstruction, particularly when the iliac veins were involved. Of the 73 limbs tested for VOF in both groups, only 7 limbs (9.6%) had their venous outflow markedly reduced by occlusion of the superficial veins.

CONCLUSIONS

The anatomical extent of venous obstruction and the development of collateral circulation determine the hemodynamic severity of the chronic venous obstruction. The deep collaterals seem to be more important than the superficial venous system in bypassing the obstruction. The VOR and the A-F PD tests can be used to identify those patients who have venous obstruction, whereas the use of the VOF test may reduce the need for performing the above tests in 50% of the patients.

Ultrasonic carotid artery plaque structure and the risk of cerebral infarction on computed tomography

PURPOSE

The North American and the European Symptomatic Carotid Endarterectomy Trial investigators reported a conclusive benefit of carotid endarterectomy for patients with symptomatic 70% to 99% internal carotid artery (ICA) stenosis. However, it has been suggested that plaque structure may be an even more important factor in producing stroke than the degree of stenosis. The aim of this study was to test the hypothesis that the ultrasonic characteristics of carotid artery plaques were closely related to symptoms and to the prevalence of cerebral infarcts on computed tomography (CT).

METHODS

One hundred five carotid artery plaques causing greater than 70% stenosis in the ICA in 83 consecutive patients who underwent brain CT were characterized into four ultrasonic types: echolucent plaques, predominantly echolucent plaques, predominantly echogenic plaques, and echogenic plaques. Patients with permanent neurologic deficit were excluded.

RESULTS

There was a significant ipsilateral association between type 1 plaques and symptomatic hemispheres (p < 0.002). Twenty-six of the 105 cerebral hemispheres assessed by CT had infarcts. There was an increased incidence of brain infarcts in type I plaques (37%) compared with 18% in types II, III, and IV combined (p < 0.02).

CONCLUSION

Our results support the hypothesis that echolucent plaques are more frequently associated with symptoms and cerebral infarctions and provide further evidence that these plaques are unstable and tend to embolize. Studies on the natural history of asymptomatic carotid artery stenosis should investigate whether plaque characterization could identify a high-risk group.

Venous reflux in patients with previous deep venous thrombosis: correlation with ulceration and other symptoms

PURPOSE

Deep vein thrombosis (DVT) in many cases leads to chronic symptoms in the damaged leg, even though the affected veins have recanalized. The major hemodynamic defect in such recanalized veins is reflux. The incidence and extent of reflux has been studied in patients with proven DVT and correlated with concurrent symptoms.

METHODS

Two hundred seventeen limbs in 183 patients were examined by duplex scanning from January 1989 to October 1992. All limbs had previous DVT diagnosed by venography. Sites and extent (proximal, distal, or both) of reflux were identified by meticulous duplex scanning of the whole venous system and correlated with presenting symptoms.

RESULTS

The patients were classified into nine groups on the basis of the classification of the system involved (superficial, deep, or superficial and deep) and whether the reflux was found proximal or distal to the knee or both. Eight-one limbs belong to chronic venous insufficiency class 1, 92 belong to class 2, and 38 belong to class 3. Reflux was confined to the deep venous system in 84 limbs (38.7%), to the superficial system in 31 (14.3%) limbs, and to both systems in 102 (47%) limbs. It was confined to proximal veins only in 48 (22.1%) limbs, distal only in 56 (25.8%) limbs and throughout the limb in 113 (52.1%) limbs. The incidence of swelling was increased by distal or a combination of proximal and distal reflux regardless of which system was involved. In limbs with superficial venous insufficiency (SVI) or deep venous insufficiency (DVI) only, the incidence of skin changes was not affected by the extent of reflux. However, in limbs with combined SVI and DVI, it was increased in the presence of reflux throughout the limb. Absence of distal reflux was associated with a low incidence of skin changes even in the presence of DVI. Ulceration increased with an increased extent of reflux in the presence of SVI. Absence of superficial reflux was associated with a low incidence, even in the presence of DVI.

