Duplex Ultrasound Investigation Research Articles

Varicose disease in pregnant women: clinical patterns and duplex ultrasound investigation of the veins

The objective of the study was to improve the medical care of pregnant women with varicose disease based on the results of duplex ultrasound examination of the veins of the lower extremities, as well as on the clinical and laboratory parameters.We evaluated the data of 128 pregnant women with varicose veins and performed ultrasound to examine the venous system measuring the diameter of the great saphenous vein (GSV) into saphenofemoral junction, midthigh, lower thigh and investigating the venous reflux.The diameter of competent and incompetent GSVsincreased between the first and third trimester in the both groups(p < 0.001). The mean diameter was 4.3 (2.69–5.86) mm in the main group at 22–24 weeks of gestation, 4.6 (2.96‒5.86) mm at 32‒34 weeks, 4.5 (2.91–5.74) mm ‒ after delivery. The diameter of the GSV with reflux was significantly larger than that of GSVs without reflux in the saphenofemoral junction (R = 0.758, p < 0.001).Pregnancy induces the alterations of venous physiology. Examination of clinical and ultrasound data of pregnant women with varicose veins is an important step to prevent the disease progression during pregnancy and childbirth.

COVID-19 ASSOCIATED REDUCTION IN HYPERTENSION-RELATED DIAGNOSTIC AND THERAPEUTIC PROCEDURES IN EXCELLENCE CENTERS OF THE EUROPEAN SOCIETY OF HYPERTENSION

Objective: The Covid-19 pandemic necessitated a decrease in non-Covid-19 related diagnostic and therapeutic procedures in many countries. We explored the impact on hypertension care in the Excellence Center (EC) network of the European Society of Hypertension. Design and method: We conducted an electronic survey regarding 6 key procedures in hypertension care among our ECs. Results: Overall, 54 ECs from 18 European and 3 non-European countries participated. From 2019 to 2020, there was a significant decrease in the median number per center of ambulatory blood pressure monitorings (ABPMs; 544 vs 289), duplex ultrasound investigations of renal arteries (DUS RA; 88.5 vs 55), computed tomographic investigations of renal arteries (CT RA; 66 vs 19.5), percutaneous renal artery angioplasties (PTA RA; 5 vs 1), laboratory tests for catecholamines (2019: 116 vs 67.5) and for ennin/aldosterone (146 vs 83.5). All comparisons were statistically significant with p < 0.001, respectively (Figure). While the reduction in all diagnostic and therapeutic procedures was observed in all 3-months period comparisons between 2019 and 2020, the most profound decrease occurred from April to June 2020, which was the period of the first wave and the first lockdown in most countries. In this period, as compared to 2019, the median reduction in 2020 was 50.7% (ABPM), 47.1% (DUS RA), 50% (CT RA), 57.1% (PTA RA), 46.9% (catecholamines) and 41% (ennin/aldosterone), respectively. Based on Friedman test, overall differences in reduction between 3 months time intervals were statistically highly significant. Conclusions: Diagnostic and therapeutic procedures related to hypertension were dramatically reduced during the first year of the Covid-19 pandemic, with the largest reduction during the first lockdown. The long-term consequences regarding blood pressure control and, ultimately, cardiovascular events remain to be investigated.

Duplex Ultrasound Investigation for the Detection of Obstructed Iliocaval Venous Stents

Duplex Ultrasound Investigation for the Detection of Obstructed Iliocaval Venous Stents

Duplex Ultrasound Investigation for the Detection of Obstructed Iliocaval Venous Stents

Duplex ultrasound (DUS) is used for routine surveillance of stents in iliocaval veins, but direct visualisation is often challenging. Duplex ultrasound criteria for detecting venous stent obstruction (VSO) have not been defined to date. A nested case control study of 120 patients (42±17 years, 53% women, mean 2.7±1.8 stents) was performed, and the performance of various duplex parameters for detecting VSO (defined as>50% lumen diameter reduction or occlusion) was tested, confirmed by biplane venography or intravascular ultrasound (IVUS). Forty patients with VSO (25 with stent occlusion, 15 with >50% in stent stenosis) were matched to 80 control patients by age, gender and index diagnosis who fulfilled the following criteria: (1) ongoing symptom control (Villalta score<5), (2) good image quality of entire stent segment, (3) spontaneous colour Doppler signal>50% of lumen in entire stent segment, (4) at least two DUS where the baseline DUS was obtained within 24h after successful venous intervention. The best test was the combination of peak flow velocity and flow pattern analysis at the stent inlet. A peak flow velocity >10cm/s and a flow pattern spontaneously modulated by respiration ruled out VSO with a specificity of 93.7% (95% CI 86.0%-97.3%). A peak flow velocity ≤10cm/s or any Doppler flow pattern other than spontaneously modulated by respiration was 92.1% (95% CI 79.2%-97.3%) sensitive to detect VSO. The combination of peak flow velocity and analysis of Doppler flow pattern at the stent inlet is accurate to diagnose or rule out stent occlusion. Indirect criteria should always be combined with direct visualisation of iliocaval stents since those may be less sensitive for detecting stent stenosis.

