Ges

Failure in chronic venous insufficiency, 43, 171 history of valve surgery, 12, 579-580 physiology, 42 prosthetic valves animal studies, 593-594 autogenous valve studies, 595-596 clinical trials, 594-595 endovascular surgery, 597 prospects, 597-598 rationale, 593 remodeling distal venous hypertension, 535 primary venous insufficiency, 121 surgery, see Valvuloplasty Valvuloplasty clinical experience, 584-586 complications, 590-591 outcomes, 588, 590 preoperative evaluation, 586-588 reflux pattern...

Angiojet Working

Several authors have evaluated multiple PMT catheters in the treatment of DVT. However, to date, there is no prospective, randomized trial data available. In one review, Vedantham et al. used percutaneous mechanical thrombectomy (several devices tested including Amplatz Thrombectomy Device, Microvena, White Bear Lake, MN AngioJet Trerotola Percutaneous Thrombectomy Device, Arrow International, Reading, PA Oasis, Boston Scientific Meditech, Natick, MA) with catheter-directed thrombolysis for the...

Elevated Blood Pressure And Mechanotransduction Mechanisms

One of the oldest treatments for CVD is purely mechanical, a compression bandage wrapped around the diseased leg. Such compression therapy has an anti-inflammatory effect104 although inflammatory markers require weeks of treatment105 before a reduction of inflammation may be detectable. Although the exact mechanism is unknown, it is evident we need to consider mechanical stress. The evidence that normal and shear stresses exerted by plasma on cell membranes may control the shape of blood...

Role Of Transfemoral Venogram

Since accurate hemodynamic tests are unavailable, diagnosis and treatment must be based on morphological findings. New promising noninvasive morphological tests with spiral CT and MRV are under evaluation, but their role in the workup of venous obstruction is not yet defined. Still the single-plane transfemoral venogram is the standard investigation and may show definite obstruction and development of collaterals. Although a defined lesion may be obvious, findings on the anterio-posterior (AP)...

Physiological Effects Of Compression Therapy

Some physiological effects of compression therapy as documented in several studies are summarized in Table 10.3.112 The application of continuous compression is contraindi-cated in patients with advanced peripheral arterial disease or severe sensory impairment. Several effects of compression therapy have been demonstrated in the acute experiment using intermittent pneumatic compression. It may be assumed that similar effects will also occur during walking with inelastic bandages. TABLE 10.3...

Compression Therapy

Compression therapy is the oldest and until recently the only therapeutic option available to treat PTS. It has been reported anecdotally to be ineffective in PTS but no systematic study has been undertaken. Compression therapy remains the initial approach in chronic venous disease including PTS. Some patients do fail compression therapy despite faithful compliance. Noncompliance, however, is the major cause of compression failure and recurrent symptoms.27-29 Noncompliance is high even in cold...

Physiologic Noninvasive Testing

The use of pressures and plethysmography in evaluation of the patient for surgery can be helpful in confirming that there is significant venous disease, but is seldom helpful in determining critical details of the preoperative workup. These tests are global in nature, especially the venous pressure test, and for this reason it can be used on a highly selective basis. Plethysmography provides more detail and is more practical than venous pressure, especially the VFI (venous filling index), which...

Preoperative Evaluation

Good surgical results begin with accurate diagnosis of the venous problem. The goal of the preoperative evaluation for deep vein reconstruction is to identify sites of both reflux and obstruction in all the venous segments from the inferior vena cava to the calf. This task is readily achieved with the aid of expert duplex scanning and venographic techniques. It is incumbent upon the surgeon who undertakes deep vein reconstruction to have expert scanning available to guide his choices at all...

Clinical Contributions To The Experience Of Deep Vein Valve Repair

Following the report of repair of primary venous valve reflux in 1975,3 a succession of clinical investigators initiated their own case series and developed innovative technical approaches to valve repair and valve substitution, generating diverse clinical results that resulted in new knowledge about lower extremity reflux disease. Interval reports from the Straub Clinic experience appeared in 1975,3 1979,23 and 1982,24 describing results of reconstruction in an enlarging group that initially...

Surgical Considerations Arising From Deep Vein Reflux Patterns

The axial reflux patterns of primary deep venous disease must be thoroughly diagnosed prior to planning deep vein valve repair. Primary cases often present with a single axial reflux tract that courses from the CFV through the femoral vein of the thigh to the popliteal and into the calf veins. In this case, a single valve repair in the femoral vein has been shown to be all that is needed to restore clinical compensation to the venous return. These cases usually have little or no communication...

Distribution Of Primary Incompetent Valves

Primary incompetent veins and valves may occur in segmental or axial distribution. Axial reflux occurs most frequently in the saphenous veins, and often is limited to the saphenous veins in primary disease. The presence of axial reflux in the deep veins is significant in the more serious cases of primary reflux, which present with extensive aching, swelling, and disability. This distribution of reflux is different than that of post-thrombotic disease where isolated reflux is often found in the...

Treatment Of Deep Vein Reflux Prior To 1968

There was great interest in the aggressive management of the chronic venous disease (CVD) leg prior to 1960, which is well summarized in the papers of Robert Linton of Boston from 1938 to 1953.2,7 Linton refers to the epic work of Homans8 who drew attention to the importance of the perforator veins and concentrated on the excision of the diseased skin and scar tissue in the lower leg. Homans' understanding of the pathophysiology of CVD is amazing in view of the fact that he had no imaging...

