Deep Vein System Research Articles

Analysis of the type of course of arteriovenous malformations of the brain on the basis of the evaluation of the personalized features of angioarchitectonics of venous drainages

Background. Arteriovenous malformations of the brain are a rare congenital vascular pathology. At the moment, the study of the venous component of arteriovenous malformations is a hot topic of many studies. Most authors believe that the angioarchitectural features of the venous link of arteriovenous malformations can have a significant impact on assessing the natural course of the pathology and determining the tactics of treating these patients. Objective. In our work, we conducted a assessment and compared the personalized features of venous drainage of arteriovenous malformations of the brain with the type of clinical course. Design and methods. We analyzed the results of a survey of 61 adult patients with arteriovenous malformations of the brain, observed in the neurosurgical department No. 3 of the RNSI n. a. prof. A. L. Polenov in the period from 2014 to 2021. Gender and age characteristics and neuroimaging data, as well as features of the venous outflow of arteriovenous malformations were analyzed. Groups of patients were composed according to the type of the course of the disease and a personalized analysis was carried out with the characteristics of the venous outflow, as well as their features. The male/female ratio was 1.5/1 (37/24). Patients under 45 years of age prevailed (77.1 %). By types of clinical course: hemorrhagic type — 18 cases (29.5 %); epileptic type — 24 patients (39.3 %); torpid type — 19 patients (31.2 %). Results. A correlation was found between the deep location of the body of the malformation, as well as drainage exclusively into the deep vein system, and the hemorrhagic type of course (p = 0.034), while the male gender and superficial localization of the malformation were more characteristic of the epileptic type (p = 0.01). The torpid flow type did not have significant relationships with the studied features. Conclusion. According to our data, an analysis of the personalized characteristics of venous drainage of cerebral arteriovenous malformations can help in assessing the clinical course, which will improve the treatment outcomes of these patients.

Adult dural arteriovenous fistulas in Galen region: More to be rediscovered.

Dural arteriovenous fistulas (DAVFs) in the Galen region are the most deeply located and most complex type of dural arteriovenous fistulas. However, cases of DAVFs in this region have not been well described. Thus, we aimed to summarize the characteristics of Galenic DAVFs involving clinical symptoms, anatomical architecture, and drainage patterns, providing experientially therapeutic strategies for these lesions based on our 20 years of clinical experience. We retrospectively examined 31 patients with Galenic DAVFs between January 2000 and June 2021. A comprehensive analysis was carried out based on the symptoms, imaging features, feeding arteries, draining veins, number and location of the fistulas, choice of treatment methods, and prognosis assessment. Twenty-nine patients received endovascular embolization, and no perioperative deaths occurred. A transarterial approach was performed in 27 patients, and a combined transarterial and transvenous approach in one. And in one case, access was established by surgical drilling and embolization was done via the venous route. Twenty-four cases were completely obliterated after first embolization, and another five cases received a second period treatment. Only one patient developed cognitive dysfunction after embolization, and the outcomes of the remaining patients were improved at long-term follow-up. The understanding of symptoms of non-hemorrhagic neurological deficits in DAVF needs to be further clarified. Lesions with pial feeders may be considered first when determining surgical orders. Multi-approach and multi-stage embolization would be safe and effective. Excessive embolization and deep-vein system obstruction should be avoided. Approach creation by surgery would be an innovative interventional therapy.

The relationship between morphometric characteristics of venous drainages of arteriovenous malformations of the brain and types of clinical course

