Mechanisms in experimental venous valve failure and their modification by Daflon 500 mg.

OBJECTIVES: To characterize the acute response of the vein wall to venous hypertension and associated altered fluid shear stress and to test the effect of micronized purified flavonoid fraction (MPFF, Daflon 500), on this response. MATERIAL AND METHODS: A femoral arteriovenous fistula was created in Wistar rats (n=48). A cohort of 24 rats received oral treatment with MPFF (100 mg/kg/day body weight), 24 rats underwent the arteriovenous fistula procedure and received no treatment. At days 1, 7 and 21 the animals (n=8 at each time point) were killed. Experimental parameters measured included limb circumference, blood flow at the sapheno-femoral junction, leukocyte infiltration and gelatinase activity (matrix metalloproteinase, MMP). RESULTS: The acute rise in venous hypertension was accompanied by limb edema and venous reflux together with an eventual loss of valve leaflets in the saphenous vein. There was an increase in granulocyte and macrophage infiltration into the venous wall and the surrounding tissue, and a lesser increase in T- and B-lymphocyte infiltration. These changes were accompanied by a local increase in the proteolytic enzymes, MMP-2 and MMP-9. Administration of MPFF reduced the edema and lessened the venous reflux produced by the acute arteriovenous fistula. Decreased levels of granulocyte and macrophage infiltration into the valves were also observed compared with untreated animals. CONCLUSIONS: Venous hypertension caused by an arteriovenous fistula resulted in the development of venous reflux and an inflammatory reaction in venous valves culminating in their destruction. MPFF was able to delay the development of reflux and suppress damage to the valve structures in this rat model of venous hypertension.

Venous hypertension, inflammation and valve remodeling.

OBJECTIVES: To identify possible mechanisms for destruction of valves in chronic venous hypertension and the results of treatment with an anti-inflammatory micronized purified flavonoid fraction. MATERIAL AND METHODS: The saphenous vein valves in a rat model of venous hypertension caused by a femoral arterial-venous fistula were studied. Studies included femoral venous pressure, valve morphology, femoral venous reflux and selected molecular inflammatory markers as examined by immunohistochemistry. The effects of treatment with the anti-inflammatory micronized purified flavonoid fraction (S 5628, Servier, 50 and 100 mg/kg/day) were investigated. RESULTS: The femoral venous pressure was elevated close to arterial values for a period of 3 weeks. We then examined the morphology of the veins and selected molecular inflammatory markers were assessed. The results show that in this model venous reflux develops in response to venous hypertension. This can be inhibited by the administration of the anti-inflammatory micronized purified flavonoid fraction (S 5628, Servier, 50 and 100 mg/kg/day). The valve becomes incompetent by a combination of venous dilation and shortening of the valve leaflets. This is not inhibited by treatment with S 5628. The valve leaflets are infiltrated with granulocytes, monocytes and T-lymphocytes, and the endothelial cells express enhanced levels of P-selectin and ICAM-1. Cells in the valves are subject to extensive apoptosis although no enhancement of MMP 2,9 expression could be detected at the three-week time point examined in this study. CONCLUSIONS: These results indicate that in this model chronic elevation of venous pressure is associated with an inflammatory reaction in venous valves, a process that may lead to their dysfunction, reflux, and upstream elevation of venous pressure. These effects are mitigated by the anti-inflammatory micronized purified flavonoid fraction in a dose dependent manner.

Treatment of varicose veins: proximal saphenofemoral ligation comparing adjunctive varicose phlebectomy with sclerotherapy at a military medical center.

