Recurrent Incompetence Research Articles

Unilateral double great saphenous vein: A clinically significant case report

Great saphenous vein (GSV) is the longest vein in the body originating from the dorsum of the foot at medial malleolus to the level of groin skin crease. It is one among the clinically significant superficial veins of the lower limb. Double or duplication of GSV is considered to be one of its rarest variant forms, which might be often mistaken with the accessory saphenous vein. The overall incidence of duplicated GSV is reported to be 1%. We report herein, a unilateral duplication of GSV with its morphological and clinical perspectives. The major clinical complication that is often encountered from its duplication is recurrent incompetence of the GSV, which predisposes varicosity. Therefore, a thorough knowledge of venous anatomy is important for clinicians and sonographers.

Duplication of Great Saphenous Vein - A Rare occurance

Great saphenous vein is one of the longest vein in the body. As other venous channels this is also known to have different types of variation in its course and numbers. During the routine cadaveric dissection of undergraduate students in S.I.M.S. &R.C. Shimoga we found that the great saphenous vein was duplicated on the right side along with the presence of accessory tributaries joining it at various levels. In our case great saphenous vein was duplicated from its origin near medial malleolus and continued till the knee joint where it was joined by a tributary and later in the lower one third of the thigh it branched like a mesh and formed three trunks which ascended in the thigh and in the upper one third of the thigh two trunks joined to form anterior accessory saphenous vein and great saphenous vein proper which received the terminal tributaries later emptied into the femoral vein by piercing the cribriform fascia. The duplication of the great saphenous vein can explain the recurrent incompetence of the great saphenous vein. Also presence of such accessory trunks can be used for vascular grafting in cases of ischaemia and arterial blocks. The knowledge of such type of variation is important for surgeons, orthopaedicians and interventional radiologists who operate in this region.

Randomized clinical trial comparing endovenous laser with cryostripping for great saphenous varicose veins

The aim of this randomized single-centre trial was to compare the 2-year results of endovenous laser ablation (EVLA) and cryostripping for varicose veins. A total of 120 patients with uncomplicated great saphenous varicose veins were randomized equally to one of the two treatments. Principal outcomes measures were: freedom from recurrent varicose veins on duplex imaging, and improvement in Venous Clinical Severity Score (VCSS) and Aberdeen Varicose Vein Severity Score (AVVSS) 6, 12 and 24 months after treatment. Life-table analysis showed overall freedom from recurrent incompetence at 2 years in 77 (95 per cent confidence interval (c.i.) 72 to 78) per cent of patients after EVLA and in 66 (95 per cent c.i. 60 to 67) per cent after cryostripping (P = 0.253). VCSS and AVVSS values improved significantly after treatment, but the differences between the treatments were not significant. EVLA provided significantly more favourable results than cryostripping with respect to duration of operation, postprocedural pain, induration and resumption of normal activity. EVLA and cryostripping were similarly effective in patients with varicose veins, but patients favoured EVLA because of less pain and postoperative morbidity, and quicker return to normal activity. ISRCTN33832691 (http://www.controlled-trials.com).

Decalcification of the Mitral Annulus: Surgical Experience in 81 Patients

Mitral valve surgery in the presence of extensive calcification of the mitral annulus is a technical challenge and increases perioperative risk. This study reviews our experience with decalcification of the mitral annulus in patients undergoing mitral valve reconstruction or replacement. From 1995 to 2003, 81 patients (mean age 64 +/- 13 years, 30 male, 51 female) with extensive calcification of the mitral annulus underwent mitral valve repair (n = 42) or replacement (biological n = 20, mechanical n = 19). The mean follow-up was 24 months. Patients presented with a mean EuroSCORE of 7. Concomitant surgical procedures were performed in 62 %. Patient outcomes were retrospectively assessed. Perioperative survival was 97.5 % (n = 79) and hospital survival was 91.3 % (n = 74). Two-year survival was 88.9 %. Eight patients needed reexploration due to bleeding and five patients required prolonged mechanical ventilation. No perioperative stroke was observed. Freedom from reoperation was 90.2 % (n = 73). Early reoperation for recurrent incompetence was necessary in 3 patients and late reoperation in 5 patients. Despite the elevated perioperative risk and the high risk of reoperation with this procedure, decalcification of the annulus and repair/replacement of the mitral valve could be performed with good clinical results.

Recurrent varicose veins: correlation between preoperative clinical and hand-held Doppler ultrasonographic examination, and anatomical findings at surgery.

