MRI associated factors of clinical efficacy of embolization in patients with pelvic venous insufficiency.

PURPOSE: The purpose of this study was to identify anatomical findings at magnetic resonance imaging (MRI) associated with successful percutaneous embolization in women with pelvic venous insufficiency (PVI). MATERIAL AND METHODS: Between 2008 and 2018, 168 consecutive women (mean age, 39±9 [SD] years; range: 21-69 years) who underwent percutaneous embolization for PVI confirmed by MRI and phlebography were included. Clinical efficacy of embolization was evaluated by patients' opinion or visual analogue scale. Associated factors of success of embolization were searched by comparing MRI findings in women with successful embolization with those in women with failed embolization using univariate analyses. RESULTS: The mean follow-up was 36±29 (SD) months (range: 12-138 months). Clinical efficacy of embolization was obtained in 126/168 women (75%), complete symptom improvement in 33/168 women (20%) and significant partial improvement in 92/168 women (55%). No symptom improvement and symptoms exacerbation were observed in 17/168 (10%) and 2/168 (1%) women, respectively. At univariate analysis, right ovarian vein diameter≤7mm and vulvar varicosities were associated with successful embolization (P=0.04 and P=0.01, respectively) and left ovarian vein diameter≤7mm was associated with a complete improvement of symptoms (P=0.03). At multivariate analysis, a small right ovarian vein diameter was the single MRI variable associated with clinical efficacy of embolization (P=0.04). CONCLUSION: Small ovarian vein diameters on MRI are associated with best clinical efficacy of percutaneous embolization in PVI. Right ovarian vein diameter>7mm should warrant further phlebography to exclude venous insufficiency.

Presentation, diagnosis, and management of popliteal artery entrapment syndrome: 11 years of experience with 61 legs.

Popliteal artery entrapment syndrome (PAES) is still underdiagnosed yet it may significantly interfere with lifestyle, especially among young sportspeople, with symptoms like intermittent claudication. Although case reports and small case series are sometimes published, studies with larger populations are quite rare. This study summarizes our experience with PAES on 61 limbs (35 patients) over a period of 11 years, describing the demographics, the disease, and the diagnostic and therapeutic methods used with PAES patients. In a population of 327 consecutive explored symptomatic sportspersons, PAES was confirmed in 35 patients on 61 pathologic limbs. The median time with the symptoms before diagnosis was 34 months (range, 3-180 months). The mean age of patients was 30.5 years (range, 17-52 years) with 83% of males. The proportion of patients diagnosed with bilateral PAES was 74%. The main sports practiced were running (15 patients, 43%), soccer (nine patients, 26%), rugby (two patients), and athletics (two patients). Among 21 patients, intra-compartmental pressure measurements (ICP) found 18 (86%) to have an associated chronic exertional compartment syndrome (CECS). Among the patients followed up after PAES surgery, 80% were able to resume sport at a level comparable to that before the onset of pain. PAES could be sought earlier in young sportspeople who experience unexplained leg pain during exercise to diagnose the disease and avoid complications in a timely manner. Compartmental pressures should systematically be measured in the search for an associated CECS.

Percutaneous cryoablation of symptomatic venous malformations as a second-line therapeutic option: a five-year single institution experience.