Preliminary results of endovascular aneurysm sealing from the multicenter Italian Research on Nellix Endoprosthesis (IRENE) study

ObjectiveBecause of advances in technology and experience of the operator, endovascular aneurysm repair (EVAR) has supplanted open repair to treat abdominal aortic aneurysm (AAA). The low 30-day mortality and morbidity of EVAR make the endovascular approach particularly suitable for patients at high surgical risk. However, endoleak or endograft migration requiring secondary intervention or open surgical conversion is a limitation of EVAR. The Nellix system (Endologix, Inc, Irvine, Calif) has been designed to seal the entire AAA to overcome these limitations with EVAR. We report the results of a retrospective, multicenter study with endovascular aneurysm sealing (EVAS) aimed to assess technical success, procedure-related mortality, complications, and reinterventions. MethodsThis study included patients selected for elective treatment with the Nellix device per the endovascular repair protocol at 16 Italian vascular centers. All patients were enrolled in a postoperative surveillance imaging program including duplex ultrasound investigations, computed tomography, and magnetic resonance controls following local standards of care. ResultsFrom 2013 to 2015, there were 335 patients (age, 75.5 ± 7.4 years; 316 men) who underwent elective EVAS. In 295 cases (88.0%), EVAS was performed under standard instructions for use of the Nellix system. Preoperative aneurysm diameter was 55.5 ± 9.4 mm (range, 46-65 mm). The inferior mesenteric artery and lumbar arteries emerging from the AAA were patent in 61.8% and 81.3% of cases, respectively. Chimney grafts were electively carried out in eight cases (2.4%). One (0.3%) intraprocedural type IB endoleak was observed and promptly corrected. Device deployment was successful in all patients, with no perioperative mortality. Early (≤30 days) complications included 1 (0.3%) type IA endoleak, 2 (0.6%) type II endoleaks (0.6%), 2 (0.6%) stent occlusions (0.6%), 3 (0.9%) distal embolizations, and 2 (0.2%) femoral artery dissections. Six (2.9%) patients underwent reinterventions. At 1-year follow-up, complications included 3 (1.1%) type II endoleaks, 4 (1.4%) type IA endoleaks, 1 (0.3%) type IB endoleak, 2 (0.7%) distal stent migrations, 5 (1.8%) distal embolizations, and 1 (0.3%) stent occlusion. Twelve patients (3.7%) underwent reinterventions, including four (1.4%) surgical conversions due to aortoduodenal fistula (1), endograft infection (1), and type IA endoleak that was unsuccessfully treated percutaneously (2). Two AAA-related deaths occurred. Freedom from aneurysm-related reintervention was 98.3% at 1-month and 94.7% at 12-month follow-up. ConclusionsThe preliminary results of this real-world multicenter study showed that EVAS with Nellix for the management of AAAs appears feasible. This device platform is associated with acceptable procedure-related mortality and low overall complication and reintervention rates. Definitive conclusions on the value of this novel device await long-term follow-up data.

