Great saphenous vein ablation with steam injection: results of a multicentre study.

OBJECTIVE: To assess the safety and efficiency of steam vein sclerosis (SVS) of the great saphenous vein (GSV) in a multicentre open prospective cohort study. DESIGN: 75 consecutive adult patients with GSV reflux, CEAP C2-C5 and vein diameter 4-13 mm. METHODS: Patients treated using an SVS™ generator delivering homogenous pulses of superheated steam were followed up at 8 days and 1, 3, 6 and 12 months (clinical, duplex ultrasound, quality of life [QoL] with SF12). RESULTS: 88 veins were treated in 75 patients. At 6 months, 72/75 (96%) veins were obliterated (95% CI: 89-99) and Kaplan-Meier analysis found an obliteration rate of 96.1% at 12 months. QoL increased at 6 months for both the physical and mental components (p = 0.049 and p < 0.001 respectively). SVS was well tolerated: no major complications were reported. Adverse events occurred mainly at day 8 and incidents amounted to ecchymosis (n = 60) and pain (n = 7). CONCLUSIONS: SVS achieved an obliteration rate similar to that of other thermal ablation techniques. It was well tolerated with minimal post-operative pain.

Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and review of the literature.

OBJECTIVE: Popliteal venous aneurysms (PVAs) are an uncommon but potentially life-threatening disease because they can be a source for pulmonary emboli (PE). With the widespread use of venous duplex scanning, PVAs are increasingly found in patients with deep or superficial vein insufficiency, and questions have arisen as to the management of these aneurysms. The purpose of this study was to review our experience in the management of PVAs diagnosed in patients with PE and in patients with chronic venous diseases. METHODS: Twenty-five patients with PVAs were treated in two centers between 1985 and 1999. There were 20 women and five men, with an average age ranging from 33 to 79 years (mean age, 59 years). Twenty-four percent (6/25) presented with PE, and 76% (19/25) of PVAs were discovered during investigation for chronic venous disease (varicosities, n = 13; post-thrombotic symptoms, n = 6). The diagnosis of PVA was achieved in all cases with venous duplex scanning and phlebography. Aneurysms were located in the proximal popliteal vein (n = 17) and at the saphenopopliteal junction (n = 8). Seventy-two percent (18/25) of PVAs were saccular, and 40% (10/25) had an intraluminal thrombus. Two patients with PE underwent cardiac arrest, with one requiring a pulmonary embolectomy. The Fisher exact test showed a statistically significant correlation between PE and the presence of thrombus (50% vs 7% without thrombus, P =.02). Aneurysms were treated with tangential aneurysmectomy and lateral venorrhaphy (n = 19), resection with end-to-end anastomosis (n = 2), resection with interposition of the greater saphenous vein (n = 2) or the superficial femoral vein (n = 1), and resection with vein transposition (n = 1). Two patients who experienced a PE had an inferior vena cava filter placement before surgical repair of the PVA. RESULTS: Mean follow-up was 63 months (range, 11-168 months). No operative deaths occurred, and no patient had evidence of a recurrent PE. Postoperative minor complications (20%) included transient common peroneal nerve palsy (n = 2), postoperative hematoma (n = 2), and wound infection (n = 1). Postoperative thrombosis of the surgical repair occurred in three patients, and patency was restored with anticoagulation therapy. CONCLUSION: Despite its rarity, PVAs should be ruled out with venous duplex scanning in patients with PE and in patients presenting with chronic venous diseases. Because of the unpredictable risk of thromboembolic complications, surgical treatment that is accompanied by a low morbidity rate is indicated in all PVAs. Tangential aneurysmectomy with lateral venorrhaphy is the procedure of choice.

Clinical application of digital indocyanine green angiography in choroidal neurofibromatosis.