Background. Arteriovenous malformations of the brain are a rare vascular pathology. Many studies focus on the features of venous drainage of arteriovenous malformations. The angioarchitectural and hemodynamic features of the venous component of arteriovenous malformations can influence on the patient management.Objective. To evaluate the relationship between the features of venous drainage of arteriovenous malformations of the brain and the types of clinical course. Design and methods. Survey included 61 adult patients of the neurosurgical department № 3 of the Polenov RNSI with arteriovenous malformations of the brain of supratentorial localization. Demographic and morphometric characteristics, as well as features of venous drainage of arteriovenous malformations, were assessed. Groups of patients were distinguished according to the type of the course of the disease.Results. The dependence of the hemorrhagic type of course on such factors as drainage exclusively into the deep vein system, as well as the presence of a combination of macrofistula with venous lacunae. The epileptic type was more typical for patients with superficial localization of the arteriovenous malformation. The torpid type of course had no distinctive features.Conclusion. Drainage exclusively into the deep vein system and the presence of a combination of macrofistula and venous lacunae is characteristic of the hemorrhagic type of course. The epileptic type of course was characterized by superficial localization of the malformation.

Causes and symptoms of varicose veins

Background: Varicose veins are a common disease that cause edema, heaviness, pigmentation, and skin ulcers, ultimately affecting the quality of life. Various treatments have recently been developed; therefore, clinicians need to understand the anatomy, pathophysiology, risk factors, and symptoms of varicose veins to provide optimal treatment.Current Concepts: Lower extremity veins are composed of deep, superficial, perforating, and communicating vein systems, and the main axial superficial veins are composed of the great and small saphenous veins. Venous circulation primarily relies on muscle pumps in the foot and calf. Pressure on the sole and contraction of calf muscles compress the veins, sending blood upward or to the deep vein system. Varicose veins are caused by valvular abnormalities, muscle pump failure, etc., and associated risk factors include age, pregnancy, obesity, and family history. The main symptoms include heaviness, fatigue, and edema.Discussion and Conclusion: Varicose veins have complex anatomical structures and are developed by various factors. Therefore, appropriate treatments should be selected considering patients’ symptoms, anatomical structure, and economic aspects.

Point of care ultrasound for bedside diagnosis of venous thrombosis in PICU

Background : Use of Point of care ultrasound (POCUS) for venous thrombosis is a newer approach for pediatric intensivists. Deep venous thrombosis may result from various causes and fairly common in ICU setup due to fluid deficit state in critically sick children, immobility of such patients, and on-going sepsis. It can lead to life threatening events by causing embolic events. Doppler ultrasound is done to diagnose such lesions but difficult to perform in a bed ridden critically sick patient. Transport of a critically sick patients is usually a challenge. The solution may be bedside ultrasound examination of deep vein system by the intensivist. Bedside POCUS is a quick, noninvasive and radiation free investigation. In this report we show POCUS appearance of Internal jugular vein and femoral vein thrombosis of three patients. Methods : POCUS was performed with Aloka SSD-90 machine with a frequency (7.5 MHz), linear transducer. The patient was in supine position. Transverse images below the inguinal ligament were taken by putting the probe 1 cm below the inguinal ligament the pointer towards the lateral side for FVT. For IJV scanning probe was put on lateral neck midpoint through its length with the pointer towards lateral side. Results : The thrombus was seen as a grey area (intensity towards hyperechogenicity) within the lumen of femoral vein and internal jugular vein. The IJV thrombus was very large that it displaced internal carotid artery. On performing the compressibility test the vein did not compress. The etiolology in two patients was due to severe staphylococcal sepsis while in IJV patient it was probably secondary to tuberculosis. Subcutaneous heparin therapy was started followed by warfarin. Both patients are in follow up and in good health. Conclusion : POCUS is a very useful investigation for quick diagnosis of deep vein thrombosis in critically sick patients.

