Computerized venous strain-gauge plethysmography is a reliable method for measuring venous function.

OBJECTIVES: To achieve reference values for computerized strain-gauge plethysmography (SGP), to assess reproducibility, and to evaluate the influence of different factors such as age, gender, body mass index, and symptomatic post-thrombotic disease on commonly used variables. METHODS: Sixty-three healthy controls and 56 patients with previous deep venous thrombosis (DVT) were included. All participants underwent computerized SGP with evaluation of outflow capacity, as well as evaluation of venous reflux and muscle pump function. RESULTS: All variables were significantly reduced in DVT limbs, both compared with contralateral limbs and with healthy controls. Only two patients had all values within normal ranges (=mean ± 2 SD in controls). Measures of outflow capacity had a coefficient of variation (CV) of 5-6% and exercise-induced volume changes a CV of 10-15%. In symptomatic post-thrombotic limbs half-refilling time was significantly related to presence of edema (R = -0.28, p < .05) and to chronic skin changes (R = -0.58, p < .001). CONCLUSIONS: We suggest that our values in healthy controls can be used as new reference values for computerized venous strain-gauge plethysmography. The computerized design ensures high reproducibility and the results indicate that this is a very useful and sensitive test for functional quantitative assessment of patients with venous disease.

Outcome after 7 years of carotid artery stenting and endarterectomy in Sweden - single centre and national results.

OBJECTIVES: The aim was internal vascular centre quality-control measures to compare single-centre results with the national perspective, as well as analysing the Swedish results from carotid artery stenting (CAS) and comparing a relatively high-volume single centre with the Swedish Vascular Registry (Swedvasc) data. The second aim was to compare CAS and carotid artery endarterectomy (CEA) outcomes for the same 7-year period. DESIGN: Retrospective review of a single high-volume centre (Södersjukhuset (SÖS)) (approximately 30 CAS year(-1) approximately 90 CEA year(-1)) versus Swedvasc National data. MATERIALS AND METHODS: All consecutive selective patients treated with CAS at SÖS for a stenosis of the internal carotid artery (n = 208) or CEA (n = 552) between 2004 and 2011 were compared with all patients in Swedvasc registered for CAS (n = 258) and CEA (n = 6474). Primary outcome was 30-day frequency of stroke or death. Secondary outcome was stroke/death/acute myocardial infarction (AMI). RESULTS: The 30-day frequency of any stroke or death after CAS at SÖS compared to the national data was 2.9% and 7.4%, respectively (P = 0.04). The 30-day AMI/stroke/death frequency was 3.4% and 9.5%, respectively (P = 0.01). After CEA during the same time period, the Swedvasc national data had a 4.4% frequency of 30-day stroke and death and 5.8% for AMI/stroke/death. CONCLUSIONS: CAS is not as safe as CEA from a national perspective but our results indicate that a single centre can achieve acceptable results with CAS.

Asymptomatic deep venous thrombosis is associated with a low risk of post-thrombotic syndrome.

UNLABELLED: Post-thrombotic syndrome (PTS) is a well-recognized condition that develops after symptomatic deep venous thrombosis, but the clinical significance and late complications of asymptomatic deep venous thrombosis (ADVT) are unclear. OBJECTIVE: To determine whether ADVT following minor surgery affects venous function and contributes to the later development of PTS. PATIENTS/METHODS: The study included 83 patients operated on for Achilles tendon rupture; 38 patients with postoperative ADVT and 45 patients without (control group). The follow-up examinations five years after the operation comprised computerised strain-gauge plethysmography, colour duplex ultrasonography, clinical scoring of venous disease, and quality of life (QOL). RESULTS: Villalta scores, CEAP classification and QOL did not differ between groups. PTS (=Villalta score > or =5) was found in three ADVT patients (8%) and in two controls (4%). Ultrasonography revealed post-thrombotic changes in 55% of ADVT patients and in none of the controls. Deep venous reflux occurred in 22 ADVT patients and in three controls (P<0.001). There was no difference between groups in plethysmographic variables, demonstrating that the ultrasonographic abnormalities were of negligible haemodynamic significance. CONCLUSIONS: PTS is not a common sequel to ADVT after minor surgery. Although more than 50% of patients with ADVT developed post-thrombotic changes according to ultrasound, these changes did not result in haemodynamically significant venous dysfunction.

