Cellular senescence at the saphenofemoral junction in patients with healthy, primary varicose and recurrent varicose veins - A pilot study.

OBJECTIVES: Cellular senescence could play a role in the development of venous disease. Superficial venous reflux at the saphenofemoral junction is a common finding in patients with primary varicose veins. Furthermore, reflux in this essential area is associated with higher clinical stages of the disease and recurrent varicose veins. Therefore, this pilot study aimed to investigate cellular senescence in the immediate area of the saphenofemoral junction in patients with healthy veins, primary varicose veins and additionally in patients with recurrent varicose veins due to a left venous stump. METHODS: We analyzed vein specimens of the great saphenous vein immediately at the saphenofemoral junction. Healthy veins were collected from patients who underwent arterial bypass reconstructions. Samples with superficial venous reflux derived from patients who received high ligation and stripping or redo-surgery at the groin, respectively. Sections were stained for p53, p21, and p16 as markers for cellular senescence and Ki67 as a proliferation marker. RESULTS: A total of 30 samples were examined (10 healthy, 10 primary varicose, and 10 recurrent varicose veins). We detected 2.10% p53+ nuclei in the healthy vein group, 3.12% in the primary varicose vein group and 1.53% in the recurrent varicose vein group, respectively. These differences were statistically significant (p = 0.021). In the healthy vein group, we found 0.43% p16+ nuclei. In the primary varicose vein group, we found 0.34% p16+ nuclei, and in the recurrent varicose vein group, we found 0.74% p16+ nuclei. At the p < 0.05 level, the three groups tended to be significant without reaching statistical significance (p = 0.085). There was no difference in respect of p21 and Ki67. CONCLUSION: We found significantly higher expression rates of p53 in primary varicose veins at the saphenofemoral junction than in healthy veins. p16 expression tended to be increased in the recurrent varicose vein group. These preliminary findings indicate that cellular senescence may have an impact in the development of varicose veins or recurrence. Further studies addressing this issue are necessary.

"Quality of Life after Varicose Vein Surgery in Patients with High-ligation and Stripping, External Valvuloplasty and Sapheno-femoral Redo Surgery".

BACKGROUND: High-ligation and stripping (HL/S) and external valvuloplasty (eVP) with the implantation of an external device to restore the valve's function, are surgical methods to eliminate reflux at the saphenofemoral junction. Furthermore, redo-surgery (RedoS) can be performed in terms of same side groin recurrences. It is unclear, if there is a difference in quality of life (QoL) between these 3 surgical treatment options. Therefore, it was the aim of our study to elucidate QoL in patients before and after surgical treatment at the saphenofemoral junction by comparing HL/S, eVP, and RedoS. METHODS: A total of 303 participants (156 HL/S, 81eVP, 64 RedoS) were recruited during the daily clinical routine. QoL was measured at admission and 6 weeks after the surgical procedure by means of SF-12 (12 item short form health survey) and Aberdeen Varicose Vein Questionnaire. RESULTS: The mean value of Aberdeen Varicose Vein Questionnaire was 14.5 (SD 2.1) preoperatively and 4.9 (SD 3.3) postoperatively in the HL/S group, 16.4 (SD 1.4) preoperatively and 6.8 (SD 2.5) postoperatively in the eVP group and 15.5 (2.2) preoperatively and 5.8 (SD 4.2) postoperatively in the RedoS group, which was statistically significant (P< 0.05) in all groups. Postoperatively, the mean values were statistically significant within the groups. Concerning physical aspects of the SF-12 we found a significant improvement in the RedoS group, while mental aspects were significantly better in the HL/S and eVP group postoperatively. Nevertheless, the clinical relevance of these SF-12 differences is questionable under consideration of the minimal important difference. CONCLUSIONS: Varicose vein surgery leads to a significant improvement of QoL in all groups. The implantation of an external patch could have a negative influence in QoL.

External valvuloplasty of the saphenofemoral junction in insufficient great saphenous veins - six weeks results of a prospective multicentre trial.