There is no consensus as to the single best approach to the treatment of varicose veins. There has been a trend toward less invasive procedures to reduce the number of incisions and provide more selective ablation of varicosities. Ultimately, therapeutic decisions have depended on surgeon preference and the patient population. The active duty military population presents a unique challenge in the treatment of varicose veins. This mobile and active population requires a treatment method that provides maximum relief with the lowest possible morbidity and rapid recovery. The authors previously reported their experience with 104 patients who underwent saphenofemoral ligation combined with perforator point ligation and staged sclerotherapy. This group was compared to 103 patients who underwent saphenofemoral ligation, point perforator ligation, and stab avulsion phlebectomy as a single procedure. Follow-up for the sclerotherapy group included patient satisfaction surveys and documentation of recurrent varicosities. All ambulatory phlebectomy patients responded positively with respect to symptomatic and cosmetic results. Overall satisfaction was favorable and there was no significant difference in patient satisfaction between the ambulatory phlebectomy and sclerotherapy groups. Twelve per cent of the sclerotherapy patients developed true recurrences or new varicosities compared to 11% in the ambulatory phlebectomy group. The most common complication was superficial thrombophlebitis (20% ambulatory phlebectomy, 16% sclerotherapy) which was mild in all cases. All but three patients in the ambulatory phlebectomy group returned to work within 7 days and 75% returned to full duty within 72 hours. Completion of therapy was accomplished in a much shorter period for the ambulatory phlebectomy group. Overall patient satisfaction was achieved for both ambulatory phlebectomy and sclerotherapy patients. Completion of therapy was achieved in a shorter period with fewer clinic visits in the ambulatory phlebectomy group and this has become our procedure of choice for active duty military patients.

Growing the vascular surgical practice: venous disorders.

For the 48th meeting of the International Society for Cardiovascular Surgery, North American Chapter in June 2000, we were asked to organize a presentation with the title displayed above. We welcomed this opportunity because the phrase 'growing the practice' literally means giving greater service to underserved patients with vascular disorders. Underserved individuals with vascular disorders include those with nonatherosclerotic arterial disorders, patients with lymphedema, and individuals with a variety of venous disorders including venous insufficiency. The majority of these conditions are not surgical, but venous insufficiency commands attention because its treatments are interventional. Therefore, this presentation will discuss prevalence of venous insufficiency, a unifying concept of its pathophysiology, how treatment may be selected, what the new technology provides, and then a description of coding issues and whether or not interventions are actually worthwhile from the point of view of the patient.

Internal to external carotid artery transposition to repair recurrent stenosis after carotid artery stenting.

Recently, carotid artery stenting (CAS) has emerged as a treatment option for carotid artery stenosis. Since the procedure is new, management of its complications is not standardized. This case report describes one method of arterial reconstruction after failed CAS. A 64-year-old male underwent CAS of his right internal carotid artery (ICA) for an asymptomatic 65% stenosis. Seven months later the stented area had narrowed to 95%. Arteriography revealed that the common and external carotid arteries (ECA) were free of disease so we elected to perform a transposition of the distal ICA onto the proximal ECA. The ECA and its branches were completely mobilized and the ascending pharyngeal and lingual arteries divided. The ICA was divided distal to the stent. Transection of the occipital artery provided an arteriotomy for an end ICA to side ECA anastamosis, thus preserving ECA flow. Postoperative surveillance after 8 months has revealed no recurrent stenosis. Operative repair of restenosis after CAS may be challenging if standard endarterectomy is not possible. Other options for reconstruction are feasible but if the common and external carotid arteries are disease-free, an ICA to ECA transposition provides a simple all-arterial repair that avoids bypass and prosthetic material.

Defining the role of extended saphenofemoral junction ligation: a prospective comparative study.

