Thigh Veins Research Articles

Diagnostik der akuten tiefen Beinvenenthrombose mit der Kompressionssonographie

We studied the accuracy of compression sonography in 238 patients suspected of deep venous thrombosis comparable to phlebography. The veins in the thigh were considered to be occluded when their lumen did not collapse under slight pressure with the scanner. In the lower leg, incompressible echosparse strings were regarded to be equivalent to thrombosed veins. Since in some patients both legs were submitted to phlebography, 301 x-ray-examinations of one leg were compared to ultrasound. 153 thromboses were detected by venography. Ultrasound diagnosis of venous occlusion was made with a sensitivity of 96% and a specificity of 99%. In 91% it was possible to predict the extent of the clot. Thigh vein thromboses were correctly seen with a sensitivity of 97% and a specificity of 99%. Isolated calf vein thromboses were detected with a sensitivity of 90% and a specificity of 99%. In 10% of the examinations ultrasound brought new essential information compared to phlebography. We conclude that compression sonography is an accurate method in the diagnosis of deep venous thrombosis and that it should be applied liberally in patients with suspected venous occlusions.

“Extended length” endoscopic harvest of the great saphenous vein for coronary artery bypass grafting

The endoscopically harvested vein from thigh usually falls short by half to one length in patients requiring multiple conduits. Increased risk of complications precludes routine endoscopic vein harvest from the leg and an extra incision for open technique is often required thereby nullifying the sole purpose of the former. We employed the endoscope to harvest this extra length of vein from the upper half of the leg with little or no extra risk. From January 2006 to September 2006 we endoscopically harvested the vein in thigh as well as the leg using the same entry point incision over the medial epicondyle in 40 cases. The only exclusion criterion for the study was a superficial location and subcutaneous visibility of the vein in the leg. We made 3 incisions in each patient of average size 2.5 cm. Five patients required conversion to the open technique. The average harvest time was 59 minutes. Average length of the conduit was 48 cms. Complications included 1 minor wound infection, 1 case of superificial wound dehiscence, 1 haematoma requiring aspiration and minor erythema at the incision site in 2 patients. Most common complication observed was ecchymosis in 6 patients (5 high; 3 leg). None of the patient developed lymphoedema and none required re-hospitalization for vein harvest related wound complications. “Extended endoscopic vein harvest” and avoidance of the open incision was possible in most patients with no additional risk and that the procedure could be routinely employed in patients requiring multiple conduits.

Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment for Varicose Veins

We report an anaphylactic reaction following ultrasound guided foam sclerotherapy (UGFS) to lower limb varicosities. A tortuous anterolateral thigh vein of a 62 year-old woman was unsuccessfully ablated with UGFS. A further session of UGFS, 6 months later, resulted in a non-fatal anaphylactic reaction that required resuscitation with adrenaline. The patient was not known to be allergic to the sclerosant used and had not suffered any adverse effects after her initial treatment. This case demonstrates the possibility of anaphylaxis following UGFS. Those performing sclerotherapy require appropriate resuscitation equipment and training. Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose VeinsEJVES ExtraVol. 13Issue 6PreviewWe report an anaphylactic reaction following ultrasound guided foam sclerotherapy (UGFS) to lower limb varicosities. A tortuous anterolateral thigh vein of a 62 year-old woman was unsuccessfully ablated with UGFS. A further session of UGFS, 6 months later, resulted in a non-fatal anaphylactic reaction that required resuscitation with adrenaline. The patient was not known to be allergic to the sclerosant used and had not suffered any adverse effects after her initial treatment. This case demonstrates the possibility of anaphylaxis following UGFS. Full-Text PDF Open Access

Anaphylaxis Following Foam Sclerotherapy: A Life Threatening Complication of Non Invasive Treatment For Varicose Veins

We report an anaphylactic reaction following ultrasound guided foam sclerotherapy (UGFS) to lower limb varicosities. A tortuous anterolateral thigh vein of a 62 year-old woman was unsuccessfully ablated with UGFS. A further session of UGFS, 6 months later, resulted in a non-fatal anaphylactic reaction that required resuscitation with adrenaline. The patient was not known to be allergic to the sclerosant used and had not suffered any adverse effects after her initial treatment. This case demonstrates the possibility of anaphylaxis following UGFS. Those performing sclerotherapy require appropriate resuscitation equipment and training.