Background: Varicosis of the great saphenous vein (GSV) is a common disease. Most of the therapeutic concepts attempt to remove or destroy the truncal vein. However, the absence of the GSV could be harmful for further treatments of artherosclerotic disease as the GSV is often used as bypass graft in lower extremity or coronary artery revascularisations. External valvuloplasty (EV) is one of the vein-sparing treatment options. The aim of this clinical study was to describe the outcome, safety and complications of this procedure in a prospective multicentre trial. Patients and methods: The function of the terminal and preterminal valve was restored by external valvuloplasty. Furthermore, multiple phlebectomies of tributaries were performed. Patients were reinvestigated six weeks after surgery. Primary endpoint was the function of the external valvuloplasty measured by diameter of the GSV and the prevalence of reflux in the GSV. The eligibility of the vein as a potential bypass graft was noticed. CEAP class and VCSS scores were analysed. Results: A total of 359 patients were included in the study. After six weeks 297 patients could be reinvestigated. The function of the external valvuloplasty was sufficient in 284 patients (95.6%). Treatment failed in 8 patients (2.6%) due to an occlusion or junctional reflux despite valvuloplasty. The GSV was estimated as suitable as a bypass graft in 261 patients (87.8%). Reflux at the saphenofemoral junction was significantly reduced after treatment and the diameter of the GSV near the saphenofemoral junction significantly decreased from 4.4 mm to 3.8 mm (p < 0.05). The VCSS was significantly reduced from 4.6 preoperatively to 2.6 postoperatively. Conclusions: External repair of the great saphenous vein can reduce venous symptoms and may preserve the great saphenous vein as a bypass graft. Nevertheless, this treatment option is only suitable for a limited number of patients.

Barrier Patch Implantation during Redo Surgery for Varicose Vein Recurrences in the Groin: 1-Year Results.

BACKGROUND: Rerecurrences after redo surgery for recurrent varicose veins in the groin are a common problem. The present report looks at the efficacy of an additional barrier patch implantation in reducing these rerecurrences. METHODS: A retrospective review of a prospectively collected database was conducted. This included 67 patients with 86 legs who underwent redo-groin surgery for symptomatic recurrences. In addition, a polytetrafluoroethylene-barrier patch was placed at the former saphenofemoral junction. All patients had undergone ligation and stripping of the great saphenous vein a mean of 13.9 years earlier. All patients were examined by duplex ultrasound before and 1 year after the procedure. RESULTS: Perioperatively, minor complications occurred in 5.8% of cases, the groin infection rate was 2.4%. In 85 of 86 legs, the duplex follow-up examination was performed after 1 year. This revealed an overall rerecurrence rate of 12%, of which only 2.4% were caused by recurrent neovascularization in the groin bypassing the barrier patch. The remaining 9.6% were caused by different sites of reflux (pelvic veins and perforators). CONCLUSIONS: Redo-groin surgery with additional barrier patch implantation seems to be a safe and effective way to prevent rerecurrences in the groin. In our experience, it provided very promising 1-year results with a very low rate of recurrent neovascularization.

Konsensuspapier zur symptomorientierten Therapie der chronischen Venenerkrankungen.