Indocyanine green angiography (ICGA) was used to investigate 2 cases of type 1 systemic neurofibromatosis that had appeared at birth with café-au-lait skin spots, gradually developing into multiple cutaneous neurofibromas. Patients underwent periodical visual acuity examinations, the fundus was checked and fluorescein angiography (FA) was done; all findings appeared extremely stable. In 1995 these 2 patients underwent ICGA to check for pathological choroidal involvement. In both cases the initial examination stages showed multiple extensive areas of hypofluorescence, their morphology and extension coinciding with the retinal pigment epithelium (RPE) lesions shown by FA and by ophthalmoscopic examination. In later stages the hypofluorescent areas became smaller, generally shrinking to small isolated dots in the middle of the original areas. These initially hypofluorescent areas appeared to be due to slow focal choroidal filling caused by deep alterations to the walls of the choroidal arterioles induced by the disease. Chronic hypoperfusion of the choriocapillaris results in impairment of the overlying RPE, causing it to atrophy. The late hypofluorescent areas could be either persistent nonperfused lobules of choriocapillaris or neurofibromatose choroidal nodules. ICGA examination showed that the FA lesions described in the literature as choroidal nodules are in fact alterations to the RPE secondary to areas of hypoperfusion in the choriocapillaris.

Albumin-impregnated prosthetic graft for infrarenal aortic replacement: effects on the incidence and volume of perioperative blood transfusion.

We retrospectively reviewed 290 cases in which an albumin-impregnated polyester prosthetic graft was used for surgical management of aortic bifurcation disease between November 1987 and December 1990. The purpose of this review was to determine the incidence and volume of blood transfusion and to evaluate the rate of patency and the incidence of infection achieved using this type of prosthesis. The indication for surgery was abdominal aortic aneurysm (AAA) in 218 cases (190 elective procedures and 28 emergency procedures) and occlusive disease of the aortic bifurcation (ODAB) in 72 cases. Mean follow-up was 25.5 +/- 13.4 months (range: 1 and 50 months). The incidence of blood transfusion for elective AAA and ODAB surgery was 30.2% and 32.3% intraoperatively, 21.3% and 12.9% postoperatively, and 40.4% and 42.6% overall. The mean number of red cell packs transfused for elective AAA and ODAB surgery was respectively 1 and 0.8 intraoperatively, 0.4 and 0.6 postoperatively, and 1.4 and 1 overall. No immediate or late graft infection prosthesis was observed in any patient in this series. Primary and secondary patency was 95.5% and 97.5% at 6 months with no graft thrombosis during further follow-up. The fact that use of an impregnated graft in management of aortic bifurcation disease was accompanied by a high incidence and volume of blood transfusion suggests that these grafts do not reduce perioperative blood loss. Use of an impregnated prosthesis had no effect on the rate of patency and the incidence infection.

The impact of knee joint flexion on infrainguinal vascular grafts: an angiographic study.

OBJECTIVES: To characterise the morphologic behaviour of infrainguinal vascular grafts during flexion of the knee. DESIGN: A prospective angiographic study. MATERIALS AND METHODS: In 64 infrainguinal bypass grafts, intravenous digital subtraction angiography was performed within the first postoperative week. Frontal and lateral projection angiograms with the knee joint extended and with a 80-90 degrees flexion were taken. The distal anastomosis of the bypass was performed below-knee in 49 cases (18 in situ veins, 8 reversed veins with an anatomic course, 2 reversed veins with an extra-anatomic course, 4 composite grafts, 15 synthetic grafts with an anatomic course (14 polytetrafluoroethylene (ePTFE), 1 polyurethane), and two synthetic grafts with an extra-anatomic course. Fifteen ePTFE prostheses were implanted in the above-knee position. RESULTS: Out of 64 cases a total of 16 grafts showed stenotic kinking during flexion: two of the 18 in situ vein grafts, four of the 12 reversed vein grafts implanted with an anatomic course, one of the two reversed vein grafts implanted in an extra-anatomic site, eight of the 15 synthetic grafts crossing the knee, 0 of the two extra-anatomic ePTFE grafts, and one of the 15 cases of above-knee femoropopliteal ePTFE grafts. CONCLUSIONS: Stenotic kinking due to knee flexion can affect all kinds of bypass grafts including vein grafts placed anatomically and above-knee prostheses.

[Recurrent varicose veins in the groin after surgery]. / Les récidives au pli de l'aine après chirurgie des varices.