Stenting Of Chronic Nonmalignant Obstruction

A few studies describe stenting of nonmalignant chronic obstruction with no adjuvant therapy in patients with chronic venous disease. Bl ttler and Bl ttler reported in 1999 treatment of chronic venous and neurogenic claudication due to pelvic venous blockage and achieved 100 patency in 11 successfully stented limbs with a mean follow-up of 15 months (range 1-43 months).4 A group of 18 patients were reported by Hurst et al.16 Twelve limbs were treated for chronic obstruction. The primary patency...

Clinical Outcome After Stenting

The reports referred to earlier describing patency rates indicate clinical improvement in most patients (> 80 ).3,4,37 Hurst et al. showed resolution or substantial improvement in 72 of limbs.16 However, five remaining patients continued to have pain despite resolved swelling and widely patent stents on venogram. In addition to assessment of ulcer healing, Raju and Neglen have evaluated pain, swelling, and quality-of-life. Median follow-up 789 993 limbs in the updated material was 11 months...

Open Surgical Reconstruction

Open surgical bypasses can be performed to alleviate severe venous outflow obstruction. The operations most frequently used are femoro-femoral crossover or unilateral ilio-caval bypass for proximal iliofemoral vein occlusion. Reconstruction with sapheno-popliteal bypass for distal femoro-popliteal obstruction is today of historical note only. Right iliac artery transposition and iliac vein patch angio-plasty have been used in selected patients with focal iliac vein compression syndrome, but are...

Practical Implications

There are no reliable tests to measure a hemodynamically significant stenosis. This lack of gold standard is the major obstacle to assess the importance of chronic outflow obstruction, select limbs for treatment, and evaluate the outcome. Although a positive noninvasive or invasive test may support further studies, a negative test should not exclude it. The diagnosis and treatment must presently be based on invasive morphological investigations of the iliac venous outflow (transfemoral...

Diagnosis Of Venous Obstruction

Often when algorithms are constructed for workup of patients with chronic venous insufficiency, investigations for estimating the degree of reflux are emphasized, and testing for outflow obstruction is omitted completely. This is mainly owing to a lack of accurate objective noninvasive or invasive tests for evaluation of hemodynamically significant chronic venous obstruction. There are many tests for delineating focal and global reflux, but this is not so for outflow obstruction. There is no...

Clinical Considerations

Indications for USGS are not different from indications to surgical interruption of perforating veins. Cases of symptomatic chronic venous disease from C2 to C6 clinical class (CEAP) that have demonstrable incompetent perforating veins at duplex ultrasound constitute the majority of indications. In primary disease, USGS can be performed at the time of initial treatment of saphenous reflux, or as a separate stage. In secondary (post-thrombotic) disease, careful consideration should be given to...

Historical Perspective

The first description of the perforating veins of the lower extremities is attributed to JC Von Loder, a German anatomist who worked at the end of the eighteenth century,1 but it was not until the work of John Homans when the role of incompetent perforators was postulated followed by development of surgical treatment.2 After the precise definition of principles for perforator control was formulated in the 1930s by Robert R. Linton of Boston, and detailed investigations were performed by Frank...

Presentation Of Patients With

A commonly held perception is that less severe CVI (CEAP clinical classes 2-3) is typically a sequela of superficial venous reflux, whereas more severe CVI (CEAP classes 4-6) is associated with deep venous reflux. For this reason, the majority of patients treated with venous leg ulcers are never referred to a venous specialist for consideration of a corrective procedure. It is mistakenly believed that all are due to deep venous disease and that none are candidates for correction of reflux or...

Risk Factors For Venous Thromboembolism

In order to improve survival, avoid recurrence, prevent complications, and reduce health care costs, the occurrence of venous thromboembolism must be reduced. To reduce venous thromboembolism incidence, persons at risk for venous thromboembolism first must be identified. Independent risk factors for venous thromboembolism include patient age, surgery, trauma, hospital or nursing home confinement, active malignant neoplasm with or without concurrent chemotherapy, central vein catheterization or...

Epidemiology And Socioeconomic Consequences

They are not easy to determine as most studies are retrospective, analyzing patients that were not evaluated preoperatively by duplex scanning (DS), and usually the detailed operative report is not available. In a 34-year follow-up,12 varicose veins were present in 77 of the lower limb examined and were mostly symptomatic. Fifty-eight percent were painful, 83 had a tired feeling and edema had reappeared in 93 . Two recently published prospective studies are available with a follow-up of five...

Principles of Ambulatory Phlebectomy

RAINES Ambulatory phlebectomy (AP) is a surgical procedure designed to allow outpatient removal of bulging varicose veins. This treatment originally was described and performed by Aulus Cornelius Celsus (56 bc-30 ad) in ancient Rome.1 However, the art of AP was revived, redefined, and practiced by the sagacious Swiss dermatologist Robert Muller in 1956. Prior to Muller's reintroduction of AP, veins were removed with relatively large incisions and ligation of...

Marianne De Maeseneer

At the beginning of the twenty-first century, surgical treatment of varicose veins continues to be marred by the development of recurrent varicosities. This has always been a very disappointing phenomenon for patients and surgeons alike. Most commonly, recurrent reflux develops in the area of the saphenofemoral junction (SFJ), causing recurrent varicose veins from the thigh downward to the entire leg (see Figure 26.1).1 Even in clinical centers with a special focus on minimizing recurrence...

Pretreatment Assessment

The examination should always begin with a complete medical history. Data concerning family and personal venous history, symptoms, clinical findings, and previous venous treatments are collected. Comorbidities, allergies, and pharmacologic history must be documented.2 The BMI is calculated from the patient's height and weight and should be recorded. The patient should be examined in a standing position to demonstrate patterns of teleangiectasias, reticular veins, and varicose veins.5 Cold light...