Primary deep vein thrombosis in the upper limb: A retrospective study with emphasis on pathogenesis and late sequelae.

BACKGROUND: Thrombosis of the upper extremity (UEDVT) is an uncommon disease with an incidence of 2-3% of all deep vein thromboses. The aim of this study was to determine the frequency of thrombophilia, post-thrombotic symptoms (PTS), and the rate of complications and recurrences in patients with primary UEDVT, which includes idiopathic and effort-related thrombosis. METHODS: Thirty-two patients with primary UEDVT were participants in the study. All patients with malignancies and intravenous devices were excluded. Two different scoring instruments - the Villalta and the DASH - were used to diagnose PTS, and a visual analogue scale (VAS) was used to estimate pain and disability. To evaluate working capacity, an arm exercise test was performed. Blood samples were taken for antithrombin, protein C and S deficiencies, antiphospholipid antibodies, mutation of factor V, fibrinogen, D-dimer, and von Willebrand factor antigen. RESULTS: None of the patients developed malignancy, pulmonary embolism, or recurrent UEDVT. Twenty-eight percent of the patients had mild to moderate PTS according to the scoring instruments. The arm exercise test and the VAS did not provide any additional information about the severity of PTS. The prevalence of thrombophilia was 40%; the most frequent disorders were the mutation of factor V (19%) and elevated fibrinogen (22%). CONCLUSIONS: This study supports the belief that primary UEDVT is a benign disorder with a low risk for recurrence but with a high frequency of PTS. For a majority of the patients, the underlying cause of the thrombotic event is unclear.

High sensitivity with color duplex sonography in thrombosis screening after ankle fracture surgery.

BACKGROUND: Phlebography is regarded as the reference standard for diagnosing asymptomatic deep vein thrombosis (DVT) in studies of thromboprophylaxis. However, technical advances with noninvasive color duplex sonography (CDS) have made this procedure an interesting alternative. OBJECTIVES: The objective of the present prospective study was to compare the sensitivity and specificity of CDS with those of phlebography. PATIENTS: The first 180 consecutive patients included in a larger randomized trial for prolonged thromboprophylaxis were subject to unilateral CDS and to phlebography after ankle fracture surgery. The patients were examined 6 weeks after surgery, all examinations being evaluated blindly. After patient drop outs and exclusions, 144 patients were left for analysis. RESULTS: Phlebography and CDS examinations were inconclusive or were not completed for 19% of these patients (28/144). DVT was diagnosed by phlebography in 21% (24/116) of the remaining patients. Most of the thrombi were isolated calf DVTs (18/24). In contrast, DVT was diagnosed by CDS in 31% of these patients (36/116): only one case diagnosed by phlebography was missed by CDS. The specificity of CDS is thus 86% and its sensitivity is 96%. The positive predictive value is 64%, and the negative predictive value is 99%. CONCLUSIONS: CDS is a safe method for detecting asymptomatic distal DVT. It has a high sensitivity and high negative predictive value, which means that the method is highly reliable to rule out DVT. Our results indicate that CDS could be considered as an alternative method for DVT screening.

Hemodynamic performance of cryopreserved aortic homograft valves during midterm follow-up.

OBJECTIVES: The aim of this prospective study of adult patients operated with a cryopreserved aortic homograft was to use serial echocardiographic data to evaluate the postoperative hemodynamic performance of these valves. BACKGROUND: Only limited data on hemodynamic performance of aortic homografts at rest and during exercise are available. Controversy also exists regarding incidence and progression of aortic regurgitation (AR). METHODS: Fifty-nine patients aged 39-86 years who received an aortic homograft (median size 21 mm) implanted with subcoronary technique were studied with serial Doppler-echocardiography (D-E). In 31 of these patients, D-E also was performed during supine exercise. RESULTS: Overall survival was 100% during a median follow-up of 28 months (range 4-54). During follow-up AR grade II or more was detected in 25% of the patients with an increasing time-related risk of developing AR. Maximum and mean pressure differences at 7 months follow-up calculated with the short form of the Bernoulli equation were 11.4 (4.6) and 5.5 (2.1) mm Hg, respectively. During supine exercise that increased cardiac output 72%, maximum pressure difference increased from 11.9 (5.2) to 18.5 (9.5) mm Hg. CONCLUSIONS: The aortic homograft valve shows low pressure differences at rest and during exercise, but AR grade I or II is often seen during follow-up. As AR progresses with time we stress the importance of echocardiographic follow-up of patients with aortic homografts.

