Prediction of Post-interventional Outcome in Great Saphenous Vein Incompetence: The Role of Venous Plethysmography with Selective Superficial Vein Occlusion.

OBJECTIVE/BACKGROUND: To evaluate whether the outcome of radiofrequency ablation (RFA) treatment of great saphenous vein (GSV) incompetence may be predicted using strain-gauge plethysmography (SGP) with selective occlusion of the superficial venous system. METHODS: Seventeen patients (20 limbs) underwent endovenous RFA treatment for GSV incompetence (Clinical Etiology Anatomy Pathophysiology classification C2-C5; "C-group"). Duplex ultrasound (DUS) and SGP were performed with selective occlusion of superficial veins before and after RFA. Selective superficial occlusion was validated, in a control group (C-group) of 12 patients (14 legs), by ascending phlebography. In the RFA group, the time taken to reach 50% and 90% (T50, T90) of maximum venous volume was measured, as well as relative maximal reflux rates (%EV/min). The methodological error and coefficient of variation (CV) were assessed. RESULTS: Nineteen of 20 legs had complete post-operative GSV obliteration using DUS, and refilling times were improved after RFA (T50 11 ± 3 vs. 19 ± 3 s; p < .001; T90 27 ± 5 vs. 47 ± 6 s; p < .001). With SGP, the methodological error and CV for T50 were 4 s and 16%, respectively. Equivalence between pre-operative superficial occlusion and post-operative baseline measurements was achieved in 15 of 17 legs for T50, and 12 of 17 for T90 (three of the 20 legs were excluded due to treatment failure [n = 1], and untreated perforating veins [n = 2]). Mean differences (95% confidence interval) were within the equivalence ranges (T50 1 [-1 to 3] seconds; T90 -3 [-11 to 4] seconds). In the C-group superficial vein occlusion was possible in 12 of 14 legs. The remaining patient (two legs) showed incomplete superficial vein occlusion at ankle level (lipodermatosclerosis) and complete superficial vein occlusion at calf level. CONCLUSION: SGP with standardized superficial venous occlusion seems to be a reliable method for identifying venous reflux and may be useful in predicting the results of successful RFA treatment.

[Ultrasound duplex an important tool in diagnosis of vascular diseases]. / Ultraljudsduplex värdefullt redskap i kärldiagnostik.

Ultrasound duplex scanning has caused a revolution to noninvasive diagnostics of disease in arteries and veins. A duplex examination (duplex = gemini, twin) initially implied the use of a combination of black and white 2D image and spectral Doppler, but now also includes colored directional Doppler and energy (nondirectional) Doppler. Late ultrasound developments are: low frequency (tissue) Doppler, 2nd harmonics image and doppler, contrast enhancement of blood flow, 3- and 4 dimensional reconstruction of image and flow, and compound imaging, every modality with new and improved information. It is possible to image the arterial and venous circulation in detail, including the vessel wall and the atherosclerotic atheroma, viewing both anatomical, functional, dynamic and mechanical properties. Furthermore, it is possible to use low-energy diagnostic ultrasound for intervention, for example to enhance thrombolysis. Duplex scanners now are used as the prime diagnostic tool in vascular laboratories. Even for traditionally morphological diagnostic purposes, flow information is valuable. A duplex examination is normally entirely noninvasive and nontraumatic, and thus without risks or discomfort for the patient. The technic has improved gradually and now may complement or even replace angiography and venography, for example for detection of carotid, iliac and femoral stenosis, venous insufficiency and venous thrombosis. As the examination is performed in real time, momentary flow and wall movements may be studied, for example during exercise and in drug research.

Ultrasound determined carotid and femoral atherosclerosis in Lithuanian and Swedish men: the LiVicordia study.