CONCLUSIONS

The data suggest that as far as the skin changes and ulceration are concerned, distal reflux and reflux in the superficial veins are more harmful than reflux confined to the deep veins, even when such reflux extends throughout the deep venous system.

Recurrent varicose veins: investigation of the pattern and extent of reflux with color flow duplex scanning

BACKGROUND

This study was conducted to investigate with color flow duplex imaging the patterns and the extent of venous valvular incompetence in recurrent varicose vein disease.

METHODS

One hundred thirty-four limbs of 123 unselected patients who arrived in the outpatient clinic with residual or recurrent varicose veins after undergoing an operation were included. Limbs with history of compression sclerotherapy before or after the operation were excluded. The long (LSV) and short saphenous vein (SSV) systems in all limbs were examined with color flow duplex imaging for detection of the sites and the extent of reflux.

RESULTS

Various patterns of recurrent valvular reflux were seen in both the LSV and SSV systems. Reflux confined to saphenofemoral junction alone or associated with reflux in the LSV system was seen in 29% of the limbs. Reflux in the whole LSV system was very common after saphenofemoral junction ligation was performed (chi-squared test, p<0.01). Most of the limbs (53%) with recurrence in the LSV system had incompetent perforating veins. Incompetent perforators in the thigh were more common after ligation (23%) than stripping (10%), but this finding was not true in the calf. After saphenopopliteal junction ligation was performed, the more common pattern was the reflux in the SSV (75%), whereas after SSV stripping was performed, it was the reflux in the SSV tributaries (64%).

CONCLUSIONS

Multiple patterns of reflux develop in recurrent varicose veins. Precise mapping of the reflux and identification of the possible causes are required to instigate appropriate treatment. Color flow duplex imaging is an efficient noninvasive diagnostic technique to identify venous reflux.

Compensatory arterial enlargement is a common pathobiologic response in early atherosclerosis

BACKGROUND

Human arteries are dynamic conduits that respond to different stimuli by remodeling their structure and size. Arterial dilatation has been shown to occur in moderate and advanced atherosclerosis in studies that evaluated only one artery, either coronary, carotid, or superficial femoral artery (SFA). The purpose of this study was to quantify and compare compensatory arterial enlargement throughout the peripheral vascular system in early atherosclerosis.

METHODS

Seventy-two patients (40 male, 32 female, mean age 67 +/- 12 years) underwent transcutaneous B-mode ultrasound imaging during routine examinations. Thirty-nine carotid, 19 aorta, 19 iliac, 23 common femoral (CFA), 21 SFA, and 23 popliteal arteries were longitudinally imaged. Eight healthy volunteers (6 male, 2 female, mean age 27 +/- 2.2 years) had the same arteries evaluated (n = 48). Internal diameter (ID) and external diameter (ED) were measured in disease-free areas and in paired adjacent areas exhibiting increased intima-media thickening (IMT) and small atherosclerotic plaques. The percent change in ID, ED, IMT, and plaque thickness were calculated.

RESULTS

There was no observed change in ID or ED in all arteries of the healthy volunteers. When compared with normal vessel segments, all arteries demonstrated a marked decrease in ID and increase in ED in areas of small, hemodynamically insignificant plaque. The aorta had a 6.00% +/- 1.92% increase in ED, which was significantly less than the percent increase in ED observed in carotid (8.14 +/- 4.5%. P = 0.05), CFA (9.73 +/- 3.54%, P = 0.0001), SFA (9.15 +/- 4.25%, P = 0.005), and popliteal arteries (9.67 +/- 4.34, P = 0.002). In all arteries there was a strong correlation between plaque thickness and percent change in ED with the best correlation observed in the popliteal artery (R2 = 0.823, P < 0.0001). IMT was significantly increased in all normal vessel segments of the patients when compared with the healthy volunteers (P < 0.001).

CONCLUSION

All peripheral arteries dilate in response to intima-media thickening and early atherosclerotic plaque formation. This adaptive response occurs at the site of the lesion to preserve luminal area. The percent change in ED is strongly related to plaque thickness and is greatest in the more distal arteries.