Circulating markers of inflammation are related to carotid artery atherosclerosis.

AIM: The role of inflammation in atherothrombotic disorders is becoming increasingly recognized. The present study prospectively investigates relationships between inflammatory markers and hemostatic variables, and non-invasive measures of carotid artery atherosclerosis. METHODS: Markers of hemostasis (sP-selectin and fibrinogen), cytokines (IL-6, IL-8, TNF-a and MCP-1), inflammatory variables (hsCRP, SAA and calprotectin) and cell adhesion molecules (ICAM-1 and VCAM-1) as well as ultrasonography of the carotid arteries were assessed in 111 consecutive outpatients with manifest or suspected coronary artery disease (CAD). RESULTS: Thirty-eight patients with manifest cardiovascular disease had higher IL-6 (P < 0.01) but not hsCRP levels. Higher levels of IL-6, calprotectin and VCAM-1 (all P < 0.05) were found in 35 patients with carotid plaques. In the whole study population (n = 109) an increased common carotid artery lumen diameter (LD) and cross sectional intima-media area (CIMA) was related to higher IL-6, IL-8 and MCP-1 levels (all P < 0.05), and increased LD also to higher hsCRP, calprotectin (both P < 0.05), sP-selectin and fibrinogen levels (both P < 0.01). Both LD and CIMA were related to VCAM-1 (both P < 0.01), but not to ICAM-1 levels. The intima-media thickness of the carotid artery was only positively related to MCP-1 levels (P < 0.05). Only the relation between IL-6 and LD remained significant after adjustment for age, gender, body mass index, smoking status or present lipid-lowering treatment. CONCLUSIONS: Several biomarkers of inflammation are related to ultrasonographic measures of carotid artery atherosclerosis in patients with moderate to high prevalence of CAD. IL-6 seems to be an independent and useful biomarker of atherosclerosis in this group of patients.

Effects of exercise on Doppler-derived pressure difference, valve resistance, and effective orifice area in different aortic valve prostheses of similar size.

The effects of increased transvalvular volume flow on Doppler-derived measurements were compared in similarly sized, normally functioning, mechanical prostheses, stented and stentless porcine bioprostheses, and homografts. Homograft and stentless valves showed the largest effective orifice area and the lowest pressure differences and valve resistance at rest and during exercise-induced increase in flow rates.

Pulmonary function following adjuvant chemotherapy and radiotherapy for breast cancer and the issue of three-dimensional treatment planning.

BACKGROUND AND PURPOSE: The frequency and grade of pulmonary complications following adjuvant radiotherapy for breast cancer are still debated. This study focuses on loss of pulmonary function. MATERIALS AND METHODS: We have measured the reduction of pulmonary function 5 months following radiotherapy in 144 node-positive stage II breast cancer patients by using pulmonary function tests. RESULTS: No deterioration of pulmonary function was detected among the patients who were treated with local radiotherapy. On the contrary, there was a mean increase in diffusion capacity by 7% (P = 0.004) following radiotherapy, which most likely was explained by the adjuvant chemotherapy administered prior to the baseline pulmonary function tests. Patients undergoing loco-regional radiotherapy showed a mean reduction in diffusion capacity by 5% (P < 0.001) and in vital capacity by 3% (P = 0.001). The subset of patients (9%) who were diagnosed with severe pulmonary complications needing cortisone treatment had significantly larger mean paired differences in vital capacity (-0.446 L, -15% (equivalent to 15 years of normal ageing or the loss of 3/4 of a lung lobe)) compared to the patients who were asymptomatic (-0.084 L) (P < 0.05). When the effects of potential confounding factors and different radiotherapy techniques were tested on the reduction of pulmonary function by stepwise multiple regression analysis, a significant correlation was found only to locoregional radiotherapy including the lower internal mammary lymph nodes. CONCLUSIONS: We conclude that a clinically important reduction of pulmonary function is seen in the subset of patients who are diagnosed with severe pulmonary complication following loco-regional radiotherapy for breast cancer. The results of this study warrant further studies based on individual lung dose volume histograms.

