Computerized venous strain-gauge plethysmography is a reliable method for measuring venous function.

OBJECTIVES: To achieve reference values for computerized strain-gauge plethysmography (SGP), to assess reproducibility, and to evaluate the influence of different factors such as age, gender, body mass index, and symptomatic post-thrombotic disease on commonly used variables. METHODS: Sixty-three healthy controls and 56 patients with previous deep venous thrombosis (DVT) were included. All participants underwent computerized SGP with evaluation of outflow capacity, as well as evaluation of venous reflux and muscle pump function. RESULTS: All variables were significantly reduced in DVT limbs, both compared with contralateral limbs and with healthy controls. Only two patients had all values within normal ranges (=mean ± 2 SD in controls). Measures of outflow capacity had a coefficient of variation (CV) of 5-6% and exercise-induced volume changes a CV of 10-15%. In symptomatic post-thrombotic limbs half-refilling time was significantly related to presence of edema (R = -0.28, p < .05) and to chronic skin changes (R = -0.58, p < .001). CONCLUSIONS: We suggest that our values in healthy controls can be used as new reference values for computerized venous strain-gauge plethysmography. The computerized design ensures high reproducibility and the results indicate that this is a very useful and sensitive test for functional quantitative assessment of patients with venous disease.

Outcome after 7 years of carotid artery stenting and endarterectomy in Sweden - single centre and national results.

OBJECTIVES: The aim was internal vascular centre quality-control measures to compare single-centre results with the national perspective, as well as analysing the Swedish results from carotid artery stenting (CAS) and comparing a relatively high-volume single centre with the Swedish Vascular Registry (Swedvasc) data. The second aim was to compare CAS and carotid artery endarterectomy (CEA) outcomes for the same 7-year period. DESIGN: Retrospective review of a single high-volume centre (Södersjukhuset (SÖS)) (approximately 30 CAS year(-1) approximately 90 CEA year(-1)) versus Swedvasc National data. MATERIALS AND METHODS: All consecutive selective patients treated with CAS at SÖS for a stenosis of the internal carotid artery (n = 208) or CEA (n = 552) between 2004 and 2011 were compared with all patients in Swedvasc registered for CAS (n = 258) and CEA (n = 6474). Primary outcome was 30-day frequency of stroke or death. Secondary outcome was stroke/death/acute myocardial infarction (AMI). RESULTS: The 30-day frequency of any stroke or death after CAS at SÖS compared to the national data was 2.9% and 7.4%, respectively (P = 0.04). The 30-day AMI/stroke/death frequency was 3.4% and 9.5%, respectively (P = 0.01). After CEA during the same time period, the Swedvasc national data had a 4.4% frequency of 30-day stroke and death and 5.8% for AMI/stroke/death. CONCLUSIONS: CAS is not as safe as CEA from a national perspective but our results indicate that a single centre can achieve acceptable results with CAS.

Deep venous thrombosis after surgery for Achilles tendon rupture: a provoked transient event with minor long-term sequelae.

BACKGROUND: Deep venous thrombosis (DVT) occurs frequently in patients undergoing orthopedic surgery, but there is a lack of knowledge regarding long-term sequelae of DVT after different types of surgical procedures. OBJECTIVE: To describe the long-term effect of symptomatic (SDVT) and asymptomatic (ADVT) deep venous thrombosis on venous function and subsequent incidence of post-thrombotic syndrome (PTS) in patients who have undergone surgery for Achilles tendon rupture. PATIENTS/METHODS: This observational follow-up study includes 83 patients with postoperative DVT, examined after a mean of 7 years. There were two series of patients: 45 with SDVT and 38 with ADVT. In both series, more than 90% of the DVTs were limited to calf veins. Follow-up examinations comprised color duplex ultrasonography (CDU), strain-gauge plethysmography (SGP), clinical examination including scoring for venous disease and questionnaires for quality of life (QOL). RESULTS: A mild degree of PTS was found in 11% of the patients: 13% in SDVT and 8% in ADVT patients. The rate of recurrent ipsilateral DVT was 2%. Deep venous reflux was more common in patients with SDVT than in ADVT patients (84% vs. 55%, P < 0.01). Only a few patients had plethysmograpically abnormal findings without difference between the two groups. CONCLUSION: DVT after surgery for Achilles tendon rupture consists mainly of distal DVTs and are associated with a low risk for PTS. Deep venous reflux was more common in SDVT than in ADVT patients, probably as an effect of larger DVTs in the former group.

