Trends of hospital-based surgery for varicose veins in the elderly.

OBJECTIVE: The treatment of varicose veins has shifted during the past decade to the office setting. Although recent studies have demonstrated the safety of venous ablation for the elderly in the office, a paucity of data is available on the contemporary outcomes of surgery for varicose veins in the operating room. The present study analyzed the trends and outcomes of varicose vein surgery in the elderly using a large national database. METHODS: The American College of Surgeons National Surgical Quality Initiative Program database (2005-2017) was reviewed. Patients undergoing vein ablation or open surgery (ie, high ligation, stripping, phlebectomy) for venous insufficiency were identified using Current Procedural Terminology codes and the principal diagnosis. The patients were stratified into 3 age groups <65, 65 to 79, and ≥80 years. The preoperative and operative characteristics and outcomes were compared. Logistic regression was performed to identify the risk factors associated with any adverse event, defined as any morbidity or mortality. RESULTS: A total of 48,615 venous surgeries had been performed, with 9177 (18.9%) performed in patients aged 65 to 79 years and 1180 (2.4%) in patients aged ≥80 years. The proportion of patients in the 65- to 79-age group had steadily increased during the study period from 12.8% in 2005 to 22.3% in 2017 (P < .01). The proportion of patients aged ≥80 years had remained stable (P = .23). Patients aged ≥80 years had significantly more comorbidities, were more likely to have undergone vein ablation alone (P < .01), were more likely to be treated for ulceration (P < .01) and less likely to have received general anesthesia (P < .01) compared with the younger age groups. Overall morbidity increased significantly with increased age group (P < .01) but remained low (2.5%). Mortality was very low (0.02%) and not significantly different among the age groups. The factors independently associated with any adverse event were dialysis (odds ratio [OR], 7.12; 95% confidence interval [CI], 3.3-15.6), American Society of Anesthesiologists classification per unit increase (OR, 1.2; 95% CI, 1.02-1.3), use of general anesthesia (OR, 1.2; 95% CI, 1.0-1.4), and combined venous ablation and open procedures compared with venous ablation alone (OR, 1.3; 95% CI, 1.0-1.5). However, age was not associated with adverse events (OR, 1.0; 95% CI, 1.0-1.0). CONCLUSIONS: Varicose vein surgery is safe for all age groups and is being increasingly offered to the elderly. High-risk patients might benefit from the avoidance of hybrid procedures and general anesthesia when possible to minimize the occurrence of adverse events. Conservative measures should be exhausted before surgery for the dialysis population.

Severe varicose veins and the risk of mortality: a nationwide population-based cohort study.

OBJECTIVE: Varicose veins (VVs) are common and although considered benign may cause morbidity. However, the association between VV severity and cardiovascular and mortality risks remains unknown. The aim of this study was to investigate the factors associated with overall mortality in patients with VV. METHODS: A total of 4644 patients with newly diagnosed VV between 1999 and 2013 were identified from Taiwan's National Health Insurance Database. VV severity was classified from grade 1 to 3 according to the presentation of ulcers or inflammation. Moreover, 9497, 2541 and 5722 age-matched, sex-matched and chronic cardiovascular risk factor-matched controls, as assessed based on propensity score, were separately selected for three grading VV groups. Enrolled patients were analysed using conditional Cox proportional hazards regression analysis to estimate risk of mortality and major adverse cardiovascular events (MACEs) in the VV and control groups. RESULTS: Most patients with VV were free from systemic disease. However, compared with matched controls, patients with VV showed a 1.37 times increased risk of mortality (95% CI 1.19 to 1.57; p<0.0001). Compared with matched controls, older (age ≧65 years) (adjusted HR: 1.38; 95% CI 1.17 to 1.62; p=0.0001) and male patients with VV (adjusted HR 1.41; 95% CI 1.18 to 1.68; p=0.0001) showed increased risk of mortality. Furthermore, compared with controls, patients with VV showed 2.05 times greater risk of MACE. Compared with matched controls, population at grade 3 increased 1.83 times risk of mortality and 2.04 to 38.42 times risk of heart failure, acute coronary syndrome, ischaemic stroke and venous thromboembolism. CONCLUSIONS: This nationwide cohort study demonstrated that patients with VV are at a risk of cardiovascular events and mortality. Our findings suggest that presence of VV warrants close attention in terms of prognosis and treatment.