Temporal variability of exercise Doppler echocardiography in patients with nonstented aortic bioprostheses.

Temporal variability and reproducibility of Doppler-derived variables obtained during supine symptom-limited exercise was investigated in 26 patients who were in clinically and hemodynamically stable condition with normally functioning nonstented aortic bioprostheses (stentless porcine, n = 13; cryopreserved homografts, n = 13). All patients had normal systolic left ventricular function and underwent 2 similar exercise tests within 12 months (mean time interval 7.2 +/- 1.9 months). The coefficient of variation was 8% to 9% for primary Doppler-derived variables (ie, velocities and velocity time integrals) at rest and during exercise. The coefficient of variation for calculated maximal pressure difference was 16% at rest and 15% at peak exercise. Measurement variability assessed from repeated measurements from the same videotaped recording was approximately 2%. High reproducibility was shown for most variables with intraclass correlation coefficients of 0.85 or more. We conclude that Doppler echocardiography can be used in patients with nonstented aortic bioprostheses with the same high reproducibility during exercise as at rest. The results provide clinically useful information regarding temporal variability for Doppler-derived variables.

A prospective follow-up study of acute deep venous thrombosis using colour duplex ultrasound, phlebography and venous occlusion plethysmography.

OBJECTIVE: To study the extent of deep venous thrombosis (DVT) and thrombus regression over time and to compare the results obtained with different diagnostic techniques. EXPERIMENTAL DESIGN: A prospective follow-up study with repeated examinations during a 6-month period. SETTING: Patients studied at clinical vascular laboratories. PATIENTS: Forty patients hospitalised for acute DVT. Thirty-six of these completed the follow-up period. MEASURES: The diagnosis of DVT was confirmed with phlebographic and/or ultrasonographic techniques. The patient were then re-examined with colour duplex ultrasound and venous occlusion plethysmography after one week, 3 months and 6 months and with phlebography after 1 week and 6 months. The extent of DVT and number of occluded segments were determined with phlebographic and ultrasonographic techniques. Venous occlusion plethysmography was used to evaluate the functional degree of outflow obstruction. RESULTS: Colour duplex scanning at 3 months' and 6 months' follow-up showed that 55% and 74% of initially occlusive thrombi, respectively, were recanalized, with thrombus resolution occurring faster and more completely in those initially limited to popliteal and/or calf level. Discrepancies between phlebography and duplex scanning were found in 6% (26/441) of venous segments investigated by both methods, primarily concerning flow in the veins below the knee. CONCLUSIONS: In comparison with phlebography, colour duplex scanning is an accurate method for evaluation and follow-up of patients with DVT. The non-invasive nature of colour duplex scanning makes this method extremely suitable for repeated studies and thus a potentially very valuable tool for both clinical and research studies of circulatory changes involved in acute and chronic DVT.

Assessment of deep venous incompetence: a prospective study comparing duplex scanning with descending phlebography.

In this prospective study duplex scanning was performed in 21 consecutive patients (23 lower extremities) referred for descending phlebography. The grade of deep venous insufficiency (Grades 1-4) was estimated in a blinded fashion with phlebography and duplex technique. Agreement occurred in 15 of 23 lower extremities. Discrepancies were found particularly in patients with minor degrees of reflux. The patients with reflux below the knee according to phlebography were also identified with ultrasonography. The authors found duplex scanning to be accurate method of evaluating deep venous valvular function. With duplex--but not with phlebography--it was also possible to diagnose isolated lower extremity valvular insufficiency.

Clinical and hemodynamic effects of stepwise lowering of hemoglobin concentration in patients with intermittent claudication.