OBJECTIVE: This study explores the added effect of extended saphenofemoral junction (SFJ) ligation when the greater saphenous vein (GSV) has been eliminated from participating in thigh reflux by means of endovenous obliteration. GSV obliteration, unlike surgical stripping, can be done with or without SFJ ligation to isolate and study SFJ ligation's specific contribution to treatment results. METHODS: Sixty limbs treated with SFJ ligation and 120 limbs treated without high ligation were selected from an ongoing, multicenter, endovenous obliteration trial on the basis of their having primary varicose veins, GSV reflux, and early treatment dates. RESULTS: Five (8%) high-ligation limbs and seven (6%) limbs without high ligation with patent veins at 6 weeks or less were excluded as unsuccessful obliterations. Treatment significantly reduced symptoms and CEAP clinical class in both groups (P =.0001). Recurrent reflux developed in one (2%) of 49 high-ligation limbs and eight (8%) of 97 limbs without high ligation by 6 months (P =.273). New instances of reflux did not appear thereafter in 57 limbs followed to 12 months. Recurrent varicose veins occurred in three high-ligation limbs and four limbs without high ligation by 6 months and in one additional high-ligation limb and two additional limbs without high ligation by 12 months. Actuarial recurrence curves were not statistically different with or without SFJ ligation (P >.156), predicting greater than 90% freedom from recurrent reflux and varicosities at 1 year for both groups. CONCLUSION: These early results suggest that extended SFJ ligation may add little to effective GSV obliteration, but our findings are not sufficiently robust to warrant abandonment of SFJ ligation as currently practiced in the management of primary varicose veins associated with GSV vein reflux.

Left iliac vein occlusion: its clinical spectrum.

The cases reported here demonstrate the variability of the clinical manifestations of left common iliac venous occlusive disease. In each instance, therapy must be adjusted to meet the symptomatic needs of the individual patient. The experience reported here should reinforce the fact that occlusions even 25 months or longer in duration may be reopened. Continuing patency can be enhanced by stent placement.

Expression of adhesion molecules and cytokines on saphenous veins in chronic venous insufficiency.

The objective of this study was to assess the relationship of signaling molecules to monocyte/ macrophages as a precursor to venous valve and venous wall dysfunction in patients with varicose veins. One of the hallmarks of venous dysfunction is destruction of venous valves with subsequent reflux and elevation of distal venous pressure. We recently observed that monocytes/macrophages migrate into the venous walls and valves of patients with venous insufficiency. There, they may play a role in the pathogenesis of primary venous insufficiency. If so, an important element in their performance would be the interaction between the monocytes and the endothelium as a precursor of damage to venous valves and the venous wall. To explore this interaction, immunohistochemistry was carried out to detect adhesion molecules and cytokines in surgical specimens removed during surgical therapy. Twenty-four surgical specimens consisting of proximal saphenous vein and subterminal valve were obtained using minimally traumatic technique in 6 males and 18 females who ranged in age from 31 to 79 years. Reflux was confirmed preoperatively by duplex technique, and severity was classified by the CEAP classification of the American Venous Forum. Ten patient limbs were class 2, eight were class 3, four were class 4, and two were class 6. The venous specimens were labeled using monoclonal antibody against ICAM-1, E-selectin, IL-1alpha, and TNF-alpha. CD68 was used for detection of monocytes/macrophages. Our results indicate that not only luminal venous endothelium but also endothelium in the vasa vasora of refluxing saphenous veins is activated, as indicated by the up-regulation of ICAM-1. However, IL-1alpha and TNF-alpha were increased in only selected specimens and are mainly detected in the vein wall. The factors that serve as trigger mechanisms to activate cells in the pathogenesis of primary venous dysfunction remain to be explored.

Extensive tissue necrosis following high-concentration sclerotherapy for varicose veins.

BACKGROUND: Tissue necrosis after sclerotherapy has been observed, but is unexplained. OBJECTIVE: To present the complication of extensive tissue necrosis following high-concentration sclerotherapy for varicose veins. METHODS: Cases coming to the attention of the authors are presented briefly with commentary and discussion to explain the mechanisms of tissue destruction. RESULTS: Although the complication of extensive tissue necrosis has been ascribed to intra-arterial injection, in fact, careful study of the cases described here shows that intravenous injection was present in each case. A theory of distribution of the sclerosant into the arterial arborization is proposed. This theory would explain the distribution of sclerosant into the arterial tree and would also explain the causation of extensive tissue necrosis. Mention is made of experimental work in which intra-arterial injection was not the mechanism of causation of tissue necrosis. CONCLUSION: Extensive tissue necrosis following high-concentration sclerotherapy may be rare, but its occurrence is serious and its treatment may be incomplete.

Failure of nonoperative management of isolated superior mesenteric artery dissection.

