Application of the Caprini Risk Assessment Model for Evaluating Postoperative Deep Vein Thrombosis in Patients Undergoing Plastic and Reconstructive Surgery.

BACKGROUND: The optimal approach for assessing the risk of venous thromboembolism (VTE) in patients undergoing plastic surgery is yet to be established. This study aimed to determine the validity of the Caprini Risk Assessment Scale in identifying patients undergoing plastic surgery who are at a high risk of developing VTE. METHODS: Between December 2014 and November 2015, we enrolled 90 patients. Risk factors for VTE were assessed at baseline. The Caprini Risk Assessment Model was used to stratify patients into Caprini <4, Caprini 5-6, Caprini 7-8, and Caprini >8 groups before examination. We preoperatively screened for deep vein thrombosis (DVT) using duplex ultrasound. During operation, surgical duration and blood loss were recorded. Duplex ultrasound was repeated 2 and 7 days postoperatively to evaluate for DVT. We used a univariate analysis to determine risk factors for postoperative VTE. Confounding predictors were finally tested using a multivariate logistic regression analysis. RESULTS: One patient had preoperative DVT and was excluded from the study. Eighty-nine patients were included in the final analyses. Of the 89 patients, 7 (8%) developed postoperative DVT. Mean age, body mass index, Caprini score, and surgical duration were significantly higher in patients who developed postoperative DVT. Variables associated with increased risk of postoperative DVT using univariate analysis were Caprini scores of 7-8 and >8. Multivariate logistic regression analysis finally identified Caprini scores 7-8 [odds ratio (OR) 13, 95% confidence interval (CI) 1.67-101.98, P = 0.014] and >8 (OR 19.5, 95% CI 1.02-371.96, P = 0.048) to be independently associated with postoperative DVT. CONCLUSIONS: Although the incidence of postoperative DVT is relatively low among patients undergoing plastic surgery, Caprini scores can be used to predict postoperative VTE complications.

One-stage reconstruction by dual-innervated double muscle flap transplantation with the neural interconnection between the ipsilateral masseter and contralateral facial nerve for reanimating established facial paralysis: A report of 2 cases.

The authors developed a one-stage double-muscle reconstruction technique for facial paralysis using a latissimus dorsi (LD) flap and a serratus anterior (SA) flap, which were dually reinnervated by the contralateral facial nerve (FN) and ipsilateral masseter nerve (MN). The procedure was performed for 61-year-old man 3-years after resection of a malignant tumor and a 24-year-old woman 10-years after temporal fracture with facial paralysis. A double-muscle flap comprising left LD and SA flaps was harvested, a 15-cm thoracodorsal nerve (TN) section was attached to the LD flap, and 5-cm and 1-cm sections of the long thoracic nerve (LTN) were attached to the proximal and distal sides of SA flap. The LD flap and SA flap were sutured along the direction of motion of the zygomaticus major and risorius muscles, respectively. The contralateral FN and ipsilateral MN were interconnected by nerve suturing: the medial branch of TN to the distal end of LTN, the proximal end of LTN to the ipsilateral MN, and the buccal branch of contralateral FN to the main trunk of TN. After surgery, good contraction of the transferred flaps resulted in reanimation of a natural symmetrical smile; no complications were observed during the 12-month follow-up period.

Estimation of Mastectomy Volume Using Preoperative Mastectomy Simulation Images Acquired by the Vectra H2 System.