Coronary heart disease mortality is four times higher in Lithuanian compared to Swedish middle-aged men. Using the same equipment (Acuson XP10 with 5 MHz linear transducer) and staff, we compared the amount of atherosclerosis in carotid and femoral arteries in 100 randomly sampled 50-year-old men in each of the cities Vilnius, Lithuania and Linköping, Sweden. Atherosclerotic plaques were more abundant in Vilnius men compared to Linköping men (53 versus 28% in the common carotid artery, 73 versus 37% in the common femoral artery, P < 0.001 for both). Plaques were thicker and more extended in arteries of Vilnius men, and an ultrasound atherosclerosis score was higher in both carotid and femoral arteries (P < 0.001 for all). More Vilnius men had a maximal intima-media thickness of the common femoral artery above 1 mm (P<0.005). Stiffness in the common carotid artery was higher in Vilnius men (P<0.001). In a linear regression model of the pooled material, after adjustment for city was made, smoking, systolic blood pressure, low density lipoprotein cholesterol and beta-carotene (inversely) significantly contributed to a high total ultrasound score (r2 = 0.32). These findings show that the higher coronary mortality noted in Lithuanian men goes together with a higher prevalence of early peripheral atherosclerosis.

One year of prospective follow-up after carotid thrombendarterectomy--a clinical and duplex study.

OBJECTIVES: The aim of this study was to make a prospective evaluation of the carotid arteries after thrombendarterectomy by combined clinical and duplex examination, to define an exact time of development of postoperative restenosis/occlusion and to relate early morphological changes to occurrences of new neurological events. MATERIAL AND METHODS: Sixty-four patients (66 operations), 48 men and 16 women, mean age of 63+/-8 (SD) years, with transient ischaemic attacks or minor stroke were examined clinically 1 day before and after the carotid surgery. All except 3 patients had stenosis > or =50%. Duplex scanning and periorbital Doppler were performed before aortic arch angiography, within 2 weeks after operation and thereafter at 3, 6 and 12 months. RESULTS: 10 patients experienced minor stroke and one major stroke after operation, in 5 patients connected with occlusion on the operated side, which differed (P<0.01) from 56 patients with open vessels in whom 6 ipsilateral minor strokes occurred. Four of 6 patients with minor stroke, in whom the operated vessels were open, recovered, whereas the neurological deficits were permanent in all 5 patients with occlusion (P<0.05). Duplex scanning confirmed 10 new occlusions and 2 high grade stenoses >75% postoperatively. Persisting morbidity was 11% and no mortality at 3 months' control. At 12 months' control, 1 patient had stroke related to preoperatively diagnosed occlusion on the non-operated side and 14 flow reducing lesions >75% (11 occlusions and 3 stenoses >75%) were found in 57 (24.6%) of examined vessels. CONCLUSION: occlusion occurs in immediate postoperative period and seems to be a serious complication connected with significantly higher number of persistent neurological events than open vessels.

The ability of non-invasive physiological tests to detect arterial occlusions in the lower extremity. An ROC study with particular regard to recruitment of patients for clinical trials.

In the prerandomization phase of a clinical trial it is essential to be able to exclude, in a non-invasive way, patients who cannot be randomized into the trial. The ability of routine non-invasive physiological examinations to detect arterial occlusion in the lower extremities was investigated in 182 patients with hypercholesterolaemia. Ankle blood pressure measurement, pulse oscillometry, digital pulse plethysmography and treadmill and cycle exercise tests were performed as part of the prerandomization phase of the Probucol Quantitative Regression Swedish Trial (PQRST). The PQRST was designed to compare the antiatherosclerotic effect of two different lipid-lowering regimens. Before randomization the patients also underwent aorto-femoral arteriography, which was used as 'gold standard'. The results were analysed with ROC methodology. Ankle blood pressure measurement (ABP) and inclination time (IT), measured with digital pulse plethysmography, without significant mutual difference, were the variables, best able to detect occlusions. For ABP, the AZ-values were 0.85, 0.82 and 0.94 in detection of right-sided, left-sided and bilateral occlusion, respectively. The corresponding figures for IT were AZ = 0.86, 0.91 and 0.93. If a bilateral occlusion was predicted in a patient with an ABP value of < = or 0.98, a specificity of 0.90 and a sensitivity of 0.87 were obtained, using arteriography as reference method. For IT, with a critical value of 320 ms, sensitivity and specificity were 0.83 and 0.90, respectively.

Relationship between the flow pattern and vasomotor reactivity in the ophthalmic artery, siphon and vessels within the circle of Willis in the unilateral internal carotid artery occlusion.

