Exsanguination From an Ulcerated, Atypical, Superficial Venous Malformation.

Venous malformations (VMs) are the most common vascular malformations, and their diagnosis can be challenging. They may develop in any region of the body, with highly variable clinical presentations. Although they typically present early in life, many case reports have documented the sudden appearance of a previously unrecognized venous malformation in adulthood. Pain is the major complaint in most of the cases, and other complications include phlebolith formation and bleeding. To our knowledge, fatal hemorrhage from a VM has not previously been reported in the medical literature. We present a case of exsanguination from a previously undiagnosed lower limb superficial VM. This case stresses the importance of proper diagnosis and management of VM.

Utility of Adjunctive Digital Subtraction Venography for the Treatment of Saphenous Vein Insufficiency.

PURPOSE: To report the use of adjunctive venography for the treatment of superficial venous reflux. METHODS: Two hundred consecutive patients (mean age 60.9 years, range 33-86; 128 women) with chronic venous disease underwent saphenous or perforator vein ablation in 268 limbs (305 venous trunks) guided by adjunctive venography and fluoroscopy in addition to ultrasound between October 2010 and May 2016. Intraprocedural venograms were independently evaluated by 2 vascular specialists to identify the presence of venous anomalies and the need for fluoroscopy-guided maneuvers to successfully complete venous ablation. Intraprocedural venography results were compared with preoperative venous duplex scan reports to ascertain if the duplex study could be of value in identifying preoperatively any anatomical variants that may pose a technical challenge to the operator. RESULTS: In this cohort, 542 venograms (2.0/limb) were performed with a mean duration of 4.9±9.1 minutes (range 1-48). Two thirds of patients (132, 66%) had anomalies or abnormalities within the target vein; more than a third (88, 44%) required an endovascular maneuver to successfully complete the ablation and 17% (34) of cases were impossible to complete without adjunctive fluoroscopic guidance. Per-patient comparison of intraprocedural venography with preoperative venous duplex reports identified 21 (11%) patients with abnormalities detected on ultrasound (23 anomalies) compared with 123 (64%) on venography (193 anomalies). This gave ultrasound a 17.1% sensitivity, 100% specificity and positive predictive value, and 40.7% negative predictive value. CONCLUSION: Venography is a valuable addition to ultrasound to facilitate complete ablation of insufficient saphenous veins in selected patients with complex anatomy.

A synopsis of current international guidelines and new modalities for the treatment of varicose veins.

BACKGROUND: The UK National Institute for Health and Care Excellence released new guidelines in 2013 recommending that endovenous thermal ablation (laser or radiofrequency) and ultrasound-guided foam sclerotherapy should be offered before conventional surgery for treat-ment of varicose veins and saphenous vein reflux. OBJECTIVE: The aim of this article is to provide a synopsis of current international guidelines and recent advances for the treatment of varicose veins. DISCUSSION: Conventional surgery involving classical high ligation and stripping of the saphenous vein has been standard practice for nearly a century. Surgery requires general anaesthesia and hospitalisation, and there is a high rate of recurrent disease. In the past decade there has been an international trend where the minimally invasive techniques of endovenous thermal ablation and ultrasound-guided foam sclerotherapy, which do not require hospitalisation, are beginning to displace surgery. These changes in technique have been supported by recently published international guidelines.

Proposal for Classification of the Great Saphenous Vein Aplasia by the B-mode Ultrasound.

BACKGROUND: The lack of the great saphenous vein (GSV) in its compartment is rarely mentioned in literature, although it happens in individuals with or without insufficiency of it. With the help of the B-mode ultrasound examination this vein can be easily identified. The aim of this study was to propose a classification for the findings. METHODS: Prospective study carried out for a period of 6 months in a sample of 2,665 lower limbs with ages ranging from 17 to 85, being that 1,286 patients are female. These patients underwent B-mode ultrasound examination as recommended by the literature. This evaluation determined whether there was a GSV aplasia by the analysis of its location in the saphenous compartment. RESULTS: After images were taken they were classified as: type I-aplasia only along the thigh, type II-aplasia only along the calf, type III-aplasia in the distal section of the thigh and proximal calf, type IV-vein in the saphenous compartment in the thigh and aplasia in the whole calf, type V-vein in the saphenous compartment only in a short segment in the proximal thigh, and type VI-vein with short segment in the saphenous compartment in the distal calf. From the total of 2,665 limbs, aplasia was found in 442 (16.6%). CONCLUSIONS: These anatomic findings attain an important role in daily practice, influencing the surgical decision, particularly with the arrival of endovascular procedures, such as the use of laser and thermoablation.