Optimal endoscopy timing in patients with acute variceal bleeding: A systematic review and meta-analysis.

Although current guidelines recommend performing endoscopy within 12 hours for acute variceal bleeding (AVB), the optimal timing remains controversial. This study aimed to assess the effect of endoscopy timing on the mortality and rebleeding rates in AVB through a systematic review and meta-analysis of all eligible studies. PubMed, Cochrane Library, and Embase were searched for relevant publications up to January 2019. Overall mortality, rebleeding rate, and other clinical outcomes were determined. For the non-randomized studies, the risk of bias assessment tool was used to assess the methodological quality of the included publications. The Mantel-Haenszel random-effects model of the RevMan software (Cochrane) and the inverse variance method were used to analyse binary end points and continuous outcomes, respectively. This meta-analysis included five studies with 854 and 453 participants who underwent urgent (≤12 hours) and non-urgent endoscopies (>12 hours), respectively. All the included studies were retrospective in nature, because of obvious ethical issues. No significant differences in the severity indexes were found between the urgent and non-urgent groups. Three studies showed 6-week mortality and the others in-hospital mortality as main outcomes. No significant difference in overall mortality rate was found between the groups (odds ratio [OR]: 0.72, 95% confidence interval [CI]: 0.36-1.45, p = 0.36). The rebleeding rate was similar between the two groups (OR: 1.21, 95% CI: 0.76-1.93, p = 0.41). Other outcomes such as successful haemostasis, need for salvage therapy, length of hospital stay, and number of blood transfusions were also similar between the groups. We demonstrated that endoscopy timing does not affect the mortality or rebleeding rate of patients with AVB. Therefore, an appropriate timing of endoscopy would be more important than an urgent endoscopy depending on each patient's condition.

Functional polymorphism rs1024611 in the MCP1 gene is associated with the risk of varicose veins of lower extremities.

OBJECTIVE: Monocyte chemoattractant protein 1 (MCP-1) is a chemokine responsible for monocyte, basophil, and T-lymphocyte attraction. Polymorphism rs1024611 located in the regulatory region of the MCP1 gene has previously been shown to be associated with increased MCP-1 production. In our study, we aimed to examine the association of rs1024611 with the risk of primary varicose veins (PVVs) of lower extremities. METHODS: The case group comprised 470 patients with PVVs, and the control group included 269 individuals without a history of chronic venous disease. All cases and controls were ethnic Russians. Genotypes were determined by real-time polymerase chain reaction allelic discrimination. Association was studied by logistic regression analysis. RESULTS: We revealed the association of genotype G/G with the increased risk of PVVs (odds ratio [OR], 1.87; 95% confidence interval [CI], 1.02-3.44; P = .04). In the subgroup analysis, association was revealed only in patients with C2 Clinical, Etiology, Anatomy, and Pathophysiology class (allele G: OR, 1.62 [95% CI, 1.13-2.33; P = .008]; genotype G/G: OR, 3.22 [95% CI, 1.43-7.27; P = .005]), in patients with age at onset of PVVs before 30 years (allele G: OR, 1.41 [95% CI, 1.08-1.85; P = .01]; genotype G/G: OR, 2.35 [95% CI, 1.22-4.55; P = .01]), and in patients who declared no family history (allele G: OR, 1.46 [95% CI, 1.02-2.09; P = .04]; genotype G/G: OR, 2.50 [95% CI, 1.11-5.63; P = .03]). CONCLUSIONS: Our results provide evidence for MCP-1 involvement in the development of PVVs and indicate that inflammation could be implicated in the pathogenesis of this condition.

