Vein Surgery Research Articles

Important protective effects of toll like receptor 3 and downstream interferon regulating factors on vein graft remodelling

Purpose: Toll like receptors (TLRs) are key regulators of innate immunity and are highly involved in vein graft remodelling. Activation of most TLRs results in MyD88 and NFκB signalling and induction of inflammatory cytokines. In vascular disease models this leads to pro-inflammatory profiles resulting in augmentation of lesion formation and remodelling. TLR3 however, has protective effects on vascular diseases, although the molecular mechanism is not yet fully clarified. Interestingly, TLR3 is unique among the TLRs since signalling occurs in a MyD88 independent manner; via activation of TRIF and key interferon regulating factors IRF3 and IRF7 resulting in induction of type I interferons. The aim of this study was to investigate the role of TLR3 pathway constituents on vein graft remodelling. Methods: This study was performed in compliance with Dutch government guidelines and principles of laboratory animal care (NIH Publication no. 85-23 revised 1985). Donor caval veins were engrafted in carotid arteries of recipient Tlr3-/-, Irf3-/-, Irf7-/- and control C57BL/6 mice (n=7-10/group). 28 days after surgery vein grafts were harvested and analyzed for vessel wall morphology, cell content and cytokine RNA levels. Results: Tlr3-/- mice developed substantially larger vein grafts than the control mice (155%, p<0.001). Also Irf3-/- and Irf7-/- mice showed increased vein graft thickening (Irf3-/-; 39%, p=0.185, Irf7-/-; 68% p=0.003). The lumen area did not deviate between these strains and their control mice, resulting in outward remodelling in all three strains (Tlr3-/-; 52%, p<0.001, Irf3-/-; 26%, p=0.081, Irf7-/-; 42%, p=0.049). Since macrophages produce large amounts of TLRs, we looked at the influx of these cells in the vein grafts. Tlr3-/-, Irf3-/- and Irf7-/- mice showed significant more influx of macrophages than the control mice. The relative percentage smooth muscle cells and collagen in the vein graft walls did not deviate between the three strains and controls. RNA analysis of vein grafts revealed that pro-inflammatory cytokines TNFα and CCL2 were significantly increased in the Tlr3-/- mice, whereas Irf3-/- and Irf7-/- mice showed no increases in gene expression compared to controls. Conclusions: The TLR3 pathway seems to be protective for vein graft remodelling since Tlr3-/-, as well as the key downstream factors Irf3-/- and Irf7-/- vein grafts show increased vessel wall thickening and outward remodelling. This increased remodelling in the knock out mice is the result of a pro-inflammatory response as reflected by the increase in macrophages and cytokines in the vein graft wall.

Subfascial endoscopic perforator surgery for posterolateral perforators performed in the prone position

Subfascial endoscopic perforator surgery (SEPS) is usually performed for posteromedial perforators in the supine position, but subfascial endoscopic perforator surgery for posterolateral perforators in the prone position has not been reported. A 51-year-old male suffered from a venous stasis ulcer around his lateral malleolus because of reflux in the small saphenous vein and incompetent perforating veins around the ulcer. Stripping of the small saphenous vein and subfascial endoscopic perforator surgery utilizing screw-type ports was successfully conducted in the prone position. The prone position enables interruption of the posterolateral perforators, because gravity-dependent flattening of the muscles enables creation of sufficient subfascial space.

Efficacy and comfort of medical compression stockings with low and moderate pressure six weeks after vein surgery

The first two authors contributed equally to this work. A prospective, randomized study to evaluate efficacy, safety, and comfort of thigh-high, round knitted medical compression stockings (MCSs) with different pressure six weeks after vein surgery. Female patients undergoing vein surgery were randomized for a compression therapy with low (18-21 mmHg, group A) or moderate (23-32 mmHg, group B) pressure MCSs. Follow-up was done by a phlebological experienced, blinded physician (pressure control, clinical aspect, duplex scan, and questionnaire) one and six weeks after surgery. Totally, 88 patients (41 in group A and 47 in group B) were analyzed. One week after surgery, patients of group B had significantly lower edema scores than patients of group A either in the clinical assessment (0.7 vs. 0.3; p = 0.016) or in the B-mode scan (0.9 vs. 0.4; p = 0.013). Significant less patients of group B had a feeling of "tightness" (p = 0.01) and significant more a reduction of discomfort (p = 0.01) after week 1 but with no significance in week 6. There was no significant difference according to other clinical and ultrasound findings such as hematoma, infection, hyperpigmentation, cording, or thrombosis after one or six weeks. In week 1 and week 6, more patients suffered from pain in group A (week 1 p = 0.24, week 6 p = 0.063). Application of the MCSs was easier in group A in week 1 but similar in groups A and B in week 6. Muscle vein thrombosis occurred in one patient of group A. Compression stockings with a pressure of 23-32 mmHg facilitate a faster resolution of clinical and ultrasound verified edema and the subjective feelings of pain, tightness, and discomfort of the leg in the early period after surgery but have no difference in the longer post-surgical period compared to stockings with a pressure of 18-21 mmHg.

