Characteristics, clinical presentation, and treatment outcomes of venous malformation in the extremities.

OBJECTIVE: The clinical presentation of venous malformations (VMs) is variable and not well documented. The present study was designed to determine the clinical characteristics and outcomes in association with the type and extent of VM in the extremities. METHODS: Patients with a diagnosis of a VM using ultrasound, computed tomography, or magnetic resonance imaging were included in the present study. The VM extent and tissue involvement, signs, and symptoms were retrospectively collected. Those with arteriovenous malformations, Klippel-Trenaunay syndrome, lymphedema, and symptoms from other unrelated diseases were excluded. The VMs were classified as extensive or localized according to whether different tissues or the entire compartment was involved. The clinical outcomes and imaging studies were obtained for both the treated patients and those who had chosen to not undergo any intervention. RESULTS: A total of 72 patients, of whom 26 were men, were included in the present study, with a median age of 30 years. The VM had extended into the subfascial space in 40 patients (55.6%). Patients with VM distributed on their leg had mostly experienced pain, which was more evident during physical activity (n = 40; 80.0%), with swelling worsening with prolonged standing (n = 35; 70.0%). For those with VMs in the upper extremities, the most prominent complaints were venous enlargement (n = 10; 45.5%), pain (n = 9; 40.9%), and swelling (n = 11; 50.0%). The symptoms were related to the extent of the lesion (odds ratio, 7.664; 95% confidence interval, 2.006-29.291; P = .003). Treatment was decided by the extent and depth of the lesions. Excision was performed in 15 patients (20.8%), sclerotherapy in 12 (16.7%), sclerotherapy with phlebectomy or coil embolization in 8 (11.1%), and stripping in 2 (2.8%). An excellent result was achieved with the treatment of localized VMs. For those with extensive VMs, the symptom intensity was reduced or controlled after multiple treatments. CONCLUSIONS: VMs of the extremities affect patients' quality of life significantly owing their appearance and the resulting pain. The VM extent was associated with symptom severity. The clinical outcomes have been excellent for localized VMs; however, extensive VMs will require multiple treatments to reduce the symptom intensity.

The comparison of monitored anesthesia care with dexmedetomidine and spinal anesthesia during varicose vein surgery.

PURPOSE: The purpose of this study was to investigate the effectiveness and safety of monitored anesthesia care (MAC) using dexmedetomidine for its sedative and analgesic effect during varicose vein surgery. METHODS: Forty-two patients, who underwent varicose vein surgery, were divided into the MAC group (n = 20) or the spinal anesthesia group (n = 22) for randomized clinical trial. In the MAC group, dexmedetomidine was administered by a loading dose of 1 µg/kg for 10 minutes, followed by a maintenance infusion of 0.2-1.0 µg/kg/hr. Ketamine was used for intermittent injection. In the spinal anesthesia group, midazolam was used for sedation. Intraoperative vital signs, the number of adverse events, and the satisfaction of patients and surgeons concerning the anesthetic condition were compared between the two groups. RESULTS: Systolic blood pressure was intraoperatively significantly different over time between the two groups. The groups had statistical differences in the change in heart rate with regard to time. In the postanesthetic care unit, patients and surgeons in the MAC group had a lower satisfaction score, compared to patients and surgeons in the spinal anesthesia group. However, in the recovery period, patients had a positive perception concerning MAC anesthesia. In addition, without significant adverse events, the MAC group had a shorter time to possible ambulation, which indicated an early recovery. CONCLUSION: We believe that MAC using dexmedetomidine in combination with ketamine may be an alternative anesthetic technique for varicose vein surgery with regard to a patient's preference and medical condition.

Laparoscopic cholecystectomy in patients with anesthetic problems.

Laparoscopic cholecystectomy is a standard operation for benign gallbladder disease. As experience with laparoscopic cholecystectomy has increased, the procedure has become possible in patients with anesthetic problems. Patients with ankylosing spondylitis or severe kyphosis represent a challenging group to anesthesiologists and laparoscopic surgeons since these diseases are associated with difficult intubation, restrictive ventilatory defects, and cardiac problems. The relatively new approach of awake fiberoptic intubation is considered to be the safest option for patients with anticipated airway difficulties. Laparoscopic cholecystectomy is usually performed under general anesthesia but considerable difficulties in anesthetic management are encountered during laparoscopic surgery; for example, hemodynamic instability may develop in patients with cardiopulmonary dysfunction due to pneumoperitoneum and position changes during the operation. Nonetheless, regional anesthesia can be considered as a valid option for patients with gallbladder disease who are poor candidates for general anesthesia due to cardiopulmonary problems. We report three cases of laparoscopic cholecystectomy successfully performed in patients with anesthetic problems that included cardiopulmonary disease, severe kyphosis, and ankylosing spondylitis.