PURPOSE: To report the mid-term outcomes of percutaneous cryoablation (PCA) performed as second-line therapeutic option of venous malformations (VM). MATERIAL AND METHODS: From 2011 to 2015, PCA was offered in 24 patients (mean age: 31 years, range: 12-64) as second-line treatment for recurrence of symptoms after sclerotherapy and when resection was not possible (due to lesion location or previous failure) or refused by the patient. Adverse effects were recorded, disease-free survival (DFS) and local tissue control (LTC) rates were calculated based on symptoms and volume evolution. RESULTS: Mean follow-up was 18.7 months (6-48). Nine (37.5%, 9/24) adverse effects occurred and three (12.5%, 3/24) were severe. Mean pain assessed by visual analog scale (VAS) was 41.7 mm (0-80) before treatment and 20.3 mm (0-80) (p=0.01) after. Mean volume decreased significantly after treatment from 22.4 cm3 (0.9-146) to 8.35 cm3 (0-81.3) (p<0.001). Pain recurred in nine patients and size of one lesion increased. The DFS and LTC rates were 54% [95%CI: 22.94-77.27] and 93.33% [61.26-99.03] at 24 months, respectively. Only VM volume >10 cm3 was associated with a higher risk of local recurrence (p=0.05). CONCLUSION: PCA as second-line treatment appears to be safe and effective for local control of VM according to mid-term results. KEY POINTS: • Percutaneous cryoablation of venous malformations appeared well tolerated. • Size of venous malformations decreased significantly after percutaneous cryoablation (p<0.001). • Pain decreased significantly after percutaneous cryoablation of venous malformations (p=0.01).

Embolization for persistent type IA endoleaks after chimney endovascular aneurysm repair with Onyx®.

PURPOSE: The purpose of this study was to determine retrospectively the safety and technical success rate of embolization using ethylene vinyl alcohol copolymer (Onyx®) for persistent type 1A endoleaks after chimney endovascular aneurysm repair (EVAR) for complex aortic aneurysms. MATERIAL AND METHODS: Nine consecutive patients (6 men, 3 women) with a mean age of 78.6 years (range: 62-87 years) presenting with persistent type IA endoleaks after chimney EVAR and an increase of aneurysm size were treated using transarterial embolization with Onyx®. RESULTS: Technical success was obtained in all patients (100%) and no complications were observed. Mean follow-up was 16 months (range: 3-35 months). Primary clinical efficacy was obtained for 8/9 patients (89%) and primary technical efficacy for 6/9 patients (67%). Secondary clinical efficacy was 100%, and secondary technical efficacy was 78%. CONCLUSION: Our results suggest that arterial embolization using Onyx® appears as a feasible and safe endovascular procedure of type IA endoleaks after chimney EVAR, although further validation is now required.

Percutaneous Image-Guided Cryoablation as Second-Line Therapy of Soft-Tissue Venous Vascular Malformations of Extremities: A Prospective Study of Safety and 6-Month Efficacy.

PURPOSE: To report the safety and short-term efficacy of percutaneous image-guided cryoablation performed as second-line therapy of venous vascular malformations (VVM) of extremities. MATERIALS AND METHODS: In this non-blinded, no-randomized trial, cryoablation was proposed in 14 patients presenting with symptomatic VVM for recurrences after treatment. Eligibility criteria were: cryoablation feasible, localization at least 5 mm from skin and nerves, absence of contra-indication for anesthesia. Safety was evaluated by the common terminology criteria for adverse events (AE). Clinical response was assessed by evaluating pain at day 7, month 2 and 6 using visual analog scale; quality of life before cryoablation and at 2 and 6 months after using questionnaire. Evolution of volume was evaluated by MRI at 6 months. Comparison was performed using the Wilcoxon test. RESULTS: A technical success was observed in all cases. While 11 patients (78.6%) presented AE (13 grade 1-2 and 3 grade 3), only two severe AE (grade 3) related to cryoablation occurred in two patients (14.3%) during the 6-month follow-up: one immediate sciatic paralysis and one delayed paresthesia. A clinical response was observed in 12 patients (85.7%) at 6 months. Pain decreased significantly from 42.5 ± 14.2 mm before the intervention to 11.8 ± 17.9 mm at 6 months (P = 0.002). A significant decrease in the mean volume from 12.8 ± 14.3 to 3 ± 2.7 cm3 was observed at 6 months (P = 0.002). CONCLUSION: Percutaneous cryoablation is a promising alternative treatment for sclerotherapy-resistant venous malformations. However, to improve safety, careful patient selection and treatment planning will be mandatory.

Safety and efficacy of embolization using Onyx® of persistent type II endoleaks after abdominal endovascular aneurysm repair.