Doxycycline speeds up healing of chronic venous ulcers

Venous ulcers are common, with an overall prevalence of up to 2% in the general population of western countries, and have significant socioeconomic impact. Matrix metalloproteinases (MMPs) are involved in the alteration of extracellular matrix that could lead to venous ulceration. Sixty-four patients with venous ulcers were recruited in a 22-month period. All patients were subjected to the most appropriate treatment considering also the patient's wishes (compression therapy followed or not by vein surgery). Patients were randomised into two groups of 32 persons in each (groups A and B). Patients of group A in addition to the basic treatment, described above, received the administration of oral low doses of doxycycline 20 mg b.i.d. for 3 months, whereas patients of group B received basic treatment only. Healing was assessed by means of direct ulcer tracing with computerised planimetry. Group A showed a higher healing rate compared with group B. In group B, the lower healing rate was related to higher levels of MMP-9; neutrophil gelatinase-associated lipocalin and vascular endothelial growth factor, documented in plasma; wound fluid and biopsies executed and compared between both groups. Pharmacological treatments, as doxycycline administration, which by means of its immunomodulatory and anti-inflammatory actions, through the inhibition of MMP, could improve extracellular matrix functioning and represent a possible solution to support wound healing.

Low molecular weight heparin improves healing of chronic venous ulcers especially in the elderly

Venous ulcers are common, especially in the elderly, accounting for more than 50% of all lower extremity ulcers with important socioeconomic problems. Improving extracellular matrix functioning, by heparin administration, seems to be a way to support wound healing. A total of 284 patients with venous ulcers were recruited in a 4-year period. All patients were subjected to the most appropriate treatment after considering their preference (compression therapy followed or not by vein surgery). Patients were randomised into two groups of 142 persons in each (group A and group B as cases and controls, respectively). Patients of group A, in addition to the basic treatment as described earlier, received administration of nadroparin 2850 IU/0.3 ml through subcutaneous injection once a day for 12 months, whereas group B patients received basic treatment alone. Healing was assessed by means of direct ulcer tracing with computerised planimetry. Group A showed a healing rate of 83·80% at 12 months, whereas that of group B was 60·56%. Results by age group surprisingly showed that the group of older patients took the most advantage from long-term treatment with low molecular weight heparin; this group also had lowest recurrence rate.

Compression and venous ulcers

Compression therapy is considered to be the most important conservative treatment of venous leg ulcers. Until a few years ago, compression bandages were regarded as first-line therapy of venous leg ulcers. However, to date medical compression stockings are the first choice of treatment. With respect to compression therapy of venous leg ulcers the following statements are widely accepted: 1. Compression improves the healing of ulcers when compared with no compression; 2. Multicomponent compression systems are more effective than single-component compression systems; 3. High compression is more effective than lower compression; 4. Medical compression stockings are more effective than compression with short stretch bandages. Healed venous leg ulcers show a high relapse rate without ongoing treatment. The use of medical stockings significantly reduces the amount of recurrent ulcers. Furthermore, the relapse rate of venous leg ulcers can be significantly reduced by a combination of compression therapy and surgery of varicose veins compared with compression therapy alone.

Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein (Br J Surg 2012; 99: 1062-1070)

Randomized clinical trial of ultrasound-guided foam sclerotherapy versus surgery for the incompetent great saphenous vein (<i>Br J Surg</i> 2012; 99: 1062-1070)

May-Thurner syndrome

May-Thurner syndrome, a pelvic vein congenital anomaly is the consequence of compression of the left common iliacal vein by the overlying right common iliacal artery that results in an increased risk for ileofemoral deep vein thrombosis. Authors present a case of a young female with aberration of the pelvic vein, who had also heterozygous Leiden mutation. After confirmation of the diagnosis of May-Thurner syndrome, plastic surgery of the common iliacal vein was performed and anticoagulant treatment was given.

