Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American subfascial endoscopic perforator surgery registry. The North American Study Group.
PURPOSE: The safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery (SEPS) for the treatment of chronic venous insufficiency were established in a preliminary report. The long-term clinical outcome and the late complications after SEPS are as yet undetermined. METHODS: The North American Subfascial Endoscopic Perforator Surgery registry collected information on 148 SEPS procedures that were performed in 17 centers in the United States and Canada between August 1, 1993, and February 15, 1996. The data analysis in this study focused on mid-term outcome in 146 patients. RESULTS: One hundred forty-six patients (79 men and 67 women; mean age, 56 years; range, 27 to 87 years) underwent SEPS. One hundred and one patients (69%) had active ulcers (class 6), and 21 (14%) had healed ulcers (class 5). One hundred and three patients (71%) underwent concomitant venous procedures (stripping, 70; high ligation, 17; varicosity avulsion alone, 16). There were no deaths or pulmonary embolisms. One deep venous thrombosis occurred at 2 months. The follow-up periods averaged 24 months (range, 1 to 53 months). Cumulative ulcer healing at 1 year was 88% (median time to healing, 54 days). Concomitant ablation of superficial reflux and lack of deep venous obstruction predicted ulcer healing (P <.05). Clinical score improved from 8.93 to 3.98 at the last follow-up (P <. 0001). Cumulative ulcer recurrence at 1 year was 16% and at 2 years was 28% (standard error, < 10%). Post-thrombotic limbs had a higher 2-year cumulative recurrence rate (46%) than did those limbs with primary valvular incompetence (20%; P <.05). Twenty-eight of the 122 patients (23%) who had class 5 or class 6 ulcers before surgery had an active ulcer at the last follow-up examination. CONCLUSIONS: The interruption of perforators with ablation of superficial reflux is effective in decreasing the symptoms of chronic venous insufficiency and rapidly healing ulcers. Recurrence or new ulcer development, however, is still significant, particularly in post-thrombotic limbs. The reevaluation of the indications for SEPS is warranted because operations in patients without previous deep vein thrombosis are successful but operations in those patients with deep vein thrombosis are less successful. Operations on patients with deep vein occlusion have poor outcomes. (+info)
Bypass graft of an occluded inferior vena cava: report of a case with patency at five years.
Venous reconstructive surgery for chronic occlusive disease has evolved slower than its arterial counterpart. Factors intrinsic to the venous system that have been implicated in discouraging experimental and clinical results include enhanced graft thrombogenicity, low velocity of blood flow, and wall collapsibility. 1,2 We present a case of a 24-year-old man with symptomatic occlusion of the inferior vena cava, treated with a prosthetic bypass graft to the supra diaphragmatic cava. The graft was patent 5 years later, and the patient remained asymptomatic. (+info)
Endothelial activation response to oral micronised flavonoid therapy in patients with chronic venous disease--a prospective study.
BACKGROUND: Endothelial activation is important in the pathogenesis of skin changes due to chronic venous disease (CVD). Purified micronised flavonoid fraction has been used for symptomatic treatment of CVD for a considerable period of time. The exact mode of action of these compounds remains unknown. AIM: To study the effects of micronised purified flavonoidic fraction (Daflon 500 mg, Servier, France) treatment on plasma markers of endothelial activation. MATERIALS AND METHODS: Twenty patients with chronic venous disease were treated for 60 days with DAFLON 500 mg twice daily. Duplex ultrasonography and PPG was used to assess the venous disease. Blood was collected from a foot vein immediately before starting treatment and within 1 week of stopping treatment. Plasma markers of endothelial activation were measured using commercial ELISA kits. RESULTS: Reduction in the level of ICAM-1, 32% (141 ng/ml: 73 ng/ml) and VCAM 29% (1292 ng/ml: 717 ng/ml) was seen. Reduction in plasma lactoferrin (36% decrease, 760 ng/ml: 560 ng/ml) and VW factor occurred in the C4 group only. CONCLUSIONS: Micronised purified flavonoidic fraction treatment for 60 days seems to decrease the levels of some plasma markers of endothelial activation. This could ameliorate the dermatological effects of (CVD). This could also explain some of the pharmacological actions of these compounds. Our study demonstrates the feasibility of using soluble endothelial adhesion molecules as markers for treatment. (+info)
Movement-related variation in forces under compression stockings.