Preoperative prediction of breast volume is very important in planning breast reconstruction. In this study, we assessed the usefulness of a novel method for preoperative estimation of mastectomy volume by comparing the weight of actual mastectomy specimens with the values predicted by the developed method using the Vectra H2. Methods: All patients underwent skin-sparing mastectomy and immediate autologous breast reconstruction. Preoperatively, the patient's breast was scanned using the Vectra H2 and a postmastectomy simulation image was constructed on a personal computer. The estimated mastectomy volume was calculated by comparing the preoperative and postmastectomy three-dimensional simulation images. Correlation coefficients with the estimated mastectomy volume were calculated for the actual mastectomy weight and the transplanted flap weight. Results: Forty-five breasts of 42 patients were prospectively analyzed. The correlations with the estimated mastectomy volume were r = 0.95 (P < 0.0001) for actual mastectomy weight and r = 0.84 (P < 0.0001) for transplanted free-flap weight. The mastectomy weight estimation formula obtained by linear regression analysis using the estimated mastectomy volume was 0.98 × estimated mastectomy volume + 5.4 (coefficient of determination R2 = 0.90, P < 0.0001). The root-mean-square error for the mastectomy weight estimation formula was 38 g. Conclusions: We used the Vectra H2 system to predict mastectomy volume. The predictions provided by this method were highly accurate. Three-dimensional imaging is a noncontact, noninvasive measurement method that is both accurate and simple to perform. Use of this effective tool for volume prediction is expected to increase in the future.

Changes in calf muscle deoxygenation after foam sclerotherapy in patients with superficial venous insufficiency.

OBJECTIVE: This study assessed changes in the calf muscle deoxygenated hemoglobin (HHb) level during light-intensity exercise after ultrasound-guided foam sclerotherapy (UGFS) for superficial venous insufficiency. METHODS: UGFS with 1% or 3% polidocanol foam (POL-F) was used to treat unilateral great saphenous vein reflux in 84 patients. Near-infrared spectroscopy (NIRS) was used to measure calf muscle HHb levels before and 3 months after UGFS. The calf venous HHb blood-filling index was calculated on standing, the calf venous HHb ejection index was obtained after one tiptoe movement, and the venous HHb retention index was obtained after 10 tiptoe movements. The primary end point was an evident improvement in calf muscle deoxygenation after UGFS. The secondary end point was obliteration of the great saphenous vein. RESULTS: Treatment consisted of 1% POL-F in 48 limbs and 3% POL-F in the remaining 36. Ultrasound imaging at the 3-month follow-up demonstrated complete occlusion in 56.3% of the patients who received injections of 1% POL-F and in 66.7% of those who received injections of 3% POL-F. The difference in treatment outcome between the groups was not significant (P=.333). Reflux was absent in 39 limbs (81.3%) treated with 1% POL-F and in 34 limbs (94.4%) treated with 3% POL-F, and no significant difference was observed between the two groups (P=.076). Postsclerotherapy NIRS demonstrated significant reductions in the levels of the HHb filling index in both treatment groups (P=.039, P=.0001, respectively) and significant reductions in the levels of the HHb retention index (P<.0001, P=.008, respectively). However, the differences in the levels of the HHb ejection index before and after UGFS were not significant (P=.250, P=.084, respectively). CONCLUSIONS: Our present findings suggest that changes in the values of these parameters may be of potential use for assessing the effects of foam sclerotherapy in patients with superficial venous insufficiency.

Fibroblast Growth Factor-Impregnated Collagen-Gelatin Sponge Improves Keratinocyte Sheet Survival.