Asymptomatic deep venous thrombosis is associated with a low risk of post-thrombotic syndrome.

UNLABELLED: Post-thrombotic syndrome (PTS) is a well-recognized condition that develops after symptomatic deep venous thrombosis, but the clinical significance and late complications of asymptomatic deep venous thrombosis (ADVT) are unclear. OBJECTIVE: To determine whether ADVT following minor surgery affects venous function and contributes to the later development of PTS. PATIENTS/METHODS: The study included 83 patients operated on for Achilles tendon rupture; 38 patients with postoperative ADVT and 45 patients without (control group). The follow-up examinations five years after the operation comprised computerised strain-gauge plethysmography, colour duplex ultrasonography, clinical scoring of venous disease, and quality of life (QOL). RESULTS: Villalta scores, CEAP classification and QOL did not differ between groups. PTS (=Villalta score > or =5) was found in three ADVT patients (8%) and in two controls (4%). Ultrasonography revealed post-thrombotic changes in 55% of ADVT patients and in none of the controls. Deep venous reflux occurred in 22 ADVT patients and in three controls (P<0.001). There was no difference between groups in plethysmographic variables, demonstrating that the ultrasonographic abnormalities were of negligible haemodynamic significance. CONCLUSIONS: PTS is not a common sequel to ADVT after minor surgery. Although more than 50% of patients with ADVT developed post-thrombotic changes according to ultrasound, these changes did not result in haemodynamically significant venous dysfunction.

Primary deep vein thrombosis in the upper limb: A retrospective study with emphasis on pathogenesis and late sequelae.

BACKGROUND: Thrombosis of the upper extremity (UEDVT) is an uncommon disease with an incidence of 2-3% of all deep vein thromboses. The aim of this study was to determine the frequency of thrombophilia, post-thrombotic symptoms (PTS), and the rate of complications and recurrences in patients with primary UEDVT, which includes idiopathic and effort-related thrombosis. METHODS: Thirty-two patients with primary UEDVT were participants in the study. All patients with malignancies and intravenous devices were excluded. Two different scoring instruments - the Villalta and the DASH - were used to diagnose PTS, and a visual analogue scale (VAS) was used to estimate pain and disability. To evaluate working capacity, an arm exercise test was performed. Blood samples were taken for antithrombin, protein C and S deficiencies, antiphospholipid antibodies, mutation of factor V, fibrinogen, D-dimer, and von Willebrand factor antigen. RESULTS: None of the patients developed malignancy, pulmonary embolism, or recurrent UEDVT. Twenty-eight percent of the patients had mild to moderate PTS according to the scoring instruments. The arm exercise test and the VAS did not provide any additional information about the severity of PTS. The prevalence of thrombophilia was 40%; the most frequent disorders were the mutation of factor V (19%) and elevated fibrinogen (22%). CONCLUSIONS: This study supports the belief that primary UEDVT is a benign disorder with a low risk for recurrence but with a high frequency of PTS. For a majority of the patients, the underlying cause of the thrombotic event is unclear.

High sensitivity with color duplex sonography in thrombosis screening after ankle fracture surgery.

BACKGROUND: Phlebography is regarded as the reference standard for diagnosing asymptomatic deep vein thrombosis (DVT) in studies of thromboprophylaxis. However, technical advances with noninvasive color duplex sonography (CDS) have made this procedure an interesting alternative. OBJECTIVES: The objective of the present prospective study was to compare the sensitivity and specificity of CDS with those of phlebography. PATIENTS: The first 180 consecutive patients included in a larger randomized trial for prolonged thromboprophylaxis were subject to unilateral CDS and to phlebography after ankle fracture surgery. The patients were examined 6 weeks after surgery, all examinations being evaluated blindly. After patient drop outs and exclusions, 144 patients were left for analysis. RESULTS: Phlebography and CDS examinations were inconclusive or were not completed for 19% of these patients (28/144). DVT was diagnosed by phlebography in 21% (24/116) of the remaining patients. Most of the thrombi were isolated calf DVTs (18/24). In contrast, DVT was diagnosed by CDS in 31% of these patients (36/116): only one case diagnosed by phlebography was missed by CDS. The specificity of CDS is thus 86% and its sensitivity is 96%. The positive predictive value is 64%, and the negative predictive value is 99%. CONCLUSIONS: CDS is a safe method for detecting asymptomatic distal DVT. It has a high sensitivity and high negative predictive value, which means that the method is highly reliable to rule out DVT. Our results indicate that CDS could be considered as an alternative method for DVT screening.

