Eibert Einarsson

Thrombectomy with temporary arteriovenous fistula: The treatment of choice in acute iliofemoral venous thrombosis

The treatment of choice in acute iliofemoral venous thrombosis is still controversial. This prospective randomized study compares the results of conventional anticoagulation of 32 patients with the results obtained in 31 patients undergoing acute thrombectomy combined with a temporary arteriovenous fistula and anticoagulation. Early complications were few in both treatment groups, and significant pulmonary embolism developed in only one conservatively treated patient. At 6-month follow-up in all surviving patients, leg swelling, varicose veins, and venous claudication were more frequent after conservative treatment. Only 7% (2 of 27) of these patients were completely free from postthrombotic symptoms compared with 42% (10 of 24) of the operated patients (p less than 0.005). Contrast phlebography demonstrated an excellent venous outflow through the iliofemoral segment in 35% (9 of 26) of the conservatively treated and in 76% (16 of 21) of the operated patients (p less than 0.025). Open femoropopliteal veins with competent valves were recorded in 26% (7 of 27) in the conservative group and in 52% (12 of 23) in the thrombectomy group (p less than 0.05). Thus thrombectomy combined with arteriovenous fistula decreases early symptoms and preserves venous outflow and valvular function better than conservative treatment. This procedure is therefore recommended for young patients with acute iliofemoral thrombosis to avoid development of incapacitating postthrombotic sequelae.

Long-term results of venous thrombectomy combined with a temporary arterio-venous fistula*

Forty-one patients with acute iliofemoral venous thrombosis were randomised to conventional anticoagulation or acute thrombectomy combined with a temporary arterio-venous fistula (AVF) and anti-coagulation. Follow-up after 5 years in 22 medical and 19 surgical patients revealed slightly more asymptomatic patients (37 vs. 18%) and less frequent severe post-thrombotic sequelae (16 vs. 27%) in the surgical group (N.S.). The iliac vein was more frequently (P less than 0.05) normal following thrombectomy (71 vs. 30%) as demonstrated by radionuclide angiography, but occlusion plethysmography showed an outflow capacity (61 vs. 45 ml/min/100 ml) that was not significantly better. There was no obvious difference in muscle pump function (EVrel) and reflux (Q/EVrel) assessed by foot volumetry. Still, the ambulatory venous pressure was significantly (P less than 0.05) lower in the surgical group. There was a tendency towards better results following thrombectomy in patients with fresh thrombosis and a successful initial procedure. Although the numbers of observations in many cases were too small to provide statistical evidence of benefit with venous thrombectomy + AVF, this procedure seems to improve the long-term outcome following acute iliofemoral venous thrombosis. Since the difference in outcome is not very striking, anticoagulation treatment is still an acceptable alternative.

Sclerotherapy or Surgery as Treatment for Varicose Veins: A Prospective Randomized Study:

Objective: To compare the long-term results following radical surgery or compression sclerotherapy (CST) of primary varicose veins. Design: Prospective, randomized study of 164 patients. The patients were assessed with clinical tests and foot volumetry, before the 6 months, 1, 3 and 5 years after treatment. Setting: Department of Surgery, University of Lund, Sweden. Patients: 164 patients referred to the clinic for treatment of symptomatic primary varicose veins. Eighty patients were randomized to surgery and 84 to CST. Interventions: Sclerotherapy was applied using the ‘empty vein’ technique followed by compression bandage for 6 weeks. The extent of surgery was determined by each patients disease and included flush ligation of the long or short saphenous veins and subsequent stripping, ligation of incompetent perforating veins and resection of local varicosities. Main outcome measures: The recurrence rate of varicose veins and incompetence of perforators and saphenous veins. Results: Good results were achieved in both treatment groups immediately after the procedure, but the failures appeared earlier in the CST group and the number was higher compared with the surgery group. After 5 years only 10% of the operated patients were considered as treatment failures compared with 74% of the patients treated with CST. The clinical results were supported by the foot volumetry measurements. Conclusions: This study clearly indicates that patients with primary varicose veins and incompetent saphenous veins should be treated with surgery, and CST should be confined to local varicosities, isolated insufficient perforators or recurrences after adequate surgery.

Femoral vein pressure measurements for evaluation of venous function in patients with postthrombotic iliac veins

Fifty patients with postthrombotic disease were examined by phlebography and by bilateral femoral vein pressure measurements. The degree of obstruction to venous flow was best evaluated by measuring the pressure elevation and pressure difference after exercise and the time required for these parameters to return to pre-exercise levels; pressures during rest and exercise were less conclusive indicators of obstruction. Good correspondence was found between femoral vein pressure and the severity of postthrombotic symptoms, while phlebography provided largely morphologic, rather than functional, information. We, therefore, consider it important to determine femoral vein pressure during and after exercise to evaluate the significance of postthrombotic iliac vein disease.