Catheter Foam Sclerotherapy of the Great Saphenous Vein, with Perisaphenous Tumescence Infiltration and Saphenous Irrigation

This was a prospective observational study to assess the short- to mid-term efficacy and safety of catheter foam sclerotherapy (CFS) of the great saphenous vein (GSV), including peri-saphenous tumescence infiltration (PST) and intra-saphenous saline irrigation (ISI), in combination with phlebectomy of the varicose tributaries. Eighty-eight limbs in 82 patients (19 male, 63 female, mean age 55.7 years) affected by varices related to GSV incompetence were submitted to CFS of the refluxing GSV segment after PST and ISI, combined with phlebectomy of the varicose tributaries. Sodium tetradecylsulfate (STS) 3%+CO2/O2 sclerosant foam (SF) (median 7mL) was injected in the GSV trunk (median caliber 7.1mm) by means of a 4F catheter. Clinical and colour duplex ultrasound (CDU) investigation was performed pre-operatively, and 40 days, 6, 12, and 36 months post-operatively. A visual analogue scale (VAS) was used to assess procedure related symptoms and venous symptoms before and 40 days after the treatment. Clinical recurrence (visible varices) at 40 days, 6 and 12 months was 0%, whereas at 36 months it was 4.7%; VAS pre-operative score of heaviness, pain, and cramps/paraesthesiae decreased from 6 (IQR 6-8) to 1 (IQR 0-3), from 3 (IQR 0-7) to 0 (IQR 0-1), and from 3 (IQR 0-7) to 0 (IQR 0-1) respectively at 40 days. The CDU based occlusion rate at 40 days, 6, 12, and 36 months was 100% (88/88), 100% (88/88), 94.3% (83/88), and 89.4% (76/85) respectively. Six of the nine patent saphenous veins (average diameter 1.4mm) had anterograde flow (overall 96.5% reflux free GSVs). One superficial venous thrombosis was recorded without any further relevant complication. GSV treatment by means of CFS and adjuvant PST+ISI, combined with phlebectomy of varicose tributaries, proved to be safe and effective in terms of clinical and duplex based outcomes at short/mid-term follow-up.

Treatment of lower extremity superficial vein thrombosis with low molecular weight heparin.

The aim of our study was to ascertain the efficacy of low-molecular-weight heparin (LMWH) in the treatment of patients with SVT. A group of 336 outpatients with clinical diagnosis of SVT was evaluated in this prospective study. At the beginning of the study all patients were examined by clinical investigation, laboratory tests and duplex ultrasound investigation (examination). All patients included into the study were treated with LMWH. Clinical and ultrasound evaluation was carried out on days 10, 30 and 90 of the follow-up. This clinical study of SVT treatment with LMWH was organized in 18 outpatient departments in the Slovak Republic. After 10 days of treatment with LMWH in full therapeutic dosage, an improvement in the clinical symptoms was demonstrated in 93 % of patients; a complete resolution of clinical symptoms was demonstrated in 4 % of patients. On day 30 (after 10 days of LMWH treatment in full therapeutic dosage and further treatment in halved therapeutic dosage up to 20 days) a complete resolution of clinical symptoms was observed in 59 % (n = 189) of patients. Patients were further clinically evaluated on day 90, after two months of no anticoagulation treatment. The clinical evaluation revealed a complete resolution of symptoms in 88 % (n = 283) of patients and improvement in symptoms in 11.6 % (n = 34). Two patients developed pulmonary embolization; extension of SVT was seen in one patient and SVT recurrence in two patients. Superficial vein thrombosis can propagate into the deep veins with the risk of pulmonary embolism. The results indicate that current ambulatory treatment regimen using LMWH in the treatment of SVT is effective and safe (Fig. 4, Ref. 30).

Determining the origin of superficial venous reflux in the groin with duplex ultrasound and implications for varicose vein surgery.

The purpose of this paper was to describe patterns of superficial reflux in the groin with respect to the terminal valve (TV), which is located at the saphenous opening to the common femoral vein, the great saphenous vein, and its tributary veins. This study included 2019 legs with chronic venous insufficiency that received endoluminal varicose vein treatment because of varicosities with insufficiency of the saphenofemoral junction (SFJ). In a preoperative duplex ultrasound investigation of the superficial vein system, reflux after provocation in the SFJ, great saphenous vein, cranial veins (superficial external pudendal vein, superficial epigastric vein, superficial circumflex iliac vein), and anterior and posterior accessory saphenous veins was recorded and classified on the basis of the origin of reflux. In 1348 legs (66.8%), the reflux had its origin exclusively in the common femoral vein. In 170 legs (8.4%), the reflux had its origin in the common femoral and cranial veins. In 430 legs (21.3%), the insufficiency was due to saphenocranial reflux only. In 71 legs (3.5%), the origin of reflux could not be determined. Reflux in the SFJ does not involve the TV in 24.8% of the legs, implying that routine high ligation and ablation close to the TV might be overtreatment in these patients.

