Compression stockings after endovenous laser ablation of the great saphenous vein: a prospective randomized controlled trial.

OBJECTIVES: To determine if the duration of wearing compression stockings after endovenous laser ablation (EVLA) of the great saphenous vein (GSV) has influence on pain and quality of life. METHODS: This was a prospective randomized controlled trial. Between December 2006 and February 2008, 109 consecutive patients with EVLA of the GSV were analyzed. Deep vein insufficiency, ulceration, more than one insufficient vein in one leg, and use of anticoagulants were exclusion criteria. Group A used compression stocking for 48 hours after therapy, group B for 7 days. Pain (visual analogue scale [VAS]) and quality of life (SF-36) were analyzed 48 hours, 1 week, and 6 weeks after therapy. Three months after treatment, duplex ultrasound imaging was performed to assess occlusion rates. RESULTS: Both groups (group A, n = 37; group B, n = 32) where comparable at baseline. After 1 week, there was a significant difference in pain (VAS score 3.7 [± 2.1] vs. 2.0 [± 1.1], p ≤ .001), and physical dysfunction (group A, 85.1 [± 11.2] vs. group B, 95.7 [± 10.1]; p < .001) as well as vitality (group A, 75 [± 13.0] vs. group B, 83.7 [± 13.4]; p = .03), all in favor of group B, which disappeared after 6 weeks. After 6 weeks, no significant differences in all endpoints were present. Duplex ultrasound imaging revealed complete GSV occlusion in all patients, while no cases of deep venous thrombosis had developed. CONCLUSIONS: Prescribing compression stockings for longer than 2 days after endovenous GSV ablation (without simultaneous phlebectomies) leads to reduced pain and improved physical function during the first week after treatment.

Innovative treatments in chronic venous insufficiency: endovenous laser ablation of perforating veins: a prospective short-term analysis of 58 cases.

OBJECTIVE: To evaluate the efficacy of endovenous laser ablation of incompetent perforating veins. STUDY DESIGN: Prospective cohort study. PATIENTS: A total of 58 perforating veins in 33 limbs of 28 patients were treated between March 2008 and February 2009 in an outpatient clinic setting. The average age was 65 years (range 30-81 years); 64% female; CEAP clinical stage C4 (67%), C5 (17%) and C6 (16%) (Clinica, Etiology, Anatomy and Pathophysiology, CEAP). METHODS: All patients underwent a standardised clinical examination and duplex ultrasonography. Guided by duplex ultrasonography, the perforating veins were cannulated percutaneously and tumescent local anaesthesia was given. An 810-nm diode laser was used to deliver 14 W power. Mean total energy delivered was 187 (range 87-325) J. Three months post-treatment, all patients underwent a further duplex ultrasound examination, to determine the treatment outcome. RESULTS: Occlusion of the perforating veins was achieved after 3 months in 78% of the cases. In the CEAP C6 group, four of five ulcers had healed after 6 weeks. No serious complications, including deep venous thrombosis, were encountered. CONCLUSIONS: Endovenous laser therapy for treating incompetent perforating veins is a safe and technically feasible technique. The initial occlusion rate is acceptable.

Screening for aneurysms of the abdominal aorta using a simple screening device.

INTRODUCTION: Several countries advocate screening for aneurysms of the abdominal aorta (AAA) in selected patients. In the Netherlands, routine screening is currently under review by the National Health Council. In any screening programme, cost-efficiency and accuracy are key. In this study, we evaluate the Aorta Scan (Verathon, Amsterdam, Netherlands), a cost-effective and easy-to-use screening device based on bladder scan technology, which enables untrained personnel to screen for AAA. METHODS: We subjected 117 patients to an Aorta Scan and compared the results to the gold standard (abdominal ultrasound). We used statistical analysis to determine sensitivity and specificity of the Aorta Scan, as well as the positive and negative predictive values, accuracy, and inter-test agreement (Kappa). RESULTS: Sensitivity and specificity were 0.86 and 0.98, respectively. Positive predictive value was 0.98 and negative predictive value was 0.88. Accuracy was determined at 0.92 and the Kappa value was 0.85. When waist-hip circumferences (WHC) of > 115 cm were excluded, sensitivity raised to 0.96, specificity stayed 0.98, positive and negative predictive value were 0.98 and 0.96, respectively, accuracy to 0.97, and Kappa to 0.94. CONCLUSION: Herein, we show that the Aorta Scan is a cost-effective and very accurate screening tool, especially in patients with WHC below 115 cm, which makes it a suitable candidate for implementation into clinical practice, specifically in the setting of screening selected populations for the presence of AAA.

