Deep Venous Insufficiency Research Articles

Catheter directed thrombolysis for early left lower extremity deep venous thrombosis without vena cava filters protection

To investigate the indications, safety and efficacy of catheter directed thrombolysis for early left lower extremity deep venous thrombosis (DVT) without vena cava filters protection. Clinical data of 54 cases of early left lower extremity DVT received catheter directed thrombolysis without vena cava filters from July 2008 to June 2010 were retrospectively analyzed. The thrombosis was entire without free floating clots and no thrombosis in vena cava detected with ultrasound scan. Twenty-five patients were male and 29 were female with the average age of 52.8 years. Fifty-one of which were iliofemoral and popliteal, the other 3 were iliofemoral. The course were ≤ 7 d in 45 cases and these were 8 to 30 d in 9 cases. Urokinase of 300 000 U was infused through catheters per 2 h twice a day. Meanwhile 4000 U of low weight heparin was administered subcutaneously per 12 h, or heparin infusion at dosage of 18 U×kg(-1)×h(-1). The procedure technically succeeded in all patients. In total cases venous score decreased to 4.6 ± 2.1 post 6 to 10 d of thrombolysis from 10.8 ± 1.0 with thrombolysis rate of 58% ± 18% which was not significantly different between groups of ≤ 7 d and 8 to 30 d (t = 1.02, P = 0.34). On 14(th) day, 11 patients (20.4%) completely recovered, 35 cases (64.8%) experienced large improvement, 8 patients (14.8%) had mild improvement and nobody was failed, resulting in total efficacy of 100%. No patient developed clinical symptomatic pulmonary embolism. SpO2 did not alter markedly post thrombolysis [(91.0 ± 2.6)% vs. (90.8 ± 2.4)%, t = 2.03, P = 0.05]. No patients suffered from cerebral hemorrhage and haemoturia, and catheter induced inflammation occurred in 4 cases (7.41%). There was mild bleeding in puncture sites in 11 patients (20.4%) during the course. There were 36 patients (66.7%) had been followed up with the time of 6 to 21 months. In which 31 cases had no lower extremity edema or had mild edema after activities. Two patients developed serious edema after activities for deep venous insufficiency. Three cases combined with malignant tumor or renal failure recurred. For early left extremity DVT which is entire without free floating clots and no thrombosis in vena cava, catheter directed thrombolysis without filter protection maybe administered with safety, efficiency and lower expense.

Application of colour Doppler in encircling constriction of the superficial femoral vein in primary deep venous insufficiency of the lower limbs

1. The aim of the present study was to evaluate the clinical value of colour Doppler application in encircling constriction of the superficial femoral vein in deep vein insufficiency. 2. A total of 87 patients with primary deep venous insufficiency (PDVI) using ascending venography were randomly divided into group A (44 patients) and group B (43 patients). All patients underwent encircling constriction of the superficial femoral vein, high ligation and ablation of the great saphenous vein and perforator vein. The duration of venous reflux at operation was monitored with colour Doppler in group A (but not group B) to evaluate the immediate effects. Clinical grading and scoring of the clinical, etiological, anatomical, pathophysiological (CEAP) classification system were used to evaluate the follow-up curative effect. 3. In four cases from group A, completely destroyed valves were identified at the time of operation and autografting of the vein segment with a valve was carried out. The intraoperative examination of colour Doppler in group A showed a much shorter duration of vein reflux after the encircling constriction procedure than the presurgery condition. According to the results of CEAP grading, the success rate of group A (95.0%, 38/40) was significantly higher than that of group B (76.7%, 33/43). Postoperative clinical scores were markedly lower than preoperative scores in both groups A and B. 4. In conclusion, our data suggest that application of colour Doppler in encircling constriction of superficial femoral vein might enhance surgical pertinence and improve surgical effect for PDVI.