Intracranial Collateral Flow Estimated by Color Velocity Imaging Quantification Ultrasound: A Protector of Recurrent Stroke in Patient with Carotid Stenosis?

Stroke patients with carotid disease have a high risk of recurrence of disease. By measuring cerebral blood flow volume (BFV) using extracranial duplex technique for clinical estimation of intracranial collaterals, we aimed to investigate the relationship between the presence of intracranial collaterals and stroke recurrence in stroke patients with carotid disease. Consecutive stroke patients indicated for carotid duplex ultrasound investigations in our hospital were recruited during three years' period. Carotid stenosis was diagnosed as ≥50% stenosis and extracranial arterial BFV was measured by using color velocity imaging quantification ultrasound (CVIQ) software. Presence of intracranial collateral flow was defined as a blood flow volume of either ≥370 mL/min in common carotid artery or ≥120 mL/min in vertebral artery. Univariate and multivariate analyses were performed to determine the independent predictors of recurrent stroke. One hundred and twelve stroke patients (19.1%) with ≤50% carotid stenosis were recruited from consecutive ischemic stroke patients. During a mean follow-up of 28.6±13.1 months, recurrent stroke was recorded in 32 (28.6%) out of the total recruited patients. Estimated by blood flow volume measured by CVIQ, the patients with intracranial collateral flow had a lower rate of recurrent stroke than those without (9.5% vs. 33%, P=0.032). After adjusting for potential confounders, the presence of CVIQ-estimated intracranial collateral flow was an independent protector of recurrent stroke (OR, 0.169; 95% CI, 0.034- 0.842; P=0.03). It could be concluded that blood supply through intracranial collateral flow estimated by CVIQ technique may protect stroke patients with carotid stenosis from suffering recurrent stroke.

Analysis of 1338 Patients with Acute Lower Limb Deep Venous Thrombosis (DVT) Supports the Inadequacy of the Term “Proximal DVT”

For decades acute lower limb deep venous thrombosis (DVT) has been subdivided into distal DVT (isolated to the calf veins) and proximal DVT (extending above calf vein level). The aim of this study was to analyse the anatomical site and extent of thrombus in a large cohort of patients with acute DVT. A retrospective analysis of all patients aged >18 years, presenting with unilateral DVT according to duplex ultrasound investigation was performed at the University Hospital of Antwerp, Belgium (1994-2012). The anatomical site and extent of thrombus was registered and subdivided into five segments: calf veins (segment 1), popliteal vein (segment 2), femoral vein (segment 3), common femoral vein (segment 4), and iliac veins, with or without inferior vena cava (segment 5). The median age of the 1,338 patients (50% male) included was 62 years (range 18-98 years). Left sided DVT was predominant (57%). DVT was limited to one segment in 443 patients, of whom 370 had DVT isolated to the calf veins (28% of total cohort). In 968 patients with what was previously called “proximal DVT”, the median number of affected segments was three (range 1-5 segments). In this group iliofemoral DVT (at least involving segment four and/or five) was present in 506 patients (38% of total cohort), whereas the remaining patients had femoropopliteal DVT (at least in segment two and/or three but not in four or five). Iliofemoral DVT without thrombus in segments one and two was present in 160 patients (12% of total cohort). This study illustrates the large diversity of thrombus distribution in patients previously described as having “proximal DVT”. Therefore, this term should be abandoned and replaced with iliofemoral and femoropopliteal DVT. Patients with iliofemoral DVT (38%) could be considered for early clot removal; 12% of all patients with DVT would be ideal candidates for such intervention.

Diagnostics of ulcus cruris venosum

SummaryClinical diagnostics of venous leg ulcers set the course for efficient therapy. Precise clinical findings with an objectification of signs and symptoms of chronic venous insufficiency are essential. Duplex ultrasound investigations of the leg veins are necessary in the very early stages after the appearance of leg ulcers. Furthermore, not only a clinical investigation of the arterial perfusion but also the determination of the ankle-brachial-index is obligatory. Microbiological diagnostics are currently seen as useful in Germany, due to discussions on MRSA, even though they don´t have an immediate therapeutic consequence without the presence of clinical signs of infection. Therapeutic achievements can be objectified by a continuous documentation of the wound size, the wound bed, the wound exudate and signs of infection as well as the life quality of patients with chronic wounds.