HINTERGRUND: Chronische Venenerkrankungen sind eine Volkskrankheit. Venöse Symptome wie Schwellungs- und Schweregefühl können bereits früh ohne sichtbaren Befund auftreten und werden als belastend erlebt. Ein Fortschreiten im Sinne einer objektivierbaren Varikose bzw. chronischen venösen Insuffizienz schränkt die Lebensqualität erheblich ein. METHODIK: Pubmed-gelistete Publikationen sowie relevante Leitlinien zur Therapie chronischer Venenkrankheiten bilden die Basis der vorliegenden Konsensusempfehlungen. Inkludiert in die Bewertung wurden ausschließlich aussagekräftige randomisierte Studien (RCT) und Übersichtsarbeiten (Reviews/Metaanalysen). ERGEBNISSE: Die symptomorientierte Behandlung chronischer Venenerkrankungen stützt sich auf drei Säulen mit nachgewiesener Wirksamkeit: invasive Therapie, Kompressionstherapie und orale medikamentöse Therapie. Gemäß Empfehlungen aktueller Leitlinien sollte zunächst eine Sanierung des venösen Gefäßbetts erwogen werden, um einen störungsfreien venösen Blutfluss wiederherzustellen und Symptome und pathologische Veränderungen zu beseitigen oder zu bessern. Ist ein invasiver Eingriff nicht möglich bzw. nicht erwünscht oder bestehen nach einem Eingriff noch Restsymptome, gilt es, die symptomatischen Therapieoptionen optimal auszuschöpfen. Kompressionstherapie und medikamentöse Therapie können allein oder in Kombination angewendet werden. Welche Strategie den größten Erfolg verspricht, ist individuell zu entscheiden. SCHLUSSFOLGERUNGEN: Chronische Venenerkrankungen sollten auf der Basis der individuellen pathophysiologischen Störung behandelt werden. Sie symptomorientierte Behandlung chronischer Venenerkrankungen fußt auf der invasiven Therapie, der Kompressionstherapie und der medikamentösen Therapie. Bei der Indikationsstellung sind objektive Symptome ebenso wie subjektive Beschwerden zu berücksichtigen.

Consensus statement on the symptom-based treatment of chronic venous diseases.

BACKGROUND: Chronic venous diseases are very common. Early symptoms such as a sensation of swelling and heaviness may occur without objectifiable findings, but are nevertheless perceived as bothersome. Progressive disease - marked by varicose veins and symptoms of chronic venous insufficiency - is associated with considerable impairment in quality of life. METHODS: The present consensus recommendations are based on publications in Pubmed-listed journals as well as relevant international therapeutic guidelines on chronic venous diseases. Only conclusive randomized controlled trials (RCTs) and review articles/meta-analyses were included. RESULTS: Symptom-based treatment of chronic venous diseases is based on three therapeutic pillars with proven efficacy: invasive therapy, compression therapy, and oral pharmacological treatment. According to current therapeutic guidelines, invasive procedures aimed at restoring unimpaired venous blood flow as well as improving or eliminating pathological changes should be the first-line approach. If an invasive approach is infeasible or undesirable, or if symptoms persist following a therapeutic intervention, optimal use of symptom-based treatment options is recommended. Compression and pharmacological therapy may each be used as sole treatment or in combination. To guarantee maximum therapeutic success, individual treatment decisions should be made on a case-by-case basis. CONCLUSIONS: Chronic venous diseases should be treated on the basis of individual pathophysiological disturbances. Symptom-based treatment of chronic venous disorders encompasses invasive therapy, compression therapy, and oral pharmacological therapy. Considerations in choosing the appropriate treatment option should include both objective signs as well as subjective symptoms.

Effectiveness of antiplatelet therapy in atherosclerotic disease: comparing the ASA low-response prevalence in CVD, CAD and PAD.

Although acetylsalicylic acid (ASA, aspirin) reduces the risk of ischemic events in patients with atherosclerosis, a substantial number of incidents continue to occur. As only limited data exist we evaluated the antiplatelet effectiveness of ASA in patients with different manifestations of atherosclerosis as in cerebrovascular, coronary artery and peripheral arterial disease (CVD, CAD, PAD). For the evaluation of the antiplatelet effectiveness of ASA we used whole blood aggregometry (Chrono-log Model 590). The patients in the different subgroups received ASA 100, 200 or 500 mg daily. We analysed 737 consecutive patients: 47.5 % with CVD, 33.6 % with CAD, and 18.9 % with PAD. We identified 28.0 % of the CVD, 18.1 % of the CAD and 21.6 % of the PAD patients to be ASA low-responder (ALR). Comparing subgroups treated with 100 mg ASA, 36.4 % were ALR in the CVD group as were 13.1 % of the CAD and 21.6 % of the PAD patients. Multivariate regression analysis revealed an odds ratio for being ALR of 4.50 (95 % confidence interval (CI) 1.70-11.9) when 100 mg and of 2.97 (95 % CI 1.58-5.60) when 200 mg ASA was taken compared to a dose of 500 mg. Despite the proven benefits of antiplatelet therapy in the secondary prevention of atherosclerotic disease, current antiplatelet management is suboptimal as up to 36 % of patients failed to achieve an adequate platelet inhibitory effect. Our findings may explain, at least in part, the high rates of cardiovascular events observed in the course of atherothrombotic disease and support the need to improve antiplatelet therapy.