Deep vein thrombosis after total hip replacement: A clinical and phlebographic study

Two hundred and forty-seven phlebograms (113 bilateral and 21 unilateral) were performed in 134 patients 10--14 days after total hip replacement. Fifty-eight per cent of the patients were found to have deep vein thrombosis. The patients with DVT were significantly older than patients without DVT, but there was no difference regarding sex, type of hip prosthesis, side of operation or day of mobilization. No difference was found in the duration of operation and anaesthesia, the operative haemorrhage and the amount of bank blood transfused in patients with and without DVT. Fifty per cent of the thrombi were confined to the calf veins. Ninety-seven per cent of these thrombi were asymptomatic and were as frequent on the operated as on the non-operated side. The remaining 50 per cent of the thrombi engaged the thigh with or without simultaneous calf vein involvement. These thrombi produced symptoms in 23 per cent of the cases and were significantly more common on the operated than on the non-operated side. It is concluded that DVT after hip replacement can be of two different types: thrombosis caused by stasis and the general effects of trauma and thrombosis caused by local factors involving the thigh veins of the operated leg.

Radiofrequency Endovenous Obliteration versus Stripping of the Long Saphenous Vein in the Management of Primary Varicose Veins: 3-Year Outcome of a Randomized Study

We evaluated the 3-year outcome of a series of patients with primary varicose veins who were randomized to radiofrequency endovenous obliteration vs. stripping of the long saphenous vein (LSV). Twenty-eight patients were included in the study: 15 were randomized to the radiofrequency endovenous obliteration procedure and 13 to LSV stripping. At 3-year follow-up, five patients (33.3%) of the endovenous group had recurrent or residual varices and in three of them a reflux in the thigh veins was detected. None of the primarily occluded LSV segments was recanalized. In the stripping group, three patients (23.1%, p = 0.68) showed varicosities at clinical and duplex examinations. In one patient, a patent duplicate LSV trunk was detected. In the remaining two patients, no reflux in the thigh region was detected. According to the present results, radiofrequency endovenous obliteration of the LSV is associated with somewhat poorer short-term results compared with the stripping operation.

Chronic Venous Insufficiency

Chronic Venous Insufficiency

Prevalence, anatomic patterns, valvular competence, and clinical significance of the Giacomini vein

Coursing the posterior thigh as a tributary or trunk projection of the small saphenous vein (SSV), the Giacomini vein's clinical significance in chronic venous disease (CVD) remains undetermined. This cross-sectional controlled study examined the prevalence, anatomy, competency status, and clinical significance of the Giacomini vein across the clinical spectrum of CVD in relation to the SSV termination. One hundred eighty-nine consecutive subjects (301 limbs) with suspected CVD (109 men, 80 women; age, 18-87 years [median, 61 years]) underwent examination, clinical class (CEAP) stratification, and duplex ultrasound determination of the sites and extent of reflux >0.5 sec) and Giacomini vein's anatomy. A Giacomini vein was found in 70.4% of limbs (212 of 301; 95% confidence interval, 65%-75.6%). Extent, pattern, and sites of reflux in all named superficial and deep veins were evenly distributed in limbs with and without a Giacomini vein; perforator vein incompetence in thigh and calf was also balanced (all, P > .2). Giacomini vein had no effect ( P > .2) on SSV termination anatomy, displaying a similar prevalence in classes C(0-6) . In 212 limbs, either as a tributary or trunk projection of the SSV, the Giacomini vein ascended subfascially (n = 210) to the lower (8%; n = 17), middle (47.6%; n = 101), or upper (44.3%; n = 94) thigh, and terminated at the deep system (45.3%; n = 96) and/or perforated the fascia (64.2%; n = 136), to join the superficial system. Giacomini vein morphology was not affected by the SSV termination anatomy and CEAP clinical class. Incompetence was detected less often (P < .001) in the Giacomini vein (4.7%; n = 10 of 212) than in the saphenous trunks cumulatively (53.3%; n = 113 of 212). Yet the odds ratio of Giacomini incompetence was 11.94 (7 of 33 over 3 of 169) in the presence of SSV reflux, and 11.67 (6 of 23 over 4 of 179) when both the great saphenous vein (proximal, proximal plus distal) and SSV were incompetent. Found in more than two thirds of limbs, the Giacomini vein has a complex anatomy that is linked vastly to the deep or superficial veins of the posteromedial thigh, but is unaffected by the anatomy of SSV termination and CEAP clinical class. Its presence proved insignificant to the extent, pattern, sites, and clinical severity of venous incompetence, yet the Giacomini vein was far less often susceptible to reflux than the saphenous trunks were. Routine Giacomini vein investigation is not justified in view of these findings. Investigation could be considered selectively in limbs with SSV incompetence, with or without great saphenous vein incompetence, supported by the high odds of concomitant Giacomini vein reflux.