This study evaluates the effect of stepwise lowering of the hemoglobin (Hb) concentration on maximal walking distance (MWD) and hemodynamics in patients with intermittent claudication. The results in a study group (n = 6) were compared with those of a control group (n = 6) whose members were not subjected to venesections. An average decrease of Hb concentration from 151 +/- 4 to 121 +/- 3 g/L did not significantly influence MWD, the result being 282 +/- 62 meters before venesections and 255 +/- 54 meters after three to five (mean four) repeated venesections. Transcutaneous oxygen pressure was measured at the dorsum of the foot before and after exercise and did not change with a gradual decrease of the Hb concentration. Maximal heart rate, painfree walking distance, ankle pressure, and blood lactate concentration were also unchanged. An average venesection volume of about 1.4 liters whole blood within fourteen days, without isovolemic replacement, did not change the blood volume, which was 5.1 +/- 0.4 liters before and 5.0 +/- 0.5 liters after venesections. In conclusion, hemodilution accomplished by venesections did not have a clinically or physiologically beneficial effect in patients with severe intermittent claudication. However, hemodynamics and clinical symptoms were not affected by a considerable decrease in the arterial oxygen content within the normal Hb concentration range.

Plethysmographic evaluation of volume changes of the foot and the distal calf in healthy subjects and in patients with distal venous pump dysfunction.

In the present study, plethysmographic methods were used to evaluate the function of the foot pump and the distal calf pump and to characterize the relationship between simultaneously assessed volume changes of the foot and the distal calf in healthy subjects and in patients with distal venous valvular insufficiency. Expelled volume of the foot was found to be more compromised than that of the distal calf in patients where Doppler examination demonstrated deep venous reflux at ankle level. Consequently, EV of the distal calf was less useful in evaluating these patients. Half-refilling time at the two levels was sensitive and equally useful for determining deep valvular function at ankle level.

[Varices and venous insufficiency--therapeutic philosophy prior the 2000's]. / Varicer och venös insufficiens--behandlingsfilosofi inför 2000-talet.

Varicose veins represent everything from a cosmetic problem to a risk of venous leg ulcers. Predicting the risk of complications has been difficult, not least due to less than satisfactory diagnostic procedures. Recent investigations have pointed out some important new concepts: Superficial venous incompetence may give rise to an ulcer, and such an ulcer may be prevented by varicose vein surgery. Recanalization and stenting may be useful in treating chronic iliac and caval venous occlusions; however, long-term outcome is yet to be established. Venous diameter can be reduced, thus effecting valve competence. To what extent this result is long-lasting is not known. Neither has the method been attempted on deep veins. Clinical diagnosis is never sufficient in cases of suspected chronic venous incompetence. The minimum requirement is the use of a hand-held Doppler. Frequently, a more detailed ultrasonographic analysis is required, and for a global assessment of venous function, plethysmographic techniques are useful. Primary health care may contribute effectively to the care of venous leg ulcers.

Deep venous thrombosis after surgery for Achilles tendon rupture: a provoked transient event with minor long-term sequelae.

BACKGROUND: Deep venous thrombosis (DVT) occurs frequently in patients undergoing orthopedic surgery, but there is a lack of knowledge regarding long-term sequelae of DVT after different types of surgical procedures. OBJECTIVE: To describe the long-term effect of symptomatic (SDVT) and asymptomatic (ADVT) deep venous thrombosis on venous function and subsequent incidence of post-thrombotic syndrome (PTS) in patients who have undergone surgery for Achilles tendon rupture. PATIENTS/METHODS: This observational follow-up study includes 83 patients with postoperative DVT, examined after a mean of 7 years. There were two series of patients: 45 with SDVT and 38 with ADVT. In both series, more than 90% of the DVTs were limited to calf veins. Follow-up examinations comprised color duplex ultrasonography (CDU), strain-gauge plethysmography (SGP), clinical examination including scoring for venous disease and questionnaires for quality of life (QOL). RESULTS: A mild degree of PTS was found in 11% of the patients: 13% in SDVT and 8% in ADVT patients. The rate of recurrent ipsilateral DVT was 2%. Deep venous reflux was more common in patients with SDVT than in ADVT patients (84% vs. 55%, P < 0.01). Only a few patients had plethysmograpically abnormal findings without difference between the two groups. CONCLUSION: DVT after surgery for Achilles tendon rupture consists mainly of distal DVTs and are associated with a low risk for PTS. Deep venous reflux was more common in SDVT than in ADVT patients, probably as an effect of larger DVTs in the former group.