A consecutive series of 118 patients (148 legs) presenting with recurrent varicose veins underwent preoperative clinical and hand-held Doppler ultrasonographic examination by a single observer. The presence of saphenofemoral, mid-thigh perforator and saphenopopliteal reflux was noted. Ultrasonography markedly improved the accuracy of clinical assessment at all three potential sites of reflux compared with operative findings. Of 71 patients undergoing repeat groin dissection, only 20 (28 per cent) had a tied saphenofemoral junction, 31 (44 per cent) had intact major tributaries and 52 (73 per cent) had an intact long saphenous vein (LSV) in the thigh. There was a positive association between mid-thigh perforator reflux giving rise to recurrent varices and the presence of an intact LSV in the thigh. Of 45 legs with saphenopopliteal reflux, only four had previously undergone saphenopopliteal ligation, suggesting that most short saphenous varicosities had either appeared after or had not been recognized at the time of primary surgery. This study indicates that even an experienced vascular surgeon can have difficulty in assessing the presence or absence of recurrent deep to superficial reflux by means of clinical examination alone and that Doppler ultrasonographic examination is mandatory. Recurrence continues to be associated with persistent or recurrent incompetence at the site of previous inadequate surgery.

Recurrent incompetence of repaired floppy mitral valves and the severity of myxomatous degeneration.

The purpose of this study was to clarify whether or not severe myxomatous degeneration impairs the stability of a repaired mitral valve after valve-conservative surgery. A total of 21 patients who underwent successful valve-conservative surgery for pure isolated mitral incompetence were classified into two groups, one comprising those with stable mitral valve function and the other comprising those who developed recurrent incompetence within 1 year after surgery. The histological severity of myxomatous degeneration of the mitral leaflet was compared between the two groups, based upon microscopic observation and quantification of the myxomatous area in the fragment that had been surgically excised from the floppy mitral leaflet during valve-conservative surgery. The degree of myxomatous degeneration of the surgically excised fragment was significantly higher in the "recurrent" group than in the "stable" group (P = 0.02). As a microscopically confirmed severely degenerative myxomatous mitral valve may develop recurrent incompetence after valve-conservative surgery within a relatively short period, careful and regular follow-up is required.

Recurrent varicose veins: correlation between preoperative clinical and hand-held Doppler ultrasonographic examination, and anatomical findings at surgery

A consecutive series of 118 patients (148 legs) presenting with recurrent varicose veins underwent preoperative clinical and hand-held Doppler ultrasonographic examination by a single observer. The presence of saphenofemoral, mid-thigh perforator and saphenopopliteal refux was noted. Ultrasonography markedly improved the accuracy of clinical assessment at all three potential sites of reflux compared with operative findings. Of 71 patients undergoing repeat groin dissection, only 20 (28 per cent) had a tied saphenofemoral junction, 31 (44 per cent) had intact major tributaries and52 (73per cent) had an intact long saphenous vein (LSV) in the thigh. There was a positive association between mid-thigh perforator reJrux giving rise to recurrent varices and the presence of an intact LSV in the thigh. Of 45 legs with saphenopopliteal reJux, only four had previously undergone saphenopopliteal ligation, suggesting that most short saphenous varicosities had either appeared after or had not been recognized at the time of primary surgery. This study indicates that even an experienced vascular surgeon can have d@culty in assessing the presence or absence of recurrent deep to superficial reflux by means of clinical examination alone and that Doppler ultrasonographic examination is mandatory. Recurrence continues to be associated with persistent or recurrent incompetence at the site of previous inadequate surgery.

Incompetent Transplanted Arm Vein Valves: Surgical Correction and Result

Nine arm vein valve transplantations were performed when the valves of femoral or popliteal veins were damaged beyond valvuloplasty in deep-valve correction. In four of the nine arm vein valves (44%) incompetence was recognized immediately following transplantation. Valvuloplasty successfully restored valvular competence of the four transplanted arm veins. Intraoperative direct venous pressure of the dorsalis pedis in the supine position improved by 5–30 mmHg (mean 8 mmHg) in six of seven limbs following vein-valve transplantation. Competence of the arm vein valve should be tested before and after transplantation. Valvuloplasty of the incompetent transplanted valves is feasible and has produced no added susceptibility to thrombosis and recurrent incompetence.

Fascia lata aortic valve reconstruction: long-term results in 33 patients.

Aortic valve reconstruction with autologous fascia lata was performed in 33 patients (mean age 35 years) in 1966 and 1967. Eighty-two per cent had cusp extension rather than replacement, while 33% required additional intracardiac procedures. There were seven hospital deaths (21%) and 11 late deaths (33%), a total mortality of 54% over four years. Six late deaths followed reoperation for recurrent incompetence, and two other patients survived reoperation. Endocarditis (rickettsial, fungal, and bacterial) occurred in five cases, all required reoperation for incompetence, and four died. Sixty-nine per cent of the survivors of operation left hospital with competent valves and did better than the 31% with leaking valves in terms of late deaths, endocarditis, and reoperation for incompetence. Of the 15 patients (45%) still alive, 13 still have their original fascial valve, and of these only two (or perhaps three) have no diastolic murmur. Seven have insignificant murmurs and three have aortic incompetence. These poor results, particularly in the long term, make us sceptical about current enthusiasm for fascia lata heart valves.