C. Vaughan Ruckley

Recurrent Varices after Surgery (REVAS), a Consensus Document

Report of the meeting† held in Paris on 17th & 18th July 1998 with participation oft: Ugo Baccaglini, Italy; Pierre Barthelemy. France; Jean-Claude Couffinhal. France: Denis Creton. France: Simon Darke, United Kingdom; Ralph De Palma, United States of America; Bo Eklof, United States of America; Ermenegildo Enrici, Argentina; Gilbert Franco, France; Jean Pierre Gobin, France; Louis Grondin, Canada; Jean-Jerome Guex. France; Georges Jantet. France; Claude Juhan. France; Jordi Maeso y Lebrun. Spain; Philippe Nicolini. France; Andreas Oesch, Switzerland; Marcelo Paramo-Diaz. Mexico; Michel Perrin. France; Paul Puppinck, France; Eberhard Rabe, Germany: Rene Rettori, France; John Royle, Australia; Vaughan Ruckley, United Kingdom; Michel Schadeck, France; Jean Claude Schovaerdts, Belgium; John Scurr, United Kingdom; Georgio Spreafico, Italy; Jan Struckman, Denmark; Frederic Vin, France Recurrent varicose veins after surgery (REVAS) are a common, complex and costly problem. The frequency of REVAS is stated to be between 20 and 80% depending on the definition of the condition. A consensus meeting on the topic (Paris 1998, July) decided to adopt a clinical definition: the presence of varicose veins in a lower limb previously operated on for varices. The pathology of recurrent varicose veins has been poorly correlated with clinical examination and operative findings. Clinical diagnosis remains essential but does not allow a precise assessment of REVAS. Consequently, the use of imaging investigations is essential. Duplex scan is considered as the method of choice. Both clinical diagnosis and imaging investigations allow the development of a classification for every day usage and future studies. This new classification of CEAP needs to be expanded to define the sites, nature and sources of recurrence, the magnitude of the reflux and other (possible) contributory factors. Methods for REVAS treatment include compression, drugs, sclerotherapy and redo surgery. There was no general consensus in favour of sclerotherapy, surgery or both to treat REVAS. Very few data were available to assess the results of treatment. Factors responsible for recurrence and recommendations for primary prevention were debated and are presented in this article. Guidelines for well-planned prospective studies have been produced.

Lifestyle factors and the risk of varicose veins: Edinburgh Vein Study.

The objective of this study was to determine the inter-relationships between a range of lifestyle factors and risk of varicose veins to identify which factors may be implicated in the etiology. An age-stratified random sample of 1566 subjects (699 men and 867 women) aged 18 to 64 years was selected from 12 general practices throughout Edinburgh. A detailed self-administered questionnaire was completed, and a comprehensive physical examination determined the presence and severity of varicose veins. The slightly higher age-adjusted prevalence of varicose veins in men than in women (39.7% versus 32.2%) was not explained by adjustment for an extensive range of lifestyle risk factors (male odds ratio [OR] 2.11, 95% confidence interval [CI] 1.51-2.96). In both sexes, increasing height showed a significant relationship with varicose veins (male OR 1.50, 95% CI 1.18-1.93 and female OR 1.26, 95% CI 1.01-1.58). Among women, body mass index was associated with an increased risk of varicose veins (OR 1.26, 95% CI 1.02-1.54). The current study casts doubt as to whether varicose veins occur predominantly in women. In addition, no consistent relationship with any lifestyle factor was shown. Self-reported evidence suggested a familial susceptibility, thereby warranting future genetic studies.

Accuracy and reproducibility of duplex ultrasonography in grading femoropopliteal stenoses

PURPOSE The aim of this study was to determine the accuracy of Doppler waveform characteristics in grading femoropopliteal stenoses and to determine the interobserver and intraobserver reproducibility of measuring the same waveform characteristics. METHODS Thirty patients with isolated areas of stenosis found by arteriography were evaluated by color duplex sonography. Each patient underwent scanning by two observers on two separate occasions. Each observer was blind to the others results. Doppler spectra were recorded in areas where color change suggested the highest velocity and also at the nearest normal proximal area. Peak systolic velocity, spectral broadening, and waveform configuration were measured at each site. RESULTS An increase in peak systolic velocity of more than 200% accurately predicted a 50% or greater reduction in luminal diameter on angiography (70% sensitivity, 96% specificity). The presence of spectral broadening and an abnormal waveform shape were found to correlate poorly with the degree of stenosis. Analysis of variance showed no significant difference between observers in velocity measurements (p = 0.78). CONCLUSIONS We conclude that although stenoses of greater than 50% can be distinguished from minor stenoses, more precise definition of the degree of narrowing is unlikely. The good repeatability of the velocity ratio makes it an excellent tool for monitoring major changes in the progression of disease.