Diagnosis of Lower-Extremity Deep Vein Thrombosis in Outpatients

A 68-year-old man was referred to your outpatient clinic following a cemented right hip arthroplasty procedure 3 weeks before your examination. He reports that he has had pain in his right calf and thigh since being discharged from the hospital and that these symptoms limit his ability to ambulate. He also reports difficulty getting in and out of bed. You find that he has a swollen right lower extremity and that he complains of pain when you palpate his right posterior calf and knee. You suspect that he may have a deep vein thrombosis (DVT), but you also consider that it is likely that the lower-extremity symptoms are attributable to the recent surgical procedure. Do you contact the patient's physician? The diagnosis of DVT in patients who are hospitalized is well recognized, but DVT associated with outpatient care is less frequently discussed.1 The purpose of this update is to summarize evidence-based approaches to the clinical examination of outpatients who are at risk for DVT. We also review radiological and laboratory-based diagnostic tests used to confirm or refute the diagnosis of DVT. Venous thromboembolism (VTE) is a vascular disease that manifests as DVT or pulmonary embolism (PE). Both DVT and PE can be symptomatic or asymptomatic. Newly diagnosed cases of symptomatic VTE are estimated to occur in approximately 250,000 Americans per year, and DVT accounts for approximately two thirds of these cases.2 Deep vein thrombosis most commonly appears in the lower extremity and is typically classified as being either proximal (affecting the popliteal and thigh veins) or distal (affecting the calf veins). Proximal deep vein thrombosis (PDVT) is the more dangerous form of lower-extremity DVT because it is more likely to cause life-threatening PE and may result in a greater risk of postthrombotic syndrome.3,4 Calf DVT, …

Deep vein harvest: predicting need for fasciotomy

ObjectiveDeep thigh veins, including the superficial femoral, superficial femoropopliteal, and profunda femoris veins, are versatile autogenous conduits for arterial reconstruction. Although late venous complications are unusual, deep vein harvest may induce severe venous hypertension and predispose the limb to acute compartment syndrome. The purpose of this study was to define the frequency of fasciotomy in patients undergoing deep vein harvest and to identify clinical predictors of the need for fasciotomy after deep vein harvest. MethodsOver 9 years, 162 patients underwent arterial reconstruction with deep vein harvested from 264 limbs. Indications for deep vein harvest included aortofemoral reconstruction in 127 patients, brachiocephalic arterial reconstruction in 22 patients, and visceral arterial reconstruction in 13 patients. ResultsFasciotomy was performed in 47 of 264 limbs (17.8%) after deep vein harvest. The prevalence of fasciotomy after deep vein harvest was 20.6% for patients requiring aortofemoral reconstruction, whereas no patients underwent fasciotomy after deep vein harvest for mesenteric or brachiocephalic arterial reconstruction (P = .0068). Fasciotomy was performed in 20.7% of limbs after complete deep vein harvest to a level below the adductor hiatus, but no fasciotomies were performed in patients undergoing subtotal deep vein harvest, ending above the adductor hiatus (P = .0023). The mean preoperative ankle-brachial index (ABI) was significantly lower in limbs requiring fasciotomy (ABI, 0.39 ± 0.05), compared with patients who did not require fasciotomy (ABI, 0.79 ± 0.02; P < .0001). Fasciotomy was performed in 76.0% of limbs undergoing concurrent ipsilateral greater saphenous vein (GSV) and deep vein harvest, compared with 11.7% of patients undergoing deep vein harvest alone (P < .0001). The mean volume of intraoperative fluid administered to patients requiring fasciotomy was almost 50% higher than the fluid resuscitation received by patients who did not require fasciotomy (9.6 ± 1.2 L vs 6.5 ± 0.6 L; P < .0001). Logistic regression analysis determined that lower preoperative ABI (odds ratio [OR], 60.1; 95% confidence interval [CI], 12.5-289.3; P < .0001) and concurrent harvest of the ipsilateral GSV (OR, 9.9; 95% CI, 3.1-31.3; P < .0001) were predictors of the need for fasciotomy. ConclusionsOne in four patients undergoing deep vein harvest for aortofemoral reconstruction may be expected to develop acute compartment syndrome and require fasciotomy. The risk appears to be greatest in patients with severe lower extremity ischemia and in patients undergoing simultaneous GSV and deep vein harvest. Prophylactic fasciotomy may be appropriate in patients with both risk factors, but vigilance for the development of compartment syndrome after deep vein harvest is required in all patients undergoing deep vein harvest for aortofemoral reconstruction.