Pretreatment Ultrasound Mapping

Duplex venous scanning is the essential pretreatment investigation prior to either sclerotherapy or UGS of major varicose veins and truncal incompetence. Through duplex scanning, patterns of venous incompetence will be found to be extremely variable and often unexpected. Duplex scanning involves B-mode imaging of the deep and superficial veins combined with directional pulsed Doppler assessment of blood flow. Color-duplex imaging superimposes blood flow information onto the B-mode ultrasound...

Intravascular Effect Of Circumferential Compression

Direct observation using ultrasound has shown that compression stockings of 35 mm Hg have no noticeable effect on the morphology or function of large varicose veins. Since the vein preserves its dimensions, there is nothing to prevent the formation of a thrombus. Even when rolls of gauze or other nonelastic cylinders are placed on the varicose vein and strongly compressed by a bandage of little elasticity (Peha-Haft Hartmann), no reduction in the diameter of trunk varicose veins is produced on...

Primary Venous Insufficiency

The manifestations of simple primary venous insufficiency appear to be different from one another. However, reticular varicosities, telangiectasias, and major varicose veins are all elongated, dilated, and are tortuous. Investigations into valve damage and venous wall abnormalities eventually may lead to an understanding of the problem, and therefore, a solution by surgery or pharmacotherapy.1-4 Scanning electron microscopy has shown varying degrees of thinning of the varicose venous wall....

The Future Of Laser Therapy

The laser treatment of leg veins continues to gain momentum with advances in laser, pulsed light, and combined radiofrequency pulse light technologies. Other advances include enhancement of longer wavelength treatment systems, improved cooling technologies, varied spot size, pulse durations, and fluence-related monomodal approaches and combined lasers radiofrequency systems. The continued development of laser technologies not only enhances the phlebologist's armamentarium in the treatment and...

Addressing The Common Pitfalls In Laser Therapy

The laser treatment of leg veins is not free of common pitfalls (see Box 16.3). Retreatment or double pulsing of the target vessels vessel should be avoided to prevent excessive thermal damage that potentially can result in scarring and ulceration. The physician or the medical personnel admin- Avoid immediately retreating or double-pulsing vessels when no instantaneous changes are present. Allow treated areas to cool before attempting a second pass. Always use the lowest possible effective...

The Benefits Of Laser Therapy

With its increasing momentum, laser therapy has become one of the most effective treatment options for treating varicosities of the lower extremity. Generally at the time of treatment, both the patient and the physician may observe a disappearance of small telangiectatic vessels giving an immediate visual record of success of treatment. However, the larger telangiectasias and the deeper reticular veins typically do not demonstrate resolution at the time of treatment, often resolving gradually...

Effect Of Position On Varicose Geometry

For the following sections, refer to Figure 13.4. For a standing patient with a superficial varicosity of 2 cm in diameter, the final concentration at a distance from the injection site of 10 cm (4 inches) is 30 times lower than the initial concentration. Doubling the initial concentration serves only to double the final concentration, which will still be 15 times weaker than the concentration in the syringe. In other words, if 1 cc of a 3 solution is injected, the final concentration at the...

Symptoms Of Primary Venous Insufficiency

It is well known that the presence and severity of symptoms do not correlate with the size or severity of the varicose veins present. Symptoms usually attributable to varicose veins include feelings of heaviness, tiredness, aching, TABLE 12.2 Symptoms of Varicose Veins and Telangiectasias Aching Heaviness (on standing, prolonged sitting) Aching Pain (on standing, prolonged sitting) Burning (venous neuropathy) Itching (cutaneous inflammation) Nocturnal Cramps (recumbent edema reduction) TABLE...

Theoretical Risk Factors

One popular hypothesis for the development of varicose veins is Western dietary and defecation habits, which cause an increase in intraabdominal pressure. Population studies have demonstrated that a high-fiber diet is evacuated within an average of 35 hours.24 In contrast, a low-fiber diet has an average transit time of 77 hours. An intermediate diet has a stool transit time of 47 hours. Defecatory straining induced by Western-style toilet seats has also been cited as a cause of varicose veins,...

Refinement Of Cclasses In Ceap

The essential change here is the division of class C 4 into two subgroups that reflect different severity of disease, and carry a different prognosis in terms of risk of ulceration C0 No visible or palpable signs of venous disease C1 Telangiectasies or reticular veins C2 Varicose veins distinguished from reticular veins by a diameter of 3 mm or more C3 Edema C4 Changes in the skin and subcutaneous tissue secondary to CVD (now divided into two subclasses to better define the differing severity...

Terminology And New Definitions

The CEAP classification deals with all forms of chronic venous disorders. The term chronic venous disorder (CVD) includes the full spectrum of morphological and functional abnormalities of the venous system from telangiectasias to venous ulcers. Some of these, like telangiectasias, are highly prevalent in the normal adult population, and in many cases the use of the term disease is not appropriate. The term chronic venous insufficiency (CVI) implies a functional abnormality of the venous system...

Venous Volume and Venous Blood Flow Velocity

Depending on the exerted pressure and the body position, external compression is able to narrow or to occlude superficial and deep leg veins.14 In the supine position an external pressure of 1015 mm Hg is enough to decrease the venous diameter. The resulting increase of blood flow velocity as clearly shown by measuring the circulation time with isotopes15 is the rationale for recommending light compression stockings for thromboprophylaxis in bedridden patients. Venous volume can be assessed...

Types And Distribution Of Leukocytes

The most striking differences in cell type and distribution were observed with mast cells and macrophages (see Figure 9.3). In both gaiter and thigh biopsies, mast cell numbers were two to four times greater than control in Class 4 and 5 patients around arterioles and PCVs (p < 0.05). Class 6 patients demonstrated no difference in mast cell number compared to controls. Mast cell numbers around capillaries did not differ across groups in either gaiter or thigh biopsies. Macrophages...

