Ultrasound-guided foam sclerotherapy as a therapeutic modality in venous ulceration.

OBJECTIVES: The objective of this systematic review and meta-analysis was to evaluate rates of ulcer healing following ultrasound-guided foam sclerotherapy (UGFS). METHODS: The MEDLINE, CENTRAL and Embase databases were used to search for relevant studies using the terms ' (sclerotherapy AND ulcer) OR (vein AND ulcer) OR (sclerotherapy AND vein)'. Heterogeneity between studies was quantified using the I2 statistic. A random effects model was used to calculate risk ratios where substantial heterogeneity was found. RESULTS: The initial search yielded 8266 articles. 8 studies were included in the qualitative synthesis and 3 in the meta-analysis. Superior complete ulcer healing rates were noted in patients treated with foam sclerotherapy versus compression therapy alone (pooled OR 6.41, 95% CI = 0.3-148.2, p = 0.246, random effects method). A marked degree of heterogeneity was observed between studies (I2 = 81%). CONCLUSION: A prospective, trial is warranted in order to determine the true merits of UGFS in the setting of venous ulceration.

Incidental discovery of a long standing arteriovenous fistula after thrombectomy for acute lower limb ischaemia.

INTRODUCTION: Arteriovenous fistula (AVF) is the abnormal connection between an artery and vein. Congenital AVF of the popliteal artery is very rare. PRESENTATION OF CASE: 89 year old lady presented with right acute lower limb ischaemia. She had unilateral chronic venous hypertensive change in the right leg. Femoral embolectomy was performed. Backflow was achieved. Arteriotomy was closed. The patient's leg continued to deteriorate. She returned to theatre. On-table angiogram showed an occluded SFA. Thrombectomy was completed. SFA was patent but no blood flowed into the distal popliteal artery. A second on table angiogram revealed AVF between popliteal artery and vein. Dissection to the posterior aspect of the knee revealed the fistula. The vein was arterialized and enlarged. The AVF was ligated. Normal distal blood flow was achieved. Retrospectively we measured the leg lengths. Right leg was 3cm longer than the left. The right leg circumference was 7cm greater than the left. She reported chronic venous change from a young age. She did not report any history of trauma to the limb. DISCUSSION: Popliteal artery to popliteal vein fistula is a rare. Trauma is the most common cause of popliteal AVF. Should the condition develop before closure of the epiphyses, there may be an increase in leg measurements. CONCLUSION: We postulate that this case of AV fistula may be congenital due to discrepancy in leg measurements and unilateral chronic venous hypertensive change. Rarely persistent remnants of the embryonic sciatic artery can lead to arteriovenous anastomoses, which may be a possible aetiology.

Local anaesthetic flush reduces postoperative pain and haematoma formation after great saphenous vein stripping--a randomised controlled trial.

OBJECTIVES: To observe the effect of local anaesthetic flush through the great saphenous vein (GSV) tunnel on postoperative pain and haematoma formation following saphenous vein stripping operations. DESIGN: Prospective, double-blind, randomised, control trial. METHODS: One hundred patients were randomized to receive 20 ml of local anaesthetic (bupivacaine 0.25% + adrenaline) or saline control flush through the GSV tunnel after stripping in a double-blind study. Visual analogue pain scores were used to measure postoperative pain daily for the 1st week, then at 3 weeks and 6 weeks. Patients were examined during the 1st, 3rd and 6th week for haematoma formation. RESULTS: In the control group the median postoperative pain score was 4 (range 0-7) in the immediate postoperative period compared to a median of 1 (range 0-4) in the LA group (p<0.001). The median pain score on day-4 was 4 (range 1-6) (control) vs. 1 (range 0-3) (LA group) (p<0.001, Mann-Whitney Utest) and on day-6 it was 1 (range 0-5) (control) vs. 0 (range 0-5) (LA group) (p<0.001, Mann-Whitney). Twelve patients (24%) developed a haematoma in the GSV tunnel in the control group compared to three patients (6%) in the LA group (p = 0.007). CONCLUSION: Flushing of the GSV tunnel with bupivacaine plus adrenaline significantly reduces postoperative pain and haematoma formation in patients undergoing GSV stripping for varicose veins.