Compression sclerotherapy of anterolateral thigh primary varicose veins (lateral accessory saphenous varicose veins): a prospective five-year follow-up study

Aim: To determine the percentage of varicose vein recurrence after compression sclerotherapy of a specific primary varicose vein, the anterolateral thigh vein (lateral accessory saphenous vein), without saphenofemoral junction (SFJ) incompetence at yearly intervals in a long-term follow-up study, and to investigate factors influencing recurrence. Patients and methods: Of 117 patients recruited, 11 were lost to follow up; therefore 106 patients were evaluated: 97 women, mean age 42 years (range 21-72) and nine men, mean age 47 years (range 21-67). If SFJ incompetence was present, surgical ligation of the junction was performed. Primary varicose veins were treated with compression sclerotherapy using polidocanol. A total of 111 limbs were studied. Results: Recurrent varicose veins were found after six months in 6% of cases, after one year in 18% (cumulative percentage), after two years in 28%, after three years in 36%, after four years in 46%and after five years in 54%. No differences could be detected between the recurrence group and the group without recurrence regarding length of varicose veins, amount of polidocanol used, number of injections, circumference of the leg or age of the patient. The varicose vein diameter was significantly larger in the recurrence group. Conclusions: Compression sclerotherapy with polidocanol of the anterolateral thigh vein (lateral accessory saphenous vein) without SFJ incompetence results in a high recurrence rate. Recurrence depends only on the vessel diameter, and not on the length of the varicose vein, amount of sclerosant used or patient age.

De novo lymph node formation in chronic inflammation of the human leg.

Organized lymphoid tissue is the first line of antigenic defense. Recruited by antigen located in the non-lymphoid tissues, the infiltrating lymphocytes often organize themselves as follicle-like structures that contain germinal centers, similar to those in secondary lymphoid follicles of lymph nodes. These extranodal tertiary lymphoid follicles are found in various autoimmune diseases. We investigated 153 patients with protracted lymph stasis of the lower limb, caused by lymphatic damage incurred through soft tissue bacterial inflammation or mechanical trauma of soft tissues and bones. In 10% of patients with post-inflammatory, and in 25% with post-traumatic lymph stasis, "newly-formed" lymph nodes were detected by means of lymphoscintigraphy. They were located along the large calf and thigh veins. Although scattered nodes are normally detected in these areas, the number and total mass of visualized nodes substantially exceeded those seen in healthy subjects. The calculated surface area of "newly formed" nodes attained 50-70% of the area of ipsilateral inguinal nodes. Histological evaluation of nodal biopsy specimens in three such patients revealed, in one, a lymph node structure without differentiation into cortical and medullary areas, and in a second, a follicle-like structure within a dilated lymph vessel. Lymph clot removed from another dilated vessel contained a lymphocyte/dendritic cell aggregate. The "newly formed" nodes likely originate from primordial lymphoid follicles and/or lymphoid cell aggregates formed in response to chronic stimulation by microbial products and self-antigens from the damaged tissues. Detection of "newly-formed" lymph nodes in the limb is evidence of an ongoing inflammatory process and requires appropriate therapy.