Circulating markers of inflammation are related to carotid artery atherosclerosis.

AIM: The role of inflammation in atherothrombotic disorders is becoming increasingly recognized. The present study prospectively investigates relationships between inflammatory markers and hemostatic variables, and non-invasive measures of carotid artery atherosclerosis. METHODS: Markers of hemostasis (sP-selectin and fibrinogen), cytokines (IL-6, IL-8, TNF-a and MCP-1), inflammatory variables (hsCRP, SAA and calprotectin) and cell adhesion molecules (ICAM-1 and VCAM-1) as well as ultrasonography of the carotid arteries were assessed in 111 consecutive outpatients with manifest or suspected coronary artery disease (CAD). RESULTS: Thirty-eight patients with manifest cardiovascular disease had higher IL-6 (P < 0.01) but not hsCRP levels. Higher levels of IL-6, calprotectin and VCAM-1 (all P < 0.05) were found in 35 patients with carotid plaques. In the whole study population (n = 109) an increased common carotid artery lumen diameter (LD) and cross sectional intima-media area (CIMA) was related to higher IL-6, IL-8 and MCP-1 levels (all P < 0.05), and increased LD also to higher hsCRP, calprotectin (both P < 0.05), sP-selectin and fibrinogen levels (both P < 0.01). Both LD and CIMA were related to VCAM-1 (both P < 0.01), but not to ICAM-1 levels. The intima-media thickness of the carotid artery was only positively related to MCP-1 levels (P < 0.05). Only the relation between IL-6 and LD remained significant after adjustment for age, gender, body mass index, smoking status or present lipid-lowering treatment. CONCLUSIONS: Several biomarkers of inflammation are related to ultrasonographic measures of carotid artery atherosclerosis in patients with moderate to high prevalence of CAD. IL-6 seems to be an independent and useful biomarker of atherosclerosis in this group of patients.

A 16-year haemodynamic follow-up of women with pregnancy-related medically treated iliofemoral deep venous thrombosis.

OBJECTIVES: to evaluate clinical and functional long-term outcomes following pregnancy-related medically treated iliofemoral deep venous thrombosis (DVT). DESIGN: retrospective follow-up of patients identified through a registry search. MATERIAL AND METHODS: twenty-five women underwent clinical examination, colour duplex ultrasound and computerised strain-gauge plethysmography on two occasions a mean of nine and 16 years after DVT. RESULTS: 40% of the patients were completely asymptomatic and 52% had no clinical signs of venous disease after a mean follow-up of 16 years. The clinical signs were in general mild, and none of the 25 patients had skin changes or ulcers. Deep venous reflux was found in 36% of the patients; the same percentage at nine- and 16-years follow-up, and 24% had normal ultrasonographic appearance of all deep veins. None of the patients had plethysmographic evidence of outflow obstruction. There was a significant relationship between measures of venous reflux and the presence of leg swelling, but there was no clear relation between functional abnormalities and the extent of the initial DVT. CONCLUSION: even after 16 years there are relatively mild symptoms and signs of venous disease in women with medically treated pregnancy-related iliofemoral DVT. Our results do not support earlier stated opinions that these patients represent a particular risk group for developing post-thrombotic syndrome.

Carotid atherosclerosis in relation to symptoms from the territory supplied by the carotid artery.