And Functional Status In

In 1988, Thomas et al. reported that 24 fewer white cells left the venous circulation after a period of recumbency in patients with CVI as compared to normal patients.37 They studied three groups of 10 patients each. Group 1 consisted of patients with no signs of venous disease. Group 2 were patients with uncomplicated primary varicose veins, and group 3 were patients with long-standing CVI as determined by Doppler ultrasonography, strain-gauge plethysmography, and foot volumetry. Patients had...

Genetics and the Role of Deep Venous Thrombosis DVT

Unlike arteries, veins are thin-walled, low pressure conduits whose function is to return blood from the periphery to the heart. Muscular contractions in the upper and lower extremities propel blood forward and a series of intraluminal valves prevent retrograde flow or reflux. Venous reflux is observed when valvular destruction or dysfunction occurs in association with varicose vein formation. Valvular reflux causes an increase in ambulatory venous pressure and a cascade of pathologic events...

Alterations in Extracellular Remodeling and the Wound Fluid Environment

The extracellular matrix (ECM) is an important structural and functional scaffolding made up of proteins that are necessary for cell function, wound repair, epithelialization, blood vessel support, cell differentiation and signaling, and cellular migration. The ECM is particularly important in providing a substrate for keratinocytes to migrate and establish coverage in both acute and chronic wounds.39 Alterations in protease activity and the relation to abnormalities in ECM metabolism in wounds...

Alterations in Cellular Proliferation Motility and Regulation

Fibroblasts are an important cell in wound healing in acute and chronic wounds and, in microscopic analysis, have been determined to be a major cell type in dermal biopsies from venous ulcer and lipodermatosclerotic skin.25 Interest in alterations in fibroblast growth and growth factor response from patients with venous ulcers was evaluated by biopsies taken from the ulcer margin and compared to normal ipsilateral thigh fibroblasts of the same patients. The authors found a significant reduction...

Alterations in Smooth Muscle Cells Dermal Fibroblasts and Collagen

Several studies have investigated cultured smooth muscle cells derived from varicose veins to determine if the extracellular matrix modifications seen in varicose vein tissue are related to smooth muscle cells. Smooth muscle cells cultured from varicose veins were found to have decreased number of cells staining for collagen type III and fibronectin, although the transcriptional products of these two proteins were not dissimilar. The synthesis and deposition of collagen type III but not type I...

Abnormalities with Matrix Metalloproteinase Metabolism

Varicose veins have characteristically tortuous and dilated venous walls. A possible explanation for these findings may be the influences of proteolytic enzymes known as matrix metalloproteinases (MMPs) and their inhibitors known as tissue inhibitors of metalloproteinases (TIMPs), which lead to venous wall remodeling and subsequent dilatation and valvular incompetence. MMPs are highly homologous zinc-dependent endopeptidases that cleave most of the constituents of the extracellular matrix. To...

And Molecular Adhesion Mechanisms

The modern developments of the pathophysiological basis of the skin changes in CVD can perhaps be traced back to the simple observation that leukocytes have quite different biomechanical properties than the red cells. Even though they are clearly in the minority, they contribute to many microvascular events.46,47 One of them is local accumulation in the microcirculation and thus it is highly significant that blood returning from feet that have been passively dependent for 40 to 60 minutes is...

Interpretation of Data from Existing Studies

Endothelial adhesion is a normal physiological activity of neutrophils and monocytes. During venous hypertension the fall in blood flow to the lower limb and increase in diameter of capillaries result in a fall in the shear rate in cutaneous capillaries. This favors leukocyte adhesion, which may be observed, even in control subjects, but is of greater magnitude in patients with venous disease, presumably due to the modifications that take place in the endothelium in chronic venous disease. It...

Histological Search for Angiogenic Factors

The vascular proliferation seen in the skin of patients with venous disease has been known for many years, but has not been explained. In recent years many angiogenic factors that stimulate the growth of blood vessels have been recognized. Immunohistochemistry was used to evaluate the presence of a number of such factors in the skin of patients with venous disease.40 Skin biopsies were taken at the time of surgery for varicose veins from the legs of patients with and without skin changes as...

Symptoms By Visible And Functional Disease

To estimate the relative importance of each symptom to the clinical picture of venous disease we evaluated the odds ratios (OR) for each symptom in each of the 12 categories of venous status formed by crossing the three categories of functional disease with the four categories of visible disease using logistic regression adjusted for age, sex, BMI, education, and racial ethnic group (see Table 3.4). Aching (OR 2.20) and swelling (OR 2.99) were significantly associated with DFD even in subjects...

Risk Factors For Cpvd

We have completed an extensive analysis of risk factors for visible and functional CPVD.8 Table 3.3 summarizes this work and shows odds ratios for significant predictors of visible and functional venous disease in our population. Age was positively consistently related to all levels of visible and functional disease in both sexes. In comparison with non Hispanic whites (NHW), African-American Asian had less TSV and VV in both sexes, less TCS in men, and less DFD in women. Our results thus...

Concordance Of Visible And Functional Disease

Figure 3.1 shows the concordance of visible and functional disease in the individual 4422 legs of the 2211 participants for this analysis. The majority of legs showed TSV, but the majority of legs were also functionally normal. If we consider TSV as a normal visible finding, visible disease would be defined as VV or TCS, and functional disease as SFD or DFD. The concordance between visible and functional disease was 92 , 17.4 concordant for disease presence and 74.6 concordant for disease...