The saphenofemoral valve: Gate keeper turned into rear guard

ABSTRACTObjective: Trendelenburg's theory was based on theconcept of a descending valvular incompetence com­mencing at the saphenofemoral junction (SFJ) withsubsequent distal progression ofreflux. The aim ofthisstudy was to evaluate the distribution of reflux inpatients with superficial venous incompetence in order toassess validity ofthe above hypothesis.Procedures: The superficial and deep venous system ofaconsecutive series of 443 patients presenting withprimary varicose veins was examined by one vasculartechnologist using colour flow ultrasonography.Results: Six hundred and eleven lower limbs in 443patients were examined. The distribution of longsaphenous vein (LSV) reflux was the following: Ofthe611 limbs 454 showed LSV reflux, with 240 legsexhibiting total reflux (SFJ and LSV) and 214 legsexhibiting reflux in evolution (LSV reflux withcompetent saphenofemoral valve, isolated posteriorarch reflux and lateral anterior thigh vein reflux withSFJ reflux).Conclusion: These results suggest that reflux startsdistally and progresses proximally, thus throwing theTrendelenburg theory into dispute.Keywords: Saphenofemoral valve; Long saphenousreflux

Varicose Veins Possess Greater Quantities of MMP-1 Than Normal Veins and Demonstrate Regional Variation in MMP-1 and MMP-13

Background. Studies have reported that structural proteins such as elastin and collagen are decreased in varicose veins compared to normal controls. We hypothesized that the changes observed in varicose vein wall composition may be related to alterations in extracellular matrix remodeling proteins, such as the matrix metalloproteases and serine proteases. In addition we hypothesized that there may be regional variation in the expression of these enzymes within the leg. Patients and materials. One-centimeter segments of the proximal and distal greater saphenous vein (GSV) were obtained from patients undergoing ligation and stripping for venous insufficiency (vv) ( n = 15) or GSV harvest in conjunction with coronary artery bypass grafting (CABG) ( n = 7). All vv patients had incompetence of the GSV by color flow duplex. Vein specimens were examined for MMP-1, 3, and 13, tryptase, and GAPDH mRNA using semiquantitative RT–PCR analysis. Quantification of MMP-1 and 13 (active/latent forms) and tryptase was performed using Western blot analysis. Western blots were analyzed using scanning densitometry and standardized to normal controls and values expressed as the median densitometric index (D.I.). Nonparametric statistical methods (Wilcoxan signed rank test and Mann–Whitney U test) were used for analysis. Results. We were able to amplify MMP-1, MMP-13, and tryptase mRNA from both proximal and distal segments of all greater saphenous veins studied. MMP-3 mRNA, however, was not found in either segment of any of the veins examined. A semiquantitative analysis of RT–PCR products comparing the ratio of MMP-1, MMP-13, or tryptase mRNA to GAPDH mRNA showed no difference between cases and controls nor proximal vs distal vein segments. Western blot analysis revealed larger quantities of MMP-1 in varicose veins than in nondiseased veins from CABG patients (48.0 ± 36.7 D.I. vs 12.5 ± 6.8 D.I., P = 0.036). Investigation into the regional variation of proteases revealed lower amounts of MMP-1 in distal than in proximal vein segments (37.9 ± 35.0 D.I. vs 44.1 ± 41.6 D.I., P = 0.01). Similarly, we found significantly less MMP-13 in distal segments of varicose veins than in proximal segments (152.8 ± 130.0 D.I. vs 206.7 ± 173.3 D.I., P = 0.006). Conclusions. This study found that MMP-1 protein is increased in varicose veins when compared to controls despite no differences in mRNA expression. In addition we found that there is regional variation of MMP-1 and MMP-13 in diseased varicose veins. Lower leg veins have significantly reduced amounts of these proteolytic enzymes when compared to veins of the upper thigh. These data suggest that posttranscriptional regulatory controls could be responsible for the observed differences.