OBJECTIVES: Compression therapy is widely used in the treatment of venous leg ulcers, but the efficacy of this treatment is variable. Assessment of variation in compression forces associated with movement may help to elucidate the mechanism of action of compression therapy. The aim of this study was to develop and apply a system to investigate forces under compression stockings during movement. METHOD: Three sensors were placed on the medial aspect of the left leg on six healthy volunteers to monitor forces under class 2 (Continental European classification) compression stockings. Data were recorded during dorsiflexion and plantar flexion of the left foot and also during short periods of walking. RESULTS: Changes in pressure were observed, associated with dorsiflexion and plantar flexion of the foot. These changes were dependent on sensor position. Changes in pressure during walking were also position-dependent and of variable duration. CONCLUSIONS: The system enables forces associated with compression therapy to be examined during movement and may thus be of value in further understanding its mechanism of action. Foot movement can be associated with clear changes in pressure under compression stockings and rapid changes in pressure may occur during walking. (+info)
Risk factors for erysipelas of the leg (cellulitis): case-control study.
OBJECTIVE: To assess risk factors for erysipelas of the leg (cellulitis). DESIGN: Case-control study. SETTING: 7 hospital centres in France. SUBJECTS: 167 patients admitted to hospital for erysipelas of the leg and 294 controls. RESULTS: In multivariate analysis, a disruption of the cutaneous barrier (leg ulcer, wound, fissurated toe-web intertrigo, pressure ulcer, or leg dermatosis) (odds ratio 23.8, 95% confidence interval 10.7 to 52.5), lymphoedema (71.2, 5.6 to 908), venous insufficiency (2.9, 1.0 to 8.7), leg oedema (2.5, 1.2 to 5.1) and being overweight (2.0, 1.1 to 3.7) were independently associated with erysipelas of the leg. No association was observed with diabetes, alcohol, or smoking. Population attributable risk for toe-web intertrigo was 61%. CONCLUSION: This first case-control study highlights the major role of local risk factors (mainly lymphoedema and site of entry) in erysipelas of the leg. From a public health perspective, detecting and treating toe-web intertrigo should be evaluated in the secondary prevention of erysipelas of the leg. (+info)
Leukocyte activation in patients with venous insufficiency.
PURPOSE: Cell activation may play an important role in the production of venous insufficiency, just as leukocytes participate in the cause of venous ulcer. If activated, monocytes observed on venous endothelium can migrate into the venous wall and produce toxic metabolites and free oxygen radicals that may participate in valve destruction and venous wall weakening. At present, it remains uncertain to what degree leukocytes are actually activated in patients. This study was designed to explore the level of activation and to examine whether patient plasma contains an activator that leads to leukocyte activation of unstimulated naive leukocytes from volunteers without venous insufficiency disease. METHODS: Twenty-one patients (4 men, 17 women), who ranged in age from 34 to 69 years (mean age, 53.2 years), with chronic venous disease were compared with 16 healthy control volunteers (4 men, 12 women), who ranged in age from 18 to 65 years (mean age, 48.4 years). All the patients underwent evaluation with Doppler ultrasound scanning and were classified with the CEAP score.1 Nearly all the patients who smoked or were hypertensive were excluded. The blood types (ABO and Rh) of the controls were matched to the study group. Isolates of patient whole blood, plasma, or leukocytes were incubated with isolates of control whole blood, plasma, or leukocytes to separate actual activation from spontaneously observed activation. The granulocyte activation was measured with nitroblue tetrazolium (NBT) reduction and quantitation of granulocyte pseudopod formation. Hydrogen peroxide production in patient plasma was measured with a recently developed electrode method. RESULTS: Leukocytes from healthy blood and patient plasma had significantly higher NBT-positive granulocyte counts than either patient blood, healthy blood, or patient blood incubated in healthy plasma. In a comparison of patient groups across the CEAP classes, the NBT-positive granulocyte counts were significantly greater in classes 4, 5, and 6 than in classes 2 and 3 (P <.001). Pseudopod formation was significantly greater in mixtures of granulocytes in healthy blood and patient plasma than in all other groups. There was no difference in the level of pseudopod formation in control leukocytes incubated with patient plasma in patients across the CEAP spectrum. The patient plasma produced significantly higher hydrogen peroxide values than did the controls. CONCLUSION: These results suggest that patient plasma may contain an activating factor for granulocytes. The finding that activated neutrophils were fewer in number in patient whole blood than in healthy blood incubated in patient plasma could suggest that activated neutrophils in patients with chronic venous insufficiency might be trapped in the peripheral circulation. It is unknown what factors in the plasma might induce activation of naive neutrophils, but such activators could possibly be important in the pathogenesis of primary venous dysfunction and the development of chronic venous insufficiency. (+info)
Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study.