The aim was to study a relationship between the flow pattern in the ophthalmic artery (OA), the siphon and vessels within the circle of Willis. 27 patients, 22 males and 5 females, mean age 63 +/- 15 years (SD) with unilateral occlusion of the internal carotid artery (ICA) were examined by 3-dimensional Transcranial Doppler scanner. Flow signals from the OA, the siphon and intracranial vessels were registered before and after i.v. injection of 1 g acetazolamide. Pathological flow pattern was found in 18 patients in the OA on the occluded side consisting of 12 retrograde and 6 isoelectric flow directions. After acetazolamide injection retrograde systolic velocities (SV) increased significantly (p < 0.01), but anterograde velocities remained unchanged as did 3 isoelectric flow patterns, 2 turned to retrograde and one to anterograde flow direction. In the siphon lower resting anterograde mean velocities (MV) were found on both sides (p < 0.05) compared to normal subjects. Six patients had the same retrograde flow as in the OA. After acetazolamide MV in the siphon increased (p < 0.01) only on the nonoccluded side. Baseline retrograde ophthalmic SV and MV in the siphon correlated (p < 0.01 and p < 0.05 respectively) with MV in the middle cerebral artery (MCA) according to linear regression analysis (r = 0.78 and 0.59 respectively). All patients, having impaired vasomotor reactivity (VMR) < or = 11% in the anterior cerebral artery (ACA) on the occluded side, had pathological flow pattern in the OA. Patients with greatest difference (delta) between MV in the ACA on the nonoccluded and occluded side had a tendency to anterograde flow (r = 0.56, p < 0.05). Pulsative index (PI) in the ACA on the occluded side was lowest in the category with retrograde flow in the OA (0.67 +/- 0.14) and differed (p < 0.05) from normals and from the category with isoelectric and anterograde flow. Correlation of retrograde flow direction in the OA and baseline MV in the MCA and low PI in the ACA on the occluded side indicates a supplying ophthalmic collateral to the anterior brain circulation. Impaired VMR in the ACA on the occluded side in connection with pathological flow pattern in the OA may reflect an exhaustion of the ACA as a supplying vessel.

Intracranial haemodynamics during vasomotor stress test in unilateral internal carotid artery occlusion estimated by 3-D transcranial Doppler scanner.

Seventeen patients, 14 males and 3 females, mean age 64 years (range 45-77 years) with longstanding unilateral occlusion of the internal carotid artery and minimal neurological deficit, were evaluated in order to find criteria for potential benefit of extracranial-intracranial by-pass surgery. 3-D transcranial Doppler was used for estimation of mean velocities and pulsatility index in the middle cerebral artery, anterior cerebral artery and posterior cerebral artery before and after iv injection of 1 g acetazolamide. The anterior cerebral artery was the supplying vessel to the occluded side in 16 patients and mean velocities were significantly (p < 0.001) faster on the occluded (59.3 +/- 14.5 cm sec-1) and nonoccluded (91.6 +/- 29.6 cm sec-1, p < 0.05)) side than those found in the middle cerebral artery (39.2 +/- 13.7 and 50.9 +/- 8.5 cm sec-1). In two patients a decrease of mean velocity after acetazolamide was noted in middle cerebral artery indicating 'steal' effect. In another 4 patients, poor vasomotor response was seen with less than 11% of mean velocity increase in the middle cerebral artery. Differences between posterior cerebral artery on the occluded and nonoccluded side were insignificant as well as those between middle and posterior on the occluded side. Resting values of pulsatility index differed significantly (p < 0.01) only between anterior and posterior cerebral artery on the nonoccluded side.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of probucol on femoral atherosclerosis: the Probucol Quantitative Regression Swedish Trial (PQRST).

The Probucol Quantitative Regression Swedish Trial tested whether treatment of hypercholesterolemic persons with probucol for 3 years affected femoral atherosclerosis. The primary end point was the change in atheroma volume estimated as change in lumen volume of the femoral artery assessed by quantitative arteriography. Three hundred three patients with visible atherosclerosis were randomized to probucol 0.5 g, twice daily, or to placebo. All patients were given diet and cholestyramine, 8 to 16 g/day. Twenty-nine patients were excluded because of inadequate primary end point measurements. The mean age of the remaining 274 subjects (158 were men) was 55 years. Seventeen percent had intermittent claudication and 24% had angina pectoris. After 3 years, the probucol-treated patients had 17% lower serum cholesterol, 12% lower low-density lipoprotein cholesterol, 24% lower total high-density lipoprotein cholesterol, and 34% lower high-density lipoprotein2 cholesterol levels than control subjects. All lipoprotein differences between the treatment groups remained highly significant during the trial. There was no statistically significant change in lumen volume between the probucol and the control group. Furthermore, there was no difference between the treatment groups with regard to change in arterial edge roughness or amount of aorto-femoral atherosclerosis; neither were there any differences between the treatment groups with regard to change in ST-segment depressions on exercise tests or ankle/arm blood pressure (secondary end points). In the control group, lumen volume increased (p < 0.001) and roughness of the femoral artery decreased (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

The relation of coronary and peripheral arterial disease to the severity of femoral atherosclerosis in hypercholesterolaemia.