Vascular surgery in Southern Sweden—the first year experience of a vascular registry

A vascular registry was set up in southern Sweden covering all peripheral vascular procedures performed in a population of almost 2 million. During the first year 1569 procedures were registered including 30-day follow-up, making a frequency of 84 per 100,000 inhabitants with a considerable variation between counties, from 42 to 146 procedures per 100,000 inhabitants. The operations were performed by 127 different surgeons, but only nine surgeons performed more than 50 operations each. These surgeons participated in 52.6% of all procedures. The frequency of re-operation differed from 4.0 to 17.9% between hospitals. One month postoperatively 70% of the patients had returned home while 13.2% were still in hospital. Median length of stay was 8 days. Overall mortality was 7.9%. The outcome at 30 days for various procedures was comparable with that of other recent reports from specialised centres.

Ketanserin in intermittent claudication: effect on walking distance, blood pressure, and cardiovascular complications.

In a 7-center Scandinavian double-blind placebo-controlled study of 179 patients with intermittent claudication, the effect of the serotonin antagonist ketanserin was evaluated on walking distance, brachial and ankle blood pressure, and symptoms. For all centers together, pain-free walking distance was significantly in-creased after 6 months with both ketanserin (+ 65%; 71 patients) and placebo (+ 42%; 78 patients), with no significant difference. However, there was large variability among centers. Classification of “responders” (doubling of walking distance) and patients who deteriorated (decrease of walking distance or dropout for inefficacy) showed significantly more patients responding and significantly fewer patients deteriorating with ketanserin than with placebo. Systemic blood pressure was significantly decreased by ketanserin in hypertensive, but not normotensive, patients, while ankle pressure was unaffected. The incidence and nature of side effects were equal with ketanserin and placebo, but there were more side effects causing dropout in the ketanserin group. An unexpected and possibly important observation was the occurrence of six serious cardiovascular events (myocardial infarction, cerebrovascular complications, and development of rest pain) in the placebo group but none in ketanserintreated patients. Moreover, there were four additional similar complications in the placebo run-in period. Ketanserin appears to be beneficial in a subgroup of patients with intermittent claudication. A fortuitous finding of this study is that ketanserin might possess a protective effect against thrombovascular complications in patients with intermittent claudication.

Complications secondary to thrombectomy with the fogarty baloon catheter

Thrombectomy peformed with the Fogarty balloon catheter may, in a small percentage of cases, given rise to complications. In four cases reviewed, this procedure was associated with aneurysms or arteriovenous fistulae. Careful catheter manipulation and a judicious used of fluoroscopy or angiography during the procedure can reduce the number of such complications

High Tie with Sclerotherapy for Saphenous Vein Insufficiency

The long-term results after treatment of primary varicose veins with a combination of compression sclerotherapy (CST) and high tie of the incompetent long saphenous vein were studied. Sixty-three legs in 60 patients were operated on. Subjective (by the patient), objective (by the surgeon) and functional (by foot volumetry) assessments were performed just after treatment, 6 months and 1, 3 and 5 years later. The immediate subjective results were excellent but objectively 21% of the patients still had residual varicosities. After 5 years 50% were subjectively well but only 16% of the legs were objectively cured. Among the foot volumetric parameters the expelled volume (EV; ml) and refilling flow/relative expelled volume ratio (Q/EVrel; min−1) best reflected the functional state. Mean EV increase was 56% after treatment but only 16% after 5 years. Q/EVrel normalized initially but deteriorated after 1 year. No significant improvement in any parameter was observed after 5 years. CST combined with high tie cannot replace surgery in patients with main stem insufficiency. The results emphasize the importance in following these patients for at least 5 years. On the whole, functional evaluation with foot volumetry was valuable to assess groups but could not replace the examination of individual patients.

Functional evaluation of four different compression stockings in venous insufficiency

In this study the compression pressure on the leg from four different ‘compression stockings’ was evaluated. A simple device for the measurement was constructed and is described. The effect of the stockings on venous function was also studied by foot-volumetry. Each of the four types of stockings was evaluated in 22 patients, all with mild to moderate insufficiency of the superficial venous system in the leg. Venous emptying from the foot and leg was significantly increased with all four stockings but with no difference between the types. The pressure measurements performed below knee and over the soft tissue area behind the tibia did not reveal the expected graduated compression. The pressure behind the medial malleolus, i.e. the venous ulcer area, was lower with all four stockings than higher up in the leg, indicating insufficient compression in this area.

Surgical Treatment of Iliofemoral Venous Thrombosis

The objectives of treatment in iliofemoral venous thrombosis are to prevent fatal pulmonary embolism, further swelling of the leg with development of phlegmasia caerulea dolens and the severe post-thrombotic syndrome, by preservation of venous patency and normal valves. The experience of thrombectomy and temporary AVF are presented in 155 patients where technical details of management are emphasized. A new technique with percutaneous closure of the AVF after six weeks is described. No patient died due to fatal pulmonary embolism during or immediately after surgery. In a randomized study comparing surgery with conventional anticoagulant treatment follow-up venography of the iliofemoral segment demonstrated excellent results in 76% of the operated group and 36% in the conservatively treated group, while venography of the femoropopliteal segment revealed an occlusion in about one-third of the patients in both groups. Of the patients who had an open femoropopliteal segment it was noted that 52% in the surgical group and 26% in the conservative group had preserved valves with no reflux.