Recurrence of varicose veins following surgery of the long saphenous system are common. It is important to differentiate several causes. These, in fact, dictate the therapeutic decision. Physiopathologically, there are different types of recurrences: persistent reflux from the femoral veins into the superficial varicose network due to: an incomplete long sapheno-femoral high ligation (crossectomy), a neoangiogenesis at the level of the previous sapheno-femoral junction. separate termination of an incompetent long saphenous vein (LSV) into the common femoral vein or the superficial femoral vein (antero lateral or postero medial tributaries of LSV); persistent reflux from perineal and (or) paricto-abdominal veins into the varicose network of the thigh. Dynamic popliteal phlebography was, until the advent of echo-doppler, the author's method of choice for investigation as it was easier to interpret than varicography. At the present time it is only requested on the rare occasions where doubt persists even after echo-doppler. Additionally, with this investigation, the reflux (major or minor) can be analysed at its point of origin and a map of the underlying varicose network can be drawn. Therapeutically, we make the following suggestions: in the presence of a site of major reflux (incomplete crossectomy, high flow neoangiogenesis, separate termination of the saphenous tributaries), a further operation would be justified. The removal of the site of reflux can be associated with the placing of a PTFE patch on the common femoral vein. in the presence of a site of minor reflux, sclerotherapy or, preferably, echosclerotherapy would appear to be the treatment of choice. Elimination of the site (s) of reflux must be associated with suppression of the underlying varicose network by sclerotherapy or phlebectomy.

[Deep venous insufficiency and recurrent varicose veins after surgery of superficial venous insufficiency]. / Insuffisance veineuse profonde et récidive variqueuse après chirurgie de l'insuffisance veineuse superficielle.

Combination of deep and superficial venous insufficiency is far from exceptional and often causes severe chronic venous insufficiency (CVI). Does this association increase the risk of recurrent varicose veins after surgery of superficial insufficiency? After brief clinical and instrumental considerations in this situation, four series on this topic are analysed. Those published by Almgren, Guarnera, Darke and our personal series in which valve repair in the deep system was the inclusion criteria. Among the sixty seven patients included (80 lower limbs), fifty had previous surgery for varicose veins before valvuloplasty. Recurrence rate has been evaluated in both saphenous territories: great saphenous vein: 51% and short saphenous vein: 38.5%. It appears difficult to determine whether varicose vein recurrence is related to technical error at the initial operative procedure or due to the Primary Deep Vein Incompetence (PDVI). Nevertheless recurrence of varicose vein would appear to be frequent in the four series analysed. Many questions remain unanswered in this situation.

[Forensic medical implications in surgery of chronic venous insufficiency of the legs]. / Implications médico-légales dans la chirurgie de l'insuffisance veineuse chronique des membres inférieurs.

Current literature and personal experience with these complications are discussed. Complications with medicolegal implications have been analyzed in three studies, in France by J. Natali and A. Rispoli (Marseille, 1994) and in Great Britain by W.G. Tennant and C.V. Ruckley. The incidences reported are certainly underestimated as only those complications leading to an official expert opinion were counted. We also report our personal experience with medicolegal implications after 15,340 limb operations performed from 1968 to 1994. The conclusions provide an overall view of how to reduce the number of complications and provide adequate therapeutic management.

Albumin-impregnated polyester vascular prosthesis for abdominal aortic surgery: an improvement?

AIM: To compare the peroperative blood loss and the postoperative systemic inflammatory reaction in patients receiving either a Vasculour II Albumin pre-impregnated prosthesis (VA group, n = 32) or a preclotted Vasculour II prosthesis (V group, n = 33) for elective surgery of the abdominal aorta. SETTING: University Hospital. DESIGN: Prospective, randomised study. METHODS: Peroperative blood loss was measured over two different periods: Phase I from the beginning of the operation to the completion of the proximal anastomosis, when blood loss cannot be related to the model of prosthesis implanted and phase II after the completion of the proximal anastomosis to the end of the operation. Postoperative blood loss was evaluated by the determination of the retroperitoneal drainage volume over a period of 2 days immediately following the operation. The presence of periprosthetic fluid was measured with echography at days 4, 9, 30 and 60. The postoperative systemic inflammatory reaction was evaluated by measuring the sedimentation rate and the C reactive protein levels daily from day 1 to day 9, and at days 14, 21, 28, 45, and 60, and by measuring the body temperature daily from day 1 to day 9. RESULTS: No significant differences of peroperative blood loss were observed. The same proportion of patients (35%) in both groups received homologous transfusion. The mean number of units of homologous blood transfused per patient was respectively 0.77 and 0.91 for the VA and the V group. The retroperitoneal drainage volume and the percentage of patients with periprosthetic fluid did not differ significantly. No significant differences in systemic postoperative inflammatory reaction were observed. CONCLUSION: There were no benefits in using albumin-impregnated prosthesis as opposed to preclotted prosthesis in terms of peroperative and postoperative blood loss, or by looking at the incidence of homologous blood transfusion. However, the glutaraldehyde cross-linked albumin did not induce any systemic inflammatory reaction.