Acute kidney injury predicts mortality in cirrhotic patients with gastric variceal bleeding.

BACKGROUND AND AIM: The International Club of Ascites (ICA) recently proposed a new definition of acute kidney injury (AKI) in cirrhotic patients. The study evaluated the ICA-AKI criteria and their association with the prognosis of cirrhotic patients with gastric variceal bleeding (GVB). METHODS: A retrospective cohort study using prospective database of cirrhotic patients hospitalized with the first presentation of acute GVB at Taipei Veterans General Hospital from April 2007 to December 2010 was performed to evaluate the development of AKI. The study used Cox proportional hazards model to examine the association of ICA-AKI criteria and mortality. RESULTS: Of 113 patients, 46 (41%) fulfilled the ICA-AKI criteria and most (70%) initially had stage 1 AKI. Child-Pugh score, systemic blood pressure at admission, and number of blood units transfused before endoscopy were independent predictors of AKI. Among patients with AKI, 30% progressed to higher stages with more advanced liver disease, lower serum sodium, more units of blood transfusion, higher frequency of infection, and higher serum creatinine levels at diagnosis of AKI. The 6-week mortality rate was significantly higher in patients with AKI than in patients without AKI (37% vs 3%, P < 0.001), and AKI stages were independent predictors of 3-month survival (93% in patients without AKI, 73% in stage 1, and 30% in stages 2 and 3, P = 0.005). CONCLUSIONS: The occurrence of AKI as defined by the ICA criteria is common in cirrhotic patients with acute GVB. The presence of AKI was associated with much higher 6-week mortality, and the stages of AKI further predicted 3-month survival.

Sudden death by rupture of a varicose vein: Case report and review of literature.

Venous disease, including varicose veins and chronic venous insufficiency, is one of the most common chronic medical conditions. Haemorrhage from rupture of varicose veins in the legs is rare and can lead to sudden death. Nevertheless, this condition is not included among the causes of sudden death. In this case, an 88-year-old man was found dead in a large pool of blood at home. Initially, investigators mistakenly assumed that it was a case of homicide. Bloodstain pattern analysis was performed. An external examination of the victim showed an ulcer on the left foot and evident varicose veins untreated on the lower limbs. The aim of this study is to emphasize the role of treatment of varicose veins in the prevention of adverse events such as sudden death from acute haemorrhage.

Does adding variceal status to the Child-Turcotte-Pugh score improve its performance in predicting mortality in cirrhosis?

The Child-Turcotte-Pugh (CTP) score is widely used worldwide to predict outcomes across a broad spectrum of liver diseases, mainly cirrhosis. Portal hypertension and variceal bleed are significant causes of morbidity and mortality in cirrhotic patients, although the variceal status is not incorporated into the classical CTP score. We sought to determine whether the inclusion of variceal status, specifically the Child-Turcotte-Pugh-Kumar (CTPK) score, would improve the utility of the classical CTP score to predict the clinical outcomes of cirrhotic patients in a single but high-volume center in China.We retrospectively analyzed the records of 253 patients from January 1, 2014 to December 31, 2014 and performed follow-up for at least 12 months. The CTPK score and the CTP score were obtained as soon as possible after the patient's admission. Telephone follow-up was performed to assess survival situations.At 3 and 12 months, the cumulative number of deaths was 9.1% (n = 23) and 13.8% (n = 35), respectively. In the multivariate Cox proportional hazards models, the CTPK score was independently associated with death within 3 and 12 months after adjusting for potential confounders. The predictive ability related to the 2 scores was evaluated by the area under the receiver operating characteristic curve (AUC-ROC) respectively. At 3 months of enrollment, the AUCs of CTPK and CTP were 0.814 and 0.838, respectively. At 12 months of enrollment, the AUCs of CTPK and CTP were 0.825 and 0.840, respectively. No significant difference between time points was observed. Both the CTPK score and the CTP score displayed prognostic value in cirrhotic patients, as the Kaplan-Meier analysis showed that the CTPK score could clearly discriminate patients in the intermediate term (P < 0.001).The CTPK score provides reliable prediction of mortality in Chinese cirrhotic patients for both short-term and medium-term prognoses, although it is not superior to the CTP score. Therefore, the CTP score remains an excellent tool for outcome prediction in patients with cirrhosis, and greater attention to variceal status may be in veins, even for patients with a history of variceal bleed or medium/large varices.