Number and location of venous valves within the popliteal and femoral veins – a review of the literature

Although deep venous insufficiency is common and important, the anatomy of deep vein valves is poorly understood. The aim of this study was to investigate the location, number and consistency of venous valves in the femoral and popliteal veins in normal subjects. A detailed literature search of PubMed was performed. Abstracts and selected full text articles were scrutinised and relevant studies published between 1949 and 2010 reporting anatomical details of deep vein valves were included. From 7470 articles identified by the initial search strategy, nine studies with a total of 476 legs were included in this review. All studies were cadaveric and subjects ranged from stillborn fetuses to 103 years of age. Studies suggested that femoral veins contain between one and six valves, and popliteal veins contain between zero and four valves. Deep vein valves were consistently located in the common femoral vein (within 5 cm of the inguinal ligament), the femoral vein (within 3 cm of the deep femoral vein tributary) and in the popliteal vein near the adductor hiatus. Valves are consistently located at specific locations in the deep veins of the leg, although there is often significant variability between subjects. Further anatomical and functional studies using new imaging modalities available should target these areas to identify whether certain valves play a more important role in venous disease. This may guide us in the development of new treatment options for patients with deep venous disease.

First textbook in vascular surgery

First textbook in vascular surgery

Does Distal Venous Hypertension Affect Lower-Extremity Venous Pulsatility?

Introduction Pulsatile flow in the lower-extremity venous system is commonly attributed to various cardiac abnormalities. In patients with significant venous insufficiency and resultant venous hypertension, venous capacitance may be drastically reduced. We have noted multiple patterns of venous pulsatility and theorized that the hemodynamic state of the lower-extremity venous system could in fact play a role in these patterns. If venous reflux is isolated to the superficial system, ablation of these veins could resolve the venous hypertension and potentially influence the pulsatile flow pattern. Methods We compared the presence and pattern of lower extremity venous pulsatility in 293 consecutive patients suffering from chronic venous insufficiency (Mean CEAP 3.2). Of these, 242 limbs underwent endovenous thermal ablation (EVTA) of a refluxing truncal vein. Duplex ultrasound was used to evaluate these limbs approximately 3 days post procedure and the results of 101 limbs were available for comparison with the initial exam and provide the basis of this study. Results Of the 101 limbs, 47 (46.5%) had evidence of pulsatile flow in the lower extremity venous system preoperatively which was graded into one of three categories. Forty-eight (47.5%) had deep venous insufficiency of either the femoral vein (n = 16) or popliteal vein (n = 32), which was graded as normal, >1 second, or >2 seconds. The remaining had no evidence of deep vein reflux. Paired observations using the Wilcoxon method showed no difference in the venous pulsatility post ablation. Additionally, isolating patients with no evidence of deep venous reflux also revealed no difference in pulsatility following ablation. Conclusion Ablation of refluxing truncal veins did not appear to influence the presence or pattern of venous pulsatility in the lower extremities regardless of deep system valve function.

Endovascular Treatment of Phlegmasia Cerulea Dolens with Impending Venous Gangrene: Manual Aspiration Thrombectomy as the First-Line Thrombus Removal Method

Our purpose was to report the outcome of endovascular treatment with manual aspiration thrombectomy as the first-line thromboablative method for phlegmasia cerulea dolens. Between October 2006 and May 2010, seven consecutive patients (5 women, 2 men; age range, 31-80 years) with the diagnosis of phlegmasia cerulea dolens secondary to acute iliofemoral deep venous thrombosis had endovascular treatment with manual aspiration thrombectomy. Catheter-directed thrombolysis and stent placement were used as adjunctive procedures. Phlegmasia was left-sided in five and right-sided in two patients. All patients had associated great saphenous vein thrombosis in addition to iliofemoral deep vein thrombosis (DVT). Aspiration thrombectomy completely removed the thrombus from the popliteal vein to the inferior vena cava (IVC) in all cases. Three patients with May-Thurner syndrome had stent placement in the left common iliac vein. Two patients had early recurrences. Repeated aspiration thrombectomy was unsuccessful in one patient. There were no complications related to the procedure. One patient who had been successfully treated died of sepsis and another patient who had unsuccessful repeated interventions had below-the-knee amputation. Overall, the clinical success and survival rates of patients in this study were 86%. On follow-up, three patients with successful treatment were asymptomatic with no deep venous insufficiency. One of these patients died during the 4-month follow-up period. Two patients had mild ankle swelling with deep venous insufficiency. Manual aspiration thrombectomy with adjunctive use of catheter-directed thrombolysis and stent placement is an effective endovascular treatment method with high clinical success and survival rates for phlegmasia cerulean dolens.