Decorin expression with stump recurrence and neovascularization after varicose vein surgery--a pilot study.

BACKGROUND: An evaluation of the reason for saphenofemoral recurrence (SFR, technical error vs neovascularization) after surgery is necessary to improve the method or find purchase for new therapies. Currently, differentiation by the surgeon or ultrasound are unsatisfying; histology depends mainly on the physician's experience. Decorin, an extracellular matrix component, is up-regulated in angiogenesis with antiangiogenetic effects on neovascularization. OBJECTIVE: To determine whether decorin is a reliable marker to distinguish neovascularization and stump recurrence. METHODS: Twenty specimens obtained in re-operation of patients with duplex-detected SFR were stained with hematoxylin and eosin, Elastica van Gieson, and decorin antibody. An experienced pathologist reviewed specimens for stump recurrence or neovascularization. An independent physician analyzed the specimens semiquantitatively for expression of decorin (0=none to 3=strong). RESULTS: Only low expression of decorin was found around residual stumps (1.4±0.5), but extensive expression was detectable around neovascularization (2.4±0.3, p=.001). In one specimen with neovascularization and a residual stump, decorin was a capable marker to divide the two zones. Correlation of histological and decorin-based diagnosis was 100%, but differentiation was much easier with decorin. CONCLUSION: Decorin is a marker for any easy differentiation of stump recurrence and neovascularization and can support further investigation in SFR and improvement of the primary therapy.

Functional repair of the great saphenous vein by external valvuloplasty reduces the vein's diameter: 6-month results of a multicentre study.

OBJECTIVES: External valvuloplasty (eVP) is a reconstructive surgical method to repair the function of the terminal and preterminal valves. We evaluated the 6-month outcomes of eVP regarding the diameter of the great saphenous vein (GSV). METHODS: Patients from five vein centres were included in this observational study. Follow-up involved detailed duplex sonography of the GSV. The venous clinical severity score (VCSS) and the C class of the clinical, aetiologic, anatomic and pathophysiologic (CEAP) classification were recorded. RESULTS: We enrolled 210 patients, with a follow-up rate of 58%; eVP was sufficient in 95.24% of the patients. The GSV diameters decreased significantly from 4.4 mm (standard deviation (SD): 1.39) to 3.9 (SD: 1.12), 4 cm distal to the saphenofemoral junction (SFJ); from 3.7 mm (SD: 1.10) to 3.5 mm (SD: 1.02) at the mid-thigh; from 3.6 mm (SD: 1.14) to 3.3 mm (SD: 0.94) at the knee and from 3.1 mm (SD: 0.99) to 2.9 mm (SD: 0.78) at the mid-calf. VCSS decreased significantly from 4.76 (SD: 2.13) preoperatively to 1.77 (SD: 1.57) 6 months postoperatively. CONCLUSIONS: GSV function can be restored by eVP; diameters over the total length of the GSV decreased significantly.

Minor tributary veins of the common femoral vein near the saphenofemoral junction - A postmortem study.