Primary superficial vein reflux with competent saphenous trunk

OBJECTIVES

because reflux in superficial vein tributaries is most often collectively reported with the main saphenous veins, its importance remains largely unrecognised. This study was designed to identify the distribution and extent of non-truncal superficial venous reflux and its association with the signs and symptoms of chronic venous disease (CVD).

PATIENTS AND METHODS

eighty-four limbs in 62 patients with signs and symptoms of CVD and evidence of reflux on continuous-wave Doppler were subsequently examined with colour-flow duplex imaging. Incompetent superficial vein tributaries were imaged throughout their extent and both ends were identified. Limbs with reflux in the main trunk of the saphenous veins or the deep, perforator or muscular veins, superficial or deep vein thrombosis, injection sclerotherapy, varicose-vein surgery, arterial disease and inflammation of non-venous origin were excluded from the study. The CEAP classification system was used for staging clinical severity of CVD.

RESULTS

the prevalence of tributary reflux alone was 9.7% (84/860). Reflux was detected in 171 tributaries. The number of incompetent tributaries ranged from 1 to 5 per limb. Most prevalent were the tributaries to the greater saphenous (111, 65%<0. 0001), followed by those of lesser saphenous (33, 19%) or a combination of both (12, 7%). Incompetent non-saphenous tributaries were uncommon (15, 9%). Among the named tributaries in the lower limb the posterior arch vein was most often incompetent (46, 27%) followed by the anterolateral vein of the thigh (30, 18%), the medial accessory vein (16, 9%) and the anterior arch vein (14, 8%). Reflux in above-the-knee tributaries alone was found in 18 limbs (21%), in below the knee in 23 (28%) and in both sites in 43 (51%). The vast majority of the limbs (71%,p <0.0001) belonged to CVD class 2, 14% in class 3, 9% in class 1 and only 6% in class 4. Class 3 and 4 patients tended to have a longer duration of signs and symptoms, higher number of incompetent tributaries per limb and also a higher prevalence of combined above- and below-knee reflux.

CONCLUSIONS

these data indicate that reflux confined to superficial tributaries is found throughout the lower limb. Because this reflux is present without greater and lesser saphenous trunk, perforator and deep-vein incompetence or proximal obstruction, it shows that reflux can develop in any vein without an apparent feeding source. Greater saphenous tributaries are affected significantly more often than those of lesser saphenous, while non-saphenous reflux is uncommon. Most limbs have signs and symptoms of CVD class 2 and 15% belong in classes 3 and 4.

Nonsaphenous superficial vein reflux

BACKGROUND

Information on nonsaphenous superficial venous reflux is lacking. This study was designed to determine the prevalence of reflux in nonsaphenous veins, their association and correlation with risk factors, and signs and symptoms of chronic venous disease (CVD).

METHODS

Information on 835 limbs in patients with signs and symptoms of CVD were prospectively entered into a customized database. These patients had been referred from the venous clinic to the vascular laboratory for color-flow duplex scanning evaluation of the lower-limb veins. All patients were examined for reflux in the standing and sitting positions. Nonsaphenous reflux was defined as that in superficial veins that are not part of the greater or lesser saphenous systems. Particular attention was paid to the patterns of reflux and anatomy of the nonsaphenous veins from the proximal to the distal ends, including their connections with the saphenous and deep veins.

RESULTS

Nonsaphenous venous reflux was found in 84 limbs (10%) of 72 patients, 67 of whom were women. The mean number of pregnancies in these patients was higher than that of 100 randomly selected women with saphenous reflux (3.2 vs 2.2). According to CEAP classification, 90% of the limbs were in CVD classes 1 through 3 and only 10% had skin damage (classes 4-6). Symptoms were present in 67 limbs (80%). Forty-two limbs (50%) had reflux in tributaries of lateral, posterior, and medial thigh. These veins were connected with perforators uniting with the deep femoral, femoral, and muscular veins of the thigh in 36 limbs. Reflux in these perforators was detected in 19 limbs. Reflux arising from the pelvic veins was found in 29 limbs (34%), 18 of which were from vulvar veins medial to saphenofemoral junction and 11 of which were from veins in the gluteal area. Incompetent veins from the sciatic nerve were found in nine limbs (10%). Reflux in the vein of the popliteal fossa was found in seven limbs (8%). Reflux in knee tributaries was detected in three limbs (4%), two of which were connected with posterolateral knee perforators and one with the posterior tibial nerve veins.