The Beneficial Effect of Beta-Blockers in Patients With Cirrhosis, Portal Hypertension and Ascites.

BACKGROUND: Patients with cirrhosis and portal hypertensive complications have reduced survival. As such, it has been suggested that nonselective beta-blocker therapy in patients with advanced ascites is harmful. The aim of this study was, therefore, to determine the risk of mortality in patients with cirrhosis and ascites taking nonselective beta-blocker therapy for the prevention of variceal hemorrhage. MATERIALS AND METHODS: This study was a retrospective analysis of 2,419 patients with cirrhosis and portal hypertension admitted to Parkland Memorial Hospital (a university-affiliated county teaching hospital) from 2003-2010. Patients were subdivided into those with varices only, ascites only and those with both varices and ascites. The primary outcome measure for this study was all-cause in-hospital mortality. RESULTS: Overall, 68 of 1,039 (6.5%) patients taking beta-blockers died during their hospitalization, while 223 of 1,380 (16.2%) patients not taking beta-blockers died (P < 0.001). Beta-blocker use was also assessed in specific cohorts; mortality was 21.1% in patients with severe ascites with varices who were not taking beta-blockers compared with 8.9% in patients who were taking beta-blockers (P = 0.05). Overall, fewer patients taking beta-blockers died compared with those not taking beta-blockers in patients with varices only (6.4% versus 12.1%) and those with ascites with or without varices (6.6% versus 18.1%) (P < 0.001). CONCLUSIONS: Mortality was lower in patients with cirrhosis and portal hypertension taking nonselective beta-blockers than in those not taking beta-blockers. The use of nonselective beta-blockers provided a significant survival benefit in patients with all grades of ascites, including those with severe ascites.

Surgical treatment of varicose veins and venous malformations in Klippel-Trenaunay syndrome.

BACKGROUND: Klippel-Trenaunay syndrome (KTS) is a mixed mesenchymal malformation characterised by varicose veins, venous and capillary malformations, and hypertrophy of soft tissue and bone. The purpose of this study was to evaluate the surgical outcomes in KTS patients to provide standards for comparison with endovenous therapy. METHODS: The clinical data of consecutive patient with KTS who underwent open venous surgical treatment between January 1987 and December 2008 were reviewed. Demographics, clinical presentation, operative data, and clinical outcomes were recorded. Follow-up information was obtained from the medical records, mailed questionnaires and phone calls. Descriptive statistics, the Kaplan-Meier method and Log-rank statistics were used where appropriate. RESULTS: Twenty-seven females and 22 males, (mean age 26.5 years, range 7.7-55.8) were included in this study. All had varicose veins, 36 (73%) had limb hypertrophy, and 33 (67%) had capillary malformations, with two of three clinical features present in all. The most frequent symptom was pain (N = 43, 88%). Forty-nine patients underwent operations on 53 limbs. Stripping of the GSV, small and accessory saphenous and lateral embryonic veins was performed in 17 (32%), 10 (19%), 9 (17%), and 15 (28%) limbs, respectively. Two patients developed deep vein thrombosis, one had pulmonary embolism (PE), and one patient had peroneal nerve palsy. Freedom from disabling pain at 1, 3 and 5 years was 95%, 77% and 59%, respectively, and freedom from secondary procedures was 78% at 3 years, and 74% at 5 years. At the last follow-up visit, the venous clinical severity score had decreased from 9.48 ± 3.27 to 6.07 ± 3.20 (P < 0.001). CONCLUSIONS: In selected symptomatic patients with KT syndrome, open surgical treatment is safe and durable. Three-fourths of the patients remain free of disabling pain at five years, but secondary procedures are required in one-fourth of the patients. These data can serve as standards for comparison of endovenous therapy for KT syndrome.

