Is the fibrotic parietal thickening a reliable parameter for diagnosing previous asymptomatic deep vein thrombosis?

AIM: Research of a starting point to debate about the possibility of identifying a unique sign of previous DVT. MATERIAL OF STUDY: A retrospective study involving 202 outpatients with venous insufficiency of the lower limbs (CEAP classes C 4/6), classified according to the affected venous district. Patients positive for deep vein thrombosis (DVT) were subjected to Compression Ultra Sound test (CUS test) with measurement of the wall thickness at the point of formation of the thrombus and at fixed points of common femoral and popliteal veins used also in the patients with negative history of DVT RESULTS: Among total group, only 19 patients (9.40%) had an history of DVT. No one of them had a superficial incontinence. The measurement of wall thickness in positive DVT history patients (group A) resulted in an average value of 1.10 mm (s.d=0.06), while the average value obtained in negative DVT history (group B) was 0.55 mm (s.d.= 0.20). However, in 13 patients wall thickness was > 1mm (mean: 1.04 mm). The difference between the averages of group A and B was statistically significant (p <0.05). DISCUSSION: In all positive DVT history patients and in 13 ones with negative history we found an increase in wall thickness, with a value > 1 mm. Can the wall thickening more than 1 mm be considered an indicator of previous DVT? Can it be considered a "marker" for thrombophilia status? CONCLUSIONS: The usefulness of a sign of previous DVT (even if asymptomatic), detected during a routine Doppler ultrasound check of lower limbs, could be a warning bell to investigate thrombophilia status. KEY WORDS: Chronic Venous Insufficiency, Duplex ultrasound, Hypercoagulability, Post-thrombotic Syndrome, Venous Thromboembolism.

Post-thrombotic syndrome after total hip arthroplasty is uncommon.

BACKGROUND: Deep vein thrombosis (DVT), usually asymptomatic, is common after total hip arthroplasty (THA). Post-thrombotic syndrome (PTS) is a potential late complication of DVT, but there is limited data on its occurrence. PATIENTS AND METHODS: This was a prospective cohort study of subjects at one hospital who had participated in a trial of thromboprophylaxis for THA and who had postoperative venography. Data were collected at baseline and 2-4 years later to ascertain symptoms of PTS using a modification of a validated scoring system. Outcomes were collected without knowledge of baseline characteristics or venogram results. Potential predictors of PTS were explored using exact logistic regression analyses. RESULTS: The cohort (n=188) had a mean age of 63 years, 51% were male, 35% had a BMI of>30, and 4% had a prior history of DVT. 25 patients (13%) had DVTs on venography. 12 patients (6%, 95% CI: 3-11) subsequently developed symptoms consistent with PTS, 7 with bilateral symptoms. Most affected limbs (15 of 19) had no postoperative DVT. No statistically significant predictors of PTS were found. INTERPRETATION: Symptoms of PTS are infrequent after THA in patients who receive some form of thromboprophylaxis. Our findings, which are consistent with the existing literature, suggest that there is a potential benefit to giving thromboprophylaxis for reduction of symptomatic PTS.

Hemodynamic and morphologic evaluation of sequelae of primary upper extremity deep venous thromboses treated with anticoagulation.

OBJECTIVES: This study was performed to describe venous function, residual morphologic abnormalities, and the occurrence of post-thrombotic syndrome in patients with conservatively treated primary upper-extremity deep venous thromboses (UEDVT). METHOD: This was a retrospective follow-up study of 31 patients with previous primary UEDVT treated with anticoagulation only, identified by a search of medical records. The mean follow-up time was 5 years. The patients were evaluated by interview, clinical examination, computerized strain-gauge plethysmography, and color duplex ultrasound imaging. The grade of post-thrombotic syndrome was rated according to the Villalta score (0 to 3 on each of four subjective and five clinically assessed features). RESULTS: The rate of venous emptying was significantly lower in the arms with DVTs than in the contralateral arms (P < .001). Eleven of the patients (35%) had a remaining outflow obstruction in the affected arm (venous emptying <68 mL/100 mL per min). Eighteen (58%) had a residual thrombus according to color duplex ultrasound scans, with four remaining occluded subclavian veins. None of the patients had deep or superficial venous reflux. There was no statistically significant relationship between plethysmographic and duplex findings. Most (77%) of the patients reported remaining symptoms in the affected arm, and there was a significant side difference in upper arm circumference (P < .001). Approximately one third had developed a moderate grade of post-thrombotic syndrome according to the Villalta score (total, 5 to 9). No significant relation was evident between the post-thrombotic syndrome score and duplex findings. Patients with post-thrombotic syndrome had a lower venous emptying value than those without (69 vs 84 mL/100 mL per min), but this difference was not statistically significant. CONCLUSIONS: Patients with conservatively treated previous primary UEDVT had significantly reduced venous outflow capacity and a residual thrombus was common. Swelling of the arm was the most common symptom, and one third had a moderate grade of post-thrombotic syndrome. However, there was no clear relation between hemodynamic and morphologic factors and the development of post-thrombotic syndrome in these 31 patients, examined at a mean of 5 years after an acute DVT episode.