OBJECTIVES: The extent of atherosclerosis in the superficial femoral artery and the severity of arterial disease in the aorto-iliac and femoro-popliteal arterial districts were related to clinical diagnosis of coronary and peripheral atherosclerosis in hypercholesterolaemic patients. DESIGN: The study constitutes baseline cross-sectional data of a randomized double-blind clinical trial on Probucol, using both computer based and visual estimations of angiographies as endpoints. SUBJECTS: Two hundred and ninety men and women (mean age 54 years) with hypercholesterolaemia. MAIN OUTCOME MEASURES: Atherosclerosis was estimated with arteriographies. Lumen volume and edge roughness (vessel inner wall irregularity) of a 20 cm segment of the femoral artery were estimated by computer. A visual atherosclerosis score of the abdominal aorta to the popliteal arteries was made on both sides. RESULTS: Patients with peripheral arterial disease had significantly more advanced disease according to all three angiographic variables than those without symptoms of peripheral vascular disease. Both men and women with coronary artery disease had significantly lower femoral lumen volume and higher roughness values than patients without. Men with previous myocardial infarction had significantly higher mean visual scores of atherosclerosis than those without, while lumen volume and roughness did not differ in either sex. CONCLUSIONS: Femoral atherosclerosis is an expression of a generalized disease, associated with clinical symptoms of coronary artery disease. Femoral atherosclerosis is often accompanied by atherosclerosis also in the coronary arteries.

Takayasu's disease: Ultrasonic evaluation of extracranial and intracranial hemodynamics.

In Takayasu's disease, inflammatory vessel wall changes occur in the large extracranial arteries and may consequently influence cerebral hemodynamics. This study describes the extra- and intracranial hemodynamic states in three young patients, aged 32, 29, and 22 years, without permanent neurological deficit. Extracranial vessels were investigated primarily by duplex scanner and intracranial vessels by three-dimensional transcranial Doppler before and after intravenous administration of 1 g acetazolamide. The ultrasonic findings were confirmed by aortocervical angiography. Two patients were treated by corticosteroids. In spite of extracranial vessel narrowing, all three patients had normal MCA velocities in the resting condition. Impaired vasomotor reactivity was found in the middle cerebral artery corresponding to the high degree stenosis of the brachiocephalic trunk in one patient and in the anterior and posterior cerebral arteries unilaterally in two patients and bilaterally in one. Decrease in the pulsatility index after acetazolamide administration probably depends on the vasodilation and decrease in peripheral resistance. Extra- and intracranial Doppler ultrasound is valuable to follow the progress of arteritis and to adjust treatment.

Significant association between low-molecular-weight apolipoprotein(a) isoforms and intermittent claudication.

The role of lipoprotein(a) (Lp[a]) and apolipoprotein(a) (apo[a]) isoforms in symptomatic peripheral atherosclerosis was studied in 100 randomly selected middle-aged (45-69 years) men with intermittent claudication (IC) and 100 randomly selected healthy control (C) subjects. IC and C subjects were matched pairwise for sex, age, and smoking habits. Plasma Lp(a) concentrations were significantly higher in IC subjects, with a median value of 20.12 mg/dl, compared with 11.11 mg/dl in C subjects (p less than 0.0009). The elevated Lp(a) concentration was to a great extent due to a significant difference in the frequency distribution of apo(a) isoforms between IC and C subjects (p less than 0.029). Low-molecular-weight apo(a) isoforms were more prevalent in IC than C subjects. Also, IC subjects with apo(a) S2 and S3 phenotypes had higher Lp(a) concentrations than control subjects with the same phenotypes: S2:60.70 mg/dl (IC) and 48.69 mg/dl (C), p less than 0.038; and S3: 30.18 mg/dl (IC) and 12.01 mg/dl (C), p less than 0.042, so other still-unknown factors, genetic or nongenetic, may be important. Stepwise logistic regression analysis demonstrated that Lp(a) concentration contributed significantly (p less than 0.0002) to IC, independent of age, smoking, hypertension, diabetes mellitus, plasma total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, apo B, and plasma total triglycerides. Apo(a) isoforms grouped according to molecular weight were also independent of the above risk factors associated (p = 0.016) with the occurrence of IC because of their low-molecular-weight but were not independent of Lp(a) concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Hyperhomocyst(e)inaemia: an independent risk factor for intermittent claudication.