Analysis of the postoperative hemodynamic changes in varicose vein surgery using air plethysmography.

OBJECTIVES: This study used air plethysmographic parameters to evaluate the changes in venous hemodynamics after the surgical treatment of primary varicose veins. METHODS: We retrospectively analyzed 1756 limbs of 1620 patients who had undergone surgery for great saphenous vein (GSV) reflux from January 1996 to June 2009 at Samsung Medical Center. Venous hemodynamic changes were evaluated by performing air plethysmography preoperatively and 1 month postoperatively and assessing the venous volume (VV), the venous filling index (VFI), the residual volume fraction (RVF), and the ejection fraction (EF). RESULTS: Preoperatively, median (interquartile range) values were VV, 121.6 (94.7-160.6) mL; VFI, 4.8 (2.9-7.6) mL/s; RVF, 40.6% (29.7%-50.0%); and EF, 53.5% (44.3%-64.1%). Postoperatively, the median (interquartile range) values were VV, 90.6 (69.1-116.8) mL; VFI, 1.4 (0.9-1.9) mL/s; RVF, 28.4% (17.5%-38.7%); and EF, 65.2% (54.5%-77.2%). VV, VFI, and RVF were reduced 25.2%, 71.5%, and 29.9%, respectively; EF was increased 20.3%. The results were significant for all four variables (P < .001). We compared the degree of hemodynamic changes according to the treatment modalities: the high ligation and stripping group , 1578 cases; the GSV valvuloplasty group, 124 cases; and the VNUS group (VNUS Medical Technologies Inc, San Jose, CA), 54 cases. The reduction of the VV, VFI, and RVF was greater in the GSV stripping group and in the VNUS group than in the valvuloplasty group (P < .001), yet no difference was noted in the EF increase among the surgical modalities (P = .157). CONCLUSION: Our results show that the venous hemodynamic parameters of primary varicose veins were improved after surgical treatment.

External banding valvuloplasty for incompetence of the great saphenous vein: 10-year results.

OBJECTIVES: External banding valvuloplasty (EBV) of the great saphenous vein (GSV) in patients with varicose veins is still controversial. The present study evaluated the effectiveness of EBV in selected patients with an insufficiency of the GSV after a mean follow-up of 92.6 months. METHODS: A total of 101 limbs underwent EBV for the treatment of a GSV insufficiency. Thirty-one limbs from 27 patients (three men, 24 women; mean age 44.2 years; range 19 to 58 years) were re-examined and followed for a mean of 92.6 months. The venous volume, venous filling index, ejection fraction and residual venous fraction were analyzed preoperatively and at the follow-up using air plethysmography. The diameter and reflux of the GSV were evaluated using duplex ultrasound. RESULTS: Overall, the mean (± SD) follow-up time was 92.6±22.3 months (range 46 to 138 months). At the follow-up, the preoperative venous hemodynamic states had improved significantly, to the following values: venous volume 96.0±32.3 mL to 83.4±32.6 mL; venous filling index 3.6±2.9 mL/min to 2.4±2.2 mL/min; and residual venous fraction 39.7%±18.6% to 26.1%±16.8% (P<0.05). The diameter of the GSV was 6.4±1.4 mm preoperatively and 4.8±1.7 mm postoperatively (P<0.01). Reflux in the proximal GSV was demonstrated preoperatively in 19 (61.3%) of 31 limbs. During the follow-up period, four limbs (12.9%) had high ligation and stripping of the GSV performed due to the recurrence of varicosity. CONCLUSION: EBV of the GSV provides good results in terms of the venous hemodynamics and decreasing the diameter of the GSV. EBV may be an alternative procedure to stripping or endovenous ablation therapy in selected patients.

Angiogenesis induced by autologous whole bone marrow stem cells transplantation.