PURPOSE: To retrospectively evaluate the safety and efficacy of embolization of persistent type II endoleaks occurring after abdominal endovascular aneurysm repair (EVAR) using ethylene vinyl alcohol copolymer (Onyx®). MATERIAL AND METHODS: Between 2008 and 2016, 28 consecutives patients (25 men, 3 women) with a mean age of 75.3years±9 (SD) (range: 59-90years) were treated for 29 persistent type II endoleaks with increasing aneurysm size>5mm occurring after EVAR. A total of 35 embolization procedures were performed using Onyx®, via a transarterial route (n=25) or direct puncture (n=10), with or without additional metallic coils. The endpoints were to evaluate the clinical efficacy, corresponding to the stabilization or decrease of aneurism size, and the technical efficacy, corresponding to the ability to complete the embolization. RESULTS: No severe complications were observed during and after embolization. The primary and secondary clinical efficacies were 75% (21/28) and 96.4% (27/28), respectively. Overall primary technical efficacy rate was 58.6% (17/29), greater for transarterial technique (72.8%) than for direct puncture (14.3%) (P=0.01). Secondary technical efficacy was 72.4% (21/29), with no differences between transarterial (81.8%) and direct puncture (42.8%) (P=0.06). CONCLUSION: Embolization with Onyx® of type II endoleaks after EVAR appears a safe and effective procedure.

[Treatment of below the knee lesions: Broadening the limits of vascular surgery]. / Traitement de l'artérite jambière : les frontières de la chirurgie vasculaire sont repoussées.

One third of patients with critical limb ischemia (CLI) has below the knee lesions and requires a restoration of direct blood flow into the foot. However, many of these patients are ineligible for open surgery. The primary goals thus become pain relief and limb salvage over patency. The angiosome concept helps determine the target artery to treat in priority. The endovascular approach has decreased morbidity and mortality rates compared to distal bypass surgery; while subintimal retrograde, trans-collateral and loop techniques push the limits of open surgery by reopening the plantar arch, thereby improving run-off. Early restenosis phenomena after angioplasty have been improved by the use of - limus drug eluting balloons and balloon expandable stents in case of flow limiting dissection or recoil with increased limb salvage rates. Moreover, drug-eluting stents have been proposed, and allow a reduction in reintervention and in-stent restenosis rates in short lesions; however, results on amputation rates or survival are limited. Vessel preparation is a key to overcoming some current limitations, including atherectomy, which increases technical success rates and reduces restenosis rates, especially in calcified lesions, chronic total occlusions and restenosis. These advanced techniques in distal endovascular revascularization have revolutionized limb salvage and support the interest of an endovascular first approach in CLI treatment.

Early Impact on Renal Parenchymal Vascularization of Chimney Grafts Versus Fenestrated Grafts.

OBJECTIVE: The primary objective of this retrospective study was to analyze the early impact of chimney (CG) versus fenestrated grafts (FG) on renal parenchymal vascularization and function. METHODS: All consecutive patients with juxta-renal abdominal aortic aneurysm (JR-AAA) treated by endovascular repair from December 2013 to July 2014 at the vascular unit, Pellegrin University Hospital, Bordeaux, France, were included. Serum creatinine (SCr) and estimated glomerular filtration rate (eGFR) were reported at baseline and at J2 for acute kidney injury (AKI) incidence, and at J7 for AKI staging (KDIGO criteria); renal resistive indices (RRI) were reported for renal parenchymal repercussion at J-1, J0, and J1. RESULTS: Ten patients were included in the CG group and 25 in the FG group, with 13 and 50 renal target vessels, respectively. Successful target vessel revascularization was achieved in 92.3% and 100.0% of patients. The incidence of AKI (10% and 32%), baseline SCr, and eGFR did not differ significantly. SCr was more elevated in the FG group at J1 (p = .025), J2 (p = .051), and J7 (p = .052), and eGFR was significantly lower from baseline to J1 (p = .015) and J2 (p = .014). RRI did not differ significantly between both groups. RRI augmentation was only noted in the FG group from J-1 to J0 (p = .039) and J-1 to J1 (p = .059). Patients with a KDIGO score <2 versus ≥2 showed significantly different RRI at J0 (p = .038) and J1 (p = .007). ROC curve analysis showed that RRI measures could be a predictive factor for AKI at J0 (cutoff = 0.72, sensitivity [Se] = 50%, specificity [Sp] = 86%) and J1 (cutoff = 0.71, Se = 70%, Sp = 84%). CONCLUSIONS: This study showed no significant difference in terms of RRI, eGFR, and the incidence of AKI or CKD between CG and FG. However, post-operative SCr levels were higher with FG, which was corroborated by comparison between pre- and post-operative RRI. Results are limited by the small sample size, but early repeated measures of RRI could be helpful in alerting the clinician to post-operative renal degradation, allowing better-informed attempts to preserve renal function.