Analysis of 1,338 Patients with Acute Lower Limb Deep Venous Thrombosis (DVT) Supports the Inadequacy of the Term “Proximal DVT”

For decades acute lower limb deep venous thrombosis (DVT) has been subdivided into distal DVT (isolated to the calf veins) and proximal DVT (extending above calf vein level). The aim of this study was to analyse the anatomical site and extent of thrombus in a large cohort of patients with acute DVT. A retrospective analysis of all patients aged >18 years, presenting with unilateral DVT according to duplex ultrasound investigation was performed at the University Hospital of Antwerp, Belgium (1994-2012). The anatomical site and extent of thrombus was registered and subdivided into five segments: calf veins (segment 1), popliteal vein (segment 2), femoral vein (segment 3), common femoral vein (segment 4), and iliac veins, with or without inferior vena cava (segment 5). The median age of the 1,338 patients (50% male) included was 62 years (range 18-98 years). Left sided DVT was predominant (57%). DVT was limited to one segment in 443 patients, of whom 370 had DVT isolated to the calf veins (28% of total cohort). In 968 patients with what was previously called "proximal DVT", the median number of affected segments was three (range 1-5 segments). In this group iliofemoral DVT (at least involving segment four and/or five) was present in 506 patients (38% of total cohort), whereas the remaining patients had femoropopliteal DVT (at least in segment two and/or three but not in four or five). Iliofemoral DVT without thrombus in segments one and two was present in 160 patients (12% of total cohort). This study illustrates the large diversity of thrombus distribution in patients previously described as having "proximal DVT". Therefore, this term should be abandoned and replaced with iliofemoral and femoropopliteal DVT. Patients with iliofemoral DVT (38%) could be considered for early clot removal; 12% of all patients with DVT would be ideal candidates for such intervention.

Three-Dimensional High-Definition Laparoscopic Treatment of Dunbar Syndrome (Celiac Axis Compression by Median Arcuate Ligament Hypertrophy) With Intra-Operative Laparoscopic Duplex Ultrasound Evaluation: Report of Two Cases

Introduction: Dunbar syndrome consists in a rare vascular disorder characterized by extrinsic compression of the celiac artery. This mechanic compression results in symptoms related to intermittent mesenteric ischemia. The goal of treatment is to release celiac artery compression and to restore vessel patency. Here we report two cases treated in our Surgical Department over the last four years. Case Report: A young female of 28 years-old, L.P., and 57-year-old men, E.G., both affected by recurrent post-prandial diffuse abdominal pain, diarrhea and weight loss came to our observation. A complete abdominal evaluation associated to radiologic exams made the diagnosis of CAC syndrome. Both patients were referred to a 3D laparoscopic surgical treatment of CACS with release of the median arcuate ligament. Vessels patency was checked intra-operatively using ecolaparoscopy. Conclusion: Median arcuate ligament section is the treatment of choice in Dunbar Syndrome, a rare vascular syndrome caused by extrinsic compression of the celiac trunk by a lower-inserted muscular bridge that connects the two crura of the diaphragm and crosses over the abdominal aorta. Minimally invasive 3D laparoscopic approach is ideal to treat Dunbar syndrome for the high definition and magnification of the 3D visualization. We perform an intraoperative laparoscopic duplex ultrasound investigation in the initial phase of the operation and at the conclusion of the procedure to assess the effectiveness of the treatment.

Duplex Ultrasound investigation of perforating veins

ZusammenfassungPerforansvenen verbinden die oberflächli-chen Beinvenen mit den tiefen Beinvenen. Im Ultraschall sind sie meist nur dann sichtbar, wenn sie pathologisch gedehnt sind. Die Untersuchung der Perforansvenen und ihrer Flusskurven ist eine der größeren Herausforderungen in der Duplexsonographie der Beinvenen. In diesem Beitrag soll schema-tisch und in Bildern gezeigt werden, wie die Flusskurven am häufigsten aussehen. Die meisten an einer Varikose beteiligten Perforansvenen stellen den Wiedereintrittspunkt des Blutes in das tiefe Venensystem dar und sind primär nicht pathologisch gedehnt. Selten ist eine Perforansvene selbst der oberste Insuffizienzpunkt, in der Regel liegen diese Venen dann am Oberschenkel. Auch der Fluss in Perforansvenen bei Insuffizienz des tiefen Venensystems und nach Traumata wird beleuchtet.