Commercially available cultured epithelial keratinocyte sheets (KSs) have played an essential role in wound healing over the past four decades. Despite the initial uptake by the dermal elements, the survival rate of KS on the dermis-like tissue generated by conventional artificial dermis (AD) is low, making this method unsuitable for standard treatments. Therefore, an innovative AD such as collagen-gelatin sponge (CGS) that maintains the release of human recombinant basic fibroblast growth factor (bFGF) may promote wound healing. In this study, we examined whether combination therapy with KSs and CGS with bFGF (bFGF-CGS) could enhance KS survival by heterologous grafting by transplantation of human-derived KSs in an athymic nude rat wound model of staged skin reconstruction. The CGSs were implanted into skin defect wounds on athymic nude rats, which were then divided into two experimental groups: the bFGF group (CGSs containing bFGF, n = 8) and the control group (CGSs with saline, n = 8). Two weeks after implantation, human epithelial cell-derived KSs were grafted onto the dermis-like tissue, followed by assessment of the survival and morphology at 1 week later using digital imaging, histology (hematoxylin and eosin and Masson's trichrome staining), immunohistology (von Willebrand factor), immunohistochemistry (cytokeratin 1-5-6, Ki-67), and immunofluorescence (collagen IV, pan-cytokeratins) analyses. The bFGF group showed a significantly higher KS survival area (86 ± 58 mm2 vs. 32 ± 22 mm2; p < 0.05) and increased epidermal thickness (158 ± 66 µm vs. 86 ± 40 µm; p < 0.05) compared with the control group, along with higher dermis-like tissue regeneration, neovascularization, epidermal maturation, and basement membrane development. These results indicate that the survival rate of KSs in the dermis-like tissue formed by bFGF-CGS was significantly increased. Therefore, combination treatment of bFGF-CGS and KSs shows potential for full-thickness skin defect reconstruction in clinical situations. Impact statement This study highlights how using a combination of cultures, keratinocyte sheets, and collagen-gelatin sponge containing basic fibroblast growth factors can significantly improve cell survival in athymic nude rats with staged skin reconstruction. Our study makes a significant contribution to the literature because it highlights a novel and improved strategy for treating a very common condition such as skin wounds arising from many conditions. Clinical translation of this study may be useful for treating skin wounds.

Deep vein thrombosis after total knee or hip arthroplasty is associated with increased preoperative calf muscle deoxygenation as measured by near-infrared spectroscopy.

OBJECTIVE: To assess whether the preoperative level of deoxygenated hemoglobin (HHb) in the calf muscle during light-intensity exercise is useful for identifying patients at risk of developing deep vein thrombosis (DVT) after total knee or hip arthroplasty. METHODS: Sixty-eight patients undergoing total knee or total hip arthroplasty were enrolled. The Caprini risk assessment model was used to stratify patients into Caprini 5 to 6, Caprini 7 to 8, and Caprini >8 groups. The preoperative diameter of each venous segment was measured, and the time-averaged velocity (TAV) and time-averaged flow (TAF) of the popliteal vein (POPV) were assessed. Moreover, the prevalence of venous reflux in the POPV was evaluated preoperatively. Near-infrared spectroscopy (NIRS) was used to measure the calf muscle HHb level. The calf venous blood filling index (FI-HHb) was calculated on standing, and then the calf venous ejection index (EI-HHb) was obtained after one tiptoe movement and the venous retention index (RI-HHb) after 10 tiptoe movements. All patients received low-dose unfractionated heparin preoperatively and fondaparinux for postoperative thromboprophylaxis. Patients with arterial insufficiency, those who had preoperative DVT, and those who developed bilateral DVT after surgery were excluded from the study. RESULTS: Four patients were excluded on the basis of the exclusion criteria. Among the 64 patients evaluated, 14 (21.9%) were found to have DVT postoperatively. Among the risk factors for DVT, only the previous DVT was significantly predominant in patients who developed DVT (P = .001). The diameter of the popliteal vein was significantly smaller in patients who developed postoperative DVT than in those who did not (P = .001). Similarly, the diameter of the gastrocnemius vein was significantly larger in patients with postoperative DVT than in those without (P = .010). TAV and TAF were significantly increased in the popliteal vein in patients who developed postoperative DVT (P = .043, 0.046, respectively). Both groups showed a similar prevalence of reflux in the POPV (P = .841). The preoperative NIRS-derived RI was significantly increased in patients who developed DVT relative to those who did not (P = .004). The RI increased as the Caprini score progressed; however, there were no statistically significant differences between the three categories. Using ultrasound- and NIRS-derived parameters of significance as a unit of analysis, an optimal RI cut-off point of >2.3 showed the strongest ability to predict postoperative DVT, followed by a cut-off point >0.25 cm for the diameter of the gastrocnemius vein (GV). CONCLUSIONS: NIRS-derived RI >2.3 may be a promising parameter for identifying patients at risk of developing postoperative DVT despite pharmacologic DVT prophylaxis. A GV diameter of >0.25 cm also seems to contribute to the development of postoperative DVT. These results might be helpful to physicians for deciding which patients require more intensive thromboprophylaxis.

