Incidence and risk factors for venous reflux in the general population: Edinburgh Vein Study.

OBJECTIVE/BACKGROUND: Chronic venous disease (CVD) is common, but the incidence of venous reflux, a precursor to this condition, is unknown. This study measured the incidence of venous reflux and associated risk factors, and examined the association between venous reflux and the incidence of CVD. METHODS: In the Edinburgh Vein Study, a random sample of 1566 men and women aged 18-64 years were examined at baseline. Eight hundred and eighty of these patients were followed up 13 years and underwent an examination comprising clinical classification of CVD and duplex scanning of the deep and superficial systems to measure venous reflux ≥0.5 s. RESULTS: The 13-year incidence of reflux was 12.7% (95% confidence interval [CI] 9.2-17.2), equivalent to an annual incidence of 0.9% (95% CI 0.7-1.3). The 13-year incidence of isolated superficial, isolated deep, and combined deep and superficial reflux was 8.8% (95% CI 5.6-12.0), 2.6% (95% CI 1.2-5.0), and 1.3% (95% CI 0.4-3.2), respectively. The highest incidence was in the great saphenous vein in the lower thigh (8.1%, 95% CI 5.4-11.8). There were no age or sex differences (p > .050). The risk of developing reflux was associated with being overweight (odds ratio [OR] 2.1, 95% CI 1.0-4.4) and with history of deep vein thrombosis (OR 11.3, 95% CI 1.0-132.3). Venous reflux at baseline was associated with new varicose veins at follow up (p < .001): the age- and sex-adjusted OR was 4.4 (95% CI 1.8-10.8) in those with isolated superficial reflux and 7.3 (95% CI 2.6-22.5) in those with combined deep and superficial reflux. CONCLUSION: For every year of follow-up, around 1% of this adult population developed venous reflux. In two thirds of cases, the superficial system was affected. Venous reflux increased the risk of developing varicose veins, especially when combined deep and superficial reflux was present.

Telangiectasia in the Edinburgh Vein Study: epidemiology and association with trunk varices and symptoms.

OBJECTIVE: Little research has been devoted to telangiectasia. The purpose of this study was to analyse the data in the Edinburgh Vein Study to determine the prevalence of telangiectasia in the general population, to analyse the demographic characteristics and association with symptoms and to compare the findings to those relating to varices of the saphenous systems. DESIGN: Cross-sectional population study. SETTING: Twelve general practices with catchment areas geographically and socioeconomically distributed throughout Edinburgh. PARTICIPANTS: An age stratified random sample of 1566 people (699 men and 867 women) aged 16-64 selected from computerised age-sex registers of participating practices. METHODS: Included in the population screening was a clinical examination, photography and duplex ultrasonography of the superficial veins and the deep veins down to popliteal level. Telangiectases and varicose veins were graded 1-3 according to severity. RESULTS: A total of 1322 (84%) of the population were classified as having telangiectasias in their right legs; 555 (79%) of men and 767 (88%) of women; 1226 (92%) as grade 1 and 96 (8%) as grades 2 and 3. There were no significant differences between left and right legs (p=0.144). The commonest locations for telangiectases were the postero-medial aspects of the thigh, popliteal fossa and upper one third of calf. There was a highly significant association between the degree of severity of varicose veins and the grade of telangiectasia (p<0.001). Less than 1% of subjects with grades 2-3 trunk varices were free of telangiectasia, but 51% of subjects with grades 2-3 telangiectasia had no clinical evidence of varicose veins. There was a significant linear trend in the proportion of subjects reporting heaviness, swelling, aching and cramps being highest among those with neither telangiectasia nor varicose veins, lower in those with telangiectasia or varicose veins only and lowest in subjects having both. The highest frequency of most symptoms was found in subjects with both telangiectasia and varicose veins. CONCLUSIONS: Telangiectasia is so common in the general population, especially in women, as to represent the norm. The anatomical distribution is entirely different from the distribution of the skin and subcutaneous manifestations of chronic venous insufficiency. Our confirmation of a strong association between trunk varices and grades 2-3 telangiectasia suggests the need for controlled studies into which condition should be treated. We found no evidence that telangiectasia per se was entirely responsible for leg symptoms.