Capillary-venous malformation in the lower limb.

Regional capillary malformation of a lower extremity is associated with the overgrowth of bone or soft tissue in several disorders, most commonly Klippel-Trenaunay syndrome and Parkes Weber syndrome. We have observed a subset of patients with a capillary malformation of the leg, minor growth disturbance, and prominent veins. The objective of the current study is to describe a series of patients with regional capillary malformation of the lower extremity in association with phlebectasia. This is a retrospective series of 17 patients diagnosed with capillary-venous malformation of the lower extremity. We excluded patients with clinical or radiographic evidence of lymphatic or arteriovenous malformation. Age, presentation, associated features, radiographic findings, and management were documented. In most patients the capillary malformation covered a large area without sharply demarcated borders. Four patients had one or more discrete, well-defined capillary stains involving less than 5% of the total surface area of the affected lower limb. Prominent veins were most common in the popliteal fossa and on the knee and dorsal foot. Approximately two-thirds of patients had a leg length discrepancy, with the affected leg being longer (n = 6) or shorter (n = 4); in many the affected leg was also slightly larger (n = 8) or smaller (n = 4) in girth. Radiographic imaging showed dilatation of superficial (n = 16), muscular (n = 9), and deep veins (n = 6). We characterize a subset of patients with regional capillary-venous malformation of the lower extremity with prominent veins and minor hypotrophy/hypertrophy that differs from Klippel-Trenaunay syndrome (capillary-lymphatic-venous malformation) but belongs at the minor end of the spectrum of vascular disorders with overgrowth.

[Combined methods of treatment the congenital arterio-venous fistulas of peripheral vessels].

A 10-year experience and results of combined methods of surgical treatment of arterio-venous fistulas of peripheral vessels in 50 patients were analyzed. The patients were systematized on the basis of existing classifications, clinical manifestations of the disease, methods of invasive (ultrasound dopplerography and duplex scanning) and invasive (angiography) examinations. According to many authors no one of conventional methods of surgical treatment of arterio-venous fistulas which are used singly can be effective and must not be recommended as the most optimal. Stepwise employing of traditional operations and endovascular techniques are the main conditions for preventive measures of ischemic disorders in the limbs.

Optimal conduit choice in the absence of single-segment great saphenous vein for below-knee popliteal bypass.

BACKGROUND: Single-segment great saphenous vein (SSGSV) remains the conduit of choice for femoral to below-knee popliteal (F-BK) surgical revascularization. The purpose of this study was to determine the optimal conduit in patients with inadequate SSGSV. METHODS: This was a retrospective review of a prospectively maintained vascular registry. Patients underwent F-BK bypass with alternative vein (AV; arm vein, spliced GSV, or composite vein) or prosthetic conduit (PC). RESULTS: From January 1995 to June 2010, 83 patients had unusable SSGSV for F-BK popliteal reconstruction. Thirty-three patients had an AV conduit and 50 had PC. The AV group was a lower median age than the PC group (69 vs 75 years). The two groups were otherwise similar in comorbid conditions of diabetes mellitus (57.6% vs 58.0%; P > .99), smoking (15.2% vs 32.0%; P = .12), and hemodialysis (3% vs 12%; P = .23). The groups were similar in baseline characteristics such as limb salvage as indication (93.9% vs 86.0%; P = .31), mean runoff score (5.2 vs 4.6; P = .39), and prior ipsilateral bypass attempts (18.2% vs 18.0%; P > .99). The AV and PC groups were also similar in 30-day mortality (6.1% vs 4.0%; P > .99) and wound infection rates (6.1% vs 6.0%; P > .99). PC patients were more likely to be discharged on Coumadin (Bristol-Myers Squibb, Princeton, NJ) than AV patients (62.0% vs 27.3%; P = .002). Seventeen of the 50 PC patients (34%) had a distal anastomotic vein cuff. A log-rank test comparison of 5-year outcomes for the AV and PC groups found no significant difference in primary patency (55.3% ± 9.9% vs 51.9% ± 10.8%; P = .82), assisted primary patency (68.8% ± 9.6% vs 54.0% ± 11.0%; P = .45), secondary patency (68.4% ± 9.6% vs 63.7% ± 10.4% for PC; P = .82), or limb salvage rates (96.2% ± 3.8% vs 81.1% ± 8.1%; P = .19). Multivariable analysis demonstrated no association between conduit type and loss of patency or limb. The factors most predictive of primary patency loss were limb salvage as the indication for surgery (hazard ratio [HR], 4.23; 95% confidence interval [CI], 1.65-10.9; P = .003) and current hemodialysis (HR, 3.51; 95% CI, 1.08-11.4; P = .037). The most predictive factor of limb loss was current hemodialysis (HR, 7.02; 95% CI, 1.13-43.4; P = .036). CONCLUSIONS: For patients with inadequate SSGSV, PCs, with varying degrees of medical and surgical adjuncts, appear comparable to AV sources in graft patency for below-knee popliteal bypass targets. This observation is tempered by the small cohort sample size of this single-institutional analysis. Critical limb ischemia as the operative indication and current hemodialysis predict impaired patency, and hemodialysis is associated with limb loss.