A Case of Traumatic Intractable Leg Ulcer with Lymphorrhea Diagnosed Using ICG Lymphography.

We report a case of traumatic lower extremity ulcers with lymphorrhea in a 37-year-old woman. She presented intractable ulcers without lymphedema for nearly 6 months after a traumatic injury. She was treated conservatively for 6 months at a referral hospital. Unfortunately, during conservative treatment, cellulitis was developed. Even though the inflammation resolved, the ulcer did not heal. We suspected persistent lymphorrhea as the cause of refractory ulcer, and for that reason, we performed indocyanine green lymphography. The lymphatic vessel damage site was identified; also, a collateral lymphatic vessel connected toward the central side was recognized. The lymph fluid drainage site was selectively ligated. The lymphorrhea and ulcers healed 1 month after ligation. Ulcers with lymphorrhea can be persistent and refractory to treatment. Indocyanine green lymphography can be a feasible diagnostic technique. It can identify the site of leakage and is thus useful for treatment. There are fewer reports on the evaluation of lymphorrhea with video presentation. Here, we report a case with video presentation.

Usefulness of avulsed fingertip skin for reconstruction after digital amputation.

We present four cases of fingertip amputation treated with local flap where the avulsed fingertip skin could be effectively utilized for these donor sites. The avulsed finger skin may be utilized even when replantation is not possible. This approach may serve as a new treatment option after fingertip amputation.

Keratinocyte sheets prepared with temperature-responsive dishes show enhanced survival after in vivo grafting on acellular dermal matrices in a rat model of staged bi-layered skin reconstruction.

INTRODUCTION: Bi-layered skin reconstruction can be achieved by staged grafting of acellular dermal matrices (ADMs) and cultured epithelial keratinocyte sheets (KSs). Both KSs and ADMs have been used for long; yet, their combined use has shown poor effectiveness. This outcome has been related to the enzymatic treatment used in the preparation of KSs, which impairs their adhesion potential to ADMs and the formation of a basement membrane (BM). Temperature-responsive (TR) culture dishes allow for enzyme-free preparation of KSs with preservation of BMs and intercellular adhesion proteins; yet, their use has not been previously applied to staged bi-layered skin reconstruction. Using an in vivo rat model, we tested the hypothesis that TR cultures enhance KSs survival and BM preservation after sequential grafting on ADMs. METHODS: In nude rats (n = 9/group), a 9-cm [2] full-thickness dorsal skin defect was repaired with a commercial ADM. At 2 weeks after surgery, we grafted the ADM with KSs (circular, 25 mm diameter), prepared from human cells either by enzymatic Dispase treatment (DT control group) or a TR culture dish (TR experimental group). KSs survival and BMs preservation was assessed one week later by digital imaging, histology (hematoxylin & eosin), immunohistochemistry (collagen IV, pancytokeratins) and immunofluorescence (cytokeratin 1-5-6, laminin). RESULTS: The TR group showed a significantly higher KSs survival (120 ± 49 vs. 63 ± 42 mm2; p < 0.05) and epidermal thickness (165 ± 79 vs. 65 ± 54 µm; p < 0.01) compared with the control DT group, as well as higher epidermal maturation (cytokeratin) and a denser laminin and Collagen IV expression in the BMs in vitro and in vivo. CONCLUSION: These findings suggest that KSs prepared with TR culture dishes have significantly enhanced survival when grafted on ADMs; these outcomes could help improve current clinical strategies in wound care by skin reconstruction.

Comparison of contraction among three dermal substitutes: Morphological differences in scaffolds.

Various kinds of synthetic dermal substitutes are produced and used in clinical application and contribute to wound bed preparation for subsequent skin grafting. Although their appearance and outcomes are different, the criteria for the selection of proper synthetic dermal substitutes is not well defined yet. In this study, we focused on the contraction of dermal substitutes and compared the morphological differences in scaffolds. A marked contraction was observed with Pelnac® compared to Integra® and Terudermis® in vitro. We also showed that the pore size of Pelnac® was smaller than that of Integra® and Terudermis®. The shape of the pore was oval in Pelnac®, whereas those in Integra® and Terudermis® were more circular. Differences in the morphological structure may have affected the contraction of the synthetic dermal substitutes.