Localização e papel hemodinâmico das veias perfurantes independentes das veias safenas

Background The perforating veins of the lower limbs (LL) have valves that enable the blood flow to be directed from the superficial vein system to the deep vein system and they may or may not be connected to the saphenous vein system. Objectives To use vascular ultrasonography (VUS) to identify the frequency, location, caliber, and hemodynamic role of perforating veins that do not connect to saphenous veins, during preoperative mapping of LL varicose veins. Methods A cross-sectional study was conducted using VUS in women to study the frequency, location, distance from the sole of the foot, and hemodynamic role of perforating veins. Results The frequencies of perforating veins independent of the saphenous veins were 92.6%, 5.1%, and 2.3%, in the leg, thigh, and knee, respectively, and 25.2% of them were incompetent while 72.3% were drainage veins. The mean diameters of perforating veins were 2.9 mm, 3.5 mm, and 3.7 mm, in the leg, thigh, and knee, respectively. Perforating veins were located at mean distances of 23.8 cm, 43.6 cm, and 59.4 cm above the sole of the foot in the leg, knee, and thigh, respectively. Perforating veins with reflux had a mean caliber of 3.5 mm, irrespective of location. Conclusions Perforating veins independent of the saphenous veins are most frequent in the leg, draining reflux from tributary veins. Irrespective of location, perforating veins with reflux had mean caliber of 3.5 mm.

Isolated Perfusion of the Upper Extremity with TNF-α - Double Venous Cannulation

The authors present a technical variation of the standard cannulation for cardiopulmonary bypass perfusion during hyperthermic isolated limb perfusion (ILP) procedures in selected patients with unresectable soft tissue sarcoma or malignant melanoma. Of 55 ILP procedures performed at our institution since the procedure was established in 2009, nine were performed at the upper extremity. Standard single venous cannulation was used in five cases, and extended, double venous cannulation in the last four. The standard technique for brachial vein cannulation in a small compartment of the upper extremity entails a problematic and longer perfusion of the upper extremity. This is due to the lower flow rate in the venous system and relatively large surface area with respect to weight. We present a simple technique based on a "Y" cannulation of the venous system via the deep brachial vein and superficial venous system via the basilic vein, delivering a 20% increase in flow rate in the extracorporeal circulation. Faster heating of the upper extremity and a stable thermal environment throughout upper-extremity ILP are essential for successful treatment. Extended technique of venous cannulation for extracorporeal circulation setting, due to their advantages, became standard in the upper limb ILP procedure at our institution.Key words: isolated limb perfusion - malignant melanoma - soft tissue sarcoma - upper limb - extracorporeal circulation The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.Submitted: 8. 1. 2017Accepted: 15. 1. 2017.

The Management of Symptomatic Cerebral Developmental Venous Anomalies: A Clinical Experience of 43 Cases.

BackgroundDevelopmental venous anomalies (DVAs) are rare vascular diseases becoming more frequently diagnosed. Most patients with DVAs have no clinical symptoms with the exception of a few patients with epilepsy, intracranial hemorrhage, or neuro-function deficit. There is still controversy with respect to treatment strategies for symptomatic DVAs.Material/MethodsForty-three cases of symptomatic DVAs from January 2006 to October 2015 were retrospectively reviewed and the imaging characteristics of DVAs by CT, MRI, and DSA and the treatment modalities for DVAs were studied.ResultsTypical imaging characteristics of symptomatic DVAs were wedge or umbrella-shaped collections of dilated medullary veins converging in an enlarged subependymal or transcortical collecting vein, draining to the superficial or deep vein system. Based on location and draining vein features, symptomatic DVAs were tentatively classified into six different subtypes. Of the 43 cases, 19 were treated by surgical methods and 24 were treated conservatively.ConclusionsWe concluded that the rate of accompanying abnormalities in cases of symptomatic DVAs was high. Intracerebral hemorrhage was usually attributed to associated CMs or AVMs. The associated lesions and the branches responsible for bleeding could be resected while preserving the collecting vein as far as possible.

Operative technique and morbidity of superficial femoral vein harvest.

