[High frequency ultrasonography and celluscore: an improvement in the objective evaluation of cellulite phenomenon]. / L'ultrasonographie à haute fréquence et le celluscore : un progrès dans l'évaluation objective du phénomène de cellulite.

As they usually do not have any serious effect on health condition, cellulite phenomenons are not considered as potentially hazardous by general practitioners; unfortunately they involve almost all the feminine population after the forties and may really induce bad side effects either psychological or physical whatever the confusing origin of that cutaneous deformation: heredity, nutrition, circulatory and hormonal diseases etc. Trying to appreciate in a more scientific way this superficial skin disorder, we have developed a computerised questionnaire which can be combined with the finest upto date way of skin exploration, high frequency ultrasonography. It seems possible to consider now cellulite as the result of various disorders which can be separate into fibrotic or retentional phenomenons (surrounding superficial fat tissues) and the direct adipocyte reaction (adiposis). We hope to be able in the future to extend the treatment of cellulite beyond the limits of liposuction which seems until today the only way to bring some improvement to that phenomenon in spite of the very delicacy of the surgical approach.

[Ambulatory and hemodynamic treatment of venous insufficiency (CHIVA cure). Study of 96 patients operated on between June 1988 and June 1990]. / La cure hémodynamique de l'insuffisance veineuse en ambulatoire (CHIVA). Etude de 96 patients opérés de juin 1988 à juin 1990.

96 patients were treated in two years by Ambulatory and Hemodynamic Treatment of Varicose Veins (CHIVA cure), representing 131 legs that underwent surgery. 71 patients (74%) representing 102 CHIVA cures in the long saphena territory were followed up, with a maximum of 28 months of follow-up. The CHIVA cure represents a new and interesting therapy: ambulatory, painless, it allows a very early resuming of normal life. The follow-up shows that the aesthetic and functional results are especially satisfying and seem to be steady. The CHIVA cure certainly neglects the histological and parietal aspects of venous incompetence but the treatment of the hemodynamic factor is effective. It can be applied on every type of varicose veins concerning the long saphena territory, provided that the deep venous system is normal. The interest of CHIVA cure concerning the short saphena territory remains to be demonstrated. Arteritic patients, patients with coronary arteries diseases, sportmen, young patients with a brief evolutive potential, especially women, are the best indications. The CHIVA cure is a reliable strategy in the short and medium term, offering excellent aesthetic and functional results that still have to be confirmed in the long term and or a large scale.

[Significance of venous endoscopy in the exploration and the treatment of venous insufficiency of the legs]. / Intérêt de l'endoscopie veineuse dans l'exploration et le traitement de l'insuffisance veineuse des membres inférieurs.

From a pathophysiological standpoint, the analysis of superficial valve lesions provides arguments in favour of the existence of early reflux and widens the role of valves beyond a simple antireflux system. All valves are not the same. Study of their topography in relation to collaterals and perforators enables definition of their role and of the origin of preferential hemodynamic circuits. Therapeutically, the first indications of venous endoscopy were in the visual control of deep venous thrombectomy, then in the preparation of saphenous bypasses in situ. It enables confirmation of the devalvulation of a segment of long saphenous and obstruction of afferent collaterals without an incision, by the endoscopic insertion of "micro-umbrellas". In addition, endoscopy can be used to identify incompetent deep valves suitable for valvuloplasty. In the superficial venous system, endoscopy offers a third dimension in the identification of varicosities in complex zones, such as the popliteal fossa. Furthermore, the development of a system for the endoscopic obliteration of superficial veins (ligatures, laser, umbrellas, chemical glue) could simplify the treatment of varicose veins.

[Ostial valves in a patient with varicose veins. Endoscopic examination]. / Les valvules ostiales du sujet variqueux. Examen endoscopique.

Twenty three endoscopies were performed, including six of the great saphenous region, fourteen of the small saphenous region and three involving the region of the medial gemellar perforators. Two types of valves may be seen on the basis of their endoscopic appearances: certain valves have a transparent appearance with very thin valvular tissue which tears easily when a catheter is passed against the direction of venous flow. These valves are located in the main saphenous veins and their collaterals, at a distance from bifurcations and the point of entry of perforating veins. The only type of lesion seen affecting these valves was tearing of their tissue. Their sole role appears to be to favourize the progression of venous flow in an anterograde direction. Other valves have an opaque appearance with valvular tissue thickened by an actual fibromuscular skeleton and strengthening of the free edge to form a lip. These resist counter-grade catheterisation and may prevent progression of the endoscope or of a stripper. These valves are located at the ostium of the terminal portions of the saphenous veins and directly proximal to the point of entry of certain collaterals and perforators. The latter, when reflux is present, behave as ostial valves, playing the role of an anti-reflux system as well as favourizing preferential hemodynamic circuits which explain certain varicose cartographic patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

[The value of venous endoscopy in sclerosing therapy]. / Intérêt de l'endoscopie veineuse dans le traitement sclérosant.