Percutaneous ultrasound-guided sclerotherapy with polidocanol microfoam for lymphatic malformations.

BACKGROUND: Lymphatic malformations (LMs) are low-flow congenital lesions that consist of cysts of varying size. Sclerotherapy with intralesional bleomycin and OK-432 has been reported to yield dramatically beneficial results for this disorder. However, inflammation-related symptoms are often seen after treatment with these sclerosing agents. On the other hand, polidocanol (POL) is reportedly associated with fewer allergic and inflammatory reactions. Up to now, however, very few reports have documented the use of POL microfoam for treatment of LMs. This study was performed to assess the efficacy and safety of POL microfoam sclerotherapy for LMs. METHODS: Between 2003 and 2016, cases were identified from a prospectively compiled database on low-flow congenital vascular malformations before undertaking a retrospective electronic chart review. Patients were included if they had LMs that had been treated by POL microfoam sclerotherapy. The location, size, and type of LMs were assessed using ultrasound and magnetic resonance imaging. Twenty-gauge venous catheters were inserted into the lymphatic space under ultrasound visualization. The LMs were then fully aspirated if they were macrocystic in form. Microfoam composed of 3% POL was then injected under ultrasound guidance. Microcystic LMs were treated by direct injection with POL microfoam under ultrasound guidance. The outcome was assessed by clinical examination combined with findings of postsclerotherapy imaging using ultrasound and magnetic resonance imaging. RESULTS: During a 13-year period, 32 patients met the inclusion criteria. These were 11 (34%) male patients and 21 (66%) female patients with a mean age of 18 years. The LMs were localized to the head and neck (47%), the trunk (38%), and the extremities (15%). The lesions were subdivided into macrocystic (56%), mixed macrocystic and microcystic (31%), and microcystic (13%) LMs. The average lesion size was 6.6 × 4.6 × 3.0 cm. The mean number of treatment sessions was 2.8 (range, 1-15), with a mean foam volume of 4.6 (range, 1-10) mL. Excellent (47%) and moderate (41%) responses were seen in 88% of the patients. Notably, half of the patients achieved excellent or moderate resolution with a single treatment session. Intralesional hemorrhage occurred in four patients (13%) but resolved spontaneously. Only one patient with mixed macrocystic and microcystic LMs developed post-therapy infection. However, the other patients did not develop any post-therapy inflammation-related symptoms, including fever, pain, and marked swelling. CONCLUSIONS: Percutaneous sclerotherapy using POL microfoam appears to be safe and effective for treatment of LMs. Ultrasound-guided POL microfoam sclerotherapy should be considered for such lesions, particularly those that are exclusively macrocystic.

Incidence of deep vein thrombosis in patients undergoing breast reconstruction with autologous tissue transfer.

Background Breast reconstruction is associated with multiple risk factors for venous thromboembolism. However, the incidence of deep vein thrombosis in patients undergoing breast reconstruction is uncertain. Objective The aim of this study was to prospectively evaluate the incidence of deep vein thrombosis in patients undergoing breast reconstruction using autologous tissue transfer and to identify potential risk factors for deep vein thrombosis. Methods Thirty-five patients undergoing breast reconstruction were enrolled. We measured patients' preoperative characteristics including age, body mass index (kg/m2), and risk factors for deep vein thrombosis. The preoperative diameter of each venous segment in the deep veins was measured using duplex ultrasound. All patients received intermittent pneumatic pump and elastic compression stockings for postoperative thromboprophylaxis. Results Among the 35 patients evaluated, 11 (31.4%) were found to have deep vein thrombosis postoperatively, and one patient was found to have pulmonary embolism postoperatively. All instances of deep vein thrombosis developed in the calf and were asymptomatic. Ten of 11 patients underwent free flap transfer, and the remaining one patient received a latissimus dorsi pedicled flap. Deep vein thrombosis incidence did not significantly differ between patients with a free flap or pedicled flap (P = 0.13). Documented risk factors for deep vein thrombosis demonstrated no significant differences between patients with and without deep vein thrombosis. The diameter of the common femoral vein was significantly larger in patients who developed postoperative deep vein thrombosis than in those who did not ( P < 0.05). Conclusions The morbidity of deep vein thrombosis in patients who underwent breast reconstruction using autologous tissue transfer was relatively high. Since only the diameter of the common femoral vein was predictive of developing postoperative deep vein thrombosis, postoperative pharmacological thromboprophylaxis should be considered for all patients undergoing breast reconstruction regardless of operative procedure.