BackgroundThe use of autologous superficial femoral veins (SFV) as an arterial or venous substitute represents a valuable technique in modern vascular surgery with versatile indications. The SFV autografts exhibit excellent control of infection and durable long-term results in terms of graft patency in prosthetic or arterial infections. In cases of elective use of the SFV, duplex ultrasound evaluation of the deep leg vein system should be implemented to confirm the patency of the profunda femoris vein.Material and methodsThe SFV can be harvested distal to the adductor hiatus with a proximal portion of the popliteal vein but should not exceed the level of the knee joint. Formation of a stump of the proximal SFV must be avoided. Simultaneous harvesting of the ipsilateral greater saphenous vein should be avoided to reduce the risk of significant chronic edema.ResultsEarly postoperative swelling of the donor leg can be expected but resolves spontaneously in most cases. Chronic mild edema of the leg with a possible indication for compression therapy may occur in up to 20 % of cases but severe complications are very rare if the anatomical borders for vein harvesting are respected. Temporary therapeutic anticoagulation after vein harvest is subject to individual decision making.ConclusionDuplex ultrasound is a reliable tool to assess the residual deep and superficial venous system in the long term. Excellent graft function and the tolerable adverse effects of vein harvest on the donor leg justify the use of the SFV in arterial and venous vascular surgery if indicated.

Pre- and Postoperative Evaluation by Photoplethysmography in Patients Receiving Surgery for Lower-Limb Varicose Veins

Objective. To evaluate the effectiveness of surgery in treating primary varicose veins in the lower limbs by photoplethysmography (PPG) and duplex mapping (DM). Method. Forty-eight lower limbs were clinically evaluated according to the CEAP classification system and subjected to PPG and DM exams. Each limb had a venous refill time (VRT) of <20 seconds and a normal deep vein system (DVS) by DM. Results. The mean pre- and postoperative VRTs were 13.79 and 26.43 seconds, respectively (P < 0.0001). After surgery, 42 limbs (87.50%) had normal results by PPG (VRT > 20 seconds). Four limbs (8.33%) showed improved VRTs, but the VRTs did not reach 20 seconds. In the 2 limbs (4.17%) that maintained their original VRTs, the DM exams showed the presence of insufficient perforating veins. Conclusion. In most cases, PPG allows for a satisfactory evaluation of the outcome of varicose vein surgery.

Strategies for Recognizing and Managing Intraoperative Venous Congestion in Abdominally Based Autologous Breast Reconstruction

Despite common superficial venous system dominance of the abdominal wall, the majority of transverse rectus abdominis musculocutaneous (TRAM)/deep inferior epigastric perforator (DIEP) flaps drain adequately, due to communicating veins with the deep system. In cases where such connections are inadequate, it is necessary for the surgeon to correctly recognize resultant congestion as an intrinsic flap issue, and treat it intraoperatively. A retrospective analysis of 1201 consecutive TRAM/DIEP free flaps over a 5-year period was performed. All cases of inadequate venous outflow not due to technical anastomotic problems or venous thrombosis were identified and analyzed. From a cohort of 1201 patients undergoing free TRAM and DIEP flap breast reconstruction, 11 (0.9 percent) exhibited intraoperative congestion due to persistent superficial venous system dominance, despite patent deep vein anastomosis. Most commonly (five flaps), anastomosis of the superficial inferior epigastric vein (SIEV) to a proximally dissected vena comitans of the flap deep inferior epigastric vein system (DIEV) was performed; thus, a superficial to deep venous loop was created within the flap. Intraoperative salvage rate was 100 percent. In this series, intraoperative congestion is most commonly due to a superficially dominant flap. In such flaps, the deep venous anastomosis is patent, and yet adequate venous drainage cannot be achieved due to the lack of communicating vessels between the two systems, or due to inadequate perforator selection. Anastomosis of the SIEV to a proximally dissected vena comitans of the DIEV on the flap was performed most commonly in our series. This allows anastomosis of two veins in close proximity, and avoidance of using a second recipient vein. Therapeutic, IV.