Prospective comparison of three risk scoring systems in non-variceal and variceal upper gastrointestinal bleeding.

BACKGROUND AND AIM: Data regarding the efficacy of the Glasgow Blatchford score (GBS), full Rockall score (FRS) and pre-endoscopic Rockall scores (PRS) in comparing non-variceal and variceal upper gastrointestinal bleeding (UGIB) are limited. Our aim was to determine the performance of these three risk scores in predicting the need for treatment, mortality, and re-bleeding among patients with non-variceal and variceal UGIB. METHODS: During January, 2010 and September, 2011, patients with UGIB from 11 hospitals were prospectively enrolled. The GBS, FRS, and PRS were calculated. Discriminative ability for each score was assessed using the receiver operated characteristics curve (ROC) analysis. RESULTS: A total of 981 patients presented with acute UGIB, 225 patients (22.9%) had variceal UGIB. The areas under the ROC (AUC) of the GBS, FRS, and PRS for predicting the need for treatment were 0.77, 0.69, and 0.61 in non-variceal versus 0.66, 0.66, and 0.59 in variceal UGIB. The AUC for predicting mortality and re-bleeding during admission were 0.66, 0.80, and 0.76 in non-variceal versus 0.63, 0.57, and 0.63 in variceal UGIB. AUC score was not statistically significant for predicting need for therapy and clinical outcome in variceal UGIB. The GBS ≤ 2 and FRS ≤ 1 identified low-risk non-variceal UGIB patients for death and re-bleeding during hospitalization. CONCLUSION: In contrast to non-variceal UGIB, the GBS, FRS, and PRS were not precise scores for assessing the need for therapy, mortality, and re-bleeding during admission in variceal UGIB.

Similarities and differences in the clinical features between cardia varices and esophageal varices.

BACKGROUND AND AIM: Little is known about the clinical features of cardia varices (CV). The aim was to examine the background, bleeding risk, and post-treatment outcomes of CV in patients with portal hypertension. METHODS: The subjects of this retrospective study were 277 patients (179 males, 98 females, 62.9 ± 11.5 years) with esophageal varices (EV). In patients with CV, there were 65 bleeders, and 95 patients received endoscopic treatment for primary or secondary prophylaxis. RESULTS: There were 147 patients with CV (53.1%). The higher grade of EV (P < 0.01) and the lower grade of gastric fundal varices (FV) (P = 0.046) were significant factors for the presence of CV. Significant risk factors for bleeding were: the higher grade of EV (P < 0.01), red sign on EV (P < 0.01), lower albumin (P = 0.01), and Child-Pugh B/C (P < 0.01) for EV and red sign on CV (P < 0.01) and use of non-steroidal anti-inflammatory drugs (NSAIDs)/aspirin (P < 0.01) for CV. All CV disappeared by sclerotherapy combined with argon plasma coagulation or band ligation, and 20 patients (21.1%) in EV and 18 patients (18.9%) in CV had recurrences during the median observation period of 19.4 months. There was no significant difference in the cumulative survival rate between non-bleeders, bleeders from EV, and those from CV. CONCLUSIONS: The CV were closely associated with advanced grade of EV and less-advanced grade of FV. Further, usage of NSAIDs/aspirin and red sign were significantly related to the bleeding from CV, suggesting the need for careful management.

Risk factors for venous thromboembolism in cancer: novel findings from the Vienna Cancer and Thrombosis Study (CATS).