Evidence for the use of drug eluting stents in below-the-knee lesions.

Peripheral arterial disease has become more and more present in daily practice, mostly due to the increase of cardiovascular risk factors, especially in below the knee (BTK) area in diabetic patients. Critical limb ischemia (CLI) is the most usual clinical presentation with a major amputation rate of 30%, mortality rate of 25%, and chronic pain of 20% at one year. Nowadays, endovascular treatment is usually the first choice, given the high comorbidity of those patients. Angioplasty and stenting in BTK lesions have already proven their efficacy in CLI treatment. However, BTK revascularization remains highly controversial in the treatment of intermittent claudication in TASC 2 recommendations. Restenosis being the major pitfall in BTK procedures, the use of drug-coated devices is one of the actual answers. We performed an extensive review of the literature over the last 15 years on the use of drug-eluting stents (DES) in BTK revascularization. DES has been compared to balloon angioplasty, in the ACHILLES trial, bare metal stents (BMS), in the DESTINY and YUKON trials, drug eluting balloons, in a trial guided by Siablis, and paclitaxel has even been compared to sirolimus in the PARADISE trial. In conclusion, DES is one of the solutions to the increase of BTK arteriopathy in CLI patients. Angiographic results are better, compared to BMS, in terms of primary patency, restenosis and TLR rates. However clinical results are missing. Treated lesions in the literature are short lesions. And DES is a metal balloon expandable stent with greater risks of compressions and stent fractures than nitinol self expandable stents, and such complications are known to increase post operative restenosis rates. Further reports are still needed on this matter.

The "open" chimney graft technique for juxtarenal aortic aneurysms with discrepant renal arteries.

OBJECTIVES: A straightforward original Chimney Graft (CG) protocol has been developed at our institution in selected cases of juxtarenal aortic aneurysm (JRAA). The aim of this study was to present our clinical experience of consecutive series with use of uncovered self-expanding stent (SES) as "Open Chimney" (OCh) in the endovascular repair (EVAR) of JRAA. METHODS: A standard endograft with suprarenal fixation struts is delivered with its proximal covered edge just below the highest RA in JRAA presenting the ostium of the two renal arteries at a different aortic level and the distance between the highest renal artery and the beginning of the aneurysm (improved landing zone) ≥10 mm. The low-lying renal artery is maintained patent by the OCh graft (standard SES) delivered from left brachial access (6 Fr). All clinical, anatomical, and operative data were prospectively collected and retrieved for the study analysis. RESULTS: From July 2010 to November 2012, OCh EVAR was offered to 22 consecutive patients considered unfit for JRAA open repair. All procedures were technically successful with aneurysm exclusion and patent OCh graft. One small perioperative type Ia endoleak spontaneously disappeared at the 3-month CT control. One patient died because of acute decompensated heart failure. One patient presented a left hemispheric stroke. The median follow-up of 18 months (range 7-35) showed aneurysm exclusion in all patients without type I and III endoleaks, SES stenosis, and/or renal impairment. CONCLUSIONS: OCh-EVAR is a straightforward technique that can be employed in selected cases of JRAA, avoiding the more complex and expensive fenestrated EVAR.

Percutaneous cryotherapy of vascular malformation: initial experience.