Cardiovascular Ultrasound in the Diagnosis and Management of Acute Intermediate-Risk Pulmonary Embolism

A 72-year-old obese woman, with history of arterial hypertension 17 presented to emergency department with a 10-day history of progressive dyspnoea (NYHA class III/IV). Prior this examination, she experienced 18 days before a collapse with consequent fracture of the left humerus. She has subjected to immobilization. On physical examination, the patients was a haemodinamicaly stable, with a normal auscultatory findings, a blood pressure of 120/80 mmHg, regular pulse rate of 125 bpm, and respiratory rate of 16 breaths/min. After removing immobilization left arm swelling was revealed. The electrocardiogram revealed sinus tachycardia with S1Q3T3 pattern. Blood gas analysis obtained on room air showed slightly decreased oxygen partial pressure (8 kPa) and saturation (90%). Echocardiography revealed highly mobile thrombus in the dilated right atrium (Fig. 1A and B), dilated and hypokinetic right ventricle, mild tricuspide regurgitation and moderate pulmonary artery hypertension (systolic pulmonary arterial pressure was 60 mmHg). A venous ultrasonography (Fig. 1C) demonstrated that thrombi were originated in the deep veins of the left arm. The intermediate-risk pulmonary embolism (PE) was diagnosed. Considering patient's age, functional status, and patient's consent after the therapeutic options was explained, thrombolytic therapy (streptokinase, 1.5 MU over 2 hours) was performed. Within 20 hours after thrombolysis, echocardiography demonstrated complete dissolution of the right atrial thrombus, improved right ventricular function, and reduction of the pulmonary arterial pressure (for approximately 20 mmHg). No adverse effects of the therapy were noted. Anticoagulation therapy with LWMH low molecular weight heparin and warfarin was started, and the patient was discharged after 10 days. After two months warfarin therapy, echocardiography showed normal cavities size and function, and duplex-Doppler scanning of the left arm showed completely dissolution 40 of thrombus and constitution of venous flow with vein-valve competency. Fig. 1 Transesophageal echocardiography (A and B) showed highly 76 mobile thrombus in the dilated right atrium, and duplex-Doppler scanning (C) revealed suboclusive thrombosis (*) of the left subclavian vein. RA: right atrium, RV: right ventricle, LA: left atrium, ... Recent clinical practice guidelines confirm that thrombolytic therapy is the first-line therapy for high-risk PE, and heparin the first-line therapy for non-high-risk PE.1) Routine use of thrombolysis in non-high risk PE patients is not recommended, but may be considered in selected patients with intermediate-risk after thorough consideration of contraindications.1) PE patients at higher risk of death, despite the absence of systemic arterial hypotension and cardiogenic shock, are those with right ventricular dilatation and hypokinesis or akinesis on echocardiography, right heart thrombi, pulmonary arterial systolic pressure > 50 mmHg, age > 70 years, and elevated troponin level.1),2) Patients with PE and right heart thrombi have a very poor short term prognosis with early mortality of 44%, despite their clinically stability, primarily because these highly mobile, poorly fixed clots are at high risk for fatal re-embolisation.3) In our case, additional reason for thrombolytic therapy was massive thrombus revealed in left subclavian vein. In that case, thrombolytic therapy lead to a simultaneous lysis of the thrombus in the deep vein system as well as those in the right heart and pulmonary arteries, resulting in clinical improvement and decreased re-embolization risk. Therefore, echocardiography confirmation of the right heart thrombi is a clear reason for early thrombolysis even in clinically stable patients with intermediate-risk PE, if absolute contraindications for thrombolytic treatment are not exist.

A perfusion-metabolic mismatch in Sturge-Weber syndrome: A multimodality imaging study