Systematic Review of Pharmacologic and Compression Therapies for Treatment of Post-Thrombotic Syndrome

AbstractAbstract 4207 Background:Post-thrombotic syndrome (PTS) is a chronic complication of deep venous thrombosis (DVT) characterized by chronic pain, swelling and other signs in the affected limb that can severely impact individuals' quality of life. There are no widely accepted treatments for PTS, although varied treatment strategies have been proposed.Objective: To systematically review evidence for the effectiveness and safety of pharmacologic and compression therapies for treatment of PTS. Methods:Randomized controlled trials (RCTs) of PTS treatments were sought in a search of PubMed and by reverse citation searches. Results:A total of 121 titles were reviewed and 12 full-text publications were assessed for inclusion. Seven trials were selected for inclusion in the review. Four trials (3 parallel RCTs, 1 crossover RCT) including 521 patients assessed the effectiveness of various drugs for treatment of PTS. These pharmacotherapies included rutosides, hidrosmin, and defibrotide and treatment durations ranged from 2–12 months. Three trials (1 parallel RCT, 2 crossover RCTs) including 82 patients assessed compression therapies. Two used intermittent pneumatic compression (IPC) devices worn for 4–8 weeks, while one used continuous compression in the form of graduated compression stockings (GCS) worn for at least 1 year. Follow-up in these studies ranged from 8 weeks to over 1 year. All studies identified PTS as occurring after DVT in the same leg, often requiring objective diagnosis of DVT. One study used CEAP criteria for venous insufficiency, including patients classified as C2, C3 or C4. Another required participants to have had deep venous insufficiency (not further defined) for at least 12 months. Two studies used the Villalta scale to classify patients as having PTS, while one study only included patients with a score >14, corresponding to severe PTS. Another study defined PTS as the presence of chronic and typical pain and swelling 1 year post-DVT, and another defined it as intractable symptoms causing significant limitations of lifestyle and/or morbidity. In one study, PTS was not defined. Indicators used to assess the success of the interventions varied. Clinical signs and symptoms were often assessed with a quantitative scoring system. Validated scales used included Kakkar & Lawrence, Villalta, and VEINES-Sym. Calf and ankle circumference were often measured, where significant differences in these measures were used to attest to the success of an intervention; however, the clinical significance of these changes may be questionable. The IPC studies defined treatment success based on factors such as perceived benefit, patient preference for the active treatment, and willingness to continue to use the intervention. The GCS study defined treatment failure based on symptom deterioration, work absences, and development of venous ulcer. Only 1 study assessed the effect on quality of life, using the VEINES-QOL questionnaire. Studies of pharmacotherapies demonstrated minimal benefit on symptom scores, reduced calf and ankle circumference, and ulcer healing. In one study that continued to follow-up subjects for 6 months after treatment was terminated, the effect of drug treatment was not sustained (50% of ulcers returned). Studies of compression therapy did not convincingly demonstrate benefits of GCS; but for the IPC devices, treatment success was more likely than on the placebo devices. None of these treatments were associated with any important side effects and hence, compliance was acceptable in all studies that reported it. Studies of pharmacologic and compression therapies for treatment of PTS suffer from study design limitations including lack of blinding and wash-out periods that have the potential to introduce bias. Short duration of treatment in some studies may limit the extent to which the interventions were found to be effective. Sustained effectiveness was not assessed except for one study.Conclusions: There is limited and low quality evidence for the effectiveness of rutosides, hidrosmin, and defibrotide to treat PTS. There is also limited and low quality evidence for the effectiveness of GCS, but IPC devices seem to provide at least short term relief from PTS. More rigorous studies are needed to assess the effectiveness and sustainability of pharmacologic and compression treatments for PTS, and study endpoints should focus on clinically important improvements in patient condition. Disclosures:No relevant conflicts of interest to declare.