Albumin as a sealant for a polyester vascular prosthesis: its impact on the healing sequence in humans.

OBJECTIVE: Although the healing characteristics of albumin impregnated vascular prostheses have been extensively studied in animal models, they have never been studied in humans. We therefore examined the healing sequence and the albumin degradation rate of this type of prosthesis harvested from humans. We also addressed the possible relationship between the implantation of cross-linked albumin and a specific inflammatory reaction. METHODS: Thirty albumin-impregnated polyester vascular prostheses were collected in our institution from January 1991 to February 1993. The mean duration of implantation of the prostheses was 8.4+/-9.7 (SD) months (range: 1 hour to 26 months). Twenty two prostheses were patent at the time of explantation and 4 had been thrombosed for less than 24 hours. In 18 cases, the prostheses were surgically removed because of a complication or a reoperation, and during an autopsy in 12 cases. Each harvested specimen was submitted to histological and immunohistochemical studies in order to demonstrate the presence of human albumin sealant, and to determine the inflammatory cell constituents. RESULTS: The albumin-impregnated prostheses were poorly infiltrated by healing tissues after 2 years of implantation. An external capsule was constantly observed after 2 months of implantation with a nonspecific chronic inflammatory reaction localized between the capsule and the polyester yarns. We observed large amounts of albumin sealant after 2 months, a gradual degradation with time, and traces after 2 years of implantation in humans. The luminal surface of the explant was mainly covered with organized fibrin. No histological signs of a specific inflammatory reaction were observed. CONCLUSIONS: The healing of the albumin impregnated prosthesis was poor and the degradation rate of the albumin sealant was significantly delayed, when compared to animal models. This difference in degradation rate could be related to interspecies differences of phagocytic cells enzymatic machinery. Finally, implantation of glutaraldehyde cross-linked albumin in humans is safe, since we observed an aspecific chronic foreign body inflammatory reaction.

Late complication of a Greenfield filter associating caudal migration and perforation of the abdominal aorta by a ruptured strut.

We report the case of a 67-year-old woman who was admitted for surgical removal of a Greenfield filter that had been inserted 7 years before because of recurrent deep vein thrombosis associated with pulmonary embolism. This complication appeared on a plain abdominal radiogram that showed a 7 cm distal migration of the filter, a 30-degree angulation, and rupture of a strut at the level of the hub. Computed tomography, aortography, and ascending cavography demonstrated that the inferior vena cava was perforated by the struts and that the ruptured strut had penetrated the infrarenal aorta. As demonstrated by scanning electron microscopy, the fracture was due to a structural defect of the strut at its insertion point within the hub, with no sign of corrosion. Energy-dispersive radiography analysis failed to demonstrate impurity in the metal composition.

[Surgery for aneurysms of the subrenal abdominal aorta after the age of 70 years: survival and quality of life]. / La chirurgie des anévrismes de l'aorte abdominale sous-rénale après 70 ans: survie et qualité de vie.

The aim of this study was to assess results of surgery for aneurysms of the abdominal aorta in patients over 70 years of age. Survival and quality of life were used as assessment criteria. Files of 277 patients over 70 years of age who had undergone surgery for an aneurysm of the subrenal abdominal aorta between 1974 and 1992 were examined retrospectively. There were 246 men and 31 women of whom 230 were under 80 and 47 over 80 years of age. The operation was programmed in 145 cases and was an emergency procedure in 132 (45 ruptures and 87 painful fissurations). Perioperative mortality was 1.4% in programmed surgery and 19.7% in emergency surgery. Overall actuarial survival was 60.07% at 5 years and 26.04% at 10 years. Quality of life after the operation was unchanged in 56.1%, improved in 19.3% and worse in 24.6%. Surgery for aneurysm of the subrenal abdominal aorta is justified in patients over 70 years of age. It can provide satisfactory survival in good quality of life conditions.

