A Comprehensive Review of the Pathophysiology and Clinical Importance of Iliac Vein Obstruction.

OBJECTIVE: The purpose of this comprehensive review is to give a historical account of iliac vein compression and to analyse the pathophysiological aspects and their clinical implications. METHODS: An extensive search of the databases was performed from inception until 2019. The patterns, length and site of compression, wall and luminal changes, and anatomical variations were some of the factors recorded and analysed. RESULTS: Twenty-seven studies were included in this review, divided into cadaveric, histological, and imaging. According to the literature 22%-32% of the asymptomatic population shows "spurs" at the origin of the left common iliac vein (LCIV). Imaging studies also show the presence of direct and indirect compression signs such as the presence of collateral venous flow in axial, transpelvic, or ascending lumbar collaterals, and >50% compression in 37%-44% of the asymptomatic population. In patients without thrombosis it is unknown what produces the signs and symptoms, as the obstruction pre-exists their development. Haemodynamic evaluation is found in only a few studies often including patients with previous deep vein thrombosis. Furthermore, most of the tests are performed with the patient in the supine position and therefore the haemodynamic information is relatively poor. CONCLUSION: Patients with venous obstruction have various clinical presentations from being asymptomatic to having venous claudication and skin damage. Obstruction should be placed into clinical context, together with other contributing factors. Proper evaluation and clinical judgement are important in selecting patients for treatment. Given that such selection is not always clear, further work is needed.

[The approach to the treatment of lower-limb varicose veins].

Varicose veins have been described as early as the classical period of ancient Greece, and continue to affect the quality of life of up to one third of the population in the industrialized world. In recent years considerable progress has been achieved in understanding the pathological basis of this condition and in the development of new treatment modalities. The treatment of varicose veins of the lower limbs is primarily aimed at alleviating the symptoms, which include pain, pruritus, heaviness, ulceration, hemorrhage, and at improving unaesthetic appearance, but has also been shown to significantly improve measurable parameters of patients' quality of life and functional scales. This work reviews the current evidence on the four major treatment methods at hand: 1. Compression; 2. Stripping surgery; 3. Ultrasound guided foam sclerotherapy; 4. Thermal ablation by laser, radiofrequency or steam. Compression is a simple, low-cost treatment, but has low rates of patient compliance. The remaining invasive interventions are equally efficacious but differ considerably in their demand of skilled personnel and equipment, their adverse effects, the length of expected recovery and their economic costs. The new endovenous interventions can be performed in an ambulatory clinic under local anesthesia. They are at least as efficacious as surgery in short- and medium-term follow-up, but evidence on their long-term efficacy is still Lacking.

Pain is a Limiting Factor in Patients Suitable for Transilluminated Powered Phlebectomy.

OBJECTIVES: To analyze, perioperatively and in follow-up, transilluminated powered phlebectomy (TIPP), a surgical technique for the treatment of varicose veins. METHOD: Retrospective study in one medical institution of patients undergoing TIPP between July 2015 and December 2017. Data analyzed included demographic data, surgery, and results. Postoperatively, pain was evaluated by a 10-point visual analogue scale. The Venous Clinical Severity Score (VCSS) was assessed 5-8 weeks following surgery. RESULTS: Sixty-six patients with extensive varicosities who underwent TIPP were included. Postoperative pain scores were higher in patients undergoing bilateral compared to unilateral TIPP (visual analogue score 7 versus 5; P=0.031). Following surgery, the VCSS improved in 81.8% (54/66) of the patients. However, 39.7% (25/63; data missing in 3 patients) reported that they would not be willing to undergo a similar procedure in the future. Pain was the most common reason for dissatisfaction. CONCLUSIONS: Transilluminated powered phlebectomy was associated with considerable pain and discomfort in many patients included in this study. For this reason, it should be reserved for a select group of patients in whom other treatment options are limited; TIPP could be considered in the following cases: patients with a large number of varicosities, reoperations, after extensive thrombophlebitis, obesity, or following bariatric surgery.