Venous thromboembolism (VTE) occurs frequently in patients with cancer and contributes to elevated morbidity and mortality. Risk factors for the occurrence of VTE events in patients with cancer have been investigated in numerous clinical studies. For now more than 10 years, the Vienna Cancer and Thrombosis Study (CATS) has focused on the identification of parameters predictive of future VTE occurrence. CATS has contributed to new findings, which may help identify patients at high risk of developing VTE, by means of biomarkers (such as D-dimer, prothrombin fragment 1+2, soluble P-selectin, platelet count, coagulation factor VIII activity, thrombin generation potential, etc.). The association of tissue factor bearing microparticles and the mean platelet volume with the risk of VTE was also elaborately investigated in the framework of CATS. More recently CATS has researched clinical and clinicopathologic parameters which contribute to identification of patients at risk of VTE. The type of cancer is one of the most important risk factor for VTE occurrence. Also the stage of cancer and the histological grade of a tumor have been found to be associated with the occurrence of cancer-related VTE. In further investigations, venous diseases including a history of previous VTE, a history of superficial thrombophlebitis and the presence of varicose veins, have been associated with the risk of VTE in CATS.

Treatment options, clinical outcome (quality of life) and cost benefit (quality-adjusted life year) in varicose vein treatment.

Varicose veins are an extremely common condition causing morbidity; however, with current financial pressures, treatment of such benign diseases is controversial. Many procedures allow the treatment of varicose veins with minimal cost and extensive literature supporting differing approaches. Here we explore the underlying evidence base for treatment options, the effect on clinical outcome and the cost-benefit economics associated with varicose vein treatment. The method of defining clinical outcome with quality-of-life assessment tools is also investigated to explain concepts of treatment success beyond abolition of reflux.

Prognostic assessment in patients with hepatic encephalopathy.

Hepatic encephalopathy (HE) is a common complication of liver failure that is associated with poor prognosis. However, the prognosis is not uniform and depends on the underlying liver disease. Acute liver failure is an uncommon cause of HE that carries bad prognosis but is potentially reversible. There are several prognostic systems that have been specifically developed for selecting patients for liver transplantation. In patients with cirrhosis the prognosis of the episode of HE is usually dictated by the underlying precipitating factor. Acute-on-chronic liver failure is the most severe form of decompensation of cirrhosis, the prognosis depends on the number of associated organ failures. Patients with cirrhosis that have experienced an episode of HE should be considered candidates for liver transplant. The selection depends on the underlying liver function assessed by the Model for End-stage Liver Disease (MELD) index. There is a subgroup that exhibits low MELD and recurrent HE, usually due to the coexistence of large portosystemic shunts. The recurrence of HE is more common in patients that develop progressive deterioration of liver function and hyponatremia. The bouts of HE may cause sequels that have been shown to persist after liver transplant.

The clinical characteristics, endoscopic treatment, and prognosis for patients presenting with duodenal varices.

BACKGROUND/AIMS: This study investigated the clinical characteristics, endoscopic appearances, usefulness of endoscopic treatments, and survival of patients with duodenal varices. METHODOLOGY: Twelve patients were evaluated in whom endoscopy confirmed duodenal varices (13 lesions), and patient data was retrospectively analyzed regarding underlying diseases, hepatic function, endoscopic appearance, previous treatment for other complicated varices, endoscopic treatment for hemorrhage from duodenal varices, and survival. RESULTS: Underlying diseases consisted of liver cirrhosis in 8 patients, and pancreatic cancer-related pylemphraxis in 4 patients. Endoscopic appearances of hemorrhage from duodenal varices revealed negative red color (RC) signs in all 6 lesions, and 5 of 6 lesions were F3 lesions. Three of 5 patients with hemorrhagic duodenal varices had received treatment for esophageal varices. Successful hemostasis and complete eradication by endoscopic treatments was achieved in all 5 patients (6 lesions). The 1, 3, and 5 year cumulative survival rates were 66.7%, 48.6%, and 36.5% in the patients with duodenal varices. CONCLUSIONS: The hemorrhagic factor of duodenal varices is F factor, but not RC sign. Changes of blood flow in the collateral circulatory pathway after treatment for esophageal varices may increase the risk of hemorrhage from duodenal varices. Endoscopic treatment is useful for hemorrhagic duodenal varices.