The effect of long saphenous vein stripping on deep venous reflux.

BACKGROUND: The addition of long saphenous vein (LSV) stripping to sapheno-femoral junction (SFJ) disconnection and multiple stab avulsions (MSAs) in the course of varicose vein (VV) surgery is associated with a significant reduction in recurrence, and a significant improvement in quality of life. It is hypothesised that these benefits relate, at least in part, to a favourable effect of stripping on deep venous reflux. OBJECTIVE: To examine the effect of long saphenous vein (LSV) stripping on deep venous reflux (DVR). METHODS: This was prospective study of 62 consecutive patients (77 limbs) CEAP class 2-6, undergoing SFJ disconnection and MSAs, with and without successful stripping of the LSV to the knee. A duplex ultrasound examination was performed pre-operatively and at a median (IQR) of 24 (23-25) months post-operatively. Completely stripped limbs were defined as those in whom complete stripping of the LSV to the knee was confirmed on post-operative duplex. Reflux >/=0.5 s. was considered pathological. RESULTS: Pre-operatively, 32 (42%) limbs had deep venous reflux (DVR). Post-operative duplex at 24 months revealed that the LSV had been completely stripped in 29 (38%) limbs. In patients with pre-operative DVR, complete stripping was associated with a significant reduction in the prevalence of superficial femoral vein (SFV) (p<0.001) and popliteal vein (PV) (p=0.016), McNemar test) on post-operative duplex. By contrast, in patients without pre-operative DVR, incomplete stripping was associated the development of SFV (p=0.031) and PV (p=0.008) reflux. CONCLUSIONS: Complete LSV stripping abolishes DVR in a significant proportion of limbs, whereas failure to strip is frequently associated with the development of new DVR. These data support for routine stripping and suggest that the benefits of stripping may relate, at least in part, to a favourable impact on deep venous function.

A comparison of patients who developed venous leg ulceration before and after their 50th birthday.

BACKGROUND: although chronic venous ulceration (CVU) is often viewed primarily as a disease of the elderly, recent epidemiological data suggest that a significant proportion of patients first develop CVU before middle age. Such patients may represent a distinct group in terms of aetiology, natural history, prognosis and therapeutic options. AIM: to compare patients who developed CVU before (Group 1) and after (Group 2) their 50th birthday. METHODS: one hundred and eighteen consecutive patients with "pure" CVU underwent history and examination, measurement of ankle-brachial pressure index (ABPI) and duplex ultrasound examination of the affected limb. Pure venous ulcers were defined as those of >4 weeks duration in the presence of venous reflux (>0.5) and in association with an ankle: brachial pressure index of >0.8. RESULTS: patients in Group 1 (n = 54, 46%) were more likely to be male (32/54 [59%] vs 14/64 [23%], p < 0.001 chi(2)), to have a higher median (interquartile [IQR]) body mass index (32 [27-39] vs 27 [23-34], p = 0.003, Mann-Whitney U [MWU]), to have a history of deep venous thrombosis (23/54 [43%] vs 16/64 [25%], p = 0.04 chi(2)) and of ipsilateral long bone fracture (13/54 [24%] vs 5/64 [8%], p = 0.01, chi(2)), to have previously undergone venous surgery (27/54 [50%] vs 19/64 [30%] a median (IQR) of 11.5 (6.5-19) and 10 (2-20) years earlier respectively, and to have worse disease in terms of the duration of present ulcer (12 (6-36) vs 8.5 [3-18] months, p = 0.035 MWU), the total duration of ulcer disease (216 [72-360] vs 48 [12-120] months, p < 0.001 MWU), and the number of episodes of ulceration (3 [2-7] vs 1 [1-3], p = 0.002 MWU). There was no significant difference between the two groups in the pattern and severity of venous reflux with 46/54 (85%) of Group 1 and 54/64 (84%) of Group 2 patients having surgically correctable superficial venous reflux. CONCLUSION: patients who develop CVU before their 50th birthday appear to represent a distinct group in terms of aetiology, natural history and prognosis. The importance of thrombo-embolic prophylaxis in the prevention, and the detection and correction of superficial venous reflux in the treatment, of such ulcers is re-emphasised.