Patterns of venous insufficiency after an acute deep vein thrombosis.

BACKGROUND: The purpose of this study was to investigate patterns of venous insufficiency during a 12-month period after an acute deep vein thrombosis. STUDY DESIGN: Seventy limbs in 67 patients with an acute deep vein thrombosis (DVT) involving 147 anatomic segments were evaluated with duplex scanning at 1 month, 3 months, 6 months, and 1 year. Venous segments were examined whether they were occluded, partially recanalized, or totally recanalized, and the development of venous reflux was evaluated. RESULTS: The segments investigated were the common femoral vein (38 segments), femoral vein (33 segments), popliteal vein (36 segments), and calf veins (40 segments). There were 35 limbs with isolated DVT and the remaining 35 had multisegment DVT. At 1 year, thrombi had fully resolved in 76% of the segments, 20% remained partially recanalized, and 5% were occluded. The venous occlusion was most predominant in the femoral vein (21%) at 1 year. On the contrary, rapid recanalization was obtained in calf veins than in proximal veins at each examination (p < 0.01). Deep vein insufficiency was detected as early as 1 month after development of DVT, and the reflux was most predominant in popliteal veins (56%), followed by femoral veins (18%). No reflux was found in calf veins. Multisegment DVTs had a significantly higher incidence of deep vein insufficiency than single segment DVTs at 1 year. Development of superficial venous insufficiency was found in 5 limbs (7%) and perforating vein insufficiency in 5 (7%). CONCLUSIONS: Lower extremity venous segments showed different proportions of occlusion, partial recanalization, and total recanalization. Calf veins showed more rapid recanalization than proximal veins. Venous reflux was noted as early as 1 month. The limbs involving multisegment DVTs on initial examination had a higher incidence of deep vein insufficiency and could require much longer followup studies.

[Surgical method for correction of absolute valvular insufficiency in post-thrombophlebotic disease of the lower limbs].

A new technique has been worked out for intravasal autovenous valvuloplasty. It is based on the "ink-pot that does not spill" principle with creation of two cusps and is used in the treatment of patients with post-thrombophlebotic disease of the lower limbs induced by absolute valvular incompetence of the great veins. Criteria are offered for assessment of the efficacy of the technique for formation of venous valves. Altogether 54 operations were performed including those provided to 29 patients (the main group) operated on according to the technique proposed and those in 25 patients (control group) operated on the basis of the known technique reported in the literature. In 51 patients, these operations were accomplished in combination with different variants of procedures on the communicating and saphenous veins of the lower limbs. The time of some follow ups was as long as 7 years. The beneficial short-term results were obtained in 96.5% of cases whereas the long-term outcomes were positive in 92% of the basic group patients.

Radionuclide assessment of the treatment by compression of patients with chronic venous insufficiency.

A study was made of the efficacy of the compression medical tricot in the treatment of chronic venous insufficiency (CVI). To evaluate the treatment by compression, the authors, in addition to the clinical examination, used radionuclide techniques such as examination of the regional blood volumes and phleboscintigraphy. The results of the given work have shown that the compression products under test are effective agents for the treatment of CVI by compression which improves venous return and the patients' quality of life. The data obtained point out that in addition to the lowering of blood filling, the medical tricot influences the interstitial element of the edematous syndrome, leading to the elimination of the latter one. The use of elastic bandages creates the known difficulties (the necessity of the patient training in bandaging, complexity of creating an adequate bandage, quick depreciation). In view of this fact the use of the compression tricot which possesses the fixed grade of compression for a concrete form and stage of CVI is preferable in the therapy of chronic venous diseases.

Surgical disobliteration of postthrombotic deep veins--endophlebectomy--is feasible.