OBJECTIVES: To investigate the relationship between intima-media thickness in the common carotid artery, plaque morphology in the carotid bifurcation and symptoms of cerebral embolism. Design prospective study of consecutive patients referred for carotid duplex examination. METHODS: One hundred and eighty-eight patients were classified by one of two neurologists into four categories (symptomatic, asymptomatic, undefined, uncertain). Carotid atherosclerosis was measured by means of high-resolution ultrasound technique. Carotid plaques were classified based on visual evaluation of plaque echogenicity. RESULTS: Intima-media thickness (IMT) was correlated to presence of plaques, age and gender, but not to symptoms referable to the carotid circulation. Carotid plaques were more common in symptomatic than in asymptomatic vessels (p<0.05). There was no difference in plaque occurrence between the ipsi- and contralateral sides in the symptomatic patients, neither in frequency of echolucent plaques between the sides or between symptomatic and asymptomatic patients. Echogenic plaques were more common and generally smaller than echolucent plaques. CONCLUSIONS: IMT correlates with presence of plaques, but not with symptoms from the territory supplied by the carotid artery. Echolucent plaques in the carotid bifurcation are not more frequently symptomatic than echogenic plaques are, in patients with low-to-moderate degree of carotid stenosis.

Effect of reversible hypoperfusion on left ventricular volumes measured with gated SPECT at rest and after adenosine infusion.

BACKGROUND: The aims of this study were to assess the degree of postischemic left ventricular (LV) dilatation after adenosine stress and to determine the extent to which LV volumes measured with gated single photon emission computed tomography (SPECT) correspond to those obtained by echocardiography. METHODS: Eight-frame gated SPECT with a 2-day technetium-99m tetrofosmin acquisition protocol was used. End-diastolic (EDV) and end-systolic (ESV) volumes were measured automatically with the quantitative gated SPECT algorithm. Reversible myocardial hypoperfusion was evaluated with a 16-segment, 4-point perfusion score model. LV volumes at rest were also measured with echocardiography by use of the biplane Simpson rule. RESULTS: Twenty-two patients (group 1) showed normal perfusion and normal LV systolic function, whereas 33 patients (group 2) had evident coronary heart disease with reversible hypoperfusion. Patients in group 2 had greater EDV and ESV than those in group 1 both at rest and poststress. A greater reduction in ESV from poststress to rest was seen in group 2, which resulted in a slight increase in ejection fraction for patients in this group. The change in ESV from poststress to rest was significantly influenced by the degree of reversible hypoperfusion and by the change in heart rate from poststress to rest. We found a good correlation between LV volumes measured with gated SPECT and echocardiography. CONCLUSION: LV volume measurements with quantitative gated SPECT are comparable to those obtained with echocardiography. Patients with ischemic heart disease have greater LV volumes than patients with normal perfusion. Exercise-augmented adenosine infusion in patients with ischemic heart disease affects ESV more than EDV. This response is partly modulated by the degree of reversible hypoperfusion and possibly represents a minor degree of poststress stunning.

[Varices and venous insufficiency--therapeutic philosophy prior the 2000's]. / Varicer och venös insufficiens--behandlingsfilosofi inför 2000-talet.

Varicose veins represent everything from a cosmetic problem to a risk of venous leg ulcers. Predicting the risk of complications has been difficult, not least due to less than satisfactory diagnostic procedures. Recent investigations have pointed out some important new concepts: Superficial venous incompetence may give rise to an ulcer, and such an ulcer may be prevented by varicose vein surgery. Recanalization and stenting may be useful in treating chronic iliac and caval venous occlusions; however, long-term outcome is yet to be established. Venous diameter can be reduced, thus effecting valve competence. To what extent this result is long-lasting is not known. Neither has the method been attempted on deep veins. Clinical diagnosis is never sufficient in cases of suspected chronic venous incompetence. The minimum requirement is the use of a hand-held Doppler. Frequently, a more detailed ultrasonographic analysis is required, and for a global assessment of venous function, plethysmographic techniques are useful. Primary health care may contribute effectively to the care of venous leg ulcers.

Temporal variability of exercise Doppler echocardiography in patients with nonstented aortic bioprostheses.