The effect of long saphenous vein stripping on quality of life.

PURPOSE: Long saphenous vein (LSV) stripping in the treatment of varicose veins may reduce the recurrence of varices but may also increase morbidity rates. The effect of stripping on health-related quality of life (HRQoL) is unknown. The aim of this study was to examine the effect of LSV surgery, with and without successful stripping, on HRQoL. METHODS: This prospective study comprises 102 consecutive patients who underwent varicose vein surgery that included attempted stripping of the LSV to the knee. HRQoL was assessed before surgery and at 4 weeks, 6 months, and 2 years after surgery with the Aberdeen varicose vein severity score (AVSS; disease-specific) and the Short-Form 36 (SF-36; generic). Patients defined as stripped were those in whom complete thigh stripping to the knee was confirmed with postoperative duplex scanning at 2 years. Patients defined as incompletely stripped were those in whom any LSV remnant was found in the thigh after surgery. Deep venous reflux (DVR) was defined as reflux of 0.5 seconds or more in at least the popliteal vein. RESULTS: Sixty-six of 102 patients (65%) provided complete HRQoL data at all four time points. At baseline, there was no significant difference between patients who were stripped (n = 25) and incompletely stripped (n = 41) in terms of AVSS, SF-36, age, gender, DVR, or CEAP grade. Significantly more patients in the incompletely stripped group underwent surgery for recurrent disease (29/41, 71%, versus 8/25, 32%; P =.002, with chi(2) test). Both groups gained significant improvements in AVSS scores for as much as 2 years. After adjustment for recurrent disease, stripping conferred additional benefit in terms of AVSS at 6 months (median [interquartile range]) (9 [4 to 16] versus 15 [9 to 24]; P =.031) and 2 years (7 [2 to 10] versus 9 [5 to 15]; P =.014), which was statistically significant in patients without preoperative DVR but not significant in patients with preoperative DVR. SF-36 scores were not affected by stripping. CONCLUSION: LSV surgery leads to a significant improvement in disease-specific HRQoL for as much as 2 years. In patients without DVR, stripping to the knee confers additional benefit.

Most incompetent calf perforating veins are found in association with superficial venous reflux.

PURPOSE: The indications for surgical perforator interruption remain undefined. Previous work has demonstrated an association between clinical status and the number of incompetent perforating veins (IPVs). Other studies have demonstrated that correction of IPV physiology results from abolition of saphenous system reflux. The purpose of this study was to identify which, if any, patterns of venous reflux and obstruction are particularly associated with IPV. PATIENTS AND METHODS: Two hundred thirty patients and subjects (103 men, 127 women, 308 limbs) with varying grades of venous disease were examined both clinically and with duplex ultrasound scan. The odds ratios (ORs) for the presence of IPVs were calculated for different anatomical distributions of main-stem venous reflux and obstruction. The base group are those with no main-stem venous disease. RESULTS: There were no significant associations between the proportions of limbs demonstrating IPVs and patient age or sex. The ORs for the presence of IPVs in association with other venous disease are as follows (age/sex adjusted): long saphenous vein reflux, OR = 1.86, range = 1.32-2.63; short saphenous vein reflux, OR = 1.36, range = 1.02-1.82; deep system venous reflux, OR = 1.61, range = 1.2-2.15; superficial system reflux, OR = 3.17, range = 1.87-5.4; and deep system obstruction, OR = 1.09, range = 0.51-2.33. The ORs for combinations of venous disorders were calculated. Combinations of disease produced higher odds for the presence of IPVs than those above, the highest being long saphenous vein, short saphenous vein, and deep reflux combined, OR = 6.85 (95% CI, 2.97-15.83; P =.0001). CONCLUSIONS: Although the presence of IPVs is associated with venous ulceration, the highest ORs for the presence of IPVs were found in patients with superficial disease alone or in combination with deep reflux. Many of these may be corrected by saphenous surgery alone.

Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study.

