Clive Solomon

Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography.

OBJECTIVE We observed long-term venous ultrasound and plethysmographic changes after varicose vein surgery, to determine factors that influence recurrence. METHODS AND MATERIALS This observational sequential prospective study was carried out in an institutional referral center with day surgery. Subjects were 92 consecutive patients, ages 20 to 75 years, with symptomatic varicose veins in 127 limbs, who were able to complete regular assessment. Superficial varicose vein surgery included significant perforator vessels only, defined at preoperative duplex ultrasound scanning and air plethysmography. Similar follow-up assessments were performed at 3 weeks, 3 months, and 1, 3, and 5 years. RESULTS At 3 weeks venous reflux but not muscle pump function was consistently improved in all limbs. However, inadequate surgery at the major junctions was clearly identified as contributing to recurrence of disease in 7.2% of limbs. Recurrence of varicose veins occurred in 1 of 100 limbs (1%) at the saphenofemoral junction and in 8 of 33 (25%) limbs at the saphenopopliteal junction. However, after 3 years disease recurrence at these sites had increased to 23% and 52%, respectively. Incompetent perforator vessels increased progressively in number. Clinical recurrence was 47.1%, and consistent with this was gradual deterioration in air plethysmographic measures of reflux, with physiologic recurrence (venous filling index, >2 mL/s) in 66% at 5 years. Late recurrence was predicted in limbs with multiple sites of reflux preoperatively, venous filling index greater than 2 mL/s, and some other persistent abnormality at duplex scanning at 3 weeks. There was no recurrence in 40 limbs in which these factors were normal at at 3 weeks. However, 29 of 53 limbs with normal venous filling index after operative intervention had deteriorated at 3 years. CONCLUSION Incomplete superficial surgery, in particular at the saphenofemoral and saphenopopliteal junctions, is a less frequent cause of recurrent disease, and neovascular reconnection and persistent abnormal venous function are the major contributors to disease recurrence.

Recurrent Varicose Veins: Patterns of Reflux and Clinical Severity

Duplex scanning was used to determine patterns of recurrent varicose veins in 264 limbs and to relate these to clinical factors. All limbs had previously undergone sapheno-femoral ligation in the groin. A recurrent sapheno-femoral junction was present in 172 (65.2%). Incompetence was found in long or short saphenous veins in 232 limbs (87.9%), perforators in 176 (66.7%), and deep veins in 156 (59.1%). Residual long saphenous veins were present in 43.4% and 73.6% of limbs that were with and without stripped long saphenous veins, respectively. An incompetent thigh perforator was present in 14.0% and 15.3% of these two groups, respectively. Multiple sites of incompetence were observed in the majority (75.4%). In general, no particular reflux pattern in the groin was related to an increased incidence of ulceration. However, ulceration was more frequent in limbs with deep reflux to knee or below-knee levels. None of those with isolated reflux in the groin that was unrelated to the common femoral vein had ulceration. The pattern of reflux was unrelated to striping or non-striping of the long saphenous veins and the time since initial surgery. A history of deep vein thrombosis was invariably associated with some degree of deep reflux. A system of recurrent patterns in the groin is described for the purpose of surgical audit. In 15.1%, recurrence was attributed with some confidence to inadequate surgery. These results indicate that the pattern of recurrence is highly variable and often with multiple sites of incompetence. In a few instances, the pattern of recurrence was associated with specific clinical factors. A full work-up including duplex scanning is recommended.

Chelation therapy for intermittent claudication. A double-blind, randomized, controlled trial.

BackgroundThe use of repeated intravenous infusions of EDTA, which has become known as “chelation therapy,” has been promoted for treating intermittent claudication as well as a wide range of other disorders. Multiple reports of excellent results in large numbers of patients have encouraged the use of this regimen. The lack of well-controlled studies substantiating the benefits of this treatment has limited its use mainly to private clinics. The aim of the study was to assess the benefits of chelation therapy in patients with intermittent claudication. Methods and ResultsA double-blind, randomized, controlled trial included 32 patients with intermittent claudication who were randomized to a treatment group (15) and a control group (17). Main outcome measures were subjective and measured walking distances and ankle/brachial pulse indices. Other outcome measures included lifestyle and subjective parameters of improvement, cardiac function, ECG, renal function, hematology, blood glucose, and lipid biochemistry. No clinically significant differences in main outcome measures between chelation therapy and placebo groups were detected up to 3 months after treatment. Measures of mood state, activities of daily living, and quality of life factors were not consistently affected by chelation therapy. An equal propor-tion (13%) of each group thought that they had received the active agent. The proportion of patients showing an improvement in walking distance was not significantly different between the chelation group (60%) and the control group (59%). ConclusionsChelation therapy has no significant beneficial effects over placebo in patients with intermittent claudication.