The sclerosing treatment of varices of the legs is based on palpation. Endoscopic palpation can be useful in the treatment of insufficiency of the territory of the external saphenous vein. A penetrating ulcer on the posterior surface of the thigh, with an intramuscular pathway linking the deep femoral vein with the external saphenous arch can lead to venous reflux in addition to that in the external saphenous arch. If this penetrating ulcer is overlooked, post-surgical recurrence may result within a brief period. However, a penetrating ulcer of this type cannot be detected by palpation and therefore cannot be treated by conventional sclerosis. Venous endoscopy offers a solution by permitting per-operative catheterization of the ulcer from the saphenous arch and the injection of sclerosing agents at the site of the reflux. Venous endoscopy of the saphenous arch can be of value if it makes it possible to avoid the repeated injection of rising doses. The use of chemical glues and fibrotic compounds has been discontinued due to the risk of damaging the deep veins. The future lies in a mechanical process, laser, electrocauterization or ligature.

[Angioscopy and the surgical treatment of varices in the area of the external saphenous vein]. / Angioscopie et traitement chirurgical des varices du territoire de la veine saphène externe.

The study of post-surgical relapses, by ultrasound and phlebographic examinations, shows that the difficulties in the treatment of varices of the external saphena territory are of two types: anatomical and haemodynamic. The venous endoscopy answers precisely to the requirements of the surgical treatment of varices of the popliteal space. It offers an acceptable compromise between aesthetics and efficacy, thanks to the incisions centred on the transcutaneous luminal point. It enables a per-operative control of the ultrasound-Doppler marking and the visualization of the small calibre perforating veins (less than 2 mm), not visible by ultrasound. It especially locates the deep non palpable refluxes situated above the anastomosis of the external saphenofemoral junction. The technique used is very simple thanks to the miniaturization of the equipment and the use of flexible small calibre endoscopes adapted to venous explorations.

Objectifying exercise ischemia in peripheral vascular disease: a study in 120 patients.

This study presents the results of transcutaneous oxygen pressure (TcPO2) monitoring during a treadmill test walk performed in the early stages of peripheral obliterative vascular disease. The study population consisted of a first group of 50 known arteriopathic patients presenting, on questioning, with intermittent claudication; a second group of 50 known arteriopathic patients void of any symptoms of intermittent claudication; and a third group, which was a control cohort of 20 nonarteriopathic, nonclaudicating patients. Though resting TcPO2 cannot be used to aid the clinical diagnosis of exercise ischemia it may be useful in revealing asymptomatic chronic resting ischemia (9% of cases in this series). On the other hand, a posteffort (recovery phase) fall in TcPO2 had a predictive positive diagnostic accuracy for ischemia on exercise in 99% of the cases reported here versus 87% for clinical appraisal. In the light of these results, TcPO2 measurements coupled to a treadmill test walk perfectly ascertain exercise ischemia in arteriopathic patients, whether asymptomatic or not, and avoid the false-positive results obtained by clinical evaluation.

[Hormones and venous system]. / Hormones et système veineux.

Sex hormones have an effect on venous "content" and "container" according to their chemical nature, their dosage and their mode of administration: 17 beta-estradiol (endogenous): protective effect; synthetic estrogens, at normal or low doses: thrombogenic; oral natural estrogens: thrombogenic; extra-digestive natural estrogens: non thrombogenic; non steroid progestagens (androgenic): thrombogenic; non androgenic progestagens: non thrombogenic. Clinically, the venous disease si characterized by sudden episodes occurring at key-periods of the hormonal life: puberty, pregnancy, menopause, oral contraceptives intake, substitute treatments of menopause, premenstrual syndrome. Evaluation of these different situations shows that an early treatment is possible and needed, which, although not providing a new venous wall for these constitutionally fragile patients, may act effectively at two levels: 1) correction of the haemodynamic disorder (venous reflux in the saphenous arches and the perforators; 2) resorption of tissue infiltration. As primary prevention, in a patient with hormonal disorders or who must be treated with estrogens or progestagens, the objective of our treatment is to protect the venous wall and encourage the return circulation. One must: 1) reinforce the vaso-constrictive effect and the parietal tone, 2) limit collagen and elastin alteration, 3) reinforce capillary permeability and decrease the interstitial edema, 4) normalize the haemorheological constants, 5) restore the balance hemostasis-fibrinolysis. The opinion of a phlebologist seems essential before prescribing a hormonal treatment and monitoring the effects of the treatment. Cooperation between gynaecologists and phlebologists is particularly essential in the interpretation of the clinical disorders as well as discussing the venous risk, the dosage and the administration route of sex hormones.

[Hypercoagulable ulcers. Apropos of a recent case]. / Les ulcères hypercoagulables. A propos d'un cas récent.

We describe the case of a cafe waiter aged 38, with an extensive sub-malleolar left internal varicose ulcer, which was chronic and very painful. This ulcer had been developing for 17 years and had not cicatrized for two years, which meant professional invalidity despite repeated attempts at therapy (qualified local care in a special department, hospitalizations, stripping, and filament graft). In the absence of any arterial, deep venous or lymphatic affection, deep biological disturbances meant this ulcer was classed in the category of hypercoagulable ulcers. A heparin treatment transformed the local situation and made it possible for a complementary surgical graft. Vascular ulcers resistant to properly administered local, vascular and general treatments, should lead us to investigate the possibility of hypercoagulability, whose best parameter is the high index of potential thrombodynamic (I.P.T.) calculated according to the thromboelastogram on the total blood. These hypercoagulable ulcers can be cured with a prolonged heparin treatment, in doses sufficient to normalize the I.P.T. without having to investigate true hypercoagulability with the T.C.K. It seems to us that this treatment is most effectively carried out in hospital, where it is possible to achieve constant heparinization by electric syringe and reequilibration of the biological constants.