Chronische venöse Insuffizienz bei postthrombotischem Syndrom und Varikose

Venous disorders have a high prevalence and require approximately 1% of health budgets of industrialized countries. The postthrombotic syndrome (PTS) is defined by subjective symptoms and morphologic trophical skin changes following deep venous thrombosis. Prevention of venous thromboembolism in risk situations, easy availability of diagnostic tools (D-dimers, colour-coded duplex sonography) and early detection of deep venous thrombosis, as well as immediate therapeutic anticoagulation along with leg compression during the acute phase and over a two year period of time significantly reduce the incidence of PTS. Chronic venous insufficiency (CVI) includes trophical skin and soft tissue pathologies of the lower leg due to venous hypertension in the distal venous system of the lower extremity. Roughly, two main causes can be distinguished. (A) Deep venous insufficiency (A1 in postthrombotic syndrome; A2 in primary deep venous insufficiency) and (B) superficial venous reflux, usually varicose veins. Compression therapy, surgical ablation of superficial venous reflux, and tangential ablation with split skin graft (shave treatment) of refractory venous ulcers are the mainstays in the treatment of CVI.

Deep venous external valvuloplasty using a rigid angioscope

The aim of this study was to evaluate the long-term results of deep venous valvuloplasty using a rigid metal angioscope. Forty patients who underwent deep venous external valvuloplasty using a rigid metal angioscope for primary deep venous insufficiency were enrolled. The preoperative CEAP (Clinical/Etiology/Anatomy/Pathophysiology) classifications were class 2 in 13 patients, class 3 in 8 patients, class 4 in 12 patients, class 5 in 1 patient, and class 6 in 6 patients. In 9 legs in 6 patients, the valves were either destroyed or congenitally absent, and deep venous plication was applied instead. The long-term operative results were evaluated from clinical charts and direct telephone interviews. During a mean follow-up period of 5.0 years, we experienced no deep vein thromboses or other complications. In 39 of the 40 patients, the subjective symptoms improved. The improvement after successful valvuloplasty was 82% with respect to the CEAP classification. Among the 9 legs treated by deep venous plication alone, 5 had improved CEAP classifications, while 4 showed no change. Deep venous external valvuloplasty assisted by a rigid angioscope is a safe and effective method for severe valve insufficiency. Furthermore, the long-term results are positive. Deep venous plication may therefore represent an effective alternative for patients who cannot undergo valvuloplasty.

Endovenous Laser Therapy in the Treatment of Lower-limb Venous Ulcers

To assess the efficacy of endovenous laser therapy (EVLT) in the treatment of lower-limb venous ulcers secondary to venous reflux. Forty-four of 139 patients referred for EVLT from January 2004 to August 2007 had nonhealing venous ulcers. Preprocedural duplex ultrasound (US) was performed to document saphenous venous reflux secondary to saphenofemoral/saphenopopliteal junction incompetence, deep venous insufficiency, and deep vein thrombosis. Follow-up intervals were within 1 week, monthly until ulcer healing, and every 6 months thereafter. Mean follow-up period was 35.8 months (range, 8.1-59.3 months). Mean great saphenous vein (GSV) diameter and length treated were 9.9 mm (range, 5.5-16.0 mm) and 36.7 cm (range, 20.0-60.0 cm). Mean laser energy used was 3,292 J (range, 1,392-4,971 J). Mean energy deposited per centimeter of vein was 93.6 J/cm (range, 45.2-182.0 J/cm). Mean laser time was 232 seconds (range, 99-347 sec). Fifteen patients with follow-up duplex US had no GSV flow at 6 months, with nonvisualization indicating complete obliteration. Ulcer healing occurred as early as 1 week after the procedure in some patients. Cumulative healing rates at 1, 3, 6, and 12 months were 82.1%, 92.5%, 92.5%, and 97.4%, respectively. No ulcer had recurred at 1 year, but ulcers recurred in five patients at 14, 14, 23, 35, and 52 months after EVLT, respectively. One patient with a nonhealing ulcer 2 years after treatment developed well differentiated squamous cell carcinoma. Ulcer epithelization occurred with continued GSV occlusion and loss of flow. Most ulcers healed within 3 months with no recurrence at 1 year. Nonhealing ulcers should undergo biopsy to exclude malignant transformation.