OBJECTIVE: Partial obstruction of postthrombotic veins is caused by endovenous scar tissue, which creates synechiae and septae that narrow and sometimes block the lumen. We have performed surgical disobliteration, or endophlebectomy, of chronically obstructed venous segments during various kinds of deep venous reconstructions to increase the flow through previously obstructed segments. In this article we describe the endophlebectomy technique, and report the availability of this procedure as an adjunct to deep venous reconstructions for the treatment of postthrombotic chronic venous insufficiency. Patients and methods Between July 1996 and February 2003, surgical disobstruction of 23 deep venous segments was performed in 13 patients in association with 14 deep venous reconstructions to treat advanced postthrombotic chronic venous insufficiency. Postthrombotic veins were surgically exposed, and a longitudinal venotomy was carried out at a variable length. The synechiae and masses attached to the intimal layer were carefully excised. Mean duplex scanning follow-up was 10.8 +/- 8.2 months (median, 8 months; range, 1-28 months). RESULTS: In 10 patients (77%) the treated segments remained primarily patent at median follow-up of 8 months (range, 1-28 months). Early thrombosis near the endophlebectomy site occurred in 3 patients, at 2, 5, and 12 days, respectively, after surgery. In 2 patients with early thrombosis further interventions were carried out with success. In a third patient with early postoperative thrombosis the final outcome was recanalization and reflux. These results yielded an overall secondary patency rate of 93%. No perioperative pulmonary embolism was observed. CONCLUSION: This series demonstrates that surgical disobliteration of postthrombotic deep veins is technically feasible, and led to patency of the segments for the duration of follow-up for up to 28 months (mean, 10.8 +/- 8.2 months). We used this technique with the objective of disobstructing postthrombotic veins, to increase flow through a previously narrowed lumen. Postoperative thrombosis at the site of endophlebectomy occurred in 23% of patients. Although this early experience is encouraging, further studies and longer follow-up are necessary to assess the durability of the procedure.

Division of incompetent perforator veins and subfascial interposition of a polypropylene foil in post-thrombotic syndrome. Preliminary results.

AIM: The safety, feasibility and early efficacy of subfascial endoscopic perforator surgery was gradually accepted for patients who had severe chronic venous insufficiency but, in the literature, the recurrence rate of ulceration is about 10-40%, especially in patients with previous deep vein thrombosis (DVT). METHODS: From October 1998 to February 2002, 205 patients with 280 inferior leg ulcers were followed; 115 had venous ulcers but only 20 patients had chronic ulcers with previous DVT; 4 patients were excluded and only 16 patients (9 female, 7 male, mean age 61 years) with 18 chronic ulcers were included. These patients underwent sub-aponeurotic interruption of perforating veins with blind technique in association with subfascial interposition of a hand-made polypropylene foil. Eight of these patients had persistent non-healing ulcers at the time of surgery and 10 had chronic recurrent ulceration healed at the time of the surgical procedure. All patients were assessed clinically and with duplex scanning. RESULTS: The follow-up was done clinically and with eco-Doppler from 6 to 38 months with a mean follow up period of 23.2 months. The healing rate was 100%. The 2-year life table incidence of ulcer recurrence was 0%. Hospital stay ranged from 1-2 days, early operative complications included extensive ecchymosis in 1 patient, oedema in 3 patients. CONCLUSION: The division of perforating veins, with the subfascial support of a polypropylene foil give promising results in the treatment of venous ulcers in post-thrombotic syndrome with low morbidity and short hospital stay.

The reproducibility of the ratio of volume flow in the common femoral vein and artery for quantification of the severity of venous insufficiency.

BACKGROUND: The ratio of volume flow in the common femoral vein and artery denoted as venous-arterial Flowindex (VAFI) is significantly increased in venous insufficiency according the clinical grade of the disease. This study was done to investigate the reliability and reproducibility of VAFI as quantitative pattern. PATIENTS AND METHODS: In 43 patients with varicose veins C4-6 EPAS,D,PPR (PVV), 40 with postthrombotic syndrome C4-6 ESAS,D,PPR,O (PTS) and 48 healthy volunteers volume flow in the common femoral vein (VFV) and artery (VFA) were measured by duplex. Division of VFV by VFA calculated VAFI. VAFI-measurement was repeated 5 times at an interval of ten minutes in 63 subjects (23 PVV, 20 PTS, 20 healthy) and it was performed at three different days in 68 subjects (20 PVV, 20 PTS, 28 healthy). RESULTS: Mean VAFI +/- standard deviation was 1.39 +/- 0.26 in PVV, 1.42 +/- 0.26 in PTS and 0.93 +/- 0.13 in healthy veins (p < 0.001). VAFI remained stable and significantly increased (p < 0.001) in PVV and PTS compared to healthy veins during 40 minutes and also within three different days. CONCLUSION: The venous-arterial flowindex VAFI is a reproducible pattern of the hemodynamic severity in venous insufficiency.