Relationship between abdominal aortic aneurysm wall compliance and clinical outcome: a preliminary analysis

BACKGROUND Aortic compliance, as measured by the pressure-strain elastic modulus (Ep) and stiffness (B), may allow a more precise estimate of abdominal aortic aneurysm rupture risk than size alone. AIM To determine the relationships between AAA compliance, size, growth, and clinical outcome. METHODS One-hundred and twelve patients with initially non-operated AAA (86 men, 26 women, mean age 73 years), recruited from five centres, underwent baseline compliance measurements and were then followed for a median of 7 (range 2-18) months; 85 patients underwent repeated measurements (median 3, range 2-5) 3-6-monthly over a median of 12 (range 3-18 months). RESULTS Seven patients have ruptured and 16 have undergone repair of non-ruptured AAA. AAA that ruptured had significantly lower Ep and B (more compliant). In AAA that ruptured or required repair there was an inverse relationship between diameter and Ep and B. In those undergoing repeated measurements AAA expansion was only associated with a significant increase in Ep and B in non-operated patients. CONCLUSIONS Baseline AAA compliance was significantly related to rupture and the future requirement for operative repair. Failure of compliance to increase with size may be a marker for rapid growth, developmental symptoms and rupture.

The value of computed tomography in the assessment of suspected ruptured abdominal aortic aneurysm

OBJECTIVE The objective of this study was to determine the diagnostic value of computed tomography (CT) in patients with suspected ruptured abdominal aortic aneurysm. STUDY DESIGN The study was an interrogation of a prospectively gathered computerized database. SETTING The study was performed at a regional vascular surgery unit. SUBJECTS Six hundred fifty-two consecutive patients were admitted to this unit with suspected ruptured abdominal aortic aneurysm between January 1, 1989, and December 31, 1996. Seventy-four patients (11.3%) in whom the diagnosis was in doubt on clinical grounds alone underwent urgent CT. A total of 47 men and 27 women with a median age of 73 years (range, 52 to 86 years) were evaluated. MAIN OUTCOME MEASURES CT and operative findings were compared. RESULTS CT correctly diagnosed rupture in 22 of 28 patients who underwent operation and correctly excluded rupture in 30 of 39 patients who underwent operation. The sensitivity and specificity of CT when compared with operative findings were therefore 79% and 77%, respectively. CONCLUSIONS These data indicate that CT has little additional diagnostic value. If in the opinion of an experienced vascular surgeon rupture cannot be excluded on clinical grounds alone, and the patient has no medical contraindications to abdominal aortic aneurysm repair, then the patient should be taken directly to the operating department.

Fibrin sealant reduces suture line bleeding during carotid endarterectomy: A randomised trial

OBJECTIVES To determine whether topical fibrin sealant reduced suture line bleeding during carotid endarterectomy with polytetrafluoroethylene (PTFE) patch closure. DESIGN Prospective randomised non-blinded control trial. SETTING Regional vascular surgery unit. MATERIALS Seventeen patients undergoing carotid endarterectomy were randomised either to receive fibrin sealant as a topical haemostatic agent at the arteriotomy suture line or to act as control. OUTCOME MEASURES Time taken to achieve haemostasis at the suture line. Intraoperative blood loss. Total operative time. RESULTS The median time to achieve haemostasis was 5.5 min (range 4-31 min) in the treatment group and 19 min (range 10-47 min) in the control group. This difference was statistically significant p < 0.005 by Mann-Whitney test. There was no statistical difference in total operative time. Operative blood loss was lower in the treatment group (median 420ml, range 300-500ml) than in the control group (median 550ml, range 350-1200ml) but this difference was not statistically significant. One patient in the control group suffered a perioperative thrombo-embolic event. CONCLUSION Fibrin sealant is an effective topical haemostatic agent for arteriotomy suture lines involving PTFE material.

Accuracy and reproducibility of duplex ultrasound imaging in a phantom model of femoral artery stenosis

PURPOSE The improvement of management strategies in patients with intermittent claudication might depend on a better understanding of the natural history of femoral atherosclerosis. The grading of stenoses, the monitoring of their progression, and the assessment of response to treatment are critically dependent on a methods accuracy and variability. Duplex ultrasound imaging provides a noninvasive way of measuring localized disease, but there has been relatively little objective evaluation of its accuracy and reproducibility. The aim of this study was to evaluate the accuracy and variability of duplex velocity ratio measurements of stenosis. METHODS In a laboratory flow model of the femoral artery, 14 concentric and eccentric stenoses were examined five times by three sonographers. Measurements were then repeated with a standardized technique in which Doppler angle and aperture position were fixed, giving a total of 420 measurements. RESULTS Velocity ratio showed good correlation with degree of stenosis, R2 = 0.996. Intraobserver variability was low, but interobserver variability was significant with more severe stenosis (p = 0.002, analysis of variance). Standardization of the technique did not improve accuracy or variability. The 95% confidence limit was +/- 20% for a single reading of velocity ratio for stenoses of > 50% diameter reduction. CONCLUSIONS We conclude that duplex ultrasound imaging can be used to accurately grade arterial stenosis in this range, and the potential exists for noninvasive monitoring of the progression of preocclusive femoral atherosclerosis and its response to treatment. In addition, repeated measurements of velocity ratio over time should be made by the same observer.