Novel missense mutations in theFOXC2gene alter transcriptional activity

Mutations in the FOXC2 gene that codes for a forkhead transcription factor are associated with primary lymphedema that usually develops around puberty. Associated abnormalities include distichiasis and, very frequently, superficial and deep venous insufficiency. Most mutations reported so far either truncate the protein or are missense mutations in the forkhead domain causing a loss of function. The haplo-insufficient state is associated with lymphatic hyperplasia in mice as well as in humans. We analyzed the FOXC2 gene in 288 patients with primary lymphedema and found 11 pathogenic mutations, of which 9 are novel. Of those, 5 were novel missense mutations of which 4 were located outside of the forkhead domain. To examine their pathogenic potential we performed a transactivation assay using a luciferase reporter construct driven by FOXC1 response elements. We found that the mutations outside the forkhead domain cause a gain of function as measured by luciferase activity. Patient characteristics conform to previous reports with the exception of distichiasis, which was found in only 2 patients out of 11. FOXC2 mutations causing lymphedema-distichiasis syndrome reported thus far result in haplo-insufficiency and lead to lymphatic hyperplasia. Our results suggest that gain-of-function mutations may also cause lymphedema. One would expect that in this case, lymphatic hypoplasia would be the underlying abnormality. Patients with activating mutations might present with Meige disease.

Neovalve construction in deep venous incompetence

The purpose of this study is to assess the outcome of neovalve construction in two consecutive series of patients affected by postthrombotic syndrome and valve agenesis. The technique was modified in the second series so as to correct a cause of failure. Between December 2000 and June 2007, 40 neovalve constructions were carried out in 36 patients (19 males, 17 females, median age 57, range, 29-82) affected by deep venous insufficiency. Thirty-two patients were affected by postthrombotic syndrome and 4 by valve agenesis. The 32 patients with postthrombotic syndrome were selected from among 76 patients with resistant ulcers classified C (6,S) E (S) A (S,D,P) P (R,RO) and the 4 patients with valve agenesis were selected from among 28 affected by resistant ulcers classified as C (6,S) E (C) A (S,D,P) P (R). The patients were subdivided into 2 groups. The first group included 19 operations performed in the period between December 2000 and December 2004, with a median follow-up of 54 months (range, 31-78). The second group included 21 patients operated on between January 2005 and June 2007, with a median follow-up of 5 months (range, 2-29). In the second group, a surgical variation was applied in order to prevent flap collapse and to maintain the continence of the neovalve. In the first series, ulcer healing was observed in 16 cases out of 19 (84%). Recurrent ulcers were observed in one case after 3 years. Valve competence was ascertained in 13 cases per 803 patient-months (1.6/100 patient-months). With regard to the second series, competence was achieved in all cases with a cumulative rate of 21 per 228 patient-months (9.2/100 patient-months). In the second series, the ulcer failed to heal in one case and recurred in two cases, with an intention-to-treat ulcer recurrence rate of three cases per 209 patient-months. Postoperative deep-venous thrombosis was observed in 3 patients in the first series. None was detected in the second series. The mortality rate was 0 and in neither group was pulmonary embolism detected. The modified technique applied to the second group seemed to improve valve continence results significantly. However, a longer follow-up period is required for the latter group to validate this technical enhancement.

Endovenous laser ablation: Venous outcomes and thrombotic complications are independent of the presence of deep venous insufficiency