Objective: We combined perfusion weighted imaging (PWI) with 2-deoxy-2[18F]fluoro-D-glucose (FDG) positron emission tomography (PET) to study the relationship between regional metabolic and perfusion abnormalities and their clinical correlates in children with Sturge-Weber syndrome (SWS). Methods: Fifteen children (age: 0.9–10years) with unilateral SWS underwent high-resolution PWI and FDG PET prospectively. Regional (lobar) asymmetry indices (AIs) of subcortical white matter (WM) cerebral blood flow (CBF) were correlated with corresponding cortical FDG uptake asymmetries, extent of leptomeningeal vascular malformation and clinical seizure variables. Results: Abnormal cortical glucose metabolism and/or subcortical WM CBF were seen in all lobes affected by vascular malformation and extended to lobes not affected by abnormal pial vessels in 6 patients. Lower CBF was associated with lower cortical glucose metabolism in the temporal, parietal and occipital lobes (p⩽0.02). While decreased perfusion was associated with hypometabolism in most cases, increased regional CBF (found in 6 patients) was commonly associated with relatively mild or no hypometabolism. Ten of 24 cerebral lobes with normal glucose metabolism in the affected hemisphere showed abnormal perfusion. High seizure frequency was associated with severe parieto-occipital hypoperfusion (p⩽0.03), while long duration of epilepsy was related to frontal lobe hypometabolism (p=0.015). Conclusions: Regional perfusion and cortical metabolic abnormalities can extend beyond lobes affected by leptomeningeal vascular malformations and are related to epilepsy in SWS. Despite a general correlation between perfusion and metabolism, increased WM perfusion with preserved cortical metabolism in overlying cortex is a common pattern of a perfusion/metabolic mismatch. This may represent a disease stage where cortical function is preserved while increased WM perfusion provides collateral drainage of cortex via the deep vein system.

The risk of subsequent cancer and arterial cardiovascular events in patients with superficial vein thrombosis in the legs

AbstractAlthough it has been clearly demonstrated that venous thromboembolism is associated with an increased risk of subsequent overt cancer and arterial cardiovascular events in comparison with control populations, whether this association also applies to patients with isolated (ie, without concomitant involvement of the deep vein system) superficial vein thrombosis (SVT) in the legs is unknown. In 737 consecutive patients with isolated SVT not involving the sapheno-femoral junction, we conducted a retrospective investigation to assess the rate of cancer and that of arterial cardiovascular events occurring during follow-up. The event rates were compared with those occurring in 1438 controls having comparable characteristics. Both cases and controls were followed-up for an average period of 26 ± 8 months (range, 3-45). Malignancy was diagnosed in 26 cases (3.5%) and 56 controls (3.9%), leading to a hazard ratio of 0.86 (95% confidence interval, 0.55%-1.35%). Arterial cardiovascular events occurred in 32 cases (4.3%) and 63 controls (4.4%), leading to a hazard ratio of 0.97 (95% confidence interval, 0.63%-1.50%). We conclude that the occurrence of isolated SVT in the legs does not place patients at an increased risk of malignancies or arterial cardiovascular events. Whether this conclusion also applies to patients whose thrombosis involves the sapheno-femoral junction remains to be demonstrated.

Extended Compression Ultrasound Performed by Emergency Physicians: A Modified Compression Ultrasound Examination to Detect Superficial and Deep Lower Limb Thromboses in the Emergency Department

Compression ultrasound (CUS) is being used by an increasing number of emergency physicians for patients with suspected symptomatic deep venous thrombosis (DVT). Both the two-point and three-point CUS examinations are used with excellent sensitivity to rule out DVT. This technique has some limitations: distal DVTs are difficult to detect, and therefore a second examination is required about 1 week later to look for proximal progression of thrombosis. Furthermore, the superficial veins of the lower limbs are not routinely visualized when CUS examination is performed in the emergency department. Superficial vein thrombosis is common and has long been considered as a benign disease, however, this concept has been challenged. Superficial vein thrombosis can extend into the deep vein system and cause either DVT or pulmonary embolism. At our institutions, we have developed a modified CUS examination for the lower limbs, which we have called extended CUS, because it explores both the proximal deep veins and superficial veins. In this article, we describe this examination technique.