A case of isolated dissection of the superior mesenteric artery is presented here. This rare condition was confirmed angiographically in a 46-year-old man with persistent abdominal pain. He was treated initially with anticoagulation alone. One year later, he developed recurrent symptoms and had radiologic documentation of progression of the condition. Operative repair was performed and recovery was uneventful. This case demonstrates a failure of the nonoperative approach to this rare condition and suggests that disease progression may be inevitable. Early surgical correction may ease operative management.

Arterial injury in uncomplicated upper extremity dislocations.

The purpose of this study is to analyze causes and consequences of arterial injury complicating simple dislocations of the upper extremity. This is a multicenter, 5-year, retrospective analysis of vascular injury in patients sustaining shoulder or elbow dislocations without associated fractures. Foci of the study were mechanisms of injury, preoperative imaging, incidence of closed reductions, types of arterial injury, methods of surgical repair, and ultimate outcome. Arterial injury in this patient cohort occurred in 0.74% of patients. Axillary artery injury occurred in 0. 97% and brachial in 0.47%. Both elbow and shoulder dislocations may cause severe arterial damage and strenuously test surgical expertise to achieve successful repair.

Surgical treatment of Takayasu's arteritis: case report and literature review.

Surgical intervention during the early stages of Takayasu's arteritis is rarely necessary. In the chronic stages of this disease, however, surgeons may be faced with difficult decisions regarding the timing of complex arterial reconstructions. These issues can be especially challenging in the pediatric population. We report the case of an 8-year-old girl with chronic Takayasu's arteritis complicated by malignant hypertension. Despite aggressive medical therapy, her blood pressure remained uncontrolled. Imaging studies demonstrated infrarenal aortic and right common iliac artery aneurysms with concomitant segmental stenosis of the right common iliac artery. Since her transplant kidney was based off the right external iliac artery, it was felt that this high-grade stenosis was responsible for her severe hypertension. Immediate surgical reconstruction was therefore recommended. Intraoperatively, the aneurysmal aorta and iliac arteries were found to be densely calcified. The transplant kidney was perfused during aortic clamping by placement of a suprarenal aorta to the right external iliac artery shunt. Endoaneurysmorrhaphy was then performed to reconstruct the aorta after extensive endarterectomy. In the early postoperative period, antihypertensive medications were decreased to two oral agents. She was discharged on the seventh postoperative day and placed on two agents. At a 1-year follow-up visit, she is on one antihypertensive medication. Her right leg complaints have resolved. Ultrasound surveillance revealed no evidence of recurrent aneurysmal or occlusive disease. A brief review of complications related to Takayasu's arteritis in the children and indications for surgical intervention completes this report.

Non-elastic compression: an alternative in management of chronic venous insufficiency.

Non-elastic compression has been used to treat venous insufficiency of the lower extremities for more than 150 years. The best and most recognized example is the Unna boot. When compared with other dressings, the Unna boot has performed as well as or better than other forms of compression. While the Unna boot is used worldwide, a 3- or 4-layer dressing has emerged as the dressing of choice in treating severe chronic venous insufficiency in the United States and English-speaking European countries. In the United States, non-elastic compression can also be applied as a CircAid legging. This semirigid support has been compared with heavyweight class 3 below-knee medical stockings. At 2 and 6 hours after application, inelastic compression maintained limb size and reduced venous volume better than did stockings. At 6 hours, the ejection fraction of the calf muscle pump was increased and venous filling index significantly improved with inelastic compression compared with stockings. Comparison of elastic stockings with short-stretch bandages has also been completed. The short-stretch bandage was found to be similar but not identical to the semirigid inelastic support device. The studies have shown that venous filling index improved by short-stretch bandaging and that venous reflux time was prolonged more by the short-stretch bandages than by stockings. The findings of these studies demonstrate that the inelastic support dressing mimics the action of the Unna boot in providing counter-pressure to perforating vein outflow. This may improve cutaneous and subcutaneous microcirculation in a manner similar to perforating vein surgery, which has been shown to accelerate leg ulcer healing.

Venous hemodynamic changes after external banding valvuloplasty with varicosectomy in the treatment of primary varicose veins.