[The role of endoscopic ligation of the perforating veins in the treatment of chronic venous insufficiency under conditions of the one-day surgery center]. / Rol' éndoskopicheskoi pereviazki perforantnykh ven pri lechenii khronicheskoi venoznoi nedostatochnosti v usloviiakh tsentra khirurgii odnogo dnia.

The present work is concerned with the results of endoscopic ligation of the perforating veins (SEPS) in 179 patients with chronic venous insufficiency, class 4-6, performed at the one-day surgery center. In patients suffering from varicosity, SEPS was accomplished in combination with phlebectomy in 52 (29.1%) patients. The second stage after phlebectomy involved the combination of SEPS with microsurgical reconstruction of the femoral vein valve. SEPS alone was provided to 89 (49.7%) patients suffering from postthrombotic disease. No life-threatening complications or lethal outcomes were recorded. The postoperative events were observed in 20 (11.2%) patients. Good results were obtained in 128 71.5%) patients, satisfactory in 42 (23.5%) and unsatisfactory in 9 (5%) subjects. The data obtained allow to regard SEPS as an effective, drastic and little traumatic technique which can be used successfully under conditions of the one-day surgery center.

The first experience with endovascular stenting of the iliac veins in patients suffering from post-thrombophlebitic disease.

This paper describes the results of the first experience with endovascular stenting of the iliac veins in patients suffering from post-thrombophlebitic disease. During 11 months, the patient with a history of segmental venous thrombosis and involvement of the left iliac veins received conservative treatment which included phlebotropic therapy and elastic compression. Despite these measures the patient demonstrated the symptoms of venous insufficiency such as edema, and pains in the left lower extremity. In addition, control ultrasonography and radionuclide examinations revealed chronic occlusion of the left iliac veins. In view of this circumstance we performed endovascular dilatation and stenting of the iliac veins. The postoperative period was uneventful. After two months the pains in the left lower extremity and its edema were fully removed. Control radionuclide phleboscintigraphy demonstrated complete patency of the left iliac veins. So, endovascular stenting is an effective and safe modality for the treatment of the occlusive forms of post-thrombophlebitic disease.

[Surgical therapy of venous leg ulcers]. / Operative Ulkustherapie.

Surgical treatment of venous leg ulcers is a domain of dermatology. Special knowledge of differential diagnosis considerations and various treatment options are necessary to develop complex, sometimes interdisciplinary treatment plans together with angiologists,vascular surgeons and interventional radiologists. Besides surgical treatment options aiming towards normalization of venous hemodynamics, local options such as shave or total ulcer excision are well established. Additionally, new surgical techniques such as subfascial endoscopic perforator surgery (SEPS) or implantation of iliac stents now have their place in the surgical treatment of venous ulcer disease.

Clinical presentation and anatomic distribution of chronic venous insufficiency of the lower limb in a typical Mediterranean population.

BACKGROUND: The aim of this study was to demonstrate the characteristics of lower limb chronic venous insufficiency (CVI) in a homogeneous Mediterranean population. METHODS: Investigation of 694 patients with uni- or bilateral symptoms and signs of lower limb CVI using colour duplex scanning. Limbs with previous venous surgery were excluded. The limbs were classified according to history and ultrasonic findings into those with post-thrombotic and those with primary CVI. The clinical presentation according to the CEAP classification was correlated to the anatomic distribution of venous reflux. RESULTS: Most of the symptomatic limbs (537/656, 81.5%) with primary CVI belonged to classes 1 to 3. In these limbs reflux confined to superficial veins was very common (64.5%, 424/656) whereas the prevalence of deep and perforator vein reflux was 18.5 and 25.5%, respectively. In contrast most of the limbs (69.5%) with post-thrombotic CVI belonged to classes 4 to 6, had a complex pattern of reflux, and involvement of deep and perforator veins was common (86.5 and 48%, respectively). In about a quarter (24%) of patients with suspected primary CVI no reflux was found in either limb on duplex scanning. Most of them (48%) had telangiectasis. Bilateral reflux was found in 71% of the patients with primary CVI. CONCLUSIONS: The clinical presentation was worse in limbs with post-thrombotic CVI than in those with a primary disease. Post-thrombotic CVI was associated with a complex pattern of reflux, affecting mostly the deep and perforator veins, whereas superficial reflux was the most common pattern in limbs with primary CVI. Therefore, surgery aiming to eliminate superficial reflux would confer only a minimal benefit in limbs with post-thrombotic CVI but would treat the majority of the limbs with the primary CVI. The high prevalence of bilateral reflux found in patients with primary CVI suggests a bilateral predisposition, which supports the hypothesis of the existence of a generalised venous disease.