A Rare Cause of Persistent Blood Loss after Continuous Ambulatory Peritoneal Dialysis Catheter Placement.

The laparoscopic placement of a continuous ambulatory peritoneal dialysis (CAPD) catheter is a widely used method in patients with end stage renal disease (ESRD). The potential complications of this procedure include perforation of intra-abdominal organs, surgical site infection, peritonitis, catheter migration, catheter blockage, port site herniation, and bleeding. In most cases, bleeding is considered to be an early-onset complication because it mostly occurs within the first seven days after surgery. We report a case of a 68-year-old female patient with a previous history of diabetes mellitus, myelodysplastic syndrome, extensive collateral varices, anaemia, and ESRD due to obstructive uropathy caused by retroperitoneal fibrosis, who presented with persistent blood loss after the laparoscopic placement of a CAPD catheter. Duplex ultrasonography showed that the CAPD catheter was transfixing a superficial epigastric varicose vein, a collateral vein, due to the occlusion of the left external iliac vein. Persistent blood loss after inserting a CAPD catheter without previous imaging of abdominal wall vessels is an indication for further diagnostics.

Endovenous laser ablation of the small saphenous vein: prospective analysis of 150 patients, a cohort study.

OBJECTIVE: To evaluate treatment of the small saphenous vein (SSV) by endovenous laser ablation. STUDY DESIGN: A cohort study, occlusion of the vein and safety of the procedure was analysed prospectively. PATIENTS: 150 consecutive patients (169 limbs) were treated between August 2006 and January 2008 in an outpatient clinic setting. The average age was 57 years (range 23-87); 82% female; 31% had serious varicose disease (CEAP 3-6). Treated length averaged 23 cm (range 6-53 cm). METHODS: All patients underwent a standardised assessment comprising digital questionnaire, physical examination and duplex ultrasonography. The SSV was cannulated percutaneously under ultrasound control and perivascular local anaesthesia (tumescent) was injected. An 810 nm diode laser was used, delivering 70 J/cm. Three months post-treatment all patients received a duplex ultrasound of the treated vessel. RESULTS: Complete occlusion of the SSV after 3 months was achieved in 98% of the cases. Two patients (1.3%) had sural nerve paraesthesia. Six patients developed superficial thrombophlebitis. Serious complications did not occur. CONCLUSIONS: Endovenous laser ablation for treating the incompetent small saphenous vein is a safe, effective and technically feasible technique.

Future perspectives in the treatment of femoro-popliteal arterial occlusions.

Femoro-popliteal occlusive disease represents the most frequent localization of atherosclerosis in the lower extremities. Treatment of this disease has changed remarkably in the last decade. A definite treatment strategy has still to be established. The pathophysiology is described. A general overview of the state-of-the art treatment modalities and the most recent developments is given. This is divided into non-interventional preventive and supportive therapy, endovascular interventional therapy, and surgical interventional therapy. The development of medical therapy has expanded enormously and is progressing still. In the wide range of interventional treatment modalities, there has been a change from invasive bypass surgery to more refined techniques like endarterectomy and percutaneous endovascular therapy. This trend towards restoring the patency of the artery using the vessel wall itself as a conduit, leads to a term encompassing all these treatment modalities, known as restorative intervention. Peri-procedural risks of restorative interventions are of a much lesser degree compared to bypass surgery. Reports of patency rates show a steady increase. It is expected that patency rates will eventually equal or even surpass those of bypass surgery. In conclusion, a treatment strategy for femoro-popliteal occlusions in the future is proposed as follows: the first line of interventional therapy in femoro-popliteal occlusions should be a restorative intervention. With adequate adjuvant medical therapy and sufficient monitoring, this will be the definite treatment for the majority of patients. Bypass surgery should be regarded as the second line of interventional therapy and should be reserved for those patients in whom restorative interventions fail.