Time taken to the maximum increase in the oxygenated hemoglobin level in calf muscle as a predictor of mild and moderate post-thrombotic syndrome.

BACKGROUND: Near-infrared spectroscopy (NIRS) allows continuous noninvasive monitoring of changes in the tissue levels of oxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb) and can identify the severity of chronic venous diseases. Here we investigated the predictors of post-thrombotic syndrome (PTS) using NIRS in patients with a first episode of deep venous thrombosis (DVT). METHODS: The study enrolled 129 patients with DVT. Risk factors in each patient were assessed at presentation. Venous abnormalities confirmed by ultrasound and parameters derived from NIRS were evaluated at 6 months after DVT. On standing, increases in O2Hb and HHb (ΔO2Hbst and ΔHHbst) and the times taken for each concentration to become maximal (TO2Hbst, and THHbst) were measured. During 10 tiptoe movements, O2Hb showed a continuous decrease (ΔO2Hbex), whereas venous expulsion (ΔHHbEex) and subsequent retention (ΔHHbRex) were observed. The oxygenation index (HbD; HbD = O2Hb - HHb) was also calculated at the end of standing and at the end of 10 tiptoe movements (ΔHbDst and ΔHbDex). Final clinical manifestations were evaluated at 6 years, and PTS was considered to be present if the Villalta score was ≥5. RESULTS: Thirteen patients were excluded and 116 patients were finally included. Of these, 19 (16%) developed PTS. Among various NIRS-derived parameters, TO2Hbst had the highest area under the curve (0.88; 95% confidence interval [CI], 0.80-0.93; P < .01) with the best cutoff value (TO2Hbst ≤48 seconds). On univariate analysis, variables associated with greater risk for development of PTS were stroke (odds ratio [OR], 5.59; 95% CI, 0.74-42.41; P = .06), idiopathic DVT (OR, 4.13; 95% CI, 1.36-12.55; P < .01) and iliofemoral DVT (OR, 4.31; 95% CI, 1.48-12.60; P < .01) at initial presentation, venous occlusion combined with reflux (OR, 4.24; 95% CI, 1.50-12.00; P < .01), and NIRS-derived TO2Hbst ≤48 seconds (OR, 43.03; 95% CI, 9.04-204.81; P < .01) at 6 months. Multivariate logistic regression analysis finally revealed venous occlusion combined with reflux (OR, 4.80; 95% CI, 1.03-22.36; P < .05) and NIRS-derived TO2Hbst ≤48 seconds (OR, 53.73; 95% CI, 8.43-342.41; P < .01) to be independently associated with PTS progression. CONCLUSIONS: NIRS-derived TO2Hbst ≤48 seconds is a promising time-course predictor of PTS progression.

Measurement of calf muscle oxygenation during light-intensity exercise in patients with post-thrombotic syndrome.