Ultrasound of the groin region following surgical intervention of the great saphenous vein

ZusammenfassungEin wichtiger Bestandteil der phlebologischen chirurgischen Therapie ist die Kontrolle nach der Operation – die auch im Wesentli-chen der Qualitätskontrolle dienen sollte. Hierbei spielt die Sonographie die Hauptrolle, um insbesondere auch frühe Rezidive darzustellen (1). Die Rezidive nach chirurgischem Eingriff am saphenofemoralen Übergang bilden das größte Problem nach Varizenbehandlung. Verschiedene Versuche, diese zu stratifizieren sind noch nicht zu einem hinreichend übersichtlichen Ergebnis gekommen (1, 5–7). Der vorliegende Beitrag möchte die duplexsonographische Untersuchung der Region des sapheno-femoralen Übergangs nach Krossektomie und nach endoluminal thermischen Verfahren beleuchten. Der Normalbefund und die verschiedenen Rezidivmöglichkeiten werden beschrieben.

Postprandial Evaluation of Possible Collateral Pathways in Chronic Mesenteric Ischemia with Duplex Ultrasound

Objective: Duplex scanning may be used to detect high-grade stenoses in the mesenteric vessels in patients with suspect Chronic Mesenterial Ischemia (CMI). The aim of the study was to evaluate reserve and collateral vascular function in relation to bowel symptoms in patients with CMI. Methods: Fourteen consecutive patients, referred to the vascular laboratory with suspicion of CMI, 7 men (average 79 years), and 7 women (average 66 years), were investigated by Duplex ultrasound (DUS) of the visceral arteries. All patients were examined both fasting and 30 min after a standard meal. A reference group of 10 patients with diffuse bowel symptoms (5 men and 5 women, (average 75 years) were investigated by the same DUS protocol, all showing normal mesenteric arteries. Possible collateral reserve capacity was defined as a marked increase of flow velocities (>20%) in vessels with lesions and/or in non-affected vessels. Results: All patients had a significant stenosis (>70%) in one or several visceral arteries at the baseline DUS investigation. Six patients had abdominal pain after the test meal, whilst 8 patients experienced no pain. In patients without postprandial pain a possible collateral reserve capacity was detected. In this group superior mesenteric artery (SMA) peak systolic velocity (PSV) increased significantly (baseline PSV 2.6 ± 1.3 m/s vs. postprandial PSV 4.1 ± 1.6 m/s, P < 0.05) whereas patients with postprandial pain showed no signs of collateral reserve capacity in any vessel except one patient who showed possible collateral reserve in one vessel. In the reference group a significant increase of PSV was seen in SMA only, (1.7 ± 0.6, vs. 2.5 ± 0.9, P < 0.05). Conclusion: Postprandial duplex adds information about the functional flow limitation of the stenosis and possible collateral reserve flow capacity. Further studies have to be performed to establish criteria for selection of patients appropriate for intervention.

Cross-sectional area variations of internal jugular veins during supine head rotation in multiple sclerosis patients with chronic cerebrospinal venous insufficiency: a prospective diagnostic controlled study with duplex ultrasound investigation

BackgroundNormally, chronic cerebrospinal venous insufficiency (CCSVI) has been studied using echo-colour Doppler (ECD). Subjects are examined in the supine and sitting positions, in accordance with a static protocol without rotation of the head. A dynamic approach, to assess venous sizes with different degrees of head rotation, has only been performed to improve jugular venous catheterisation. These echographic studies have suggested that head rotation to the contralateral side increases the cross-sectional area (CSA) of the internal jugular veins (IJVs) in supine subjects. Our goal was to evaluate the behaviour of CSA of the IJVs during supine head rotation in multiple sclerosis (MS) patients with CCSVI, compared to healthy controls (HCs).MethodsThe IJVs of 313 MS patients with CCSVI (male 43.8%, male/female 137/176; mean age 45 years old, range 19–77 years) and 298 HCs, matched by gender (male 43.6%, male/female 130/168) and age (mean age 46 years old, range 20–79 years), were compared using ECD. Their CSAs were evaluated with the subjects seated in a tiltable chair, first in the supine position at the level of the cricoid cartilage, with the head in a neutral position, and then after contralateral rotation to 90° from midline.ResultsSignificant differences between the jugular CSAs before and after head rotation were observed only in the MS patients for the IJVs with wall collapse (F[6,1215] = 6414.57, p < 0.001), showing on longitudinal scans a typical “hourglass” aspect that we defined as “miopragic”. No significant difference was found in the distribution of these miopragic veins with regard to MS duration. There was a strong association between the CCSVI scores and the complexity of jugular morphological types (Χ2 [9, N = 313] = 75.183, p < 0.001). Wall miopragia was mainly observed in MS patients with SP (59.3%) and PP (70.0%) clinical forms, compared to RR (48.3%) forms (p = 0.015).ConclusionA dynamic ECD approach allowed us to detect IJVs with a significant increase in their CSAs during head rotation, but only in MS subjects. This feature, most likely the expression of congenital wall miopragia, could be secondary to dysregulation of collagen synthesis, but further histochemical studies will be needed to confirm this hypothesis.