Duplication of the great saphenous vein: a definition problem and implications for therapy.

BACKGROUND: In the literature there is a range from 1% to 20 % of duplication (up to 20%) of the great saphenous vein (GSV) reported, because there is a lack of an accurate definition of the GSV and objective parameters for an anatomical identification. OBJECTIVE: To investigate the frequency of true duplications of the GSV. MATERIALS AND METHODS: A systematic review of the literature, a retrospective analysis of duplex examinations, and a prospective study of duplex examinations to investigate the frequency of true duplications of the GSV. RESULTS: In the literature review, a great variety of definitions is used for duplication of the GSV. Before the consensus of the Union International de Phlébologie (UIP) in 2006, Only in a small number of studies, the definition of the GSV in the saphenous compartment between the fascial blades is mentioned. CONCLUSION: Phlebographic studies have been the criterion standard for the identification of venous anatomy. Now, duplex is regarded as the criterion standard for accurate detection of the veins. True duplication of the GSV is less common than the previous literature has suggested, namely 1.6% to 2%. It is recommended that the duplicated GSV should be treated to avoid an important risk of recurrence of venous insufficiency.

Endovenous therapy for the treatment of congenital venous malformations.

The treatment of a congenital venous malformation using endovenous radiofrequency ablation in a patient is described. The patient initially underwent two treatments of foam sclerotherapy with moderate success. Later the main feeding vessel of the venous malformation became evident on examination with venous duplex and was identified as the great saphenous vein. At this point, endovenous radiofrequency ablation was used to ablate the feeding vessel and successfully treat the lesion. The procedure proceeded without complications, and the patient made a good recovery. It is recommended that patients presenting with such malformations be considered for endovenous therapy as early as possible.

Systematic review and meta-analysis of the anatomic variants of the saphenofemoral junction.

BACKGROUND: The aim of this systematic review was to provide comprehensive data on the prevalence of variations of the saphenofemoral junction (SFJ) to prevent misidentification of the SFJ or the incomplete ligation of the tributaries of the great saphenous vein. METHODS: A systematic review was conducted using the PubMed, Embase, and Cochrane Library databases through September 14, 2017. To be included in the meta-analysis, a study had to report prevalence data on the morphology of the SFJ or the presence of venous tributaries. RESULTS: A total of 16 studies (7433 legs) were included. The majority of studies were performed during varicose vein surgery (74.14%), with fewer studies by means of computed tomography venography and cadaveric dissection. The pooled prevalence estimate (PPE) for a duplication of the SFJ with a bifid junction was 9.6% (P = .001). The PPE for a duplication of the SFJ with two separate junctions was 1.7%. The PPE for ectasia of the SFJ was 2.3% in type 1, 1.2% in type 2, and 1.7% in type 3. The distribution of the PPE for the number of venous SFJ tributaries was approximately normal with a slight right skew; a higher rate was observed in the group with four venous tributaries to the SFJ. CONCLUSIONS: This analysis found high heterogeneity in the prevalence of SFJ anatomic variants and the number of venous SFJ tributaries. For this reason, it is highly recommended that a preoperative Doppler ultrasound assessment of the SFJ and great saphenous vein be performed.

A review of literature along with a cadaveric study of the prevalence of the Giacomini vein (the thigh extension of the small saphenous vein) in the Indian population.