BACKGROUND: Varicose veins occur commonly in the general population but the aetiology is not well established. Varicosities are associated frequently with reflux of blood in the leg veins due to valvular incompetence. Our aim was to determine in the general population which lifestyle factors were related to reflux and thus implicated in the aetiology of varicose veins. METHODS: In the Edinburgh Vein Study, 1566 men and women aged 18-64 years were sampled randomly from the general population in the city of Edinburgh, Scotland, and had duplex scans to measure reflux in eight venous segments in each leg. A self-administered questionnaire enquired about occupation, mobility at work, smoking, obstetric history, dietary fibre intake and bowel habit. A bowel record form was completed subsequently. RESULTS: In women, venous reflux was associated with decreased sitting at work (odds ratio [OR] = 0.76, 95% CI : 0.61-0.94), previous pregnancy (OR = 1.20, 95% CI : 0.93-1.54), and a lower prior use of oral contraceptives (OR = 0.84, 95% CI : 0.66-1.06). Mean body mass index was greater in women with superficial reflux compared to those with no reflux: 26.2 kg/m(2) (95% CI : 25.5-27.0) versus 25.2 kg/m(2) (95% CI : 24.8-25.6). On age adjustment, sitting at work remained related to reflux (OR = 0.78, 95% CI : 0.63-0.98) and prior use of oral contraceptives to superficial reflux (OR = 0.71, 95% CI : 0.50-1.01). In age-adjusted analyses in men, height was related to reflux, (OR = 1.13, 95% CI : 1.02-1.26) and straining at stool was related to superficial reflux (OR = 1.94, 95% CI : 1.12-3.35). No associations were found in either sex between reflux and social class, lifetime cigarette consumption, dietary fibre intake and intestinal transit time. CONCLUSIONS: This population study did not identify strong and consistent lifestyle risk factors for venous reflux although previous pregnancy, lower use of oral contraceptives, obesity and mobility at work in women and height and straining at stool in men may be implicated.

Role of ultrasound in the assessment of chronic venous insufficiency.

Chronic venous insufficiency (CVI) is responsible for significant morbidity and health expenditure. Doppler ultrasound techniques provide a noninvasive method for identifying structural and functional abnormalities associated with CVI; this information then allows treatment options to be considered. Ultrasound allows clear identification of specific venous segments and provides information on the patency of these segments, the presence or absence of reflux, perforator veins, collateral channels, or patterns of recurrence after surgery. Techniques for the assessment of the lower limb veins are described, as are the techniques for the elicitation and quantification of reflux.

Patterns of reflux and severity of varicose veins in the general population--Edinburgh Vein Study.

OBJECTIVES: several studies have used duplex ultrasound to assess valvular incompetence in symptomatic patients. This cross-sectional survey was performed to determine, for the first time in a general population sample, the relationship between trunk varices and the presence of reflux in lower limb venous segments. MATERIALS AND METHODS: 1238 subjects (554 male, 684 female), aged 18-64 years, were randomly selected. The presence and severity of any trunk varices was assessed and classified into Grades 1-3; hyphenweb and reticular varices were noted. The presence or absence of reflux > or = 0.5 s in five deep and three superficial venous segments in each leg was assessed using duplex ultrasound. RESULTS: the prevalence of reflux increased in both superficial and deep segments with more severe grades of trunk varices (p< or = 0.01), except the upper SFV in women. Fifteen per cent of females showed reflux confined to the superficial system, compared with 9% of males (p< or = 0.001); 22% of males showed deep reflux, compared with 11% of females (p < or = 0.001). 71% of men and 48% of women with Grade 2-3 trunk varices had mixed deep and superficial reflux. Above-knee popliteal segments had a higher prevalence of reflux than lower SFV segments in all groups. There was no consistent relationship between the presence of hyphenweb or reticular varices and deep or superficial reflux. CONCLUSION: segmental venous reflux can be detected in the deep and superficial leg veins of subjects without trunk varices, but superficial and mixed reflux are increasingly found in subjects with more severe varices.

The relationship between the number, competence, and diameter of medial calf perforating veins and the clinical status in healthy subjects and patients with lower-limb venous disease.