BACKGROUND AND OBJECTIVES: It has been presumed that unknown cells and growth factors in bone marrow might promote angiogenesis, so angiogenesis effect could be enhanced by autologous whole bone marrow (WBM) stem cell transplantation. We compared capillary ratio induced by autologous WBM and bone marrow-mononuclear cells (BM-MNCs) to evaluate the anigiogenic effect of auotologous WBM. In addition, the combined effect of WBM transplantation and granulocyte colony-stimulating factor (G-CSF) injection was examined in an ischemic canine model. METHODS AND RESULTS: After creating ischemic limb model, autologous WBM and isolated BM-MNCs were transplanted into the ischemic muscle. In other experiments, autologous WBM with recombinant human G-CSF (rhG-CSF) and autologous WBM without rhG-CSF were transplanted into the ischemic muscle. In this study, normal saline was injected into the contralateral sites in each ischemic model as a control group. After 8 weeks of transplantation, angiography and muscle harvest were performed, and then the anigiographic findings and capillary density, as assessed by immunohistochemical staining, were investigated and analyzed. In comparison with the control group, BM-MNCs and WBM transplantation groups showed higher ratios of the capillary density (1.5±0.01 times, p<0.001 and 1.6±0.15 times, p=0.005, respectively). Between the BM-MNCs and WBM transplantation groups, the capillary ratio was 1.2 folds higher in the WBM group than that in the BM-MNCs group, but there was no significantly different (p=0.116). The angiogensis ratios of both the WBM without G-CSF group and the WBM with G-CSF groups were higher (1.6±0.15 times, p=0.004 and 1.8 ±0.01 times, p=0.005, respectively) than that of the control groups. In comparison with the WBM without G-CSF group, the WBM with G-CSF transplantation group revealed a 1.1 folds higher angiogenesis ratio, but there was no statistically significant difference (p=0.095). CONCLUSIONS: Autologous WBM transplantation is a simpler method and it is not inferior for inducing therapeutic angiogenesis as compared with isolated BM-MNCs transplantation. In addition to autologous WBM transplantation, intravenous G-CSF injection enhances the angiogenic effect of autologous WBM in an ischemic limb.

Surgical management of Takayasu's arteritis.

The results of surgical bypass and endarterectomy in Takayasu's arteritis (TA) were reported to be poor compared to usual atherosclerosis patients. However, if ischemic symptoms due to occlusive disease were severe, surgical procedures were inevitable. We report surgical experience of 5 patients with TA. Five women (ranged from 26 to 58 yr) were operated between June 1998 and May 2004. Three patients showed occlusion of main branches of aortic arch and had symptoms of cerebral ischemia. One patient showed near total occlusion in the midabdominal aorta and had symptoms of orthopnea and uncontrolled hypertension. One patient showed total occlusion of abdominal aorta at the level of aortic bifurcation and had a symptom of severe claudication on both legs. Bypasses from the ascending aorta to the carotid artery were performed in 3 cases. Bypass from the thoracic aorta to the left common iliac artery was performed in one case and endarterectomy of abdominal aorta in one case. The ischemic symptoms related with arterial occlusion were resolved after surgery. And the symptoms of cardiac failure disappeared. The symptomatic TA frequently required arterial reconstruction. The symptomatic improvement and excellent mid-term patency could be expected after arterial reconstruction and endarterectomy.

Angiogenesis facilitated by autologous whole bone marrow stem cell transplantation for Buerger's disease.

We hypothesized that angiogenesis can be triggered by autologous whole bone marrow stem cell transplantation. Twenty-seven patients (34 lower limbs) with Buerger's disease, who were not candidates for surgical revascularization or radiologic intervention, were enrolled in this study. Six sites of the tibia bone were fenestrated using a 2.5-mm-diameter screw under fluoroscopic guidance. Clinical status and outcome were determined using the "Recommended Standards for Reports." To mobilize endothelial progenitor cells (EPCs) from bone marrow, recombinant human granulocyte colony-stimulating factor (r-HuG-CSF) was injected subcutaneously as a dose of 75 microg, preoperatively. During the follow-up period (19.1 +/- 3.5 months), one limb showed a markedly improved outcome (+3), and 26 limbs showed a moderately improved outcome (+2). Thirteen limbs among 17 limbs with nonhealing ulcers healed. Postoperative angiograms were obtained for 22 limbs. Two limbs showed marked (+3), five limbs moderate (+2), and nine limbs slight (+1) collateral development. However, six limbs showed no collateral development (0). Peripheral blood and bone marrow samples were analyzed for CD34 and CD133 molecules to enumerate potential EPCs, and EPC numbers were found to be increased in peripheral blood and in bone marrow after r-HuG-CSF injection. In conclusion, the transplantation of autologous whole BMCs by fenestration of the tibia bone represents a simple, safe, and effective means of inducing therapeutic angiogenesis in patients with Buerger's disease.