BACKGROUND: Near-infrared spectroscopy (NIRS) provides continuous noninvasive monitoring of changes in the levels of oxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb) in tissues. The purpose of this study was to investigate changes in calf muscle O2Hb and HHb levels during standing and exercise in the follow-up of deep venous thrombosis (DVT). METHODS: Forty-three patients with a first episode of unilateral proximal DVT were included. Final clinical manifestations were evaluated at a mean follow-up point of 53 months after diagnosis of DVT, and post-thrombotic syndrome (PTS) was considered to be present if the Villalta score was >5. Moreover, to assess the severity of PTS, the revised Venous Clinical Severity Score (VCSS) was employed. NIRS was used to measure changes in the levels of O2Hb and HHb in calf muscle. On standing, increases in O2Hb and HHb were calculated by subtracting the baseline value from the maximum value (ΔO2Hbst and ΔHHbst). The times taken for the O2Hb and HHb concentrations to become maximal (TO2Hbst, and THHbst) were also measured. During 10 tiptoe movements, the relative change in O2Hb was calculated by subtracting the value measured at the end of exercise from the value measured at the beginning of exercise (ΔO2Hbex). On the other hand, 10 tiptoe movements produced venous expulsion (ΔHHbEex) and a subsequent retention (ΔHHbRex). The oxygenation index (HbD; HbD = O2Hb - HHb) was also calculated at the end of standing and at the end of 10 tiptoe movements (ΔHbDst and ΔHbDex). RESULTS: Among the 43 limbs evaluated, 21 had PTS. On standing, the ΔHbDst was significantly decreased in patients with PTS relative to the patients without PTS (12 ± 8, 22 ± 11 µmol/L; P = .001). The TO2Hbst was also significantly reduced in patients with PTS relative to those without (43 ± 41, 107 ± 58 seconds; P = .001). During 10 tiptoe movements, the ΔHHbEex was significantly reduced in patients with PTS relative to those without (-2 ± 1, -3 ± 3 µmol/L; P = .016). Similarly, the ΔHHbRex was significantly increased in patients with PTS relative to those without (8 ± 7, 3 ± 2 µmol/L; P = .001). Furthermore, falls in ΔHbDex were more pronounced in patients with PTS (-10 ± 16, 10 ± 10 µmol/L; P < .001). NIRS-derived TO2Hbst (r = -0.568; P < .001) and ΔHbDex (r = -0.645; P < .001) showed strong inverse correlations with VCSS. Similarly, NIRS-derived ΔHHbEex (r = 0.409; P < .01) and ΔHHbRex (r = 0.476; P < .01) showed moderate positive correlations and ΔHbDst (r = -0.422; P < .01) had a moderate inverse correlation with VCSS. CONCLUSIONS: Changes in O2Hb and HHb concentrations differ between patients with and without PTS. The reduced TO2Hbst may indicate impairment of the venoarteriolar reflex in patients who have PTS. Furthermore, severe falls in HbD in patients with PTS might reflect the pain of venous claudication. These findings may have implications for investigations of the microcirculation in the context of post-thrombotic sequelae.

Prevalence of various congenital vascular malformations in patients with Klippel-Trenaunay syndrome.

OBJECTIVE: Klippel-Trenaunay syndrome (KTS) is a condition defined by the association of three physical features: capillary malformation, varicosities, and hypertrophy of bony and soft tissues. However, KTS is characterized by congenital vascular malformations (CVMs) that are difficult to classify. Therefore, the present study was undertaken to analyze the various CVMs in patients with KTS. METHODS: Sixty-one patients with KTS were enrolled, and their CVMs were divided into predominantly venous defects, predominantly lymphatic defects, and mixed vascular defects using the Hamburg Classification. Capillary malformations were subdivided into port-wine stain, telangiectasia, and angiokeratoma. Truncular and extratruncular vascular malformations were detected using duplex ultrasound and magnetic resonance imaging. Reflux in the superficial and deep venous systems was also evaluated. RESULTS: Forty-five patients (74%) had predominantly venous defects, four (6%) had predominantly lymphatic defects, and 12 (20%) had mixed vascular defects. Capillary malformations were detected in 54 patients (89%), among which port-wine stain was the most predominant (40 patients, 66%), followed by telangiectasia (31 patients, 51%) and angiokeratoma (18 patients, 30%). Extratruncular venous malformations were detected in 47 patients (77%). In contrast, truncular venous malformations were found in 50 patients (82%). Among these, embryonic lateral marginal vein showed the highest occurrence, accounting for 53% (32 patients). However, reflux in this vein was detected in only nine patients (15%). Twelve patients (20%) had reflux in the great saphenous vein, and four (7%) had reflux in the small saphenous vein. Deep vein hypoplasia was found in seven patients (12%), and only five patients (8%) had deep vein aplasia. Extratruncular lymphatic malformations were found in 13 patients (21%) and truncular lymphatic malformations in 17 (28%). CONCLUSIONS: Patients with KTS have a variety of CVMs, but both extratruncular and truncular venous malformations continue to be targets for intervention.