PURPOSE: The role of medial calf perforating veins in the pathogenesis of the skin changes of chronic venous insufficiency (CVI) remains controversial. This study examined the relationship between abnormal medial calf perforating vein structure and function and the clinical severity of CVI. METHODS: Duplex ultrasound was used as a means of determining the number, flow characteristics, and diameter of medial calf perforating veins, and the presence of deep and superficial main stem reflux or occlusion in 50 limbs with no clinical or duplex evidence of venous disease (clinical, etiological, anatomical, and pathological grade [CEAP] 0), 95 limbs with varicose veins only (CEAP 2/3), 58 limbs affected by lipodermatosclerosis but not ulcer (CEAP 4), and 108 limbs affected by healed or open venous ulcer (CEAP 5/6). RESULTS: The proportion of limbs in which any perforating veins and incompetent perforating veins (IPVs) were demonstrated increased significantly with deteriorating clinical status (CEAP 0, 88% and 6%; CEAP 2/3, 95% and 52%; CEAP 4, 98% and 83%; and CEAP 5/6, 98% and 90%, respectively). The total number of perforators, the total number of IPVs, and the median diameters of perforators increased with deteriorating grade (CEAP 0 median diameter, 2 mm [interquartile range, 1 to 3 mm]; CEAP 2/3 median diameter, 3 mm [interquartile range, 2 to 4 mm]; CEAP 4 median diameter, 4 mm [interquartile range, 3 to 5 mm]; and CEAP 5/6 median diameter, 4 mm [interquartile range, 3 to 5 mm]). CONCLUSION: The deteriorating CEAP grade of CVI is associated with an increase in the number and diameter of medial calf perforating veins, particularly those permitting bidirectional flow.

Laparoscopy with laparoscopic ultrasonography in the TNM staging of pancreatic carcinoma.

A prospective study was performed comparing laparoscopy with laparoscopic ultrasonography (LapUS), transabdominal ultrasonography (USS), computed tomography (CT), and selective visceral angiography with portal phase venography (SVA) for the assessment of resectability in 50 patients with pancreatic or periampullary cancer. The results were stratified by TNM stages. Tumor unresectability was demonstrated in 36 patients (72%). The sensitivity of LapUS for demonstrating the index lesion was 96%. Laparoscopic ultrasonography failed to predict factors precluding resection by T stage in six patients, and there were no significant differences in the ability of any modality to predict local resectability (predictive value 58-73%). Laparoscopic ultrasonography did not overestimate T stage and was significantly more specific for assessing unresectability compared with USS (100% vs. 64%, p<0.05) and CT (100% vs. 47%, p<0.005). No imaging investigation was able to assess the N stage accurately. Metastases were confirmed in 16 patients (32%), with LapUS proving significantly more sensitive than USS (94% vs. 29%, p<0.001) and CT (94% vs. 33%, p<0.005). The addition of LapUS to the laparoscopic examination did not change the M stage in any patient, as all metastases were superficially located. Laparoscopy with LapUS was the most reliable method for assessing overall tumour resectability and was significantly more predictive than CT (97% vs. 79%, p<0.005). These results confirm that laparoscopy is indispensable for detecting occult intraabdominal metastases. LapUS reliably predicts tumor unresectability, offsetting the tendency of USS and CT to overestimate T stage. Methods of accurate N staging remain elusive, and the use of routine SVA is not justified.

Prevalence of venous reflux in the general population on duplex scanning: the Edinburgh vein study.