Differential expression of immunoglobulin kappa chain constant region in human abdominal aortic aneurysm.

BACKGROUND: A number of the research into the pathogenesis of the abdominal aortic aneurysm (AAA) have focused on the alteration of gene expression. The current technique for elucidating alterations of gene expression has a setback in that many artifact complementary DNA (cDNA) products present abnormal polymerase chain reaction (PCR) amplification. Our study was designed to identify differentially expressed genes in AAA using the annealing control primer (ACP) system, which was recently developed to identify only authentic genes. MATERIALS AND METHODS: The tissues of the human abdominal aorta were obtained from the patients of AAA and aortic occlusive disease (AOD), and normal abdominal aorta (NA) from brain death donors. Total RNAs were isolated from three groups of human abdominal aorta (10 AAA, five NA, three AOD) and then reverse transcribed into complementary DNA (cDNA). The ACP method was done to screen the difference in the expression pattern of the mRNA (mRNA). RESULTS: One differentially expressed cDNA band was detected in AAA but not in NA and AOD. This cDNA was sequenced and computer searching against the GenBank revealed that the cDNA had more than 90% identity with the immunoglobulin kappa chain constant region (Ig kappa-C). DISCUSSION: Our finding suggests that differentially expressed Ig kappa-C gene only in AAA is a candidate gene that may play a pivotal role in the pathogenesis of AAA formation. The correlation of mRNA level and protein level is, however, not clear. Thus, to directly identify the role of Ig light chains in the pathogenic event of AAA, the further study comparing the level and kinds of expressed protein with the corresponding Ig kappa-C gene will be required.

Identification of differentially expressed genes in primary varicose veins.

BACKGROUND: A number of changes in protein expression have been described in primary varicose veins, but the altered gene expressions in this disease are unknown. The aim of this study was to identify differentially expressed genes in primary varicose veins. MATERIALS AND METHODS: Total RNAs were isolated from two groups of greater saphenous veins (four primary varicose veins and three normal) and then were reverse transcribed into cDNAs. We used the differential display reverse transcription-polymerase chain reaction technique to screen the differences in the mRNA expression profiles of the groups. RESULTS: We found that three cDNAs showed differences in expression patterns between normal and diseased saphenous veins. The cDNAs are prominently expressed only in patients with varicose veins. We identified that the cDNAs had significant similarities to the L1M4 repeat sequence of clone RP11-57L9, clone RP11-299H13, and Alu repetitive sequence of human tropomyosin 4 mRNA. CONCLUSIONS: Our results suggest that the screened cDNA clones are useful disease markers in the genetic diagnosis of primary varicose vein and that the L1 and Alu elements possibly participated in the development of primary varicose veins through their expression patterns in genes encoded with structural proteins, such as collagen, elastin, and tropomyosin. Further studies are required to elucidate the potential relationship between repeat sequences and primary varicose veins.

Venous hemodynamic changes in the surgical treatment of primary varicose vein of the lower limbs.

Venous hemodynamic changes after the surgery of primary varicose veins were evaluated. (Materials and methods) We retrospectively analyzed 1,211 patients (1,407 limbs) who underwent surgery for primary varicose veins from 1994 to 2002. The venous hemodynamics were evaluated using air- plethysmography (APG) preoperatively and one month postoperatively in the viewpoints of ambulatory venous pressure (AVP), venous volume (VV), venous filling index (VFI), and ejection fraction (EF). (Results) The surgical modalities included 958 cases of greater saphenous vein high ligation (GSV HL) and stripping with varicosectomy (VS), 222 cases of short saphenous vein (SSV) HL and VS, 143 cases of external banding valvuloplasty of GSV and VS, and 44 cases using VNUS and VS. The reduction rate of VV was 20.9 +/- 14.1% in the GSV stripping group, 12.0 +/- 14.7% in the GSV valvuloplasty group, 18.3 +/- 16.1% in the VNUS group, and 20.6 +/- 15.9% in the SSV group. The reduction rate of VFI was 63.6 +/- 20.7% in the GSV stripping group, 38.8 +/- 40.9% in the GSV valvuloplasty group, 60.1 +/- 23.9% in the VNUS group, and 37.6 +/- 30.2% in the SSV group. The increasing rate of EF was 25.0 +/- 28.2% in the GSV stripping group, 21.0 +/- 30.0% in the GSV valvuloplasty group, 29.4 +/- 31.9% in the VNUS group, and 30.0 +/- 36.5% in the SSV group. The reduction rate of AVP was 25.4 +/- 32.2% in the GSV stripping group, -6.1 +/- 58.1% in the GSV valvuloplasty group, 28.4 +/- 38.5% in the VNUS group, and 14.1 +/- 49.0% in the SSV group. All of the patients showed improvements in venous hemodynamics by showing a decrease in VV, VFI, AVP, and an increase in EF. However, there was no difference in the change of venous hemodynamics according to the type of surgery.