Haemodynamic changes of the deep vein system of the leg after surgery of the incompetent great saphenous vein

SummarySurgical treatment of chronic venous disease primarily aims to restore the normal haemodynamic conditions in the venous system. The objective of the study was an assessment of the influence of incompetent saphenous vein removal on the haemodynamical changes within the venous and arterial system of the operated extremity. Patients, materials, methods: The study utilised a group of 50 patients presenting with varicose veins (C2 according to CEAP classification) and great saphenous vein incompetence selected for saphenous vein stripping. In all patients, duplex Doppler examination of femoral and popliteal veins as well as femoral and popliteal arteries was performed before surgery, on the first postoperative day and 30 days after surgery. Results: After the removal of an incompetent great saphenous vein, a statistically significant increase in the minute volume flow in the femoral (p = 0.0004) and popliteal veins (p = 0.0011) was observed. Following saphenous vein stripping, a statistically significant reduction of the venous reflux time in the deep vein system was also observed in the common femoral, femoral and popliteal veins, as compared to a pre-operative examination. Postoperatively, normalisation of the venous reflux time was achieved in 36–40% of patients from the group with concomitant deep vein system incompetence. As far as the arterial system is concerned, an increase in the volume flow in the femoral (p = 0.0463) and popliteal arteries was observed, but statistical significance was not achieved in the latter (p = 0.2912). Conclusion: The flow in the deep vein system increases after the removal of the incompetent great saphenous vein. In some patients with an incompetent deep vein system, venous reflux time returns to normal after the incompetent saphenous vein has been removed.

Femoral Vein Injury and Transposition Techniques: A New Approach to Venous Reconstruction in the Setting of Trauma

Femoral vein (FV) injury is infrequent but potentially serious. Venous repair is the procedure of choice and multiple technical options are performed. This article describes a novel venous reconstruction technique of transposition of the injured FV into the deep femoral vein (DFV) system. Two men, 26 years and 32 years old, were evaluated after suffering penetrating wounds to the inguinal region, resulting in proximal FV injuries. Both the patients were treated with a lateral venorraphy of the common FV and transposition of the FV to DFV (end-to-side anastomosis). Venous thrombectomy was not required; intravenous unfractionated heparin and local acting heparin were administered during surgery. Low molecular weight heparin therapy was routinely administered before intervention in combination with elastic compression stockings. Duplex ultrasound at 1 month and 6 months after the injury demonstrated patency and luminal integrity of the involved vein in both the patients. Clinical follow-up without duplex at 12 months and 18 months revealed no evidence of chronic venous insufficiency. In instances of penetrating injury to the proximal FV, transposition to the DFV represents a novel and effective alternative to establishing venous outflow from the extremity. This technique is relatively simple and presents good permeability in the medium term. However, possible and often tolerated ligation of penetrating FV injuries should be considered a last option.

Fluid–rock interaction at the roots of an Eopaleozoic epithermal system, Sierra Norte de Córdoba, Argentina: Paragenesis, thermometry and fluid sources

A deep epithermal vein system hosted in Late Proterozoic to Cambrian granodiorite has been identified in the Sierra Norte de Córdoba, the easternmost range of the Sierras Pampeanas Orientales of Argentina. The vein swarm extends over an area of 3 km 2 parallel to a mylonitic belt and formed in fractured granodiorite. Thicknesses of veins are less than 0.5 m and their visible strike length is less than 100 m. Veins are either barren or weakly mineralized in base-metal sulfides. Most veins have mineral associations dominated by calcite and quartz with lesser amounts of chlorite, sericite, pyrite, and minor illite. In other less exposed albite-rich, adularia-bearing veins, chalcopyrite, bornite, galena, sphalerite, chalcocite and covellite may occur. The widespread occurrence of bladed calcite without any petrographic or microthermometric evidence of boiling implies that this particular habit of calcite may also develop under sub-near boiling fluid conditions. Thermometric calculations based on fluid inclusion data, chlorite composition and oxygen isotopes in the quartz–calcite pair, constrain the formation of the system between 300 and ∼350 °C, at pressures between 42 and 64 MPa (1.5–2.3 km). Stable isotope data suggest that W/ R interaction might have been the most probable mechanism of alteration, involving the participation of meteoric fluids; nevertheless, the metallic signature of some weakly mineralized veins as well as intermediate fluid inclusion salinities favor a magmatic input and a mixed origin for the fluids. Textures and mineral associations, as well as the absence of evidence of boiling in fluid inclusions, all suggest that the silica–carbonate vein system formed deeper than typically shallow Au and Ag-bearing boiling solutions. A 485 (±25) Ma lamprophyre dike crosscuts some of these veins locally producing metasomatic reactions and skarn formation, which constrains the age of the hydrothermal system to the Cambrian-Early Ordovician time span.