Short saphenous has most variable anatomy in the inferior extremity which become more relevant especially in varicose vein surgery. Present study on cadavers was undertaken to report the prevalence of the thigh extension of the short saphenous vein (Giacomini vein) in the Indian population and to discuss it with the prior studies reported in the literature on other populations. Dissection was performed on both the sides of 50 embalmed cadavers to study the prevalence of the Giacomini vein. Mode of termination of the proximal extension of the short saphenous vein in the thigh was studied for different criteria. Ninety-two percent of the lower extremities showed prevalence of the Giacomini vein. In 71% specimens the short saphenous vein terminated into the popliteal vein. Most common mode of extension in the thigh was anastomosis with the great saphenous vein. Prevalence of Giacomini vein in Indian population was highest (92%) compared to previous studies by various authors in other populations. Aforementioned anatomical facts including the mode of termination of the thigh extension of the short saphenous vein can be important for surgeons planning intervention in this area. The complex anatomy of this vein and different reports in the literature regarding its clinical significance suggest further studies in this direction.

Three reactive compartments in venous malformations.

Vascular malformations affect 3% of neonates. Venous malformations (VMs) are the largest group representing more than 50% of cases. In hereditary forms of VMs gene mutations have been identified, but for the large group of spontaneous forms the primary cause and downstream dysregulated genes are unknown. We have performed a global comparison of gene expression in slow-flow VMs and normal saphenous veins using human whole genome micro-arrays. Genes of interest were validated with qRT-PCR. Gene expression in the tunica media was studied after laser micro-dissection of small pieces of tissue. Protein expression in endothelial cells (ECs) was studied with antibodies. We detected 511 genes more than four-fold down- and 112 genes more than four-fold up-regulated. Notably, chemokines, growth factors, transcription factors and regulators of extra-cellular matrix (ECM) turnover were regulated. We observed activation and "arterialization" of ECs of the VM proper, whereas ECs of vasa vasorum exhibited up-regulation of inflammation markers. In the tunica media, an altered ECM turnover and composition was found. Our studies demonstrate dysregulated gene expression in tunica interna, media and externa of VMs, and show that each of the three layers represents a reactive compartment. The dysregulated genes may serve as therapeutic targets.

Repair of a combined femoral pseudoaneurysm and arteriovenous fistula using a covered stent graft.

Our purpose was to demonstrate clinical efficacy of covered stent use in the peripheral vasculature. A 68-year-old man was transferred from an outlying hospital for evaluation and treatment of a pulsatile mass in his right groin after cardiac catheterization. Imaging with duplex ultrasound and diagnostic arteriogram demonstrated a 6-cm pseudoaneurysm (PSA) of the right superficial femoral artery (SFA) and an arteriovenous fistula (AVF) of the SFA and the profunda vein. Using a covered stent extending from the proximal SFA across the origins of the AVF and PSA, complete exclusion was attained. Follow-up ultrasound at 6 weeks revealed a patent stent, no AVF, and thrombosis of the PSA. Endovascular treatment of peripheral lesions (AVF/PSA) in an elective to semi-elective setting offers patients a safe, less invasive treatment option to consider over traditional open surgery. Consequently, a formidable reduction in incision length, wound infection, and postoperative immobility can be expected.

[Ultrasound mapping of lower-limb vascular system with regard to occurrence and anatomy of additional front great saphenous vein]. / Ultrazvukové mapování zilního systému dolních koncetin s ohledem na výskyt a anatomii prední prídatné velké safény.

A primary survey study involving a set of 113 lower limbs of 66 patients was focused on the prevalence of additional front great saphenous vein (AFGSV) and the measurement of the distance between its start in the great saphenous vein (GSV) and the saphenofemoral junction (SFJ), the measurement of the distance between the passage of AFGSV through the saphenous fascia and its start in GSV, and compared the width of AFGSV anechogenous lumen with the calibre of GSV. The prevalence of AFGSV in the observed set was 42.5%. Reflux was proved in 6 AFGSVs (12.5%). The width of the AFGSV anechogenous lumen was on an average 0.29 cm (M 0.26 cm, SD +/- 0.15 cm), and the width of GSV anechogenous lumen measured on lower limbs with simultaneous occurrence of AFGSV was 0.38 cm (M 0.38 cm, SD +/- 0.11 cm) on an average. Comparison of the anechogenous lumen width of the two veins showed a statistically significant difference (p < 0,001). AFGSV in the observed set of lower limbs started in VS at an average distance of 0.8 cm from the saphenofemoral junction (M 0.8 cm, SD +/- 0.46 cm). The minimum start point distance was 0.1 cm, the maximum was 1.84 cm. In 3 cases (6.3%), AFGSV started directly in the common femoral vein (v. femoralis communis), which was the place where also the saphenous vein begins. The distance between the passage of AFGSV through saphenous fascia to upper subcutaneous layers and the start of the vein in GSV was on an average 13.2 cm (M 14.5 cm, SD +/- 6.5 cm). The maximum distance between the passage of AFGSV through saphenous fascia and the start of the vein in GSV was 4 cm, the maximum distance being 30 cm.