OBJECTIVES: Recurrent varicose veins after surgery are a frequent burden and the saphenofemoral junction is the most common source of reflux. Pre-existing branches of the common femoral vein near the saphenofemoral junction, which may increase due to haemodynamic or other reasons, could play a role in the development of recurrent varices. There exist only a few anatomical data about the prevalence of these minor venous tributaries of the common femoral vein near the saphenofemoral junction. Therefore, this study aimed to elucidate their frequency and distribution. METHOD: A total of 59 veins from 35 anatomical donors were dissected. The common femoral vein with the adherent parts of the profunda femoris vein and the great saphenous vein was exposed and analysed ex situ. The number of minor tributaries to the common femoral vein was counted and their distances to the saphenofemoral junction as well their diameters were measured. RESULTS: We could identify up to 10 minor tributaries of the common femoral vein below the level of the great saphenous vein as far as 6 cm distally and up to four veins above the level as far as 5 cm proximally. The mean diameters of these vessels ranged from 0.5 to 11.7 mm. Most of these vessels were located near the saphenofemoral junction and 3 cm distally. Directly opposite to the opening of the great saphenous vein we could find at least one minor tributary of the common femoral vein in 57%. CONCLUSIONS: There exist a vast number of minor tributaries of the common femoral vein and they are mainly located near the saphenofemoral junction. Nevertheless, their role in the development of recurrent varices is still unclear and further studies are necessary.

Multimodal approach of venous recanalization in patients with a critical limb ischemia due to phlegmasia cerulea dolens: A case series of 17 patients in a single center.

OBJECTIVES: Advanced phlegmasia cerulea dolens can be a hazardous complication of a deep vein thrombosis and rapid recanalization of the deep venous system is the most important factor. METHOD: We describe the outcome of 17 patients with critical limb ischemia due to an advanced phlegmasia cerulea dolens. Venous thrombectomy was performed by a standardized operating procedure. RESULTS: Venous recanalization was successful in all patients. An additional fasciotomy was not necessary. There were five patients with an underlying malignancy and eight patients with a simultaneous pulmonary embolism. We had one amputation of a forefoot and one death within 30 days representing a 30-day mortality and an amputation rate of 6%. CONCLUSIONS: Early recanalization and recovery of the venous outflow is mandatory for success. A multimodal therapeutic approach of high urgency surgical thrombectomy in combination with endovenous strategies could be a successful treatment option for advanced phlegmasia cerulea dolens.

Surgical thrombectomy for iliofemoral deep vein thrombosis: Patient outcomes at 8.5 years.

INTRODUCTION: Deep vein thrombosis (DVT) is a frequent burden and a post-thrombotic syndrome (PTS) can be a serious long-term consequence. Iliofemoral DVT should be associated with severe forms of PTS. Therefore an early thrombus removal has been recommended in specific conditions. The aim of this study was to find out both, the long-term results after surgical thrombectomy of iliofemoral DVT in respect of the development of PTS as well as the venous hemodynamics after surgery concerning venous reflux and venous obstruction. METHODS: Sixty-seven patients who underwent surgical thrombectomy between the years 2000 and 2014 were included in this study; iliofemoral DVT was present in 52 of these patients. 35 patients could be reinvestigated after a mean follow-up of 8.5 years. CEAP (Clinical-Etiological-Anatomical-Pathophysiological) and Villalta scores were recorded in order to describe and assess PTS. Follow-up examinations included a detailed duplex mapping. Venous hemodynamics were measured by digital photoplethysmography and venous occlusion plethysmography. RESULTS: The primary patency rate of the iliofemoral segment was 88% after 8.5 years. 48% of all patients showed reflux in deep vein segments. Mild or moderate PTS occurred in 57% of all patients. Notably, there was no patient with an active ulcer or severe PTS. The mean venous outflow volume of all patients in the treated legs was 66.1 ml/100ml/min and significantly less than in the controlled contralateral non-treated legs (p<0.05). The mean venous refilling time was 16.3 seconds, while the mean value of the non-treated contralateral legs was 25.6 seconds and therefore significantly higher (p<0.05). CONCLUSION: Even though venous hemodynamics are significantly inferior in the treated legs, this study demonstrates excellent patency rates and good clinical outcome after surgical thrombectomy of iliofemoral veins.