Treatment of varicose tributaries with sclerotherapy with polidocanol 0.5 % foam

Although foam sclerotherapy of varicose tributaries is common in daily practice, scientific evidence for the optimal sclerosant-concentration and session-frequency is still low. This study aimed to increase the knowledge on foam sclerotherapy of varicose tributaries and to evaluate the efficacy and safety of foam sclerotherapy with 0.5 % polidocanol in tributaries with 3-6 mm in diameter. Analysis of 110 legs in 76 patients. Injections were given every second or third day. A maximum of 1 injection / leg and a volume of 2 ml / injection were administered per session. Controls were performed approximately 6 months and 12 months after the start of therapy. 110 legs (CEAP C2-C4) were followed up for a period of 14.2 +/- 4.2 months. Reflux was eliminated after 3.4 +/- 2.7 injections per leg. Insufficient tributaries were detected in 23.2 % after 6.2 +/- 0.9 months and in 48.2 % after 14.2 +/- 4.2 months, respectively. Only 30.9 % (34 / 110) of the legs required additional therapy. In 6.4 % vein surgery was performed, in 24.5 % similar sclerotherapy was repeated. Significantly fewer sclerotherapy-sessions were required compared to the initial treatment (mean: 2.3 +/- 1.4, p = 0.0054). During the whole study period thrombophlebitis (8.2 %), hyperpigmentation (14.5 %), induration in the treated region (9.1 %), pain in the treated leg (7.3 %) and migraine (0.9 %) occurred. One patient with a history of thrombosis developed thrombosis of a muscle vein (0.9 %). After one year there were just hyperpigmentation (8.2 %) and induration (1.8 %) left. No severe adverse effect occurred. Foam sclerotherapy with injections of 0.5 % polidocanol every 2nd or 3rd day, is a safe procedure for varicose tributaries. The evaluation of efficacy is difficult, as it can hardly be said whether the detected tributaries in the controls are recurrent veins or have recently developed in the follow-up period. The low number of retreated legs indicates a high efficacy and satisfaction of the patients.

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

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

Tumescent anaesthesia in combination with a femoral nerve block or a sciatic nerve block for surgery of varicose veins

SummaryTumescent anaesthesia is a widley accepted anaesthetic procedure for the surgery of varicous veins. In our institution tumescent anaesthesia is regularly combined with femoral nerve block or sciatic nerve block for primary operations of the great saphenous vein (GSV) or small saphenous vein (SSV).This combined procedure is described. Retrospective data of 154 operations of the GSV and of 27 operations of the SSV are presented. We used 9.5 mg/kg body weight of prilocain for operations of the GSV and 8.6 mg/kg body weight for operations of the SSV. No serious complications occurred.

Human Saphenous Vein and Coronary Bypass Surgery: Scanning Electron Microscopy of Conventional and ‘No-Touch’ Vein Grafts

Human Saphenous Vein and Coronary Bypass Surgery: Scanning Electron Microscopy of Conventional and ‘No-Touch’ Vein Grafts

The Economics of Vein Disease

The management of cosmetic vein problems requires a very different approach than that for the majority of most other vascular disorders that occur in a vascular surgery practice. This article focuses on the business aspects of a cosmetic vein practice, with particular attention to the uniqueness of these issues. Managing patient expectations is critical to the success of a cosmetic vein practice. Maneuvering within the insurance can be difficult and frustrating for both the patient and the practice. Practices should use cost accounting principles to evaluate the success of their vein work. Vein surgery--especially if performed within the office--can undergo an accurate break-even analysis to determine its profitability.

Review of Acute Pulmonary Embolism in a General Hospital

Acute pulmonary embolism (APE) is a serious cardiovascular disease associated with high mortality rates. We analyzed the clinical characteristics, treatment, and outcome of patients with APE in a general hospital in Japan. The subjects were 14 patients with APE: 6 with out-of-hospital onset and 8 with in-hospital onset. The incidence of APE in hospitalized patients was 0.03% (95% confidence interval, 0.01%-0.05%). Eight patients suffered shock and three patients suffered cardiac arrest. Advanced age, deep vein thrombus (DVT), cancer, fracture, obesity, and surgery were common risk factors. In the hospitalized patients, surgery was a major risk factor: APE developed perioperatively in five (63%) of eight patients. Nine patients were treated with heparin alone, three were treated with thrombolysis, and two underwent surgical embolectomy for right heart thrombi. Three of the patients who suffered shock died during hospitalization and another died of recurrence 2 months after the first episode. Overall in-hospital and 3-month mortality rates were 21% and 29%, respectively, and the in-hospital mortality rate of the patients with shock was 38%. Acute pulmonary embolism was associated with high mortality rates and surgery was the most common risk factor predisposing to APE in hospitalized patients. Thus, standardized prophylaxis against DVT is essential for patients undergoing surgery.