Perforating Vein Surgery

The first to suggest selective interruption of perforators to treat varicose veins was probably Remy in 1901. In 1938, Linton proposed a medial subfascial approach to treat incompetent perforators. In 1953, Cockett and Jones proposed the epifascial ligature of medial ankle perforators. Two years later, Felder recommended that the fascial incision for perforating vein ligature should be placed in the posterior midline of the calf in order to avoid placing the lower end of the incision over the...

Modern Surgery Of Superficial Veins

Modern surgery of varicose veins started in 1806, when Tommaso Rima proposed a hemodynamic treatment with ligation of the upper GSV. This operation was reproposed in 1890 by Friedrich Trendelenburg . . . the saphenous reflux must be the first step in control distal varicosities . . . It consisted of a double ligation of the great saphenous just FIGURE 1.14 Sapenous interruption and its incannulation with the instrument called pagoda. FIGURE 1.14 Sapenous interruption and its incannulation with...

Diagnosis Of Venous Disorders

Clinical semiotics started in 1806 when the Swiss surgeon Tommaso Rima described a simple test for the diagnosis of saphenous reflux. In 1846, Sir Benjamin Brodie described a method of testing for incompetent valves by constriction of the limb and palpation. These two tests were reproposed by Friedrich Trendelenburg in 1890. In 1896, Georg Perthes of Bonn described the famous test to verify the patency of the deep veins. Finally, in 1938, John Homans described a test for detection of deep...

Subfascial Endoscopic Perforator Vein Surgery SEPS for Chronic Venous Insufficiency

PETER GLOVICZKI, MANJU KALRA, and ALESSANDRA PUGGIONI Surgical interruption of incompetent perforating veins was first suggested by Linton in 19381 to treat patients with venous ulcers. The rationale for ligating incompetent perforators was to decrease ambulatory venous hypertension in patients with advanced venous disease by decreasing abnormal transmission of pressure from the deep to the superficial veins. Linton's original operation, that required a long skin incision, resulted in a high...

Implications for Pharmacological Treatment in Venous Disease

Although bandaging and stockings have been used effectively in the treatment of chronic venous insufficiency for many years, modern pharmacological science may provide assistance in healing venous ulcers and perhaps some insight into the mechanisms of the disease. Pentoxifylline has been used for the treatment of claudication for a number of years, with moderate success. Its mechanism of action is probably through an effect on inhibition of cytokine-mediated neutrophil activation.45 Its...

B

Are present, subfascial endoscopic perforator surgery (SEPS) is the favored technique. The second group includes procedures that aim to eliminate or obliterate the refluxing varices. According to the location and type of varicose veins, various techniques can be used stab avulsion and phlebectomy are the most used techniques, and stripping or endovascular obliteration (laser, radiofrequency) usually are reserved for treating the residual saphenous trunk. The third group is represented by...

Endovenous Treatment For Ssv Reflux

Techniques are described in Chapters 29 and 31, and this chapter will summarize particular features relating to SSV reflux in our practice. Ultrasound-guided sclerotherapy (UGS) has been used by our group to treat 175 SSV systems in 144 patients. We favor foam sclerotherapy using sodium tetradecyl sulphate diluted with normal saline to a 1.5 concentration and then foamed in the ratio of two parts sclerosant to three parts air. Injection is made as far distal in the vein as possible control ling...

Management Of C4c6 Patients

For some authors,15,16 only patients who have chronic changes in the skin and subcutaneous tissues of the lower leg deserve to be referred to clinically as chronic venous insufficiency (CVI). This definition, also generally accepted, is used in this chapter, but in the updated CEAP1 C3 patients have been included in CVI. CVI is an expression of severity in chronic venous disease, therefore management guidelines for CVI patients need to be stated both in terms of investigations and treatment....

Clinical Presentation And Diagnosis

The classic presentations of DVT are swelling and tenderness, elevated temperature, and a positive Homans' sign (calf pain on dorsiflexion of the foot) (see Figure 51.1). In an extreme scenario, phlegmasia cerulea dolens, as evident by the painful blue appearance of the leg, can occur due to massive thrombosis involving the iliac veins and extending into the most distal venules in the leg. Phlegmasia cerulea dolens is a condition frequently associated with a hypercoagulable state or external...

Results Of Seps

Experience with SEPS continues to grow and results from several centers are summarized in Table 56.1. The safety and efficacy of SEPS has been established in the North American SEPS Registry17,24 and in nonrandomized case series.216,18-23 In a randomized trial SEPS had a lower wound complication rate (0 ) than traditional open surgical techniques (53 ) at 21 months after surgery.25 The North American SEPS (NASEPS) registry compiled data from 146 patients, 101 of whom had active ulcers (C6) at...

Ultrasound Monitoring During Sclerofoam Ablation Of Varicose Veins

Sclerofoam

Advent of foam sclerotherapy has added a new tool for the treatment of chronic venous insufficiency. Sclerosant agents provoke endothelial damage by several mechanisms.25 They change either the surface tension of the plasma membrane (detergents) or the intravascular pH and osmolarity. The final result is a chemical fibrosis of the treated Sclerosing foams (SF) are mixtures of gas with a liquid solution with surfactant properties. In 1993, Cabrera proposed the use of SF, made of sodium...

The Venous Microcirculation

Numerous investigations have attempted to evaluate the microcirculation of patients with CVI.40,43-46 The majority of these investigations were qualitative descriptions of vascular abnormalities, which lacked uniformity of biopsy sites and patient stratification. Prior to 1997 it was widely accepted that endothelial cells from the dermal microcirculation appeared abnormal, contained Weibel-Palade bodies, were edematous, and demonstrated widened interendothelial gap junctions.45 Based on these...