Serial 2-Point Ultrasonography Plus D-Dimer vs Whole-Leg Color-Coded Doppler Ultrasonography for Diagnosing Suspected Symptomatic Deep Vein Thrombosis

Patients with suspected deep vein thrombosis (DVT) of the lower extremities are usually investigated with ultrasonography either by the proximal veins (2-point ultrasonography) or the entire deep vein system (whole-leg ultrasonography). The latter approach is thought to be better based on its ability to detect isolated calf vein thrombosis; however, it requires skilled operators and is mainly available only during working hours. No randomized comparisons are yet available evaluating the relative values of these 2 strategies. To assess if the 2 diagnostic strategies are equivalent for the management of symptomatic outpatients with suspected DVT of the lower extremities. A prospective, randomized, multicenter study of consecutive symptomatic outpatients (n = 2465) with a first episode of suspected DVT of the lower extremities who were randomized to undergo 2-point or whole-leg ultrasonography. Data were taken from ultrasound laboratories of 14 Italian universities or civic hospitals between January 1, 2003, and December 21, 2006. Patients with normal ultrasound findings were followed up for 3 months, with study completion on March 20, 2007. Objectively confirmed 3-month incidence of symptomatic venous thromboembolism in patients with an initially normal diagnostic workup. Of 2465 eligible patients, 345 met 1 or more exclusion criteria and 22 refused to participate; therefore, 2098 patients were randomized to either 2-point (n = 1045) or whole-leg (n = 1053) ultrasonography. Symptomatic venous thromboembolism occurred in 7 of 801 patients (incidence, 0.9%; 95% confidence interval [CI], 0.3%-1.8%) in the 2-point strategy group and in 9 of 763 patients (incidence, 1.2%; 95% CI, 0.5%-2.2%) in the whole-leg strategy group. This met the established equivalence criterion (observed difference, 0.3%;95% CI, -1.4% to 0.8%). The 2 diagnostic strategies are equivalent when used for the management of symptomatic outpatients with suspected DVT of the lower extremities. clinicaltrials.gov Identifier: NCT00353093.

Superficial venous thrombosis: Prevalence of common genetic risk factors and their role on spreading to deep veins

Introduction Superficial venous thrombosis (SVT) has been considered for a long time a limited clinical condition with a low importance, but this approach has changed in recent years, when several studies demonstrated spreading to deep veins occurring from 7.3 to 44%, with high prevalence of pulmonary embolism. Materials and methods To evaluate the prevalence of genetic risk factors for VTE in patients suffering from SVT on both normal and varicose vein, and to understand their role on spreading to deep veins, we studied 107 patients with SVT, without other risk factors. Ultrasound examination was performed, and the presence of FV Leiden, Prothrombin G20210A mutation, and MTHFR C677T mutation was researched. Results In the patients where SVT occurred in normal veins, the presence of FV Leiden was 26.3% of the non-spreading and 60% of the spreading to deep veins SVT; Prothrombin mutation was found in 7.9% of the former case and in 20% of the latter; MTHFR C677T mutation was found respectively in 23.7% and 40%. In the patients with SVT on varicose veins, the presence of these factors was less evident (6.7%, 4.4% and 6.7% respectively), but their prevalence was considerably higher (35.7%, 7.4% and 21.4% respectively) in SVT spreading to deep veins than in non-spreading. Conclusions Our data demonstrate the high prevalence of these mutations, especially FV Leiden and associations, in patients with SVT on normal veins and their role in the progression to deep vein system.