The Saphenofemoral Valve: Gate Keeper Turned into Rear Guard

Objective: Trendelenburg's theory was based on the concept of a descending valvular incompetence com mencing at the saphenofemoral junction (SFJ) with subsequent distal progression of reflux. The aim of this study was to evaluate the distribution of reflux in patients with superficial venous incompetence in order to assess validity of the above hypothesis. Procedures: The superficial and deep venous system of a consecutive series of 443 patients presenting with primary varicose veins was examined by one vascular technologist using colour flow ultrasonography. Results: Six hundred and eleven lower limbs in 443 patients were examined. The distribution of long saphenous vein (LSV) reflux was the following: Of the 611 limbs 454 showed LSV reflux, with 240 legs exhibiting total reflux (SFJ and LSV) and 214 legs exhibiting reflux in evolution (LSV reflux with competent saphenofemoral valve, isolated posterior arch reflux and lateral anterior thigh vein reflux with SFJ reflux). Conclusion: These results suggest that reflux starts distally and progresses proximally, thus throwing the Trendelenburg theory into dispute.

Endoscope-assisted management of varicose veins in the posterior thigh, popliteal fossa, and calf area.

Varicose veins of the posterior thigh, popliteal fossa, and calf area were managed with the assistance of endoscopic surgery in 136 patients. Patients were divided into four types according to the normal veins involved in varicosities. With good illumination and magnified monitor viewing by means of a surgical endoscope, the main channel, tributaries of varicosities, incompetent perforating veins, and healthy veins could be clearly visualized and identified. Even though these varicosities had aberrant and tortuous courses, they could be completely dissected, divided, and then removed through one or more access incisions (2.5-3.0 cm in length). The incompetent perforating veins were also dissected and divided. The mean number of access incisions for each lower extremity was 2.2, 1.9, 1.3, and 1.0 for types I, II, III, and IV respectively. In all cases, the mean number of incisions was 1.6 in each lower limb. The most frequent morbidity was maceration of the access incision. Three wounds in 3 patients required debridement and resuturing, but the other wounds healed satisfactorily. Transient discoloration caused by bruising and numbness may present at the dissected area. There was no hematoma formation. Ischemic change with bleb formation of the dissected skin occurred in 1 patient. Subsequent secondary healing resulted in slight scarring in this area. With the assistance of endoscopic surgery, all the varicosities and the incompetent perforating veins could be completely dissected and removed. Accomplishment of removal of varicosities was double-checked between the preoperative skin marks of varicosities and the endoscopic findings. There is very little possibility for recurrence, because there were no residual varicosities or incompetent perforating veins after this operation. There was no recurrence in follow-up at least 2 months postoperatively. Patients were satisfied with the minimal surgical scarring and the complete absence of disfiguring varicosities.

Deep Venous Thrombosis: A Review of the Pathophysiology, Clinical Features, and Diagnostic Modalities

A 57-year-old man presented to the emergency room complaining of 2hours of shortness of breath and chest pain. Two weeks before, he had a similar episode associated with swelling and pain of the left lower extremity. He was hospitalized and diagnosed with pulmonary embolism resulting from deep vein thrombosis (DVT) of the left thigh veins. Treatment consisted of intravenous heparin followed by chronic warfarin therapy.

Diagnostic role of ED ultrasound in deep venous thrombosis and pulmonary embolism

Proximal deep venous thrombosis (DVT), which may lead to pulmonary embolism (PE), is one of the serious and underrecognized causes of lower extremity pain and swelling. The diagnosis of DVT requires a confirmatory objective test because clinical signs and symptoms are unreliable. Assessment of thigh vein compressibility with real-time ultrasound is an accurate test for DVT that may be performed rapidly at the bedside. Although unproven, we propose that wider use of this test in the emergency department by emergency physicians might increase the diagnosis of DVT, prevent PE, and reduce utilization of other more costly and invasive diagnostic tests. Evaluation of DVT by compression ultrasound may also be incorporated in the diagnostic workup of suspected PE. In the case of a nondiagnostic ventilation/perfusion scan, demonstration of proximal DVT by ultrasound represents a likely source of PE and an indication for anticoagulation, eliminating the need for pulmonary angiography. In the critically ill patient whose presentation is consistent with massive PE, one rapid approach to the diagnosis may be to combine transthoracic echocardiography with lower extremity ultrasound.