Perioperative changes of response to antiplatelet medication in vascular surgery patients.

INTRODUCTION: Reduced antiplatelet activity of aspirin (ALR) or clopidogrel (CLR) is associated with an increased risk of thromboembolic events. The reported prevalence data for low-responders vary widely and there have been few investigations in vascular surgery patients even though they are at high risk for thromb-embolic complications. The aim of this prospective observational monocentric study was to elucidate possible changes in ALR or CLR after common vascular procedures. METHODS: Activity of aspirin and clopidogrel was measured by impedance aggregometry using a multiple electrode aggregometer (Multiplate®). Possible risk factors for ALR or CLR were identified by demographical, clinical data and laboratory parameters. In addition, a follow-up aggregometry was performed after completion of the vascular procedure to identify changes in antiplatelet response. RESULTS: A total of 176 patients taking antiplatelet medications aspirin and/or clopidogrel with peripheral artery disease (PAD) and/or carotid stenosis (CS) were included in the study. The prevalence of ALR was 13.1% and the prevalence of CLR was 32% in the aggregometry before vascular treatment. Potential risk factors identified in the aspirin group were concomitant insulin medication (p = 0.0006) and elevated C-reactive protein (CRP) (p = 0.0021). The overall ALR increased significantly postoperatively to 27.5% (p = 0.0006); however, there was no significant change in CLR that was detected. In a subgroup analysis elevation of the platelet count was associated with a post-procedure increase of ALR incidence. CONCLUSION: The incidence of ALR in vascular surgery patients increases after vascular procedures. An elevated platelet count was detected as a risk factor. Further studies are necessary to analyse this potential influence on patency rates of vascular reconstructions.

Validity of duplex-ultrasound in identifying the cause of groin recurrence after varicose vein surgery.

INTRODUCTION: Often groin recurrences after varicose vein surgery are diagnosed and classified with the help of a duplex ultrasound scan. There are, however, no studies indicating if duplex ultrasound scans can reliably distinguish between the different forms of recurrent vessels, ie, neovascularization or a residual stump. To address this issue, we have conducted a prospective study in which ultrasound scan assessment of groin recurrences was compared to the histological classification of the recurrent groin veins. MATERIALS AND METHODS: All patients undergoing redo-surgery for symptomatic groin recurrences after previous stripping of the greater saphenous vein (GSV) during a 1-year period (May 2006-May 2007) were included in the study. Preoperatively, all patients had a duplex-ultrasound scan examination of the groin vessels. Based on the duplex scan findings, the recurrent veins in the groin were classified as either a residual stump or neovascularization. During the redo-surgery, a specimen of the recurrent groin veins was obtained and underwent histologic evaluation. Based on histologic criteria, the recurrence was also classified as a residual stump or neovascularization. RESULTS: During the 1-year study period, 125 groin recurrences in 95 consecutive patients (74 female, 21 male, mean age 58.7 years, standard deviation [SD] 10.3 years) were included. In the 119 cases where both duplex-ultrasound scan and histological evaluation were available, a residual stump was seen at the histological examination in 80.7% of cases, a neovascularization in 10.9% of cases, and a combination of both entities in 8.4% of cases. Duplex-ultrasound scan classified the recurrent groin veins as a residual stump in 68.1% of cases, as neovascularization in 26.1%, and as a combination of both in 5.8% of cases. With histological classification as the gold-standard, duplex ultrasound scans reached a sensitivity of 77.1% and a positive predictive value of 91.4% in correctly identifying a residual stump as the cause of recurrence. For the correct classification of neovascularization, sensitivity was 61.5% and the positive predictive value 25.8%, while a combination of both was recognized with a sensitivity of 10% and a positive predictive value of 14.3%. CONCLUSION: While duplex-ultrasound scan is a reliable tool to diagnose groin recurrences after varicose vein surgery, its validity in classifying the different types of recurrent groin vessels is limited. Especially the correct identification of neovascularization which is poor with a sensitivity of 62% and a positive predictive value of 26%. Histological examination should still be regarded as the gold-standard when trying to differentiate between different types of groin recurrences.