The present report describes a case of percutaneous cryotherapy in a 36-year-old woman with a large and painful pectoral venous malformation. Cryoablation was performed in a single session for this 9-cm mass with 24 h hospitalisation. At 2- and 6-month follow-up, the pain had completely disappeared, and magnetic resonance imaging demonstrated a significant decrease in size. Percutaneous cryoablation shows promise as a feasible and apparently safe method for local control in patients with symptomatic venous vascular malformations.

In-situ revascularisation for secondary aorto-enteric fistulae: the success of silver-coated Dacron is closely linked to a suitable bowel repair.

OBJECTIVES: The purpose of this study was to assess short- and mid-term results of in-situ revascularisation (ISR) using silver-coated Dacron prostheses and bowel repair for management of secondary aorto-enteric fistulae (SAEF). DESIGN: Single-centre retrospective chart review. MATERIAL AND METHODS: This study includes all the patients treated by ISR using silver-coated Dacron for SAEF between 2006 and 2010. Primary end points were mortality and survival rates. Secondary end points were reinfection-free survival and secondary patency rates. RESULTS: Eighteen male patients with SAEF with a median age of 64 years were operated by ISR using silver-coated Dacron during the study period without operative death. The 30-day mortality was 22% and the in-hospital mortality rate was 39%. Indeed, during hospitalisation, a duodenal leak was observed in four patients including three who died. Four others patients died due to multi-system organ failure. Median follow-up was 16 months (range 1-66). The survival rate at 12 months was 55%. One duodenal leak was observed leading to death. The reinfection-free survival and the secondary patency rates at 12 months were 60% and 89%, respectively. CONCLUSION: In-situ revascularisation with silver-coated Dacron provides acceptable results in terms of mortality. This treatment may be useful for simple vascular reconstruction and allow greater attention to bowel repair that is a determinant in short- and mid-term survival.

Laparoscopic surgery for coeliac artery compression syndrome: current management and technical aspects.

OBJECTIVES: The study aims to assess the feasibility and midterm outcome of trans-peritoneal laparoscopy for coeliac artery compression syndrome (CACS). DESIGN: Retrospective chart review involving four European vascular surgery departments and two surgical teams. MATERIALS AND METHODS: charts for patients who underwent laparoscopy for symptomatic CACS between December 2003 and November 2009 were reviewed. Preoperative computed tomography (CT) angiography and postoperative duplex scan and/or CT angiography were performed. RESULTS: Eleven consecutive patients (nine women) with a median age of 52 years (interquartile range: 42.5-59 years) underwent trans-peritoneal laparoscopy for CACS. All patients had a history of postprandial abdominal pain; weight loss exceeded 10% of the body mass in eight cases. Preoperative CT angiography revealed coeliac trunk stenosis >70% in all cases. One patient had additional aortitis and inferior mesenteric artery occlusion, while another patient presented with an occluded superior mesenteric artery. Two conversions occurred (one difficult dissection and one aorto-hepatic bypass needed for incomplete release of CACS). The median blood loss was 195 ml (range: 50-900 ml) and median operative time was 80 min (interquartile range: 65-162.5 years). Symptoms improved immediately in 10/11 patients (no residual stenosis) while one remained unchanged despite a residual stenosis treated by a percutaneous angioplasty. Symptoms reappeared in one patient due to coeliac axis occlusion. The mean follow-up period was 35 ± 23 months (range: 12-78 months). CONCLUSION: Our study demonstrates that trans-peritoneal laparoscopy for treating median arcuate ligament syndrome is safe and feasible. Additional patients and a longer follow-up are needed for long-term assessment of this laparoscopic technique.

Multicentric retrospective study of endovascular treatment for restenosis after open carotid surgery.

