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.

Vascular thoracic outlet syndrome: successful outcomes with multimodal therapy.

PURPOSE: Vascular thoracic outlet syndrome (TOS) can present with signs of arterial impingement or, more commonly, as venous obstruction. In an effort to decrease morbidity associated with vascular thoracic outlet syndrome, we have used an aggressive multimodal treatment approach. METHODS: Since November 1992, we have evaluated 29 patients with vascular thoracic outlet syndrome. Nine of ten patients with arterial thoracic outlet syndrome had first rib resections. Eighteen of 19 patients with venous occlusion underwent anticoagulation, thrombolysis, and first rib resection. Eight patients required additional endovascular therapy for persistent stenoses, either venous angioplasty alone (2) or angioplasty plus stent placement (6). RESULTS: Follow up extends to 75months with a mean of 24months. Patients with stents have been followed for a mean of 38months. Twenty-five of 28 patients managed with multimodal therapy were essentially asymptomatic at last follow up. CONCLUSION: Thrombolysis, anticoagulation, surgical decompression, and endovascular procedures act synergistically to improve results of therapy in patients with vascular thoracic outlet syndrome.

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.

Mechanical characteristics of lyophilized human saphenous vein valves.

PURPOSE: We investigated the mechanical characteristics of lyophilized human saphenous vein valves to determine their suitability for use as allogeneic transplants to treat chronic venous insufficiency. METHODS: Fresh cadaveric veins were lyophilized in vacuum bottles within 24 hours of harvest and were stored at room temperature. The veins were reconstituted in saline solution and then were placed in an in vitro flow circuit for evaluation. At varied flow rates, pressures proximal and distal to valves during prograde and retrograde flow were measured. Valve closure times were determined with Doppler examination and spectral analysis. The valves were also stressed to 350 mm Hg on a separate apparatus. RESULTS: All pressures proximal and distal to the valves remained less than 10 mm Hg during prograde flow. A pressure gradient developed immediately on the reversal of flow. Pressure as high as 200 mm Hg applied against the closed valves was not transmitted beyond the valve. Valve closure times had a mean of 0.31 +/- 0.03 seconds and 0.21 +/- 0.01 seconds for the Doppler examination and spectral analysis, respectively. All valves withstood stress pressures to 350 mm Hg. CONCLUSIONS: The in vitro mechanical characteristics of the valves of lyophilized veins are similar to known values for normal in vivo valves.

Nosocomial pneumonia in ventilated trauma patients during stress ulcer prophylaxis with sucralfate, antacid, and ranitidine.

OBJECTIVE: To compare the incidence of nosocomial pneumonia in critically injured patients randomized to one of three stress ulcer prophylaxis regimens. DESIGN: Prospective, randomized clinical trial. METHODS: Mechanically ventilated patients admitted to the trauma intensive care unit of a Level I trauma center received sucralfate, antacid, or ranitidine. MEASUREMENTS AND MAIN RESULTS: Two hundred forty-two patients were randomized: sucralfate, n = 80; antacid, n = 82; and ranitidine, n = 80. There was no statistically significant difference in pneumonia rates among the treatment groups (p = 0.875). Pneumonia occurred more frequently in patients with gram-negative retrograde colonization from stomach to trachea (p = 0.02), but this accounted for only 13% of all pneumonias in the study population. The death rate in patients with pneumonia was not statistically different among the three groups. Although 20% developed overt gastrointestinal bleeding, no episode was clinically significant. Mean gastric pH was > 4 in 95% of the study population, including 88% of patients receiving sucralfate. The death rate in the antacid group was significantly higher (p = 0.046) but not because of increased gastrointestinal bleeding or pneumonia. CONCLUSIONS: Our results show no difference in the incidence of nosocomial pneumonia in mechanically ventilated trauma patients during the first 4 days of stress ulcer prophylaxis with sucralfate, antacid, or ranitidine. There is a trend toward decreased pneumonia in the sucralfate group after study day 4. Even after controlling for injury severity, the mortality rate in the antacid group was significantly higher; the reasons for this are unknown.

Head CT scanning versus urgent exploration in the hypotensive blunt trauma patient.

In hypotensive blunt trauma patients with a diminished level of consciousness, it may be difficult to decide whether to proceed with immediate head CT scanning or urgent laparotomy or thoracotomy. The purpose of this study was to determine the frequency of emergency craniotomy and urgent laparotomy or thoracotomy in a group of 734 blunt trauma patients with initial hypotension (BP < 90 mm Hg systolic) admitted to the eight level I and II trauma centers in North Carolina. The mean initial systolic blood pressure was 64 +/- 26 mm Hg, and the mean Trauma Score was 8 +/- 5.8. Serious head injury (AIS head > or = 3) was present in 40% (293 of 734). Of 734 patients studied, 9.4% (69 of 734) died in the emergency department. Head CT scanning was performed on 47% (344 of 734) and produced positive results for 26% (202 of 734). Emergency craniotomy for intracranial hemorrhage was performed on 2.5% (18 of 734) (ten subdurals, three epidurals, and five other intracranial hemorrhages). Twenty-one percent (154 of 734) underwent urgent laparotomy, thoracotomy, or both. Overall hospital mortality for hypotensive blunt trauma patients was 36% (263 of 734). Although serious head injury occurs commonly (40%) in hypotensive blunt trauma patients, frequency of urgent laparotomy (21%) is 8.5 times greater than emergency craniotomy for intracranial hemorrhage (2.5%). This information may be used by trauma teams in prioritizing care for hypotensive blunt trauma patients.