Role of Physiologic Testing in Venous Disorders

ALMEIDA Of the 25 million Americans with venous insufficiency, approximately 7 million exhibit serious symptoms such as edema, skin changes, and venous ulcers.1 About 1 million seek formal medical advice annually and do so for symptoms of venous insufficiency. Approximately 80 of venous patients are managed conservatively with observation, leg elevation, and support stockings the remainder are treated surgically with vein stripping or endovenous ablation. Most...

Surgical Technique

SEPS was first performed in Germany by Hauer in 1985, who used a simple one-port endoscopic instrument to interrupt perforating veins.2 Two main techniques for SEPS have been developed. The first has been a perfection of the original technique of Hauer, by Fischer,3,5,14 with further development by Bergan and colleagues,9,11,18 Wittens and Pierik.7,13,20,25 It uses a single scope with channels for both the camera and working instruments (see Figure 56.1). Improvement in instrumentation for this...

Fibrin Cuffs

In 1982 Browse and Burnand proposed that oxygen diffusion into the tissues of the skin was restricted by a peri-capillary fibrin cuff that they had observed histologically.9 They suggested that increased capillary pressure as a consequence of venous hypertension results in an increased loss of plasma proteins through the capillary wall. This includes fibrinogen, which polymerizes to provide the fibrin cuff that may be seen around capillaries in the skin, using both his-tochemical and...

Identifying The Problem

The vasculature of the lower extremity is comprised of a complex, intertwined network of superficial and deep venous plexuses. The superficial veins, as suggested by their name, lie directly underneath the skin surface. The deep veins, in contrast, traverse the muscle of the leg. The individual flow patterns of these two networks intertwine to such a great degree that superficial spider veins may be the direct result of increased hydrostatic pressure in the deep reticular veins. In contrast to...

Peter Neglen

In the complex make-up of the multifactorial etiology of chronic venous disease (CVD), the presence of venous obstruction largely has been ignored, while reflux has been emphasized. This is perhaps owing to the fact that an efficient treatment has not been available and the physiology of venous obstruction poorly understood. Since a critical venous outflow obstruction has not been defined, no accurate hemo-dynamic test has been developed. It is, however, well known that limbs with the...

Scaffold Seeks Incorporation as Self after Implantation

Over the last few decades, several potential off-the-shelf implantable valves have been tested as a substitute for the autogenous venous valve. The valves may be allografts, xenografts, or synthetic in design. Transplantation of a fresh vein containing a valve from one canine to another without concern for rejection issues has been attempted. Of 14 fresh allografts tested, utilizing 24 hours of initial anticoagulation to boost patency, only 7 were patent and none competent over a four-week...

Conclusion

Surgical repair of deep vein valves for primary disease has been widely evaluated and found to have reproducible favorable results without recurrence in 65 to 80 of cases successfully operated upon with internal repair. The repair can be performed in many different ways with the best long-term results achieved by open surgery, but with higher risk for complications after the open techniques than after the external techniques. Its use can be recommended in resistant CVD cases in which a...

Adjunctive Techniques To Catheterdirected Thrombolysis

Percutaneous mechanical thrombectomy techniques are discussed in detail in Chapter 50. There appears to be a higher incidence of embolic complications with mechanical thrombectomy. In a prospective evaluation of pulse-spray pharmacomechanical thrombolysis of clotted hemodialysis grafts,27 it was found that PE (documented by ventilation perfusion scan) occurred in 18 of patients treated with a plasminogen activator pulse-spray solution versus 64 of patients treated with a heparinized saline...

Preoperative Mapping

Mapping is done prior to commencing AP and is a critical step in the procedure. It must be comprehensive. The key to success is accurate marking of the surface bulges with an indelible marker in the standing position (see Figure 27.1). Marking is performed in the standing position because hydrostatic pressure is no longer active when the patient is supine. Stated differently, bulging veins disappear when patients lie flat because the local venous pressure decreases to near zero mmHg. We prefer...

Detergents

In the 1930s the class of drugs known as detergents, or as fatty acids and fatty alcohols, came into use with the introduction of sodium morrhuate and sodium tetradecyl sulfate. Detergent sclerosants work by a mechanism known as protein theft denaturation, in which an aggregation of detergent molecules forms a lipid bilayer in the form of a sheet, a cylinder, or a micelle, which then disrupts the cell surface membrane and may steal away essential proteins from the cell membrane surface. The...

Uye

Transfemoral ascending venograms. (left) A normal venogram showing a smooth continuously widening iliofemoral outflow tract. (right) Common iliac vein compression with severe flattening, pancaking, in the frontal plane. A web is shown in the compression and collaterals are present. B. Transfemoral ascending venograms. (left) The stenosis of the left iliac vein due to compression by the right iliac artery is obvious. (right) Subtle thinning of contrast dye in the common iliac...

Mechanical Thrombectomy

Thrombectomy refers to physical removal of soft, fresh thrombus. The idea of doing this with a small, percutane-ously inserted device is that it atraumatically vacuums the thrombus out of the vessel. Such a device would offer the speed of surgical intervention with the advantage of minimally invasive therapy. The Fogarty balloon, a standard tool for rapid thrombus debulking, requires a surgical incision.35 A number of new devices have emerged, and their design benefits and limitations are...

1

SV Angle 0 Dep 1.9 cm Size 2.0 mm Freq 4.0 MHz WF Low FIGURE 18.7 In 2005, a panel of experts proposed a new classification to be used in a prospective multicenter study testing the A.S.V.A.L. (selective ablation of varicose veins in local anesthesia) method. The classification reports five major types of saphenofemoral reflux. The recognition of each of them can guide different therapeutic approachs, such as the A.S.V.A.L. (Adapted from Pittaluga et al.2627) FIGURE 18.7 In 2005, a panel of...