The aim of this study was to test the question of hyperhomocyst(e)inaemia as a risk factor for intermittent claudication (IC) independent of other important risk factors for peripheral atherosclerotic disease, such as smoking, hypertension, diabetes mellitus, hypercholesterolaemia, hypertriglyceridaemia, low levels of high-density-lipoprotein (HLD) cholesterol and age. The study population was recruited from an epidemiological study in Linköping County, Sweden, where all middle-aged men (n = 15,253, 45-69 years of age) were screened for IC. Seventy-eight subjects with verified IC and 98 healthy sex- and age-matched controls were randomly selected. Plasma levels of homocyst(e)ine (including the sum of free and bound forms of homocysteine and their disulphide oxidation products, homocystine, and homocysteine-cysteine mixed disulphide) were significantly higher (16.74 +/- 5.45 mumol l-1, mean value +/- SD, P = 0.0002) in IC subjects than in controls (13.80 +/- 3.21 mumol l-1), with 23% of the claudicants above the 95th percentile for controls. Stepwise logistic regression analysis revealed that the difference in plasma homocyst(e)ine was independent of the other above-mentioned risk factors. Moreover, the elevation of plasma homocyst(e)ine in claudicants was mainly confined to subjects with serum folate levels of less than or equal to 11.0 nmol l-1. The results suggest that folic acid supplementation should be tried in IC subjects with hyperhomocyst(e)inaemia.

Effect of fish oil treatment on plasma lipoproteins in type III hyperlipoproteinaemia.

Nine patients with type III hyperlipoproteinaemia and homozygosity for the apolipoprotein E2 isoform were treated with 15 g daily of MaxEPA, a fish oil preparation rich in eicosapentaenoic acid (2.7 g daily) and docosahexaenoic acid (1.8 g daily) for 16 weeks. Plasma lipoprotein and apolipoprotein concentrations were compared with those obtained during treatment with an olive oil preparation. MaxEPA treatment decreased plasma median total cholesterol, triglyceride and apolipoprotein B concentrations by 16, 53 and 19%, respectively. Plasma median very low density lipoprotein (VLDL)-cholesterol, triglyceride and apolipoprotein B concentrations were reduced by 45, 62 and 75% respectively, while the abnormal VLDL-cholesterol/triglyceride ratio remained unchanged. Individual reductions of VLDL concentrations varied considerably, for VLDL-cholesterol between 10 and 75%. In the majority of cases the abnormal late pre beta-bands on agarose electrophoresis, typical for type III hyperlipoproteinaemia normalized to pre beta-mobility on MaxEPA treatment. LDL-cholesterol and apolipoprotein B tended to increase after 8 weeks on MaxEPA but decreased again after 16 weeks. Median plasma high density lipoprotein cholesterol and apolipoprotein A-I did not change during MaxEPA treatment. It is concluded that MaxEPA have decreasing effects on plasma VLDL lipid and apolipoprotein concentrations in apolipoprotein E2 homozygous type III hyperlipoproteinaemia but that this effect is variable and unpredictable.

Detrusor pressure in cystometry compared to physiological filling in patients with a reflex urinary bladder after spinal cord injury.

The maximum detrusor pressure and the duration of detrusor contractions in 10-50 ml/min fill cystometry were compared to the corresponding measurements during 12 hours of physiological filling, in 18 patients with a reflex urinary bladder after spinal cord injury. In four consecutive cystometries with 10 min intervals the intraindividual variation of the maximum detrusor pressure and the duration of detrusor contractions were similar to the variation during physiological filling. The mean pressure values in cystometries of each patient correlated well with the mean values in registration during physiological filling. In cystometry, there was no significant difference between mean values in 50 ml/min filling compared to 10 ml/min filling nor between mean values in first and second cystometries compared to third and fourth cystometries. Thus, mean values from a series of 10 ml/min or 50 ml/min fill cystometries appear to be as useful as registrations during physiological filling to describe the mean maximum detrusor pressure and the mean duration of contractions in a patient with a spinal reflex bladder.