CONCLUSIONS

The prevalence of nonsaphenous reflux in our practice was 10%. The vast majority of these patients (93%) were women with a mean of 3.2 pregnancies. Ninety percent of these limbs have signs and symptoms assigned to CVD classes 1 to 3. These data may simply reflect the referral pattern, but also a possible association with female sex and number of pregnancies. The unusual anatomy of these veins stresses the importance of color-flow duplex scanning before surgery.

New insights into the pathophysiologic condition of venous ulceration with color-flow duplex imaging: implications for treatment?

PURPOSE

This study was conducted to investigate the distribution of reflux in the veins adjacent to or within the venous ulcer (local) and to correlate it with the pattern of disease of the axial veins (all veins away from the ulcer area) of the affected limb.

METHODS

Forty-three ulcers in 34 legs of 33 patients were examined with color-flow duplex imaging. The veins in the area of the ulcer were scanned with a sterile technique.

RESULTS

In 17 legs (50%) there was documented past deep venous thrombosis. All of the 34 limbs had reflux in the superficial or deep axial veins either alone or in combination. Fifteen of these limbs (44%) also had perforating vein incompetence, but none had perforator incompetence alone. Six ulcers showed no evidence of reflux in the local veins when scanned through the ulcer bed despite the presence of reflux in the axial veins of the limb. In 13 limbs with 17 ulcers, either the superficial axial veins alone or the deep axial veins alone were affected (with or without associated perforator incompetence). Examination of the local veins associated with these 17 ulcers revealed a similar pattern of reflux to that seen in the axial veins in 13 cases, with the remaining 4 ulcers showing no local venous abnormality. The pattern of reflux was less predictable at the local ulcer level in limbs where both superficial and deep venous incompetence coexisted in the axial veins. Only 7 of the 26 ulcers (27%) in these limbs had similar evidence of combined superficial and deep reflux in the local ulcer veins, whereas 10 ulcers (39%) were associated with local reflux in the superficial or deep veins alone.

CONCLUSIONS

These data show that 86% (37/43) of the ulcers has some degree of reflux in the local area, the pattern of which may differ from the axial vein disease. Treatment of the local hemodynamic abnormalities may be an important factor in the healing of the ulcers and in the prevention of their recurrence.

High prevalence of abdominal aortic aneurysm in patients with three-vessel coronary artery disease

OBJECTIVES

Currently, the prevalence of abdominal aortic aneurysm (AAA) in patients with coronary artery disease (CAD) and the correlation between CAD severity and AAA prevalence are not clearly known. We conducted a prospective study to determine the prevalence of AAA in patients undergoing coronary angiography and to determine the risk factors and a coronary profile associated with AAA.

METHODS

Over an 18-month period, abdominal aortic ultrasound was performed on 1,000 patients undergoing coronary angiography for suspected or known CAD, or prior to valve surgery. Clinical characteristics and coronary profile were collected from the patients.

RESULTS

The overall number of previously repaired, already diagnosed, and new cases of AAA in the study population was 42, yielding a prevalence of 4.2%. Among the patients with newly detected AAAs, only two had an AAA diameter of >54 mm and were therefore treated surgically. In men aged ≥ 65 years, the prevalence reached 8.6%, while in men with three-vessel CAD it was 14.4%. Multivariate analysis showed that age ≥ 65 years (p = .003), male gender (p = .003), family history of AAA (p = .01), current smoking (p = .002), and three-vessel CAD (p < .001) were significantly associated with a higher prevalence of AAA.

CONCLUSION

The prevalence of AAA was high in men aged ≥ 65 years and in those with three-vessel CAD regardless of age. While our findings do not prove the cost-effectiveness of screening for AAA in these high risk patients, they do support the usefulness of a quick ultrasound examination of the abdominal aorta during routine transthoracic echocardiography in such patients.