OBJECTIVES: To analyse perioperative and midterm outcomes of carotid artery stenting (CAS) for symptomatic >50% and asymptomatic >70% restenosis after open carotid surgery (OCS). DESIGN: A multicentric retrospective study. METHODS: Outcome measures 30-day death, neurologic and anatomic (thrombosis, restenosis) events. Univariant and multivariant logistic regression analyses were performed to identify predictive factors for neurologic and anatomic events. RESULTS: A total of 249 patients with a mean age of 69 years (range, 45-88) were treated for asymptomatic (86%) or symptomatic (14%) restenosis. The 30-day combined operative mortality and stroke morbidity was 2.8% in asymptomatic patients and 2.9% in symptomatic patients. Events during follow-up (mean duration, 29 months) included stroke in four cases, TIA in two, stent thrombosis in four and restenosis in 21. Kaplan-Meier estimates of overall survival, neurologic-event-free survival, anatomic-event-free survival and reintervention-free survival were 95.4%, 94.7%, 96.7% and 99.5%, respectively, at 1 year and 80.3%, 93.8%, 85.1% and 96%, respectively, at 4 years. Multivariant analysis showed that statin use was correlated with a lower risk of anatomic events (odds ratio (OR) = 0.15 (95% confidence interval (CI) 0.03-0.68), p = 0.01) and that bypass was associated with a higher risk of anatomic events than endarterectomy (OR = 5.0 (95% CI 1.6-16.6), p = 0.009). CONCLUSION: CAS is a feasible therapeutic alternative to OCS for carotid restenosis with acceptable risks in the perioperative period. Restenosis rate may be higher in patients treated after bypass.

Early and late results of contemporary management of 37 secondary aortoenteric fistulae.

PURPOSE: Evaluate the results of the two modalities used for the treatment of Secondary Aorto-Enteric Fistula (SAEF): In situ Reconstruction (ISR) and Extra-Anatomic Reconstruction (EAR). The primary endpoints of this study were early standard 30-day mortality and reinfection (RI). Secondary endpoints were perioperative morbidity, late mortality, primary graft patency, and major amputation rates. MATERIAL & METHOD: Diagnosis of SAEF was based on clinical examination and the results of pre-operative duplex or CT scans. Surgical management was performed according to local protocols at the participating institutions: - Elective surgery: ISR or staged EAR. - Emergency surgery: aortic clamping followed by ISR or EAR. - Selected high-risk patients: endovascular repair. Statistical analyses were performed using the actuarial method. Univariate analysis was used for analysis of categorical variables, and multivariate analysis was performed with a Cox proportional hazard regression. RESULTS: A total of 37 patients were included in this retrospective multicentre study. Mean follow-up was 41 months. The majority of the patients (20, 54%) presented acutely. EAR was performed in 9 patients (24%), ISR in 25 (68%), and 3 patients underwent endovascular repair. Bacteriological cultures were negative in 3 patients (9%). The most frequent organisms identified were Candida species and Escherichia coli. The 30-day mortality was 43% (16 patients). Patient age (>75 years) was the sole predictive factor associated with operative mortality (p = 0.02); pre-operative shock was not statistically significant (p = 0.08). There were 2 graft thromboses and 1 femoral amputation. Primary graft patency was respectively 89% at 1 year and 86% at 5 years; limb salvage rates were 100% at 1 and 5 years and 86% at 6 years, with no difference between ISR and EAR. RI occurred after 9.3 ± 13 months in 8 of 17 surviving patients and was fatal in all cases. For all surviving patients, the RI rate at 1 and 2 years was 24% and 41% respectively. There was no significant difference in the rate of RI after ISR or EAR. CONCLUSION: EAR does not appear to be superior to ISR. The risk of RI increased with the length of follow-up, irrespective of the treatment modality. Life-long surveillance is mandatory. Our results with endovascular sealing of SAEF should be considered a bridge to open repair.

Salvage treatment for venous aneurysm complicating vascular access arteriovenous fistula: use of an exoprosthesis to reinforce the vein after aneurysmorrhaphy.