Biologic effects of prolonged exposure to ELF electromagnetic fields in rats: II. 50 Hz magnetic fields.

To provide possible laboratory support to health risk evaluation associated with long-term, low-intensity magnetic field exposure, 256 male albino rats and an equal number of control animals (initial age 12 weeks) were exposed 22 h/day to a 50 Hz magnetic flux density of 5 microT for 32 weeks (a total of about 5000 h). Hematology was studied from blood samples before exposure to the field and at 12 week intervals. Morphology and histology of liver, heart, mesenteric lymph nodes, and testes as well as brain neurotransmitters were assessed at the end of the exposure period. In two identical sets of experiments, no significant differences in the investigated variables were found between exposed and sham-exposed animals. It is concluded that continuous exposure to a 50 Hz magnetic field of 5 microT from week 12 to week 44, which makes up approximately 70% of the life span of the rat before sacrifice, does not cause changes in growth rate, in the morphology and histology of liver, heart, mesenteric lymph nodes, testes, and bone marrow, in hematology and hematochemistry, or in the neurotransmitters dopamine and serotonin.

Biologic effects of prolonged exposure to ELF electromagnetic fields in rats. I. 50 Hz electric fields.

A three-year investigation was conducted on the biological effects of high-intensity electric field exposures of rats for up to 18% of their life span. Two hundred and forty adult male rats, divided into groups of 20 animals each, were exposed at ground potential for 8 h/day at 25-kV/m and 100-kV/m 50-Hz electric fields or were sham exposed for 280, 440, and 1240 h. The corresponding ages at sacrifice were 140, 164, and 315 days. An additional group of 40 rats was investigated under similar experimental conditions after 440 h of exposure at floating potential. Independent of exposure duration, mode of grounding, and field strength, no statistical differences in body weight, morphology, and histology of the liver, heart, mesenteric lymph nodes, and blood variables (hematology and serum chemistry) were found in comparison with sham-exposed animals. Plasma levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), and testosterone (TS) at sacrifice varied widely among experimental animals in the same group but did not differ in exposed compared with sham-exposed rats. A nonsignificant tendency toward a decrease in the testes/body weight ratio was found after 1240 h of exposure. Microscopic examination of a large number of specimens showed no quantitative or qualitative statistical differences in testes alterations either among exposed animals or between exposed and their corresponding sham-exposed groups. We conclude that 50-Hz electric field exposure, even of long duration at very high field strengths, does not induce harmful effects on tissues with high cellular turnover rates and does not impair the reproductive function of rats. Moreover, after exposure, all variables investigated were well within the normal physiological range.

Studies on the possible biological effects of 50 Hz electric and/or magnetic fields: evaluation of some glycolytic enzymes, glycolytic flux, energy and oxido-reductive potentials in human erythrocytes exposed in vitro to power frequency fields.

An attempt has been made to understand whether 50 Hz electric and magnetic fields (EMFs) are involved in producing bioeffects by exposing human erythrocytes in vitro. The study evaluated some key glycolytic enzymes, glucose consumption, lactate production, energy charge, 2,3-diphosphoglycerate, and reduced glutathione levels, all of which are biochemical parameters significant to erythrocyte function. Cells exposed to individual or superimposed EMFs have not shown any significant difference compared with the controls.

Electric and/or magnetic field effects on DNA structure and function in cultured human cells.

Exposure of cultured K562 cells to 50 Hz electric (0.2-20 kV/m), magnetic (0.002-2 G), or combined electric and magnetic fields for up to 24 h did not result in the production of detectable DNA lesions, as assayed by the filter elution technique. The rate of cell growth was also unaffected as well as the intracellular ATP and NAD+ levels. These results indicate that, under the experimental conditions utilized in this study, 50 Hz electric, magnetic and electromagnetic fields are not geno- and cyto-toxic in cultured mammalian cells.