Temporal variability and reproducibility of Doppler-derived variables obtained during supine symptom-limited exercise was investigated in 26 patients who were in clinically and hemodynamically stable condition with normally functioning nonstented aortic bioprostheses (stentless porcine, n = 13; cryopreserved homografts, n = 13). All patients had normal systolic left ventricular function and underwent 2 similar exercise tests within 12 months (mean time interval 7.2 +/- 1.9 months). The coefficient of variation was 8% to 9% for primary Doppler-derived variables (ie, velocities and velocity time integrals) at rest and during exercise. The coefficient of variation for calculated maximal pressure difference was 16% at rest and 15% at peak exercise. Measurement variability assessed from repeated measurements from the same videotaped recording was approximately 2%. High reproducibility was shown for most variables with intraclass correlation coefficients of 0.85 or more. We conclude that Doppler echocardiography can be used in patients with nonstented aortic bioprostheses with the same high reproducibility during exercise as at rest. The results provide clinically useful information regarding temporal variability for Doppler-derived variables.

Effects of exercise on Doppler-derived pressure difference, valve resistance, and effective orifice area in different aortic valve prostheses of similar size.

The effects of increased transvalvular volume flow on Doppler-derived measurements were compared in similarly sized, normally functioning, mechanical prostheses, stented and stentless porcine bioprostheses, and homografts. Homograft and stentless valves showed the largest effective orifice area and the lowest pressure differences and valve resistance at rest and during exercise-induced increase in flow rates.

Hemodynamic performance of cryopreserved aortic homograft valves during midterm follow-up.

OBJECTIVES: The aim of this prospective study of adult patients operated with a cryopreserved aortic homograft was to use serial echocardiographic data to evaluate the postoperative hemodynamic performance of these valves. BACKGROUND: Only limited data on hemodynamic performance of aortic homografts at rest and during exercise are available. Controversy also exists regarding incidence and progression of aortic regurgitation (AR). METHODS: Fifty-nine patients aged 39-86 years who received an aortic homograft (median size 21 mm) implanted with subcoronary technique were studied with serial Doppler-echocardiography (D-E). In 31 of these patients, D-E also was performed during supine exercise. RESULTS: Overall survival was 100% during a median follow-up of 28 months (range 4-54). During follow-up AR grade II or more was detected in 25% of the patients with an increasing time-related risk of developing AR. Maximum and mean pressure differences at 7 months follow-up calculated with the short form of the Bernoulli equation were 11.4 (4.6) and 5.5 (2.1) mm Hg, respectively. During supine exercise that increased cardiac output 72%, maximum pressure difference increased from 11.9 (5.2) to 18.5 (9.5) mm Hg. CONCLUSIONS: The aortic homograft valve shows low pressure differences at rest and during exercise, but AR grade I or II is often seen during follow-up. As AR progresses with time we stress the importance of echocardiographic follow-up of patients with aortic homografts.

Relationship between intima-media thickness in the common carotid artery and atherosclerosis in the carotid bifurcation.

BACKGROUND AND PURPOSE: An increase in intima-media thickness (IMT) in the common carotid artery (CCA) is commonly used as a marker of atherosclerosis. The purpose of this study was to investigate the relationship between IMT in the CCA and atherosclerosis in the carotid bifurcation. METHODS: 182 consecutive patients (mean age, 67 years) referred for carotid duplex scanning were included. We measured IMT and classified plaques by means of a high-resolution ultrasound technique. RESULTS: IMT was correlated to age, male gender, ischemic heart disease, and presence of plaques or stenoses in any of the carotid bifurcations. In men, IMT was larger on the left than on the right side. Plaques were seen in 163 carotid bifurcations, in 45 of these with > 50% stenosis. On the left side but not on the right, there was a correlation between IMT in the CCA and presence of plaques or stenoses in the carotid bifurcation. Echogenic plaques were more common than echolucent, but the latter caused significantly more stenoses. No relationship was found between plaque echogenicity and IMT. CONCLUSIONS: IMT of the CCA is correlated to the degree of atherosclerosis in the carotid bifurcations in general and on the left side also to the presence of plaques or stenoses in the left carotid bifurcation. Our results support earlier observations suggesting faster development of carotid atherosclerosis on the left than on the right side. Echogenic plaques were more common and generally smaller than echolucent plaques, but there was no correlation between plaque echogenicity and IMT.

Pulmonary function following adjuvant chemotherapy and radiotherapy for breast cancer and the issue of three-dimensional treatment planning.