We hypothesize that endovenous laser ablation (EVA) therapy is equally successful in improving venous insufficiency symptoms in patients with or without deep venous insufficiency (DVI). From January 2005 through August 2007, EVA of the great saphenous vein (GSV) was attempted in 364 patients (460 limbs) with symptomatic GSV reflux. The GSV was successfully cannulated and obliterated in all but 17 limbs. EVA was performed alone in 308 limbs (69.5%) and with phlebectomy or perforator ligation (EVAP) in 135 limbs (30.5%). Venous clinical severity scores (VCSS) were recorded preoperatively and at 30, 90, 180, and 360 days postoperatively. Patients were classified as those with or without DVI based on duplex imaging valve closure times at the common femoral vein (CFV) and popliteal vein (PV). In a subset of 181 patients undergoing EVA therapy in the operating room, perioperative thrombosis prophylaxis was administered based on a risk-stratification protocol. Patients were assessed with direct end points (VCSS) and indirect end points (vein occlusion rates). Successful performance of EVA led to complete saphenous vein ablation in 99.8% at 1 month and 95.9% at 1 year. Median VCSS preoperatively was 6 (interquartile range, 5-8), generally decreasing over all time points to 4 (interquartile range, 2-5) beyond 360 days (P < .001). Male gender was independently associated with greater improvement in scores with time (P = .019). Changes in VCSS and duration of vessel occlusion were equivalent regardless of DVI for both isolated EVA and EVAP. For EVAP, the true deep venous thrombosis (DVT) rate was 2.2%, whereas for isolated EVA, the rate was 0% (P = .028); the rate of saphenofemoral thrombus extension was 5.9% for EVAP vs 7.8% for isolated EVA (P = .554). The use of risk-adjusted heparin prophylaxis in patients undergoing EVAP did not have a significant effect on thrombotic complications. There were no differences in true DVT, thrombus extension, or superficial thrombophlebitis between patients with or without DVI. Performance of concomitant phlebectomy, DVI, gender, and age had no effect on the duration of vessel occlusion. EVA produces successful ablation and is associated with sustained improvement in VCSS. These outcomes are independent of the presence of DVI. Finally, the use of a risk-adjusted thrombosis prevention protocol had no effect on the rate of superficial thrombus extension from EVA or EVAP in patients undergoing general anesthesia.

The importance of deep venous reflux velocity as a determinant of outcome in patients with combined superficial and deep venous reflux treated with endovenous saphenous ablation

Twenty to thirty percent of patients with symptomatic chronic venous insufficiency (CVI) are found to have combined superficial and deep venous reflux on duplex testing. It is currently unclear whether endovenous ablation (EVA) of the saphenous vein will result in correction of CVI without addressing the deep venous reflux. In this study, we examined deep venous reflux velocities to determine whether these would predict outcome after endovenous ablation. Patients with symptomatic CVI and both saphenous and deep venous reflux were identified using duplex ultrasonography. Reflux times and maximal reflux velocity (MRV) in each examined vein segment were determined. In each limb, the venous filling index (VFI) and the venous clinical severity score (VCSS) were obtained both before and after laser ablation of the great and/or small saphenous veins. Preoperative venous reflux velocities were correlated with improvement in VFI and VCSS after ablation. 75 limbs with both deep and superficial venous reflux were identified. Seventy-five percent of limbs were CEAP clinical class 3 or 4 and the other 25% were class 5 or 6. Forty limbs demonstrated deep venous reflux in the femoral and/or popliteal vein. After EVA, significant improvements in VFI and VCSS were seen, but this depended on MRV in the deep vein. When MRV in the popliteal or femoral vein was <10 cm/sec, limbs had significantly better outcomes than limbs with MRV >10 cm/sec as measured by both VFI (P = .01) and VCSS (P = .03). In 35 limbs, deep venous reflux was identified only in the CFV. In this group, the average pre-procedure VFI (6.54 +/- 3.9 cc/sec) decreased significantly to 2.2 +/- 1.9 cc/sec (P < .001) and the VCSS improved markedly from 7.0 +/- 2.8 to 1.3 +/- 1.4 (P < .001). EVA of the saphenous veins can be performed in patients with concomitant deep venous insufficiency with hemodynamic and clinical improvement in most cases. Patients with popliteal or femoral reflux velocities lower than 10 cm/sec usually experience marked improvement in both the VFI and the VCSS. Patients with femoral or popliteal reflux velocities greater than 10 cm/sec have a high incidence of persistent symptoms after EVA.