Measurements of calf muscle oxygenation during standing and exercise in patients with primary valvular insufficiency.

OBJECTIVE: Despite the established role of the calf muscle pump for preventing chronic venous disorders, hemoglobin flow in the calf muscle is poorly understood. Near-infrared spectroscopy (NIRS) provides continuous noninvasive monitoring of changes in tissue-oxygenated hemoglobin (O2Hb) and deoxygenated hemoglobin (HHb) levels. The purpose of this study was to investigate the changes in calf muscle O2Hb and HHb levels during standing and exercise in patients with primary valvular insufficiency (PVI). METHODS: Eighty-three limbs in 81 patients with PVI were enrolled. The clinical manifestations of these patients were categorized according to the CEAP (Clinical, Etiologic, Anatomical, and Pathophysiologic) classification, and patients were divided into group I (C1-3S,Ep,As,d,p,Pr) and group II (C4-6S,Ep,As,d,p,Pr). Moreover, to assess the severity of PVI, the revised Venous Clinical Severity Score (VCSS) was employed. NIRS was used to measure changes in the calf muscle O2Hb and HHb levels. On standing, increases in O2Hb and HHb were calculated by subtracting the baseline value from the maximum value (ΔO2Hbst and ΔHHbst). The time elapsed until the maximum increases in O2Hb and HHb concentrations (TO2Hbst, and THHbst) were also measured. During 10 tiptoe movements, the relative change in O2Hb was calculated by subtracting the value measured at the end of exercise from the value measured at the beginning of exercise (ΔO2Hbex). On the other hand, 10 tiptoe movements produced venous expulsion (ΔHHbEex) and a subsequent retention (ΔHHbRex). The oxygenation index (HbD; HbD = O2Hb - HHb) was also calculated at the end of standing and 10 tiptoe movements (ΔHbDst and ΔHbDex). RESULTS: Among the 83 limbs evaluated, 48 were classified as group I and 35 as group II. Standing caused increases in the levels of both ΔO2Hbst and ΔHHbst. However, there were no significant differences in these increases between the two groups. In contrast, the TO2Hbst was significantly reduced in group II in comparison with group I (55 ± 29 vs 36 ± 30 seconds; P = .007). During 10 tiptoe movements, a decrease in O2Hb concentration was observed, and there was no significant difference in ΔO2Hbex between group I and group II. In contrast, the ΔHHbRex was significantly increased in group II compared with group I (6 ± 7 vs 9 ± 6 µmol/L; P = .013). Furthermore, falls in ΔHbDex were more pronounced in group II (7 ± 16 vs -7 ± 16 µmol/L; P = .001). A statistically significant correlation was found between C of CEAP and the VCSS (r = 0.778; P < .001). Moreover, NIRS-derived TO2Hbst (r = -0.312; P < .01) and ΔHbDex (r = -0.332; P < .01) showed moderate inverse correlations with C of CEAP. Similarly, NIRS-derived ΔHbDex (r = -0.501; P < .001) had a strong inverse correlation, and ΔHbDst (r = -0.383; P < .001) and TO2Hbst (r = -0.378; P < .001) had moderate inverse correlations with VCSS. CONCLUSIONS: Changes in O2Hb and HHb concentrations differ according to CEAP manifestation and VCSS. These data offer new insights into calf muscle hemodynamics at the microcirculation level in patients with PVI.