Arteriovenous fistula as a complication of transradial coronary angiography: a case report

IntroductionIatrogenic arteriovenous fistula is a vascular condition that may result from coronary angiography. Many case reports have described arteriovenous fistula occurrence after coronary angiography using the transfemoral access route, but rarely as a complication of using the transradial approach. We report a rare case of a patient with arteriovenous fistula following transradial artery coronary angiography.Case presentationA 62-year-old Caucasian man underwent emergent coronary angiography using the right radial artery approach. One month after angiography, he discovered a turbulent sound near the access site. A right radial arteriovenous fistula was found upon duplex ultrasound investigation. The patient was treated conservatively. At 1-year follow-up, the arteriovenous fistula was unchanged and the patient remained hemodynamically stable and asymptomatic.ConclusionIatrogenic arteriovenous fistula is a rare vascular complication of transradial artery coronary angiography. The natural history of arteriovenous fistula is benign and is thought to resolve spontaneously; therefore, a conservative approach, as opposed to surgical ligation, is recommended as the first-line treatment.

Comment to: Duplex ultrasound investigation of the veins of the lower limbs after treatment for varicose veins – UIP consensus document, by De Maeseneer M, Pichot O, Cavezzi A, et al. Eur J Vasc Endovasc Surg 2011;42:89-102.

The aim of this paper is to summarize the best practice for venous duplex ultrasound investigation (DUS) examination of the lower limbs after treatment. Parts of this paper have been taken from the limited evidence available in the literature and was agreed upon by a group of experts who regularly use this technology. DUS evaluation after treatment must take into consideration the pre-treatment assessment. Patients have different profiles of anatomic and hemodynamic superficial venous insufficiency. Clear documentation of pre-treatment clinical features and DUS findings is, therefore, essential as these may influence the interpretation of post treatment results and expectations The minimum requirements for pre-treatment DUS assessment are described in Table 1...

Hemodynamic patterns of reflux in primary sapheno-popliteal junction incompetence

Duplex ultrasound investigation (DUI) has considerably improved the diagnosis of anatomical venous variations in the popliteal region: however, some pitfalls still remain concerning the hemodynamics of incompetent sapheno-popliteal junctions (SPJs). Aims of this study were to assess the prevalence rates of the hemodynamic patterns of reflux, either diastolic or systolic or both, in a large series of patients with SPJ incompetence, and to analyze the origin of the systolic components of the reflux. Four hundred and fiftythree patients, 83 males and 370 females, mean age 58.0 years&plusmn;SD 13.8 with primary SPJ incompetence (512 limbs) underwent preoperative DUI using the Paran&agrave; manoeuvre, a dynamic test able to develop systolic and diastolic pressure gradients through the reflex activation of muscle pumps. Of the 512 incompetent SPJs, 420 showed isolated diastolic reflux, 9 isolated systolic reflux and 83 systolic reflux followed by diastolic reflux. Altogether, 92 SPJs over 512 (18%) showed a systolic component of the reflux, which originated from the popliteal vein in 78 cases (15%) and from the gastrocnemius veins (GVs) in 14 cases (3%). In these latter cases, the short saphenous vein and one or more GVs showed a common trunk. Our findings show that the detection of a systolic component of the reflux in incompetent SPJs is not an uncommon event and suggest that treatment strategy should be differentiated according to the origin of the systolic reflux, given their different hemodynamic behavior.