The use of video image analysis for the measurement of venous ulcers

Summary The accurate measurement of the size of skin wounds and ulceration is important for comparing the efficiency of treatment modalities and for monitoring progress in the individual patient. Although various methods of differing sophistication are in use, many of the common simpler techniques lack accuracy and reliability.

Prospective Study of Natural History of Deep Vein Thrombosis: Early Predictors of Poor Late Outcomes

BACKGROUND A proportion of patients with deep vein thrombosis (DVT) will develop postthrombotic syndrome (PTS). Currently, the only clearly identified risk factors for developing PTS are recurrent ipsilateral DVT and extensive proximal disease. The aim of the study was to assess the natural history of DVT and identify early predictors of poor clinical outcome at 5 years. METHODS Patients with suspected acute DVT in the lower limb were assessed prospectively. All patients with a confirmed DVT were asked to participate in this study. Within 7-10 days after diagnosis of DVT, patients underwent a further review, involving clinical, ultrasound, and air plethysmography assessment of both lower limbs. Patients were reassessed at regular intervals for 5 years. RESULTS One hundred twenty-two limbs in 114 patients were included in this study. Thrombus regression occurred in two phases, with a rapid regression between 10 days and 3 months, and a more gradual regression thereafter. Reflux developed as thrombus regression occurred. Segmental reflux progressed to axial deep reflux and continued to deteriorate in a significant proportion of patients with iliofemoral-popliteal-calf DVT throughout the 5-year study period. Similarly, venous filling index became progressively more abnormal, in this group, over the course of the study. Four risk factors for PTS were identified as best predictors: extensive clot load on presentation; <50% clot regression at 6 months; venous filling index >2.5 mL/sec; and abnormal outflow rate (<0.6). Patients with three or more of these risk factors had a significant risk of developing PTS with sensitivity 100%, specificity 83%, and positive predictive value 67%. Patients scoring 2 or less did not have PTS at 5 years with a negative predictive value of 100%. CONCLUSIONS This is the first study to show that venous assessment at 6 months post-DVT can predict PTS at 5 years. Those who will not develop PTS can be reassured of this at 6 months.

Acute bilateral renal artery occlusion: successful revascularization with streptokinase

A case of acute oliguric renal failure due to bilateral renal artery occlusion is described. The renal function was restored to normal 36 h after the embolic event by revascularization with streptokinase.

Hybrid systems for medical data analysis and decision making-a case study on varicose vein disorders

This paper examines the applicability of intelligent information processing techniques for the analysis of vascular laboratory data associated with varicose vein disorders. In the first section a brief description of varicose disease is provided. Next, the notion of applying different types of neural network to learning the dynamics of the disease is examined in two experiments. Subsequent to these, a new approach to visualising the output of a Kohonen network is presented. A brief discussion then follows on an architecture for combining these networks into an intelligent hybrid decision making system. Finally, directions for future research are discussed.

Artificial Computer Neural Networks for the Assessment of the Results of Venous Calf Air Plethysmography

The high cost of venous ulceration in both social and economic terms has highlighted the need for accurate diagnosis and early appropriate treatment or preferably detection of the at-risk limb and ulcer prevention. Until fairly recent times diagnostic procedures have tended to be either invasive (direct venous pressure measurement or venography) or limited as in the case of photoplethysmography.

Microcirculation and Venous Disease: Effects of Raised Venous Pressure, Walking and Temperature

While the exact pathophysiological mechanisms resulting in the skin changes and ulceration of the skin in the limbs of patients with severe chronic venous insufficiency (CVI) remain unclear, various investigative modalities have increased our understanding of the characteristic microcircultory changes present.

Degree of Failure of Elastic Laminae in Superficial Veins Correlates with Severity of Venous Insufficiency

The importance of valvular incompetence, venous reflux and high ambulatory venous pressure in the pathogenesis of venous ulceration has been well documented [1]. Why only a proportion of patients with significant reflux go onto develop severe disease is not clear and why similar findings on duplex examination are associated with varying levels of physiological dysfunction [2] has not been well explained.