PURPOSE: The prevalence of reflux in the deep and superficial venous systems in the Edinburgh population and the relationship between patterns of reflux and the presence of venous disease on clinical examination were studied. METHODS: A cross-sectional survey was done on men and women ranging in age from 18 to 64 years, randomly selected from 12 general practices. The presence of varicose veins and chronic venous insufficiency was noted on clinical examination, as was the duration of venous reflux by means of duplex scanning in 8 vein segments on each leg. Results were compared using cut-off points for reflux duration (RD) of 0.5 seconds or more (RD >/= 0.5) and more than 1.0 second (RD > 1.0) to define reflux. RESULTS: There were 1566 study participants, 867 women and 699 men. The prevalence of reflux was similar in the right and left legs. The proportion of participants with reflux was highest in the lower thigh long saphenous vein (LSV) segment (18.6% in the right leg and 17.5% in the left leg for RD >/= 0.5), followed by the above knee popliteal segments (12.3% in the right leg and 11.0% in the left leg for RD >/= 0.5), the below knee popliteal (11.3% in the right leg and 9.5% in the left leg for RD >/= 0.5), upper LSV (10.0% in the right leg and 10.8% in the left leg for RD >/= 0.5) segments, the common femoral vein segments (7.8% in the right leg and 8.0% in the left leg for RD >/= 0.5), the lower superficial femoral vein (SFV) segments (6.6% in the right leg and 6.4% in the left leg for RD >/= 0.5), and the upper SFV (5.2% in the right leg and 4.7% in the left leg for RD >/= 0.5) and short saphenous vein (SSV) (4.6% in the right leg and 5.6% in the left leg for an RD >/= 0.5) segments. In the superficial vein segments, there was little difference in the occurrence of reflux whether RD >/= 0.5 or RD > 1.0 was used; but in the different deep vein segments, the prevalence of reflux was 2 to 4 times greater for RD >/= 0.5 rather than RD > 1.0. Men had a higher prevalence of reflux in the deep vein segments than women, reaching statistical significance (P /= 0.5. In general, the prevalence of reflux increased with age. Those with "venous disease" had a significantly higher prevalence of reflux in all vein segments than those with "no disease" (P

Saphenous surgery does not correct perforator incompetence in the presence of deep venous reflux.

PURPOSE: To determine which patients require subfascial endoscopic perforator surgery (SEPS) in addition to saphenous surgery to correct pathologic outward flow within incompetent medial calf perforating veins (IPVs). METHODS: Sixty-two limbs of 47 patients undergoing sapheno-femoral ligation, stripping of the long saphenous vein in the thigh, and multiple phlebectomies (n = 51), sapheno-popliteal ligation and multiple phlebectomies (n = 10), or both (n = 1) were examined with color flow duplex ultrasound scan immediately before and a median of 14 weeks (range, 6 to 26 weeks) after the operations. Indications for surgery were varicose veins (n = 47, Clinical, Etiologic, Anatomic, Pathophysiologic grades C2&3), skin changes (n = 5, C4), and ulceration (n = 10, C5). RESULTS: Surgery resulted in a significant reduction in the total number of limbs in which IPVs were imaged (40/62 or 65% preoperatively vs 23/62 or 37% postoperatively, P <.01, chi2 test), a significant reduction in the proportion of perforators imaged that were incompetent (68/130 or 52% preoperatively vs 34/120 or 28% postoperatively, P <.01, chi2 test), and a reduction in median IPV diameter (4 mm, with a range of 1 to 11 mm preoperatively, vs 3, with a range of 1 to 8 mm postoperatively, P <.01, Mann-Whitney U test). IPVs remained in 8 of 41 (20%) limbs in which main stem reflux was abolished, compared with 15 of 21 (72%) limbs in which superficial or deep reflux remained (P <.01, chi2 test). CONCLUSION: Eradication of main stem saphenous reflux corrects IPV reflux in most cases in which reflux is confined to the superficial system. However, in patients with superficial reflux that persists postoperatively, or when there is coexistent deep venous reflux, saphenous surgery alone fails to correct IPVs reflux. In these circumstances, the only way of reliably correcting pathologic outward flow in medial calf perforating veins is to perform SEPS.

Popliteal vein reflux reduces the healing of chronic venous ulcer.

BACKGROUND: The relationship between deep and superficial venous reflux and healing of venous ulceration by non-operative compression therapy has not been studied previously. METHODS: A total of 155 patients with chronic venous ulcers underwent duplex ultrasonography before treatment with compression bandaging at a hospital-based venous clinic. RESULTS: At 24 weeks, 104 (67 per cent) of ulcers had healed. There was no significant difference in the pattern of either deep or superficial venous reflux between healed and non-healed ulcers except with respect to the popliteal vein. In healed ulcers, 39 scans (38 per cent) indicated competence of the above-knee popliteal vein compared with five (10 per cent) in the non-healing group (P < 0.001, chi 2 test). Similarly, 43 scans (42 per cent) showed below-knee popliteal vein competence in the healed ulcers compared with only five (10 per cent) performed in legs remaining ulcerated (P < 0.001, chi 2 test). CONCLUSION: Popliteal vein incompetence is an indicator of poor response to compression therapy for venous ulceration.