Use of greater saphenous venous anomalies for lower extremity revascularization.

With widespread acceptance of autogenous vein as the conduit of choice for lower extremity revascularization, the vascular surgeon should make every attempt to fashion arterial bypasses from this material. The most popular of these is the greater saphenous vein, the anatomy of which is inconstant. Several techniques are described that make use of anomalies in the greater saphenous venous system to create effective conduits for arterial reconstruction.

Anomalies encountered during varicose vein surgery.

During 5,050 stripping operations for varicose veins, three noticeable deviations from the normal anatomy were encountered. In two patients (0.04%) the long saphenous vein entered the femoral vein completely separate from its branches, which joined to form a common trunk before emptying into the femoral vein. In one patient (0.02%), the femoral vein and artery were transposed in the region of the fossa ovalis. In one patient (0.02%), a long saphenous artery was encountered. It arose from the femoral artery just proximal to the origin of the deep femoral artery and accompanied the long saphenous vein along the medial aspect of the upper thigh. In some patients, a large venous cluster overlying the fossa ovalis was encountered, usually the result of a congenital venous anomaly. Surgical problems can be minimized if the possibility of these congenital anomalies is always considered.

The value of pre-operative ultrasound mapping of the greater saphenous vein prior to 'closed' in situ bypass operations.

OBJECTIVE: The aim of this study was to test pre-operative ultrasound mapping for the detection of duplications and narrow vein segments of the greater saphenous vein (GSV) used as bypass for occlusive arterial disease surgery. PATIENTS AND METHODS: In 44 patients pre-operative ultrasound findings of duplications and lumen assessment of GSV were compared to the per-operative findings. RESULTS: In nine patients (20%) the pre-operative ultrasound examination showed a duplication. Pre-operative ultrasound had missed a duplication in two cases but had instead shown a narrow segment in both. The pre-operative ultrasound assessment of lumen diameter showed a narrow lumen segment in 10 of the 44 patients. In one patient a per-operatively narrow lumen had not been seen on pre-operative ultrasound. CONCLUSION: Pre-operative ultrasound mapping of the GSV is a sensitive tool for detection of duplications and narrow vein segments. Since these anatomical variations provide important information for the vascular surgeon, before performing a 'closed' in situ bypass operation, pre-operative vein mapping should be considered when planning such a procedure.

The caliber of the human long saphenous vein and its congenital variations.

The purpose of the present study is to evaluate the caliber of the normal human long saphenous vein (LSV) in order to verify the occurrence of congenital narrowings. The LSV morphology was evaluated by the dissection of 32 cadaveric limbs, and by ultrasonography of 102 healthy living subjects. The LSV caliber was constant in most of the limbs, showing only a mild and progressive increase from the ankle to the groin. Furthermore, great individual variation in LSV caliber was found. A segmental narrowing of the LSV was present in 39.8% of limbs. The narrow segment was visible with the naked eye during dissection or by ultrasonography in 22.4% of cases (LSV hypoplasia). In the remaining 17.4% the caliber was so reduced that it could only be detected microscopically (LSV aplasia). In relation to the narrow segments, the main ascending flow was shunted in a collateral vein running within the superficial hypodermis. The narrow segments of the LSV had a weaker and less muscular wall than did those of normal caliber. Hypoplasia and aplasia of the LSV are probably due to segmental failure in the development of the vessel, and represent a risk factor for varicosis. In fact, the ascending flow is shunted from the LSV in a collateral vein that runs in the yielding superficial fatty layer of the hypodermis. Furthermore, the high incidence of LSV segmental hypoplasia and aplasia has also to be considered whenever this vein is used as an arterial graft, because of the marked anatomical remodelling.