OBJECTIVES: We report a new salvage technique for treating venous aneurysms (VAs) complicating vascular access arteriovenous fistula (AVF) using externally reinforced venous aneurysmorrhaphy. DESIGN: A retrospective study over a 20-month period from a single centre. PATIENTS: Patients presenting to the vascular surgery department, Bordeaux University Hospital for revision of a vascular access AVF were included. METHODS: Reinforced venous aneurysmorrhaphy consisted in removal of redundant vessel wall followed by reinforcement using an external prosthetic graft. Patency, diameter and flow were assessed by duplex ultrasound at 1, 6 and 12 months after salvage. RESULTS: Thirty-eight eligible patients were identified. Five were excluded because VA was associated with central vein stenosis; the remaining 33 underwent salvage. Indications were rapidly expanding or painful VA in seven cases; VA with frequent bleeding or damaged overlying skin in eight; VA in close relation to a stenosis in two; and VA associated with high-flow rate in 16. Cannulation was attempted after 30 days. Mean follow-up time was 12 S.D. 5 months (range: 4-22). Two repaired AVFs failed. Primary 1-year patency was 93%. No aneurysm or infection occurred. Reduction of high flow was successful in 12 of 16 patients. The remaining four required re-operation. CONCLUSIONS: Reinforced venous aneurysmorrhaphy is effective in controlling venous dilation and achieving patency. Reduction of high-flow rates was not always achieved. Further study is needed to evaluate long-term efficacy of this treatment.

[Laparoscopic management of median arcuate ligament syndrome]. / Traitement du syndrome du ligament arqué médian par voie coelioscopique.

Median arcuate ligament syndrome is a rare disorder resulting from luminal narrowing of the celiac trunk. The classic management of median arcuate ligament syndrome involves the surgical division of the median arcuate ligament fibers in order to decompress the celiac trunk. This has traditionally required an upper midline incision. A few authors have described a successful laparoscopic release of celiac artery compression syndrome. Laparoscopy provides a less invasive, but equally effective method for decompressing the celiac trunk.

Association of primary varicose veins with dysregulated vein wall apoptosis.

BACKGROUND: Disordered programmed cell death may play a role in the development of superficial venous incompetence. We have determined the number of cells in apoptosis, and the mediators regulating the intrinsic and extrinsic pathways in specimens of varicose vein. METHODS: Venous segments were obtained from 46 patients undergoing surgical treatment for primary varicose veins. Controls samples were obtained from 20 patients undergoing distal arterial bypass grafting surgery. Segments of the distal and proximal saphenous trunk as well as tributaries were studied. Cell apoptoses and mediators of the mitochondrial and trans membrane pathway were evaluated with peroxidase in situ apoptosis detection, Bax and Fas detection, caspase-9 and 8 detection in the medial layer. RESULTS: Disorganised histological architecture was observed in varicose veins. Primary varicose veins also contained fewer peroxidase in situ-positive cells than control veins (2.6% S.D. 0.2% versus 12% S.D. 0.93%, P=.0001, Mann-Whitney u test), fewer Bax positive cells (2.1.% S.D. 0.3% versus 13% S.D. 0.9%, P=.0001) and fewer Caspase 9 positive cells (3.2% S.D. 1% versus 12% S.D. 1.3%, P=.0001). Similar findings were observed in saphenous trunk, main tributaries and accessory veins. In patients with recurrent varicose veins in whom the saphenous trunk had been preserved showed similar findings to primary varicose veins. Residual varicose veins contained fewer peroxidase in situ-positive cells than healthy veins (3.2% S.D. 0.6% versus 11% S.D. 2%, P=.0001), fewer Bax positive cells (2.2% S.D. 0.3% versus 12% S.D. 0.7%, P=.0001) and fewer Caspase 9 positive cells (2.6% S.D. 0.6% versus 12% S.D. 1%, P=.0001). Immunohistochemical detection for Fas and caspase 8 remained equal was the same in the varicose vein and control groups. CONCLUSION: Apoptosis is down regulated in the medial layer of varicose veins. This dysregulation is attributable to a disorder of the intrinsic pathway and involves the great saphenous vein trunk, major tributaries and accessory veins. This process may be among the causes of primary varicose veins.