Comparison of colour Doppler ultrasound and digital subtraction angiography in the diagnosis of lower limb arterial disease.

A fifteen-month retrospective review (December 1993 to February 1995 inclusive) was performed comparing findings at Colour Doppler Ultrasound (CDU) and Digital Subtraction Angiography (DSA) in patients with symptomatic peripheral arterial disease or post-operative by-pass grafts. The records of 63 patients (43 males and 20 females) who had undergone both CDU and DSA within three months of each other were analysed. The age range of case studied was 33-84 years (mean 64 yrs.) Disease in each arterial or graft segment was classified into five grades, 0 (normal) to 4 (complete occlusion). A total of 72 limbs were examined. Fifty-four patients had unilateral symptoms while both limbs are affected in 9 cases. In all 241 arterial and graft segments were studied. There was overall agreement between findings of CDU and DSA in 193/241 (80/1%) and non-agreement in 48/241 (19.9%). Of the 48 examinations that showed discrepancy, the findings in 26/48 (54.2%) were one grade apart while in the remaining 22/48 (45.8%) there was a difference of two or more grades. Agreement between CDU and DSA in the individual arterial segments studied was as follows: common femoral 42/48 (87.5%); profunda femoris 19/25 (76.0%); superficial femoral 27/39 (81.0%); anterior tibial 17/81 (94.4%) and peroneal 15/17 (88/2%). In the grafts, there was an agreement of 20/27 (74/1%) between CDU and DSA. These results show a good correlation between the two imaging modalities with complete agreement and agreement within one grade in 80.1% and 90.9% of cases, respectively, confirming that CDU can be employed as a useful screening technique for assessment of symptomatic patients, allowing selection of patients for angioplasty alone or angiography for arterial mapping or those who require by-pass graft surgery.

Smoking, atherosclerosis and risk of abdominal aortic aneurysm.

AIMS: The role of cardiovascular risk factors and atherosclerosis in the aetiology of abdominal aortic aneurysms is not well understood. The aim of this study was to determine the association between atherosclerosis and aortic aneurysm in the general population and the extent to which cardiovascular risk factors might increase the risk of aneurysm independently of an effect on atherosclerotic disease. METHODS AND RESULTS: In the Edinburgh Artery Study, 1592 men and women aged 55-74 years were followed prospectively over a period of 5 years. Forty subjects were identified as having an abdominal aortic aneurysm and, for each, five controls were randomly selected. Case showed a higher prevalence of cardiovascular disease (P < or = 0.001) and had a lower ankle brachial pressure index (P < or = 0.01). Current and recent ex-cigarette smokers had an increased risk of aortic aneurysm compared with long time ex-smokers and never smokers (odds ratio 3.08, 95% CI 1.53 to 6.21). Adjustment for concurrent atherosclerotic disease reduced the odds ratio to 2.63 (95% CI 1.26 to 5.45). The risk of aortic aneurysm was not related to elevation in diastolic blood pressure or in serum cholesterol. CONCLUSIONS: These findings indicate that atherosclerotic disease is associated with risk of aortic aneurysm in the general population. In addition, cigarette smoking appears to have a direct effect on the risk of aortic aneurysm which is independent of atherosclerosis.

Laparoscopic ultrasonography for staging gastroesophageal cancer.