Excisional surgery for chronic advanced lymphedema.

PURPOSE: We conducted a retrospective study to evaluate the efficacy of excisional surgery to treat chronic advanced lymphedema. Excisional surgery was performed to reduce the extremity size, improve limb function, and decrease the frequency of lymphangitis and prevent sepsis. METHODS: Between August 1997 and December 2001, we performed excisional surgery on one or two affected legs in 20 patients with chronic lymphedema (total 24 legs). The lymphedema was graded as stage III in 5 extremities and as stage IV in 19 extremities. Five patients had primary lymphedema and 15 had secondary lymphedema. The mean duration of follow-up was 17.8 months. RESULTS: Excisional surgery resulted in clinical improvement in 18 extremities, all of which received regular physiotherapy after surgery. However, lymphedema progressed to the preoperative status in six extremities, four of which did not receive regular physiotherapy after surgery. CONCLUSIONS: Excisional surgical therapy can be effective for chronic advanced lymphedema, but appropriate postoperative physiotherapy is essential to ensure that the effects last.

Surgical experience of carotid pseudoaneurysm.

An extracranial carotid artery pseudoaneurysm is a rare condition that is caused by various types of arteritis, trauma and infectious causes. Generally, a pseudoaneurysm may be difficult to treat surgically when dissecting the paraaneurysmal fibrotic dense inflammatory tissues. The surgical management of a peudoaneurysm of the carotid artery involves a risk of nerve and arterial injury. This paper reports the repair of a carotid artery pseudoaneurysm after the proximal and distal control of the internal carotid artery using a Pruitt-Inahara shunt (P-I shunt) and the distal control of the external carotid artery using a small sized occlusion balloon catheter.

Clinical and functional assessment after anticoagulant therapy of acute deep vein thrombosis involving the lower limb.

We assessed the clinical status after anticoagulant therapy in acute deep vein thrombosis (DVT) involving the lower limbs. Between 1994 and 2001, 139 patients suffering from acute DVT were treated with heparin therapy followed by oral anticoagulant therapy. The coagulation factor assay was done prior to any anticoagulation therapy. The duplex scan was checked serially. The mean follow-up periods was 32 +/- 19 months. There were 32 (23.0%)cases of protein C deficiency, 12 (8.6%) cases of protein S deficiency, 13 (9.4%) cases of AT-III deficiency and 11 (7.9%) cases of abnormal plasminogen level. Fourteen cases had coagulation factor abnormalities within the family. The initial lung scan showed 29 (20.9%) cases with high, 13 (9.4%) cases with intermediate and 70 (50.4%) cases with a low probability of pulmonary embolism (PE) developing. During the follow-up periods, there were 3 cases of non-fatal PE documented with chest CT scan. The patients were divided according to the extent of the thrombus; Group I (38 cases) was limited to the infrainguinal deep vein, Group II (70 cases) extended to the iliac vein and Group III (9 cases) extended to the vena cava. Partial lysis occurred in 20/35/3 (52.6/50.0/33.3%) cases and no change in 10/24/6 (26.3/ 34.3/ 66.7%) cases in Groups I/ II/ III, respectively. Deep vein valvular reflux occurred in 15/25/5 (39.5/35.7/55.6%) cases in Groups I/ II/ III, respectively. With anticoagulation therapy, most of the thrombi remained in unresolved states and there was a high rate of deep vein valvular reflux. However, there was no serious complications which affected the patients' quality of life.