BACKGROUND: To evaluate venous hemodynamic changes after an external banding valvuloplasty in the treatment of primary varicose veins with saphenofemoral incompetence. METHODS: From June 1996 to December 1997, 79 limbs (10 male and 69 female, age 20-57 years) were treated for primary saphenofemoral incompetence by external banding valvuloplasty. Tightening of the banding was accomplished using a polyester-tailored mesh to narrow the terminal and/or subterminal valve areas of the dilated greater saphenous vein (GSV), same size as its minimum diameter during spasm. Evaluation was done through a pre- and postoperative color-flow duplex scanning and an air-plethysmography (APG). RESULTS: Sixty-three limbs (79.7%) remained patent and were competent. Fourteen limbs (17.7%) remained patent but showed reflux. Two limbs (2.5%) had thrombus within the GSV after surgery. The diameter of GSV of mid-thigh was 6.7+/-1.6 mm preoperatively and 4.1+/-0.9 mm postoperatively (p-value=7.04E-10). Reduction of the diameter was 61.4+/-12.3%. Venous volume was 136.1+/-59.8 ml preoperatively and 103.5+/-39.8 ml postoperatively (p-value=1.6E-20). Reduction of the venous volume was 12.9+/-17.0%. Venous filling index (VFI) was 6.6+11.3 ml/sec preoperatively and 1.9+/-3.3 ml/sec postoperatively (p-value=1.2E-10). Reduction of the VFI was 55.0+/-29.1%. Ejection fraction (EF) was 48.9+/-13.8% preoperatively and 60.1+/-17.2% postoperatively (p-value=2.6E-17). Increase of EF was 29.4+/-43.5%. The residual volume fraction (RVF) was 42.1+/-13.9% preoperatively and 30.2+/-14.5% postoperatively (p-value=5.6E-19). Reduction of RVF was 17.6+/-43.6%. CONCLUSIONS: Early evaluation of saphenofemoral external banding valvuloplasty confirms the satisfactory patency and improvement in venous hemodynamics. Long-term evaluation is clearly indicated but the early safety and efficacy of the procedure have been confirmed.

Development of endoscopic dissection of perforating veins and fasciotomy for treatment of chronic venous insufficiency.

As the subfascial endoscopic perforator vein surgery (SEPS) has become increasingly popular, it becomes important to trace the development of this procedure first initiated in 1985. (Improvements in the technique and modifications of initial instrumentation have occurred. These changes are based on experience with greater than 1000 patients treated since 1980 at Krankenhaus der Barmherzigen Brüder in Munich, Klinikum Merheim in Cologne, and the Weilheim Hospital. Results obtained in 96 patients (140 legs) were examined retrospectively and are presented as well as the prospective evaluation of 39 patients with 56 operated legs. (Hauer G, Vasa 1985, 14:59-61; Hauer G, Barkun J, Wisser I, Deiler S, Surg Endosc 1988, 2:5-12; Schneidemann B, Inaug Diss, 1985). This report details the fact that in using our own instruments, including a specially designed videoscope, it has been possible to approach perforating veins of the medial anterior and posterior compartments. This can be done through a 2 cm incision in the proximal calf. Using these instruments, it has been possible to perform a fasciotomy under direct vision. This summary emphasizes that it is not necessary to locate perforating veins preoperatively, and that wound infection and recurrent ulcerations do not occur. This allows application of the method to patients with open ulcers. Further, this report emphasizes that patients with combined arterial and venous ulceration require arterial reconstruction rather than perforator vein interruption. The SEPS operation is relatively contraindicated if there is widespread necrosis and infection of the fascia, especially in combination with ankle ankylosis. In addition, this is the method of choice in patients with multiple incompetent perforating veins with or without open venous ulceration.

Development of open-scope subfascial perforating vein surgery: lessons learned from the first 67 cases.