The Return Of The Venous Blood

The mechanisms allowing blood to flow centripetally along the veins were described more than two hundreds years ago (see Table 1.1). The vis a tergo was described in 1670 by Richard Lower . . . the return of the venous blood is the result of the impulse given to the arterial blood . . . Furthermore, Lower acknowledged an important role to the venarum tono in venous return, and described the effects of the muscular pumping. Antonio Valsalva, FIGURE 1.4 The Sapheno-Femoral Junction according to...

Animal Models of Venous Hypertension

The underlying disturbance leading to varicose vein formation is venous hypertension and valvular incompetence. There are a few animal models that have investigated the effect of acute and chronic venous hypertension on molecular changes of the vein wall and valvular function. By creating a femoral artery and vein arterio-venous fistula an acute rat model of venous hypertension evaluated valvular changes and vein wall biochemical characteristics. At three weeks, three of four rats had...

Madelung Propose To Remove Varicose Veins

FIGURE 1.9 Schiassi's method to inject the Great Saphenous Vein at the same time of its interruption (1909). FIGURE 1.9 Schiassi's method to inject the Great Saphenous Vein at the same time of its interruption (1909). varicose veins after high ligation of the saphena. In order to avoid innumerable skin incisions, Benedetto Schiassi, from Bologna (1909), performed multiple injections of a combined iodine and potassium iodide immediately after saphe-nous interruption (see Figure 1.9). Linser...

Varicos Vens Homiyo Paithik Trtment Bihar

+, Minimal ++, moderate +++, significant. Concentration dependent. +, Minimal ++, moderate +++, significant. Concentration dependent. (American Regent Laboratories) to add to its label the warning For IV or SC use after dilution in bold red ink. As discussed previously, hematuria can occur with any sclerosing agent. Sometimes blood appears in the urine after one or two acts of micturition and occasionally at other times throughout the day. Usually there are no other ill effects, and the...

Initial Evaluation

The procedure for iliocaval reconstruction is, in many ways, similar to preparation for major surgery. The main difference is that the endovenous operation is the series of interventions that take place in the angio suite over several days, rather than a single procedure occurring, over several hours on one day, in the operating room. The interventional process we have developed over 15 years is best divided into three chronological stages the workup, the hospitalization and intervention, and...

Operative Technique

The surgical approach taken must be individually tailored to each patient and each limb. Groin-to-knee stripping of the saphenous vein should be considered in every patient requiring surgical intervention.36 In nearly all patients, this measure is supplemented by removal of the varicose vein clusters via stab avulsion or some form of sclerotherapy. Preoperative marking, if correctly performed, will have documented the extent of varicose vein clusters and identified the clinical points where...

Conventional Surgical Procedures For Correction Of

Superficial Venous Reflux Great Saphenous Vein Traditional surgical techniques for removal of the Great Saphenous vein typically have employed ligation of the vein at the saphenofemoral junction and removal of the vein between the groin and knee or groin and ankle using a stripping technique. The goal of high ligation is to identify and divide all venous branches communicating with the saphe-nofemoral junction (SFJ) to minimize the potential for recurrent reflux pathways resulting in recurrent...

Cure And Reappearance Of Varicose Veins After Stripping Operation Fischer R

REVAS is a frequent condition frustrating both patients and physicians that has been poorly evaluated. In order to build a scientifically convincing evidence base and to achieve a greater degree of comparability between studies, an international consensus on conformity is required. 1. Perrin M, Guex JJ, Ruckley CV, dePalma RG, Royle P, Eklof B et al. Recurrent varices after surgery (REVAS), a consensus document, Car-diovasc Surg. 2000. 8 233-245. 2. Beresford T, Smith JJ, Brown L, Greenhalgh...

Conclusion For Varicose Veins

US duplex ultrasound is essential in every phase of the CVI patient care. Experience, critical thinking, uniform testing, and insight in the pathology are necessary to achieve satisfactory results. 1. Labropoulos N, Leon LR Jr. Duplex evaluation of venous insufficiency, Semin Vasc Surg. 2005. 18(1) 5-9. 2. Ballard J, Bergan J, Delange M. Venous imaging for reflux using duplex ultrasonography. C. 24, 339-334. In Aburahma AF, Bergan JJ. Noninvasive vascular diagnosis, 1e. 2000. London...

Surgery Of Valves

The first attempt to restore valvular function was performed in 1953 by Eisemann and Malette, who proposed to produce valve-like structures by gathering folds at two sites of the venous wall opposite each other. In 1963, Psathakis proposed to entwine the tendon of the gracilis muscle between the popliteal artery and vein in order to obtain the compression of the vein during contraction of the muscle. A few years later, Ferris and Kistner proposed a transvalvular approach for internal repair of...

Discussion

An increasing number of patients with acute DVT are undergoing treatment with PMT. Advantages of PMT include immediate improvement of symptoms, decreased treatment times and complications when compared to CDT alone, and a possible reduction in the incidence and severity of PTS. Although many PMT catheters are commercially available, only the Trellis-8 Thrombectomy System and the ATS lytic power pulse system are approved by the FDA for treatment of acute DVT. Some PMT catheters, such as those...

Sclerofoam For Truncal Varicosities

Truncal varicosities must be assessed carefully by duplex for their whole length. This is true especially for the Great Saphenous vein, because valvular incompetence is not necessarily total and very often the terminal or preterminal valves are competent. In this situation, this part of the vein will not need to be treated. It is also necessary to remember that the saphenous trunks are always intrafascial. The frequent confusion between a varicose medial superficial tributary and the GSV trunk...