Surgical Management of Deep Venous Insufficiency Caused by Congenital Absence of the Infrarenal Inferior Vena Cava

Congenital absence of the inferior vena cava (CAIVC) is a rare vascular defect, commonly reported as a fortuitous finding because patients are typically asymptomatic of the condition itself but are symptomatic of associated conditions such as congenital heart disease, polysplenia, asplenia, and inversion of bowel viscera. The presence of CAIVC is probably underestimated because CAIVC may not be detected by compression B-mode ultrasonography. By use of computed tomography, we diagnosed a case of CAIVC in a young athletic patient with disabling venous stasis symptoms of the lower limbs. Venous prosthetic reconstruction of the infrarenal vena cava provided with early subsiding of edema and healing of stasis ulcers. An intracaval web was found as potentially responsible for the condition. We present and propose our surgical method for this rare disabling condition.

Percutaneous management of chronic deep venous reflux: review of experimental work and early clinical experience with bioprosthetic valve

Lower extremity chronic deep venous insufficiency (CDVI) is common and remains a major health problem worldwide. Selected patients benefited from direct deep vein valve surgical repair or valve transplantation. A major limitation of this approach is that most of the patients are not candidates for these procedures due to obstructions or residual thrombus throughout the vein. The past 15 years have witnessed experimental efforts at catheter-based management of CDVI. This review describes the initial designs and experimental evolution of a mechanical and bioprosthetic venous valve that can be implanted by using a transcatheter technique. These valves consisted of single, double, or triple cusp leaflets made of synthetic or biological materials attached to a carrier or frame. All described devices for percutaneous transcatheter valve placement rely on some form of a vascular stent for valve attachment.

Ulcus venosum cruris - etiopathogenesis, clinical features and surgical treatment

Treatment of venous ulcerations should be based on etiopathogenetic characteristics. Previous biochemical, histological and clinical investigations show that there are two types of venous ulcerations: caused by superficial venous insufficiency (SU) and by deep venous insufficiency or obstruction (DU). Both types include communicative (perforate) vein incompetence. Different procedures are used to block pathological blood reflux and they depend on the type of ulceration. Aim of the study was to evaluate short-term and long-term follow-up of different surgical procedures in superficial, communicant and deep veins that depend on the type of ulceration. Patients with venous ulcerations are divided into two groups: C(5-6)EpsAspPr (equivalent to SU) and C(6-6)EpsAdpPro (equivalent to DU) according to CEAP classification. In the first group operative treatment involved superficial and perforating veins, and in the second group operative treatment involved deep and perforating veins. We used chi2 test to compare the groups. Venous ulcerations are more often in women (59.1%) than men (40.9%), on the average in their late sixties. Clinical signs of venous stasis and trophic changes are more often in DU than SU. Patients with SU were operatively treated on superficial (136 partial or complete stripping of main veins), communicating (25 ligatures, 22 subfascial shearing) or by combined procedures on superficial and communicating veins (80). Patients with DU were operatively treated by perforator's ligature (17), subfascial perforator's shearing (12), superficial vein operations (4), sapheno-popliteal anastomoses (18), de Palma bypass (13) and interposition of healthy saphena segment (1). Long-term follow-up was registered after 5-15 (on average 3.7) years in 75 (58 SU and 17 DU) patients. Relapse of ulcerations were detected in 9 (15.5%) SU and 3 (17.6%) DU, i.e. (16.0%) of all operated patients with venous ulcers. In patients undergoing surgery for chronic venous insufficiency (2.274) more often present with SU (263) than DU (65). Patients with DU had more significant trophic changes and pathological blood reflux that required reconstructive procedures of deep veins. CEAP classification is equivalent to etiopathogenetic types of venous ulcerations and it is appropriate for follow-up of clinical characteristics and results of venous ulceration treatment.