Comparison of the Supraclavicular, Infraclavicular and Axillary Approaches for Ultrasound-Guided Brachial Plexus Block for Surgical Anesthesia.

OBJECTIVE: We hypothesized that ultrasound (US)-guided technique of the supra- and infraclavicular and axillary approaches of brachial plexus block (BPB) will produce a high quality of surgical anesthesia for operations below the shoulder independently of the approach and body mass index (BMI). Intercostobrachial and medial brachial cutaneous nerves will be blocked separately because they are not a part of the brachial plexus. METHODS: This is a prospective randomized observer-blinded study. The three approaches of the US-guided BPB without neurostimulation were compared for quality, performance time, and correlation between performance time and BMI. Intercostobrachial and medial brachial cutaneous nerve blocks were used in all patients. RESULTS: A total of 101 patients were randomized into three groups: SCL (supraclavicular), ICL (infraclavicular), and AX (axillary). Seven patients were excluded due to various factors. All three groups were similar in demographic data, M:F proportion, preoperative diagnosis and type of surgery, anesthesiologists who performed the block, and surgical staff that performed the surgical intervention. The time between the end of the block performance and the start of the operation was also similar. The quality of the surgical anesthesia and discomfort during the operation were identical following comparison between groups. No direct positive correlation was observed between BMI and the block performance time. The time for the axillary block was slightly longer than the time for the supra- and infraclavicular approaches, but it had no practical clinical significance. Transient Horner syndrome was observed in three patients in the SCL group. No other adverse effects or complications were observed. CONCLUSIONS: All three approaches can be used for US-guided BPB with similar quality of surgical anesthesia for operations of below the shoulder. A block of the intercostobrachial and medial brachial cutaneous nerves is recommended. Obesity is not a significant factor in relation to the time of US-guided BPB performance, or the quality of surgical anesthesia. (ClinicalTrials.gov number, NCT01442558.).

[Control of life-threatening hemorrhage from the neck and groin by a Foley catheter in cases of penetrating trauma].

This article describes the use of a Foley catheter placed through the entrance of the penetrating wound to control hemorrhage from sites that are difficult to access by direct pressure, such as neck and groin. A case describing the use of the method is presented. This technique is almost unknown in Israel even though it has been published in the medical literature. Everyone involved in treating trauma patients should know this method for use in appropriate situations.

The "DRIL" procedure--a neglected way to treat the "steal" syndrome of the hemodialysed patient.

BACKGROUND: The ischemic "steal" syndrome complicates angio-access in a growing number of hemodialysed patients. Until now, operative attempts (fistula ligation or banding) to treat this problem have met with only limited success. OBJECTIVE: To assess the results of DRIL (distal revascularization-interval ligation) procedure in treating the "steal" syndrome. METHODS: A retrospective review (1996-2002) was conducted of all 11 patients who underwent the DRIL procedure in two tertiary care hemodialysis units. RESULTS: Two patients were excluded because of inadequate medical documentation. All of the nine patients remaining suffered from overt atherosclerotic disease, six had diabetic nephropathy and four were smokers. The arteriovenous access, which led to the "steal" syndrome, was proximally located in all (antecubital in 8, thigh area in 1). "Steal" symptoms included hand pain, paraesthesia, neurologic deficits and gangrenous ulcers. DRIL was technically successful in all patients. There were no perioperative deaths. Immediate and complete relief of pain was achieved in eight of the nine patients. One patient with gangrene later required a transmetacarpal amputation. No patient required hand amputation. During follow-up (range 1-26 months) hemodialysis was continued uninterruptedly using the problematic AVA in all patients. Thrombosis occurred in the AVA in only two patients after the DRIL procedure at 9 and 24 months postoperatively, respectively. Three patient deaths were unrelated to the DRIL. CONCLUSIONS: In selected patients the DRIL procedure is a safe and effective way to treat the "steal" syndrome. AVA patency is not compromised by this operation. Preoperative angiography, before and after manual compression of the AVA, is crucial for the proper selection of patients who will benefit most from the DRIL procedure.