Continuous monitoring of detrusor pressure in patients with a reflex urinary bladder after spinal cord injury.

In spinal cord injury, the detrusor pressure, as a parameter of urinary bladder dysfunction, is related to incontinence and renal complications. In order to determine the intraindividual variation of maximum pressure and duration of detrusor contractions, in patients with a spinal reflex bladder, the detrusor pressure was registered during 24 hours of physiological filling in 16 patients. Between the bladder contractions the detrusor pressure was low in all patients, indicating high bladder complicance. During contractions the maximum detrusor pressure and its duration varied both inter- and intraindividually. In individual patients, however, mean values during the initial 12 hours correlated with mean values during the final 12 hours. Thus, mean values of a series of contractions appear to be characteristic of each patient and useful in describing the voiding pressure in spinal reflex bladder.

Development of femoral atherosclerosis in hypercholesterolemic patients during treatment with cholestyramine and probucol/placebo: Probucol Quantitative Regression Swedish Trial (PQRST): a status report.

The Probucol Quantitative Regression Swedish Trial is being performed to investigate the effects of probucol on atherosclerosis in the femoral artery. Probucol is combined with cholestyramine and dietary management in hypercholesterolemic patients, and the effects of atheroma developing in the femoral artery will be followed by a quantitative angiographic technique. A randomly selected control group is also being managed by dietary therapy and cholestyramine, but receives placebo instead of probucol. The treatment time in this double-blind trial is 3 years, and femoral angiography is performed yearly. Detailed lipoprotein and apolipoprotein analysis are performed at monthly intervals. The basic study design is described here, and some results from the open prerandomization phase of the study are presented.

Changes in skin perfusion after sympathetic block with guanethidine. Laser Doppler flowmetry in human volunteers.

Total forearm blood flow and skin microcirculation have been measured by occlusion plethysmography and by laser Doppler flowmetry (skin blood cell flux) before and after the induction of regional sympathetic block with Guanethidine. Total forearm blood flow more than doubled while the skin blood cell flux increased by 50% comparing simultaneous flows of blocked and control arms. The increase lasted for 3 days during which period the flux pattern registered by the laser Doppler flowmeter in the blocked extremities showed regular variations oscillating around the mean flux in an almost sinus wave fashion. In non-blocked arms the flux pattern registered by the laser Doppler flowmeter was highly irregular. We conclude that regional sympathetic block with Guanethidine results in an increased skin microcirculation in healthy human volunteers and that the increase lasts for 3 days. No valid conclusions can be made from this study concerning the nutritive benefit of the microcirculatory change.

Cold sensitivity after replantation in relation to arterial circulation and vasoregulation.

Cold intolerance is a common problem after injuries to the hand. To elucidate the mechanism of this cold sensitivity, eight patients with successful replantations of amputations of the thumb or index finger were studied one and half years later. In six patients the Doppler signal from the anastomosed arteries was normal and in two patients signs of mild stenosis were found. All patients had normal or slightly reduced basal finger systolic pressure in the replanted finger. Six had signs of marked vasospasm. Alpha-receptor blockade had no effect on the cold-induced decrease in finger systolic pressure in the replanted finger. It is concluded that cold intolerance after hand injuries results from a defect in vasoregulation and is not caused by organic insufficiency of the circulation.

Does peroperative external pneumatic leg muscle compression prevent post-operative venous thrombosis in neurosurgery?

Post-operative deep venous thrombosis (DVT) is a frequent and potentially life-threatening complication in neurosurgery. In this field of surgery, with its special demands for exact haemostasis, prophylaxis against deep venous thrombosis with anticoagulant drugs has been utilized only reluctantly. Postoperative pneumatic muscle compression (EPC) has been shown to be effective, although there are several practical considerations involved with this method which limit its clinical applicability. In the present study per-operative EPC was evaluated and was found to provide good protection against DVT in patients with increased risk from this complication. This method has the advantage of being effective, safe, inexpensive and readily practicable.