Pay attention to surgical indication and technique for deep venous valve insufficiency of lower limbs

原发性深静脉瓣膜功能不全是引起下肢慢性静脉功能不全(chronic venous insufficiency,CVI)的重要原因.根据国内外大多数文献报道,60%～70%的CVI患肢有深静脉瓣膜功能不全,有各种瓣膜修复和功能重建手术应用于临床。

Percutaneous autologous venous valve transplantation: Short-term feasibility study in an ovine model

Limited experience with bioprosthetic venous valve percutaneously inserted into femoral veins in 15 patients has been promising in short-term results only to show disappointing long-term results. Percutaneous autogenous venous valve (PAVV) transplantation was explored in an ovine model as a possible alternative treatment. PAVV consisted of a vein segment containing a valve that was attached to a stent template. The stent templates (n = 9) were designed and hand made in our research laboratory. They consist of two stainless steel square stents 13 or 15 mm in diameter to fit the ovine jugular veins (JV), which ranges from 10 to 15 mm in diameter. A valve-containing segment of JV was harvested and attached with sutures and barbs inside the stent template (n = 9). The valve devices were then manually folded and front loaded inside the 4 cm chamber of the 13F delivery sheath and delivered into the contralateral JV by femoral vein approach. Transplanted PAVVs were studied by immediate and 3 months venograms. Animals were euthanized at 3 months, and jugular veins harvested to perform angioscopic evaluations in vitro. PAVV transplantation was successful in all nine animals. Good valve function with no reflux was observed on immediate and 3 months venograms in eight valves. The transplanted maximal JV diameter ranged from 10.2 mm to 15.4 mm (mean 13.1 +/- 1.5 mm). Venoscopic examination revealed intact, flexible, nonthickened valve leaflets in eight specimens. One PAVV exhibited normal function of one leaflet only; the other cusp was accidentally cut during the transplantation procedure. All transplanted autologous valves were free of thrombus and incorporated into the vein wall of the host vessel. This study demonstrated that autogenous valve transplants remained patent and competent without long-term anticoagulation for up to 3 months. The percutaneous autogenous venous valve may provide in future minimally invasive treatment for patients with chronic deep venous insufficiency, but long-term studies need to be done to document its continued patency and function.

Quantification of venous reflux parameters using duplex scanning and air plethysmography

To compare different duplex- and air plethysmography (APG)-derived parameters between patients with relatively early and those with advanced chronic venous insufficiency (CVI), and to investigate the indicative parameters reflecting the progression of CVI. Prospective study at the University Hospital. In total 686 limbs in 574 patients at various clinical stages of CVI were included. The clinical manifestations were categorized according to the CEAP (clinical, aetiologic, anatomic and pathophysiologic) classification, and the patients were divided into two groups: group I (C(1-3(E(P,S)A(S,D,P)P(R,O), relatively early stage of CVI) and group II (C(4-6)E(P,S)A(S,D,P)P(R,O), advanced CVI). The distribution of venous insufficiency including the sapheno-femoral junction (SFJ), great saphenous vein (GSV), sapheno-popliteal junction (SPJ), common femoral vein (CFV), femoral vein (FV), popliteal vein (POPV), thigh perforators (TPV) and calf perforators (CPV) was determined by duplex ultrasound. The main duplex-derived parameters assessed were the reflux time (RT; s), peak reflux velocity (PRV; cm/s) and peak reflux flow (PRF; mL/s). The venous reflux was assumed to be present if the duration of reflux was > or = 0.5 s. The data obtained by APG were on VV (mL), VFI (mL/s), EF (%) and RVF (%). There was no significant difference in overall superficial venous reflux between the groups (P = 0.331). The frequency of deep and perforating vein incompetence differed only when superficial reflux was included in group II. The VFI and RVF were significantly higher in secondary CVI than in primary CVI (P = 0.0001, 0.003, respectively). In the secondary CVI, patients with reflux and obstruction showed significantly higher RVF than those with reflux alone (P = 0.003). The RT did not improve the discrimination power between the groups. In contrast, the PRV had significant discrimination power at the SFJ (P < 0.0001) and SPJ (P = 0.022), and in the GSV (P < 0.0001), the FV (P = 0.017), and the POPV (P = 0.0003). The PRF was significantly higher in group II at the SFJ (P < 0.0001), in the GSV (P = 0.002), in the CFV (P = 0.011), in the FV (P = 0.027), and the POPV (P = 0.016). This present study has suggested the importance of superficial venous insufficiency in the development of advanced CVI. In the secondary CVI, obstruction affects the RVF alone. The PRV and PRF are better parameters than the RT for discrimination of clinical severity in both superficial and deep venous insufficiency, and should be used to quantify venous valvular insufficiency.