The incidence and characteristic features of fatal hemorrhage due to ruptured varicose veins: a 10-year autopsy study.

Death due to hemorrhage from ruptured peripheral varicose veins is an uncommon event. A review of the files of Forensic Science SA (FSSA) in Adelaide, South Australia, was undertaken over a 10-year period from January 1996 to December 2005 for such cases. A total of 8 cases were found out of a total of 10,686, representing <0.01% of autopsy cases. The male to female ratio was 1:3, with an age range of 58-84 years (mean = 78 years). The victims were all located at their home addresses, where they had been alone at the time of their deaths. Scene investigations revealed considerable blood loss, with pooling around the victims' bodies, and also in other parts of the house, particularly the bathroom/toilet areas. Four ulcers were of an acute perforative type and 2 were of a chronic ulcerative type. In 2 cases, bleeding followed trauma. Toxicologic evaluation was performed in only 3 of the cases, revealing blood alcohol levels of 0.06% and 0.14% in 2 cases, respectively. A further victim had been prescribed anticoagulant drugs for an unrelated condition. Additional findings of significance were ischemic heart disease in 3 cases and deep venous thrombosis of the calf veins on the side of the fatal hemorrhage in another case (with no evidence of pulmonary thromboembolism). One victim had acute gastric erosions, suggesting that hypothermia following collapse played a role in the terminal event. Autopsy evaluation of such cases should include careful layer dissection of the area of hemorrhage to confirm the presence of the ruptured varix and to enable directed histologic sampling.

TIPSS in the treatment of ectopic variceal bleeding.

BACKGROUND/AIMS: Bleeding from ectopic varices is a well recognized life-threatening complication of portal hypertension but the optimal treatment of this problem is yet to be established. METHODOLOGY: We retrospectively reviewed patients with ectopic variceal bleeding who underwent transjugular intrahepatic portosystemic shunting for recurrent bleeding not responding to conservative management. RESULTS: Over an eleven-year period we identified ten patients who underwent TIPSS for ectopic variceal hemorrhage. Six patients bled from rectal varices and four from stomal varices. TIPSS was successful in nine patients. The Childs-Pugh grade of the patients was A=3, B=3 and C=4. The follow-up period ranged from 7 days to 1380 days. Rebleeding occurred in three patients, two of whom died. The remaining patient had a blocked TIPSS and successfully underwent repeat stenting which re-established patency. Four patients (Childs B=2, Childs C=2) died within 60 days. All three patients with Childs A liver disease were alive at one year. CONCLUSIONS: TIPSS can be used effectively to treat ectopic variceal bleeding. Patients with Childs grade A liver disease appear to do well with TIPSS. Those with advanced liver disease (Childs B & C) have a uniformly poor outcome. In these patients ectopic variceal hemorrhage is likely to represent a terminal event.

Adverse outcome of isolated fetal intra-abdominal umbilical vein varix despite close monitoring.

BACKGROUND AND OBJECTIVES: Fetal intra-abdominal umbilical vein (FIUV) varix-a focal dilatation of the umbilical vein-is an uncommon entity. Outcome varies from spontaneous resolution to fetal death. We describe here the experience of our center with this perplexing entity. METHODS: Case series review of seven cases of isolated FIUV treated in a tertiary care center from 2000 to 2003. RESULTS: We describe seven cases of isolated FIUV varix with varying natural history, follow-up strategies, and fetal outcome. In one of the cases, intrauterine fetal demise occurred despite close follow-up. CONCLUSIONS: We suggest that the course of FIUV is unpredictable, with a high fetal mortality rate. Close fetal monitoring with early delivery at 34 weeks' gestation should be advocated.