BACKGROUND: TNM staging of gastroesophageal cancer is improved by the use of laparoscopy for the detection of occult metastases and endoscopic ultrasonography for T and possibly N staging. Laparoscopic ultrasonography may combine the strengths of both of these techniques. The purpose of this study was to compare TNM staging by means of laparoscopic ultrasonography (Lap US), laparoscopy, and conventional computed tomography (CT). METHODS: TNM stage was determined by using Lap US, laparoscopy, and CT scanning in 26 surgical candidates with gastric or esophageal cancer in a blinded fashion. CT scans were also reviewed separately by an expert radiologist. Validation of findings was by means of final pathologic examination. RESULTS: Resectability for potential cure was determined by means of Lap US with a sensitivity of 100% and a specificity of 91% versus 100% and 73% for laparoscopy and 75% and 60% for CT, respectively. Overall TNM staging was 82% accurate for Lap US versus 67% for laparoscopy and 47% for CT (chi-squared, 8.64, p < 0.005, and 10.4, p < 0.005, respectively). Accuracies for Lap US versus laparoscopy versus CT for N stage were 92% versus 84% versus 70%, respectively, for T stage were 92% versus 42% versus 60%, respectively, and for M stage were 89% versus 44% versus 62%, respectively. CONCLUSIONS: T and N staging by Lap US were comparable to published results for endoscopic ultrasonography, and overall TNM staging was better. Lap US may provide the optimal preoperative staging for gastric cancer and has the potential to complement endoscopic ultrasonography in staging esophageal cancer.

Cardiovascular risk factors for early carotid atherosclerosis in the general population: the Edinburgh Artery Study.

BACKGROUND: Recent attempts to identify cardiovascular risk factors affecting early-stage carotid atherosclerosis, measured by ultrasonographically assessed intima-media thickness, have been inconclusive. OBJECTIVE: To study the relationship between traditional cardiovascular risk factors and intima-media thickness. METHODS: Ultrasonic evaluation of the intima-media thickness of the common carotid artery was included in the 5-year follow-up examination of participants of the Edinburgh Artery Study. We had valid readings of intima-media thickness for 1106 men and women aged 60-80 years. Information on a range of cardiovascular risk factors had been collected during the baseline examination. RESULTS: For men, in addition to age, lifetime smoking (measured in terms of pack years) was the only cardiovascular risk factor associated with increased intima-media thickness (P< or = 0.01) in the univariate analysis. Both systolic blood pressure (P < or = 0.001) and the high-density lipoprotein (HDL: total cholesterol ratio (P < or = 0.01) were correlated with intima-media thickness for women. When all the variables had been included in a multivariate analysis, pack years of smoking and the HDL:total cholesterol ratio were associated with early atherosclerotic development in men. In an equivalent analysis for women, alcohol consumption, systolic blood pressure and the HDL:total cholesterol ratio were associated with intima-media thickness. CONCLUSION: These data suggest that risk factors affecting intima-media thickness differ for men and women. Further sex-specific analyses of prospective population studies are required in order to clarify the role of 'traditional' cardiovascular risk factors in the early stages of carotid atherosclerosis.

Changing management of pyogenic liver abscess.

The case records of 23 patients who presented over a 5-year period with a diagnosis of pyogenic liver abscess were reviewed. Ascending cholangitis was implicated in nine cases, seven of which were associated with underlying malignancy. Haematogenous spread via the portal route accounted for five cases. Primary treatment included percutaneous abscess drainage in 15 patients. Whereas nine of the 11 patients with benign underlying pathology were managed successfully, the four with malignant biliary obstruction did not survive. Only one of the 23 patients who presented with hepatic abscess required surgical intervention. Percutaneous abscess drainage combined with appropriate antibiotic therapy is an effective means of managing hepatic abscess, but there remains a substantial overall mortality rate resulting from the increasing incidence of malignant biliary obstruction as a cause of this condition.

Comparison of venous reflux in the affected and non-affected leg in patients with unilateral venous ulceration.

In 54 patients with unilateral leg ulceration of purely venous aetiology the only difference in venous reflux between affected and non-affected legs was with respect to the popliteal and crural veins. Deep and superficial venous reflux is common in legs without the skin changes typical of chronic venous insufficiency. The significance of venous reflux in an ulcerated leg cannot therefore be determined without reference to the contralateral, clinically normal, limb. Surgery should be directed at correcting reflux present in the ulcerated limb but not in the unaffected limb. In a minority of patients this entails superficial venous surgery alone, but in the majority such an approach would, ideally, entail correction of deep venous incompetence.