The natural history of calf vein thrombosis: Lysis of thrombi and development of reflux

Purpose: Although the fact is well accepted that deep venous thrombosis (DVT) of the iliac, femoral, and popliteal veins can lead to the post-thrombotic (postphlebitic) syndrome, the significance of isolated calf DVT on the development of late venous sequelae and physiologic calf dysfunction is unknown. The purpose of this study was to review the outcome of 58 limbs with isolated calf DVT and report the clinical, physiologic, and imaging results up to 6 years after the onset of DVT. Methods: The study consisted of 58 limbs of 54 patients in whom isolated calf vein DVT was diagnosed between 1990 and 1995. Proximal propagation of clot, lysis of thrombi, and development of symptomatic pulmonary emboli were examined. Of the patients, 28 received anticoagulation therapy, and 26 did not, but they had follow-up with serial duplex scans. At late follow-up 1 to 6 years later (median, 3 years), 23 patients were examined for the post-thrombotic syndrome, and all 23 underwent clinical examination, color-flow duplex scanning, and air plethysmography. Results: Proximal propagation of DVT from the calf veins into the popliteal or thigh veins occurred in 2 of 49 cases (4%) within 2 weeks of diagnosis. No patient had clinically overt pulmonary emboli develop regardless of whether anticoagulation therapy was received or not. The most common site for calf DVT was the peroneal vein (71%). Complete lysis of calf thrombi was found in 88% of the cases by 3 months. At 3 years, 95% of the patients were either asymptomatic or mildly symptomatic, and 5% had discoloration of the limb. No ulcers occurred. By air plethysmography, physiologic abnormalities were found in 27% of the cases, which was not significantly different from normal controls. Valvular reflux by duplex scanning of the calf vein segment with DVT was found in 2 of 23 cases (9%). However, reflux in at least one venous segment not involved with DVT was found in 7 of 23 cases (30%), which was higher than, but not statistically different from, normal controls, with reflux occurring in 5 of 26 cases (19%). Conclusions: Isolated calf vein DVT leads to few early complications (ie, clot propagation, pulmonary emboli) and few adverse sequelae at 3 years. The peroneal vein is most commonly involved and should be a part of the routine screening for DVT. Lysis of clot usually occurs by 3 months. Although valvular reflux rarely is found in the affected calf vein at 3 years, reflux may be found in adjacent uninvolved veins in approximately 30% of the cases. The question of whether this will lead to future sequelae, such as ulceration, will require longer follow-up. (J Vasc Surg 1998;28:67-74.)

Neovascularisation is the principal cause of varicose vein recurrence: Results of a randomised trial of stripping the long saphenous vein

To determine whether routine stripping of the long saphenous vein reduces recurrence after varicose vein surgery. Randomised controlled trial. All operations done by a consultant vascular surgeon. Two year follow-up. One hundred patients with primary long saphenous varicose veins (133 legs) were randomised. Two year follow-up in 81 patients (113 legs) with questionnaire, clinical examination and Duplex scanning. Some 89% remained satisfied with the results of their surgery, though 35% had recurrent veins on clinical examination. Recurrence was reduced from 43 to 25% in patients who had their long saphenous vein stripped (p = 0.04, chi 2). Neovascularisation (serpentine tributaries arising from the ligated saphenofemoral junction) was detected in 52% of limbs and was the commonest cause of recurrence. Most tributaries were less than 3 mm in diameter and only caused recurrence if the long saphenous vein or a major thigh vein was intact. Twelve patients had tributaries greater than 3 mm diameter and all had recurrent varicose veins. Recurrence is common after varicose vein surgery and in this study was caused principally by neovascularisation at the ligated saphenofemoral junction. Clinical recurrence is reduced by routine stripping of the long saphenous vein.