A case of contained ruptured aortitis due to Clostridium septicum infection in a patient with a colon malignancy.

We discuss a case of contained ruptured aortitis due to Clostridium septicum infection in a 71-year-old man, who had undergone a right hemicolectomy and cholecystectomy to treat an ascending colon carcinoma. Computed tomography identified a juxtarenal abdominal aneurysm with gas formation in the right psoas muscle. Emergency abdominal exploration revealed a ruptured aortitis. After in situ graft replacement of the abdominal aorta, Clostridium septicum was identified in tissue culture. Antibiotic therapy with penicillin G was administered. The postoperative course was complicated by a retroperitoneal haematoma which necessitated surgical revision. The patient was discharged 2 months afterwards. At clinical monitoring at 6 months he is still doing well.

Different approaches in the treatment of cystic adventitial disease of the popliteal artery.

Three cases of cystic adventitial disease (CDA) of the popliteal artery and the results of a literature review are described in order to identify the treatment of first choice of this rare clinical entity. Three male patients (mean age 56,3 years) presented at our Institution due to a sudden abrupt of disabling claudication of the lower limb. The eco-color-Doppler examination showed multiple hypoechoic and anechoic masses arising in the wall of the artery consistent with CAD. The magnetic resonance imaging (MRI) confirmed this finding. In 2 cases a venous interposition grafting was performed and in the remaining patient a duplex-directed punction. The 3 patients are asymptomatic at the clinical control at 9 months after treatment. As it results after a literature review, the MRI seems to be the best diagnostic tool and the vein interposition grafting the treatment of first choice. In cases of young male patients without cardiovascular risk factors and suffering of disabling claudication of recent onset the MRI guarantees a valuable diagnosis in case of ultrasonographic suspect of CAD of the popliteal artery. The surgical resection and the vein interposition grafting represent the treatment of first choice. In selected patients, a duplex-guided punction assures satisfactory clinical results. A strict ultrasonographic follow-up guarantees an early recognition of relapse.

Reflux patterns in the ovarian and hypogastric veins in patients with varicose veins and signs of pelvic venous incompetence.

Patients with varicose veins who also had clinical and/or duplex ultrasound findings suspicious of pelvic venous incompetence (PVI) underwent selective retrograde catheter phlebography of the pelvic veins. One hundred and one patients (all female, mean age 49.3 years) underwent selective phlebography of the pelvic veins. In 68 cases (67.3%) a varicose vein recurrence after previous stripping of the greater saphenous vein was present, and about half the patients (n=45, 44.6%) were multipara ( > or =2 episodes of childbirth). The presence and extent of any reflux was documented and the ovarian and pelvic veins affected by the reflux were recorded. Retrograde selective phlebography demonstrated a PVI in 75 patients (74.2%). The left ovarian vein and the right hypogastric vein were most frequently affected by reflux (n = 41, 54.6% each). The left hypogastric vein was incompetent in 35 patients (46.6%) and the right ovarian vein in 3 cases (4%). In about half the patients with pelvic venous incompetence, reflux was demonstrated in more than one of the main pelvic veins (n=38, 50.6%). Fifty-one (68%) of the 75 patients with pelvic venous incompetence had varicose vein recurrence after previous stripping of the greater saphenous vein. Extension of the reflux into varicose veins of the groin or lower leg was demonstrated in 44 patients (58.6%). Thirty-nine patients (52%) received treatment for their pelvic venous incompetence (coil embolisation, sclerotherapy or videoscopic ovarian vein ligation). Pelvic venous reflux was present in 75% of our study population. Combined reflux in more than one pelvic vein was common and in about 60% of cases the pelvic reflux was shown to feed varicose veins of the legs. Therefore, typical clinical and/or duplex findings should lead to a strong suspicion of pelvic venous incompetence and reduce the need for selective retrograde catheter phlebography in this selected group of patients.