Serum amylase isoenzymes in patients undergoing operation for ruptured and non-ruptured abdominal aortic aneurysm

OBJECTIVE Previous work has suggested that hyperamylasemia in patients who undergo operation for ruptured abdominal aortic aneurysm (AAA) is associated with poor outcome. The aims of this study were to determine, for the first time, the source of serum amylase in such patients and to examine the prognostic significance of amylase isoenzyme expression. METHODS This study was designed as a prospective clinical and laboratory study. The study consisted of 40 patients who underwent operation for ruptured AAA and 10 patients who underwent operation for non-ruptured AAA. The main outcome measures were serum total and pancreatic and salivary amylase activities determined with enzymatic colorimetric assay before operation and 6 hours after aortic clamp release. RESULTS Five of 40 patients (12.5%) with rupture and one of 10 patients (10%) with non-rupture had elevated total amylase levels before operation, and seven of 31 patients (23%) with rupture and five of 10 patients (50%) with non-rupture had elevated total amylase levels after operation. The preoperative salivary amylase (P =.05) and postoperative pancreatic amylase (P <.02) levels were significantly lower in ruptured AAA as compared with non-ruptured AAA. The preoperative salivary amylase level was significantly lower in non-survivors of rupture, such that a level equal to or less than 45 U/L was associated with death in 11 of 13 patients (85%). CONCLUSION These data do not support previous works that suggest that hyperamylasemia is associated with poor outcome in ruptured AAA. By contrast, a low preoperative salivary amylase level was associated with increased mortality in ruptured AAA and may be a marker of the severity of shock.

Progression of varicose veins and chronic venous insufficiency in the general population in the Edinburgh Vein Study

OBJECTIVE The natural history in the general population of chronic venous disease in the legs is not well understood. This has limited our ability to predict which patients will deteriorate and to assign clinical priorities. The aims of this study were to describe the progression of trunk varicose veins and chronic venous insufficiency (CVI) in the general population, to identify important lifestyle and clinical prognostic factors, and to determine the relationship between venous reflux and progression. METHODS The Edinburgh Vein Study is a population-based cohort study in which randomly selected adults aged 18 to 64 years had an examination at baseline. This included a questionnaire on lifestyle and clinical factors, standardized assessment and classification of venous disease in the legs, and duplex scan to detect venous reflux in eight segments of each leg. A follow-up examination 13 years later included a reclassification of venous disease to ascertain progression in the development or increase in severity of varicose veins and CVI. RESULTS Among 1566 adults seen at baseline, 880 had a follow-up examination, of whom 334 had trunk varicose veins or CVI at baseline and composed the study sample. The mean (standard deviation) duration of follow-up was 13.4 (0.4) years. Progression was found in 193 (57.8%), equivalent to 4.3% (95% confidence interval [CI], 3.7-4.9) annually. In 270 subjects with only varicose veins at baseline, 86 (31.9%) developed CVI, with the rate increasing consistently with age (P = .04). Almost all subjects (98%) with both varicose veins and CVI at baseline deteriorated. Progression of chronic venous disease did not differ by gender or leg, but a family history of varicose veins and history of deep venous thrombosis increased risk (odds ratio [OR], 1.85 [95% CI, 1.14-1.30] and 4.10 [95% CI, 1.07-15.71], respectively). Overweight was associated with increased risk of CVI in those with varicose veins (OR, 1.85; 95% CI, 1.10-3.12). Reflux in the superficial system increased the likelihood of progression, especially in combination with deep reflux (OR, 2.57; 95% CI, 1.55-4.25) and when located in the small saphenous vein (OR, 4.73; 95% CI, 1.37-16.39). CONCLUSIONS Nearly half of the general population with chronic venous disease deteriorated during 13 years, and almost one third with varicose veins developed skin changes of CVI, increasing their risk of ulceration. Age, family history of varicose veins, history of deep venous thrombosis, overweight, and superficial reflux, especially in the small saphenous vein and with deep reflux, might influence the risk of progression.

How Do We Prevent Recurrence of Varicose Veins

Most surgeons in the UK, and probably elsewhere, are unaware of the long-term outcomes for their patients after varicose vein operations. Where follow-ups have been done, and published, reported rates of clinical recurrence, leading to repeat surgery, have ranged between 20% and 60% at 6–20 years of follow-up [1]. Where the intervention has been limited to high ligation combined with sclerotherapy or to sclerotherapy alone the reported recurrence rates are even higher [1]. A large part of the work of general and vascular surgeons is devoted to treating recurrent varicose veins — a disease that is more difficult to treat than the primary condition.