New Hypothesis

A useful hypothesis is that venous hypertension, caused by superficial reflux and calf compartment pressure, is transmitted to unsupported venules of the skin. It is this sum of gravitational and hemodynamic pressure that stimulates the skin changes of chronic venous insufficiency. If this is true, a large component of ankle venous hypertension emanates from normal calf exercise with calf compartment pressures transmitted directly through the incompetent perforating vein valves to the skin (see...

Simplified Diagnostic Criteria for Venous Insufficiency

These criteria may be applied to any plethysmograph. The only restriction is that the volume measurements be taken accurately. In order to simplify the diagnostic criteria for venous phlethysmographic studies we have focused on three parameters. The first is Venous Refilling Time (VRT). In patients with significant venous insufficiency, venous refilling develops secondary to venous reflux and clearly reduces the time necessary to complete the process. If VRT is > 20 seconds, the limb is not...

Background

Venous thromboembolism (VTE) is optimally treated by anticoagulation. When anticoagulation must be withheld, inferior vena cava interruption affords protection against major embolic events likely to be life threatening. Inferior vena cava (IVC) interruption historically has progressed from cava ligation to plication, caval clips, surgically inserted caval umbrellas and filters, and finally to percutaneously inserted filters. Complications associated with the historic methods of caval...

Sylvia Herdemann

In conclusion, endovenous laser of saphenous veins has left the stage of an experimental procedure, and many details have become obvious, which helped to optimize treatment results. However, prospective randomized trials of endove-nous laser treatment versus traditional surgery, versus high ligation performed at the same treatment session, or against other endovenous techniques like radiofrequency closure or sclerotreatment are still missing but urgently needed. Thanks to Drs. Sylvia Herdemann,...

Deployment Complications

Complications that may occur at the time of filter placement are largely dependent upon the equipment used to deploy the filter as well as the filter type. These complications may be generalized into tilting or malposition, incorrect anatomical placement, or failure of the device to fully deploy at its intended site. The incorrect deployment of a filter has many clinical implications and possible secondary complications. An incorrectly deployed filter may not achieve the desired effect of...

Previous Classifications Of

The most commonly used classification, particularly in Europe, was Widmer's classification from 19781 of chronic venous insufficiency Stage I Edema and dilated subcutaneous veins with corona phlebectatica Stage II Trophic lesions of the skin with hyper- or depig- mented areas Stage III Healed or active ulcer The criticism against this clinical classification was the non-specificity of Stage I, and the absence of differentiation between trophic changes in Stage II. In 19792 Hach suggested a...

Info

Postoperative venous thromboembolism in major orthopedic surgery. Apart from being of practical importance the principal mechanisms of action are of great theoretical interest. The Xa inhibitor fondaparinux and the direct thrombin inhibitor ximelagatran melagatran have been evaluated extensively in clinical studies of high quality with large sample sizes. Both substances are at least as effective or more effective than today's dominating prophylactic methods (low molecular weight heparins and...

Preoperative Preparation

Over the years, much space has been given to clinical examination of the patient with varicose veins. Many clinical tests have been described. Most carry the names of now-dead surgeons who were interested in venous pathophysiology. This august history notwithstanding, the Trendelenburg test, the Schwartz test, the Perthes test, and the Mahorner and Ochsner modifications of the Trendelenburg test essentially are useless in preoperative evaluation of patients today.28 The clinical evaluation can...

Qol

Eklof B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL et al. American Venous Forum International Ad Hoc Committee for Revision of the CEAP Classification. Revision of the CEAP classification for chronic venous disorders Consensus statement, J Vasc Surg. 2004. 40 1248-1252. 2. Evans CJ, Allan PL, Lee AJ, Bradbury AW, Ruckley CV, Fowkes FG. Prevalence of venous reflux in the general population on duplex scanning The Edinburgh vein study, J Vasc Surg. 1998. 28 767-776. 3....

Basic Ceap

Use of all components of CEAP is still encouraged but unfortunately many physicians merely use only the C-classification, which is just a modest advance beyond the previous classifications and is based solely on the clinical appearance. Venous disease is complex, but can be described by use of well-defined categorical descriptions. For the practicing physician, CEAP can be a valuable instrument for correct diagnosis to guide treatment and assess prognosis. In...

The Genetic Epidemiology Of Venous Thromboembolism

Recent family-based studies indicate that venous thromboembolism is highly heritable and follows a complex mode of inheritance involving environmental interaction.67-69 Inherited reductions in plasma natural anticoagulants (e.g., antithrombin, protein C, or protein S) have long been recognized as uncommon but potent risk factors for venous thromboembolism.70,71 More recent discoveries of impaired downregulation of the procoagulant system (e.g., activated protein C resistance, Factor V...

References

Leu AJ, Leu HJ, Franzeck UK, Bollinger A. Microvascular changes in chronic venous insufficiency a review, Cardiovasc Surg. 1995. 3 237-245. 2. Bollinger A, Leu AJ, Hoffmann U, Franzeck UK. Microvascular changes in venous disease An update. Angiology. 1997. 48 27-32. 3. Van Cleef JF, Desvaux P, Hugentobler JP, et al. tude endoscopique des reflux valvulaires sapheniens, J Mal Vasc. 1992. 17 113-116. 4. Blanchemaison P. Interet de L'endoscopie veineuse dans l'exploration et le traitement de...

Laser Background

Since the first working laser was made in 1960 at Hughes Research Laboratories in Malibu, California,13 laser technology has been applied to endeavors as varied as large-scale engineering projects and microscopic surgical procedures depending on its design, a laser can cut through steel or make incisions smaller than the size of a cell. Today, lasers are familiar sources of focused light energy, useful in medicine, technology, and meeting presentations. The word laser is actually an acronym for...