BACKGROUND AND PURPOSE: The frequency and grade of pulmonary complications following adjuvant radiotherapy for breast cancer are still debated. This study focuses on loss of pulmonary function. MATERIALS AND METHODS: We have measured the reduction of pulmonary function 5 months following radiotherapy in 144 node-positive stage II breast cancer patients by using pulmonary function tests. RESULTS: No deterioration of pulmonary function was detected among the patients who were treated with local radiotherapy. On the contrary, there was a mean increase in diffusion capacity by 7% (P = 0.004) following radiotherapy, which most likely was explained by the adjuvant chemotherapy administered prior to the baseline pulmonary function tests. Patients undergoing loco-regional radiotherapy showed a mean reduction in diffusion capacity by 5% (P < 0.001) and in vital capacity by 3% (P = 0.001). The subset of patients (9%) who were diagnosed with severe pulmonary complications needing cortisone treatment had significantly larger mean paired differences in vital capacity (-0.446 L, -15% (equivalent to 15 years of normal ageing or the loss of 3/4 of a lung lobe)) compared to the patients who were asymptomatic (-0.084 L) (P < 0.05). When the effects of potential confounding factors and different radiotherapy techniques were tested on the reduction of pulmonary function by stepwise multiple regression analysis, a significant correlation was found only to locoregional radiotherapy including the lower internal mammary lymph nodes. CONCLUSIONS: We conclude that a clinically important reduction of pulmonary function is seen in the subset of patients who are diagnosed with severe pulmonary complication following loco-regional radiotherapy for breast cancer. The results of this study warrant further studies based on individual lung dose volume histograms.

A methodological study of arterial wall function using ultrasound technique.

We aimed to establish reference values for three important properties of the arterial wall using a conventional ultrasound scanner. We measured: (1) intima-media thickness (IMT) of the carotid arteries with the internal trace function of the ultrasound system; (2) wall stiffness by pulsatile diameter changes in the right common carotid artery assessed by M-mode; and (3) endothelial function expressed as flow-mediated dilatation (FMD) of the brachial artery. IMT and wall stiffness measurements and reproducibility were compared with those obtained by external analysing systems. All variables were obtained in healthy subjects (n = 20), 29-53 years old. IMT increased with age (P < 0.01). There was no difference in IMT between men and women. The inter-operator variability for measuring IMT was 6-9%. The same order of reproducibility was obtained with an external PC-based analysing system. Regarding wall stiffness, no correlation was found with age, nor any difference between men and women. A low intra-operator variability (CV < 10%) was found for measurements of wall stiffness with both M-mode and an external wall tracking system. FMD of the brachial artery diminished with age (P < 0.01). There was a relation between FMD and brachial artery size (P < 0.01) and, therefore, as men have larger arterial diameters (P < 0.01), smaller FMD in men. We conclude that it is possible to characterize arterial wall function non-invasively in an adequately reproducible manner using a conventional ultrasound system in healthy middle-aged men and women.

In vitro endothelialisation of arteriovenous loop grafts for haemodialysis.

OBJECTIVES: To evaluate the feasibility in a pilot study of in vitro endothelialisation of PTFE grafts used as interposition arteriovenous fistulas in uraemic patients. METHODS: Autologous saphenous vein endothelial cells were harvested and cultured on PTFE grafts in seven patients undergoing maintenance haemodialysis. The patients had several previous failures of vascular access sites. The patients were followed with duplex ultrasound, clinical examination and in one case an explanted graft was examined. RESULTS: At the end of follow-up four of the seven patients had patent grafts. One patient occluded the graft immediately postoperatively and another after 3.5 months. The former patient received a second endothelialised graft. In two further patients revision of the outflow was performed. In two patients a functioning graft was excised, in one case because of bleeding of a venous aneurysm and in one case because of suspected infection. The former which was excised 5 weeks postoperatively revealed that 85% of the surface was covered by endothelial cells. CONCLUSIONS: This pilot study shows that in vitro endothelialisation of PTFE grafts used for haemodialysis is possible in uraemic patients. In this highly problematic patient group the results are promising with endothelial cell coverage after 5 weeks of implantation.