Factors influencing early results and complication rates of the thrombolytic treatment of lower limb ischemia with recombinant tissue-type plasminogen activator.

The aim of the study was to determine the effect of comorbidity conditions on the early outcome and complication rates of thrombolytic treatment of lower limb ischaemia with recombinant tissue plasminogen activator (rt-PA). Clinical and procedural data of 82 patients treated for acute/subacute arterial/graft occlusion were analysed retrospectively. Early results and adverse events were recorded and evaluated statistically. Early resolution of ischemic symptoms was achieved in 67 (82%) patients with a median dose of 25.4 mg of rt-PA. Major bleeding was reported in 9 and minor bleeding in 6 cases (intracranial hemorrhage rate 1%, mortality rate 1%, major amputation rate 1%). Comorbidity conditions and patient characteristics did not statistically influence success and complication rates. Bleeding was observed in patients who received a higher dose of the thrombolytic agent (30.0 mg vs 24.3 mg). Comorbidity conditions have no effect on early outcome and adverse events after thrombolytic management of lower limb ischemia. Higher doses of rt-PA with prolonged infusion times increase the risk of occurrence of treatment-related bleeding.

[Management of infected vascular grafts. Are there any factors predictive of early clinical success?]. / Management delle infezioni protesiche vascolari. Esistono variabili predittive di successo precoce?

The aim of the study was to define mortality and limb loss rates and to identify factors predictive of early clinical success in the management of infected vascular grafts. Clinical data of 40 patients were reviewed, evaluating comorbidity factors, laboratory findings, ischaemic symptoms, graft material and time of onset of infections. Diabetes and chronic renal insufficiency were reported in 15% of cases, malignancy in 10%, pathological C-reactive protein in 77.5% and leukocytosis in 60%. 52.5% of the patients presented with a disabling claudication, and 77.5% with an infected alloplastic graft. Early infection had developed in 57.5%. A total graft excision was performed in 72.5% of cases. Early complications were recorded in 32.5% of the patients, with a limb loss rate of 22.5% and a mortality rate of 10%. Total graft excision is the treatment of first choice in patients with an infected vascular graft. Patients presenting with critical ischaemia and early septic complications will experience poor clinical results in terms of limb loss and mortality. Pathological blood levels of C-reactive protein could help in the choice of treatment in unclear cases.

Ultrasound elastography for the age determination of venous thrombi. Evaluation in an animal model of venous thrombosis.

The exact age determination of venous thrombi is important if thrombolytic therapy or surgical thrombectomy is considered. Clinical symptoms as well as duplex-ultrasound and phlebography are unreliable in this respect and do not allow an exact age estimation. Ultrasound elastography can provide information about the elastic properties of thrombi. Since thrombus elasticity decreases with age due to the organisation process, it should be possible to use elastography to stage the degree of organisation and thereby determine the age of venous thrombi. Experimental venous thrombi aging 1, 3, 6, 9, 12 and 15 days were created in a porcine model by laparoscopic ligation of the infrarenal Vena cava in combination with transfemoral infusion of thrombin. The thrombosed iliac veins were explanted and embedded in gelatine, after that they underwent examination by ultrasound elastography. In addition, histological evaluation of the thrombi was performed. Elastography demonstrated a decline in thrombus elasticity between days 6 and 12 with the 12-day-old thrombi being about 3 times harder then the 6-day-old thrombi. This correlated with the histological findings, which demonstrated a marked increase in fibroblast and collagen production in the clots during this time, with the 12- and 15-day thrombi showing signs of advanced organisation. In conclusion, in an experimental setting, ultrasound elastography was helpful in determining the exact age of venous thrombi. The differences in elasticity were most pronounced between days 6 and 12, which is also the most relevant time frame when considering invasive therapies in human venous thrombosis.