Although perforating vein surgery in treatment and prevention of venous ulcers remains controversial, minimization of the procedure has allowed its reevaluation. We have chosen to develop the technique using a single port and an open scope using a variety of mostly nondisposable instrumentation. Since our first subfascial endoscopic perforator vein surgical (SEPS) procedure in July 1993, we have operated on 67 limbs in 62 patients (27 women, 35 men) ranging in age from 24 to 85 years. Using CEAP criteria, there were 16 limbs in class 4, 13 in class 5, and 38 in class 6. Preoperative investigations included duplex ultrasound in 35 cases, ascending phlebography in 29 cases, and selective use of physiologic testing with air plethysmography (APG) in 12 patients. A variety of initial explorations using different-diameter scopes has given way to single-port methodology for medial leg exploration. A mean of 3.08 perforators per patient was interrupted using electrocoagulation or metal clips and scissor division. This technique, as developed, allows same-day or short-stay (<24 hr) surgery. A vigorous program of thromboembolism prophylaxis was used in selected cases. From these 67 csaes we conclude that endoscopic perforating vein interruption provides a useful tool for the surgeon interested in treating severe chronic venous insufficiency. The open-scope, single-port technique accomplishes intervention objectives in a simplified manner. Although recurrent chronic venous insufficiency (CVI) is not eliminated, its postoperative treatment is markedly eased.

Leukocyte activation in patients with venous insufficiency.

PURPOSE: Cell activation may play an important role in the production of venous insufficiency, just as leukocytes participate in the cause of venous ulcer. If activated, monocytes observed on venous endothelium can migrate into the venous wall and produce toxic metabolites and free oxygen radicals that may participate in valve destruction and venous wall weakening. At present, it remains uncertain to what degree leukocytes are actually activated in patients. This study was designed to explore the level of activation and to examine whether patient plasma contains an activator that leads to leukocyte activation of unstimulated naive leukocytes from volunteers without venous insufficiency disease. METHODS: Twenty-one patients (4 men, 17 women), who ranged in age from 34 to 69 years (mean age, 53.2 years), with chronic venous disease were compared with 16 healthy control volunteers (4 men, 12 women), who ranged in age from 18 to 65 years (mean age, 48.4 years). All the patients underwent evaluation with Doppler ultrasound scanning and were classified with the CEAP score.1 Nearly all the patients who smoked or were hypertensive were excluded. The blood types (ABO and Rh) of the controls were matched to the study group. Isolates of patient whole blood, plasma, or leukocytes were incubated with isolates of control whole blood, plasma, or leukocytes to separate actual activation from spontaneously observed activation. The granulocyte activation was measured with nitroblue tetrazolium (NBT) reduction and quantitation of granulocyte pseudopod formation. Hydrogen peroxide production in patient plasma was measured with a recently developed electrode method. RESULTS: Leukocytes from healthy blood and patient plasma had significantly higher NBT-positive granulocyte counts than either patient blood, healthy blood, or patient blood incubated in healthy plasma. In a comparison of patient groups across the CEAP classes, the NBT-positive granulocyte counts were significantly greater in classes 4, 5, and 6 than in classes 2 and 3 (P <.001). Pseudopod formation was significantly greater in mixtures of granulocytes in healthy blood and patient plasma than in all other groups. There was no difference in the level of pseudopod formation in control leukocytes incubated with patient plasma in patients across the CEAP spectrum. The patient plasma produced significantly higher hydrogen peroxide values than did the controls. CONCLUSION: These results suggest that patient plasma may contain an activating factor for granulocytes. The finding that activated neutrophils were fewer in number in patient whole blood than in healthy blood incubated in patient plasma could suggest that activated neutrophils in patients with chronic venous insufficiency might be trapped in the peripheral circulation. It is unknown what factors in the plasma might induce activation of naive neutrophils, but such activators could possibly be important in the pathogenesis of primary venous dysfunction and the development of chronic venous insufficiency.

Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American subfascial endoscopic perforator surgery registry. The North American Study Group.