In vivo studies of the maintenance of peripheral transplant tolerance after cyclosporine. Radiosensitive antigen-specific suppressor cells mediate lasting graft protection against primed effector cells.

Cellular mechanisms responsible for maintenance of peripheral transplant tolerance in a rodent model were evaluated. Donor-specific tolerance was established in ACI rats given a vascularized heterotopic cardiac allograft followed by a 10-day course of cyclosporine. Tolerance was associated with a reduction in donor-specific cytotoxic T lymphocyte precursors and the presence within the spleen of cells capable of transferring suppression in adoptive transfer assays. Experiments using thymectomized animals revealed that the establishment and maintenance of tolerance occurred peripherally, independently of the thymus. Adoptive transfer experiments demonstrated that ongoing graft tolerance was mediated by suppressor cells that were antigen-restricted, radiosensitive, and capable of preventing allograft rejection by naive as well as sensitized cells in vivo. Studies designed to disrupt tolerance demonstrated a remarkable durability of graft protection once established, and give insight into the identity and mechanism of action of suppressor cells generated in this model.

The MABAL shoe, an alternative method in contact casting for the treatment of neuropathic diabetic foot ulcers.

INTRODUCTION: Total Contact Casting (TCC) is considered the gold standard in the treatment of neuropathic diabetic foot ulcers. To overcome some disadvantages of TCC we developed a removable fiberglass combicast shoe--the MABAL shoe. PATIENTS AND METHODS: The MABAL shoe was used to treat 23 plantar ulcers. RESULTS: Before treatment the mean surface area was 2.0 cm2 (0.5-7.1 cm2). Twenty-one of 23 ulcers healed, with a mean healing time of 34 days (7-75 days). CONCLUSION: The MABAL shoe provides healing of neuropathic diabetic foot ulcers comparable to existing methods of treatment, while offering some potential advantages. The main advantages are mobilization of the ankle, removability of the cast and a less time consuming form of treatment.

Extra-anatomical reconstruction in the case of an inaccessible groin: the axillopopliteal bypass.

Axillopopliteal bypass is a relatively unknown and uncommon therapeutic option for patients with critical limb ischemia in the presence of an inaccessible groin due to infection or excessive scar formation. In our center, this procedure is performed several times a year. The results of all axillopopliteal bypass reconstructions over an 11-year period were analyzed. Thirty axillopopliteal bypass grafts were performed on 24 patients (16 men, mean age 67 years). In 23 limbs, the indication was persistent groin infection after previous vascular surgery and a threatened limb. In seven limbs, the possibility to anastomose in the groin was absent. There were eight patients (27%) with diabetes mellitus, hypertension was present in 43% (n = 13), and 90% (n = 27) were current or previous smokers. During 5 years of follow-up, 11 patients died, eight during the first year after operation. The primary patency after 1 year was 64% (n = 9). The secondary patency after 1 year was 77%. Seven amputations (23%) were needed: six for ischemia and one for persistent infection. Limb salvage after 1 year was 84%. A limitation of the study is the small number of patients, which was not enough for uni- and multivariate risk analyses with sufficient statistical power. The results of axillopopliteal bypass surgery in patients with critical limb ischemia and an inaccessible groin demonstrate a high mortality rate of 29% after 1 year. However, surviving patients may benefit from the operation in terms of limb salvage because the primary patency was 64% and the secondary patency 77% at 1-year follow-up. We conclude that extra-anatomical axillopopliteal bypass is a valuable therapeutic option for limb salvage in this specific patient population.

Perforation of gastric ulcer associated with paraesophageal hernia causing diffuse peritonitis.

BACKGROUND/AIMS: Free peritoneal perforation of a gastric ulcer associated with paraesophageal hernia causing diffuse peritonitis is an extremely rare event. METHODS: Two new cases of this rare condition and the specificities of management are described. RESULTS: One patient recovered well after surgery, while the other died with signs of persisting sepsis and multiple system organ failure. CONCLUSION: In the wide spectrum of complications related to paraesophageal hernia, free peritoneal perforation of an associated ulcer seems to be one of the gravest. Early elective repair of the paraesophageal hernia is justified.