The Clinical Significance of Preserving the Petrosal Vein in Surgery of Petrous Apex Meningiomas

Objective: The importance of preserving the superior petrosal vein has received increasing attention in the surgical treatment of pathologies involving the petrous apex. However, there is no study available so far focusing on the occurrence and the frequency of postoperative complications following petrosal vein obliteration. This study aims to analyze the postoperative complications and to establish pre- and intraoperative findings related to them following petrosal vein obliteration.

The Clinical Significance of Preserving the Petrosal Vein in Surgery of Petrous Apex Meningiomas

Objective: The importance of preserving the superior petrosal vein has received increasing attention in the surgical treatment of pathologies involving the petrous apex. However, there is no study available so far focusing on the occurrence and the frequency of postoperative complications following petrosal vein obliteration. This study aims to analyze the postoperative complications and to establish pre- and intraoperative findings related to them following petrosal vein obliteration.

Leg Ulcer Recurrence and its Risk Factors: A Duplex Ultrasound Study before and after Vein Surgery

Leg Ulcer Recurrence and its Risk Factors: A Duplex Ultrasound Study before and after Vein Surgery

The morphology of the varicose short saphenous system

Objective: Surgery for the varicose short saphenous vein (SSV) remains unsatisfactory. Specific problems include locating the saphenopopliteal junction (SPJ) and whether the trunk should be stripped. Recurrence rates are high. The objective was to review the morphology of varicose SSV and to address these aspects. Methods: Retrospective study of consecutive patients scheduled for SSV surgery based on initial continuous wave Doppler assessment. Detailed analysis of preoperative duplex ultrasound examinations with quantified reflux. Results: A total of 56 limbs (unilateral) were studied, male to female ratio was 18:38 and mean age was 51 years. SPJ: severe reflux in 47, mean diameter 8.1 mm (all above the skin crease [mean 2.7 cm]). Reflux was 'focal', being confined to the peri-junctional area with normal sized and competent distal short saphenous trunks in 29. In the remainder, incompetence was 'complete' with dilatation and reflux of the entire system. In only one limb did varicosities arise distally from a proximally competent system. Long saphenous vein ( LSV): coexistent reflux in 17, with communications with the SSV in 11. Deep reflux: at least one segment of deep reflux was found in 24 limbs. In this small study, no significant association with other morphology was found apart from 'complete' SSV reflux. Conclusion: The SPJ is usually severely incompetent, enlarged and sited above the skin crease. The morphology of the varicose SSV exhibits important differences from the LSV. In over half, incompetence is 'focal', confined to the peri-junctional vein and the distal trunk is competent suggesting a case for selective trunk stripping. Varicosities arising from a distally incompetent short saphenous trunk are uncommon.

Anatomical basis of an original pedal approach to the great saphenous vein for surgery

Varicose vein repair often necessitates a distal approach to the great saphenous vein (GSV). The classic method involves a medial pre-malleolar approach. We propose a more distal approach via the medial surface of the foot where there is a cutaneous landmark, which can be used to locate the GSV in a simple, reliable and reproducible fashion. In 20 cadaveric feet, we dissected out the GSV exploiting the above-mentioned cutaneous landmark. We then extended the dissection up as far as the medial pre-malleolar region (from where the GSV is classically approached) in order to be able to compare the diameter of the vein at the two different points (in the foot and in the pre-malleolar region). We also compared the cutaneous landmark with ultrasonographic location of the GSV in 22 feet of healthy subjects. Both dissections and ultrasound examinations demonstrated the reliability of the cutaneous landmark. Moreover, no significant difference was detected in the diameter of the GSV at the two different approach points. This original distal approach to the GSV requires only minor modifications of current practice for varicose veins surgical treatment.

Pre-packed take-home analgesics in ambulatory surgery

Summary Clinical studies have revealed that a high percentage of patients experience moderate or severe pain during the first 24–48 h following ambulatory surgery. We examined, in a prospective, randomised study, if standardizing by dispensing a pre-packed take-home analgesics (fixed combination codeine phosphate/acetaminophen), would lead to high adherence with pain treatment together with an improved alleviation of pain after discharge compared to normal practice. “Normal practice” implied that analgesics were prescribed at the surgeon's discretion without any standardisation. A total of 150 patients were included (surgical procedures: knee arthroscopy, breast surgery and surgery of varicose veins or anal fistulae). Analgesic efficacy and influence of pain on daily functions after discharge were evaluated by self-assessment of pain intensity by selected items of the BPI-SF. Adherence to treatment, frequency of adverse events and analgesic intake were also recorded during the study period. No significant difference in pain intensity could be seen regardless of high adherence in the intervention group. We conclude that pre-packed medication is an opportunity to provide patients with an easy method of handling postoperative analgesics, but a high frequency of drug related adverse events and the absence of better analgesia indicates that customised analgesic therapies are warranted.