PURPOSE: The safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery (SEPS) for the treatment of chronic venous insufficiency were established in a preliminary report. The long-term clinical outcome and the late complications after SEPS are as yet undetermined. METHODS: The North American Subfascial Endoscopic Perforator Surgery registry collected information on 148 SEPS procedures that were performed in 17 centers in the United States and Canada between August 1, 1993, and February 15, 1996. The data analysis in this study focused on mid-term outcome in 146 patients. RESULTS: One hundred forty-six patients (79 men and 67 women; mean age, 56 years; range, 27 to 87 years) underwent SEPS. One hundred and one patients (69%) had active ulcers (class 6), and 21 (14%) had healed ulcers (class 5). One hundred and three patients (71%) underwent concomitant venous procedures (stripping, 70; high ligation, 17; varicosity avulsion alone, 16). There were no deaths or pulmonary embolisms. One deep venous thrombosis occurred at 2 months. The follow-up periods averaged 24 months (range, 1 to 53 months). Cumulative ulcer healing at 1 year was 88% (median time to healing, 54 days). Concomitant ablation of superficial reflux and lack of deep venous obstruction predicted ulcer healing (P <.05). Clinical score improved from 8.93 to 3.98 at the last follow-up (P <. 0001). Cumulative ulcer recurrence at 1 year was 16% and at 2 years was 28% (standard error, < 10%). Post-thrombotic limbs had a higher 2-year cumulative recurrence rate (46%) than did those limbs with primary valvular incompetence (20%; P <.05). Twenty-eight of the 122 patients (23%) who had class 5 or class 6 ulcers before surgery had an active ulcer at the last follow-up examination. CONCLUSIONS: The interruption of perforators with ablation of superficial reflux is effective in decreasing the symptoms of chronic venous insufficiency and rapidly healing ulcers. Recurrence or new ulcer development, however, is still significant, particularly in post-thrombotic limbs. The reevaluation of the indications for SEPS is warranted because operations in patients without previous deep vein thrombosis are successful but operations in those patients with deep vein thrombosis are less successful. Operations on patients with deep vein occlusion have poor outcomes.

Aortoiliac stent deployment versus surgical reconstruction: analysis of outcome and cost.

PURPOSE: The purpose of this study is to compare complication rate, primary patency, and cost of stent deployment with direct surgical reconstruction for the treatment of severe aortoiliac occlusive disease. METHODS: From March 1, 1992, to May 31, 1996, 119 patients receiving treatment for aortoiliac occlusive disease were analyzed after exclusions. Sixty-five patients had stent deployment and 54 patients had surgical reconstruction. Data were evaluated within and between the groups by univariate and multivariate logistic regression, life-table, t-test, and cross tabulation with chi2 analysis. RESULTS: There was no significant difference between the groups with regard to demographic features or presenting symptoms (all p values > 0.07). Incidence of procedure-related complications was similar (p = 0.30). However, there were more systemic complications in the surgery group (15 versus 2; RR = 5.5, p < 0.01) and more vascular complications in the stent group (16 versus 3; RR = 12, p < 0.002). Incidence and type of late complications were not appreciably different (all p values > 0.05). Cumulative primary patency rate of bypass grafts was significantly better than stented iliac arteries at 18 months (93% versus 77%), 30 months (93% versus 68%) and 42 months (93% versus 68%); p = 0.002, log rank. Multivariate analysis identified female gender (RR = 4.6, p = 0.03), ipsilateral SFA occlusion (RR = 5.6, p = 0.01), procedure-related vascular complication (RR = 9.7, p = 0.002), and hypercholesterolemia (RR = 5.0, p = 0.02) as independent predictors of bypass graft or stent thrombosis. Mean total hospital cost per limb treated did not differ significantly between surgery and stent deployment groups ($9383 versus $8626, respectively; p = 0.66, t-test). CONCLUSIONS: Treatment of severe aortoiliac occlusive disease by surgical reconstruction or stent deployment has a similar complication rate. Mean hospital cost per limb treated is essentially equal. However, cumulative primary patency rate of bypass grafts is superior to stents. Therefore, considering the elements of cost and patency, surgical revascularization has greater value. The benchmark for cost-effective treatment of severe aortoiliac occlusive disease is direct surgical reconstruction.