STUDY OBJECTIVE: To determine the prevalence of varicose veins and chronic venous insufficiency (CVI) in the general population. DESIGN: Cross sectional survey. SETTING: City of Edinburgh. PARTICIPANTS: Men and women aged 18-64 years selected randomly from age-sex registers of 12 general practices. MAIN RESULTS: In 1566 subjects examined, the age adjusted prevalence of trunk varices was 40% in men and 32% in women (p < or = 0.01). This sex difference was mostly a result of higher prevalence of mild trunk varices in men. More than 80% of all subjects had mild hyphenweb and reticular varices. The age adjusted prevalence of CVI was 9% in men and 7% in women (p < or = 0.05). The prevalence of all categories of varices and of CVI increased with age (p < or = 0.001). No relation was found with social class. CONCLUSIONS: Approximately one third of men and women aged 18-64 years had trunk varices. In contrast with the findings in most previous studies, mainly conducted in the 1960s and 1970s, chronic venous insufficiency and mild varicose veins were more common in men than women. No evidence of bias in the study was found to account for this sex difference. Changes in lifestyle or other factors might be contributing to an alteration in the epidemiology of venous disease. (+info)
Prophylactic inferior vena cava filters in trauma patients at high risk: follow-up examination and risk/benefit assessment.
PURPOSE: The efficacy of prophylactic inferior vena cava filters in selected trauma patients at high risk has come into question in relation to risk/benefit assessment. To evaluate the usefulness of prophylactic inferior vena cava filters, we reviewed our experience and overall complication rate. METHODS: From February 1991 to April 1998, the trauma registry identified 7333 admissions. One hundred eighty-seven prophylactic inferior vena cava filters were inserted. After the exclusion of 27 trauma-related deaths (none caused by thromboembolism), 160 patients were eligible for the study. The eligible patients were contacted and asked to complete a survey and return for a follow-up examination to include physical examination, Doppler scan study, vena cava duplex scanning, and fluoroscopic examination. The patients' hospital charts were reviewed in detail. The indications for prophylactic inferior vena cava filter insertion included prolonged immobilization with multiple injuries, closed head injury, pelvic fracture, spine fracture, multiple long bone fracture, and attending discretion. RESULTS: Of the 160 eligible patients, 127 were men, the mean age was 40.3 years, and the mean injury severity score was 26.1. The mean day of insertion was hospital day 6. Seventy-five patients (47%) returned for evaluation, with a mean follow-up period of 19.4 months after implantation (range, 7 to 60 months). On survey, patients had leg swelling (n = 27), lower extremity numbness (n = 14), shortness of breath (n = 9), chest pain (n = 7), and skin changes (n = 4). All the survey symptoms appeared to be attributable to patient injuries and not related to prophylactic inferior vena cava filter. Physical examination results revealed edema (n = 12) and skin changes (n = 2). Ten Doppler scan studies had results that were suggestive of venous insufficiency, nine of which had histories of deep vein thrombosis. With duplex scanning, 93% (70 of 75) of the vena cavas were visualized, and all were patent. Only 52% (39 of 75) of the prophylactic inferior vena cava filters were visualized with duplex scanning. All the prophylactic inferior vena cava filters were visualized with fluoroscopy, with no evidence of filter migration. Of the total 187 patients, 24 (12.8%) had deep vein thrombosis develop after prophylactic inferior vena cava filter insertion, including 10 of 75 (13.3%) in the follow-up group, and one patient had a nonfatal pulmonary embolism despite filter placement. Filter insertion complications occurred in 1.6% (three of 187) of patients and included one groin hematoma, one arteriovenous fistula, and one misplacement in the common iliac vein. CONCLUSION: This study's results show that prophylactic inferior vena cava filters can be placed safely with low morbidity and no attributable long-term disabilities. In this patient population with a high risk of pulmonary embolism, prophylactic inferior vena cava filters offered a 99.5% protection rate, with only one of 187 patients having a nonfatal pulmonary embolism. (+info)