The development of postthrombotic syndrome in relationship to venous reflux and calf muscle pump dysfunction at 2 years after the onset of deep venous thrombosis.

OBJECTIVE: Postthrombotic syndrome (PTS) develops in 40% to 60% of patients with deep venous thrombosis. Factors that are important in the development of PTS include venous reflux, deep vein obstruction, and calf muscle pump dysfunction (CMD). METHODS: Reflux and CMD in relationship to the severity of PTS were evaluated in a 2-year follow-up study of patients with acute deep venous thrombosis. Duplex scanning was used to measure reflux. The supine venous pump function test (SVPT) measures CMD with strain-gauge plethysmography. The base-line examination was performed within 1 to 5 days after diagnosis. The next examinations were scheduled at 3, 6, 12, and 24 months. RESULTS: The study included 86 legs, and the 2-year follow-up period was completed for 70 legs. Significantly more reflux was found in previously thrombosed vein segments, with an odds ratio of 1.8 after 3 months, of 2.1 after 6 months, of 2.5 after 12 months, and of 3.2 after 24 months. Multiple regression results showed that the most important risk factor for early clinical signs of PTS was superficial reflux in months 3, 6, and 12 (P < or =.02). Deep reflux did not have a synergistic relationship with superficial reflux in correlation with the clinical signs of PTS. The SVPT was not able to predict the development of PTS. CONCLUSION: More reflux develops in previously thrombosed vein segments. As early as after the third month, patients with superficial reflux have an increased risk of development of the first clinical signs of PTS. Within 2 years, the SVPT shows no relationship with clinical signs of PTS.

[Role of radioisotopic lymphoscintigraphy in postphlebitic syndrome of the legs]. / Ruolo della linfoscintigrafia radioisotopica nella sindrome postflebitica degli arti inferiori.

Post-phlebitis syndrome of the lower limbs is a set of symptoms that follow a state of phlebostasis and phlebolymphostasis with consequent oedema and tissue distress. We submitted 36 patients with post-phlebitis syndrome of the lower limbs to radioisotopic lymphoscintigraphy for the purposes of evaluating the vicariant function of the lymphatic system and the possible role of the lymphatic system in the genesis of dermo-epidermal abnormalities. The average age of the patients was 53.2 years (range: 43-69 years; M:F ratio: 0.50). The control group consisted of 6 healthy subjects. The average duration of the post-phlebitis syndrome in the patients studied was 8.5 years. We excluded from the study patients in whom a central cause was identified as being responsible for the pathogenisis of the oedema of the lower limbs. In addition, patients with obliterant arteriopathy were also excluded. Venous pathology was evaluated first clinically and then investigated by continuous-wave Doppler. As a first step, venous pressure was measured by Doppler phlebomanometry in clino- and orthostatism. All patients underwent radioisotopic lymphoscintigraphy with microcolloids using the Rijke technique. Radioactivity was monitored by means of a computerized gamma-camera. We classified the pathological findings of radioisotopic lymphoscintigraphy as follows: 1) delayed transit; 2) obstacles; 3) star-shaped superficial collateral lymphatic circulations; 4) lymphocoele or cutaneous lakes. A significant difference was detected (p < 0.05) between the pressure values in the post- phlebitis lower limbs and the pressure values in normal subjects. Combining the results of our measurements we recorded delayed transit in 5 patients (69.5%). This latter group included the cases with the severest forms of post-phlebitis syndrome. Therefore, better knowledge of the pathophysiology of the lymphatic system would appear to be useful in order to understand the origin and evolution of oedema of the lower limbs of patients with post-phlebitis syndrome. To this end, radioisotopic lymphoscintigraphy may be useful as a first-level examination in order to evaluate the capacity and efficiency of the lymphatic system.

[Phlebological diagnosis. Phlebography of the veins of the lower extremity]. / Phlebologische Diagnostik. Phlebographie der unteren Extremitätenvenen.

Phlebography should be weighed up against the current sonographic techniques (Doppler and Duplex) applied for visualization of venous disorder along the lower extremity veins, following a decision tree considering completeness and quality of documentation wanted, invasiveness and clinical consequences expected in the individual case. Ascending leg phlebography, incorporating Valsalva's manoeuvre, means the up-to-date standard technique, offering morphologic and functional information. Varicography and additional phlebographic techniques are considered to be additive, solving special problems, having not been visualized by the standard phlebography before. Combined phlebography and peripheral blood pressure measurements may improve the output of functional informations within one session. Quality standards of phlebography have to include standardized technique of phlebography, of documentation and interpretation, dealing with the special aspects of varicose syndrome, acute thrombosis and the post-thrombotic syndrome.