Fedor Lurie

Multicenter assessment of venous reflux by duplex ultrasound

OBJECTIVE This prospective multicenter investigation was conducted to define the repeatability of duplex-based identification of venous reflux and the relative effect of key parameters on the reproducibility of the test. METHODS Repeatability was studied by having the same technologist perform duplicate tests, at the same time of the day, using the same reflux-provoking maneuver and with the patient in the same position. Reproducibility was examined by having two different technologists perform the test at the same time of the day, using the same reflux-provoking maneuver and with the patient in the same position. Facilitated reproducibility was studied by having two different technologists examine the same patients immediately after an educational intervention. Limits of agreement between two duplex scans were studied by changing three elements of the test: time of the day (morning vs afternoon), patients position (standing vs supine), and reflux initiation (manual vs automatic compression-decompression). RESULTS The study enrolled 17 healthy volunteers and 57 patients with primary chronic venous disease. Repeatability of reflux time measurements in deep veins did not significantly differ with the time of day, the patients position, or the reflux-provoking maneuver. Reflux measurements in the superficial veins were more repeatable (P < .05) when performed in the morning with the patient standing. The agreement between the clinical interpretations significantly depended on a selected cut point (Spearmans ρ, -0.4; P < .01). Interpretations agreed in 93.4% of the replicated measurements when a 0.5-second cut point was selected. The training intervention improved the frequency of agreement to 94.4% (κ = 0.9). Alternations of the time of the duplex scan, the patients position, and the reflux-provoking maneuver significantly decreased reliability. CONCLUSIONS This study provides evidence to develop a new standard for duplex ultrasound detection of venous reflux. Reports should include information on the time of the test, the patients position, and the provoking maneuver used. Adopting a uniform cut point of 0.5 second for pathologic reflux can significantly improve the reliability of reflux detection. Implementation of a standard protocol should elevate the minimal standard for agreement between repeated tests from the current 70% to at least 80% and with more rigid standardization, to 90%.

The availability of circulating blood volume values alters fluid management in critically ill surgical patients

BACKGROUND This study evaluated whether commercially available blood volume measurements in critically ill surgical patients altered fluid management. METHODS Patients admitted to the surgical intensive care unit of a tertiary care teaching hospital were prospectively evaluated. The frequency of changes in fluid management when results of blood volume measurements were available was determined. RESULTS In a pilot study, the frequency of instances when measurement of blood volume would have altered fluid management was statistically significant (P = .0003). In 40 subsequent patients, treatment change occurred in 36% of instances when blood volume results were obtained (P < .001). In the majority, no immediate qualitative change in clinical status occurred, with a desirable clinical response in 39% and no negative treatment responses (P < .001). CONCLUSIONS Blood volume measurements may assist in the management of critically ill surgical patients by providing a direct measure of intravascular volume. Further studies are warranted to determine its effect on outcome.

Valvuloplasty in Primary Venous Insufficiency: Development, Performance, and Long-Term Results

Publisher Summary This chapter reviews the background upon which the first repair was based, and highlights what has evolved in the field of studying the clinical effects of deep vein thrombosis (DVT) in the 37 years since the first repair. Surgical repair of deep vein valves for primary disease has been widely evaluated and found to have reproducible favorable results without recurrence in 65 to 80% of cases successfully operated upon with internal repair. The repair can be performed in many different ways with the best long-term results achieved by open surgery, but with higher risk of complications after the open techniques than after the external techniques. Its use can be recommended in resistant chronic venous disease (CVD) cases in which a repairable valve is identified. In addition to pure primary disease, repairable valves can be found in the high thigh veins in a number of cases with distal deep vein thrombophlebitis when the more proximal valve(s) has been spared inflammatory involvement.

Ultrasound-Guided Sclerotherapy (USGS) of Perforating Veins in Chronic Venous Insufficiency

Publisher Summary This chapter presents the review of a nonsurgical treatment option for incompetent perforating veins, ultrasound-guided sclerotherapy, which combines the precision of surgical approach with minimal invasiveness of an injection. Recent development of new treatment options for reflux in the superficial venous system have established a new standard where patients can be treated in the office without a need for general anesthesia, can ambulate immediately after treatment, have insignificant postoperative pain, and have almost no negative impact on quality of life immediately after treatment. When venous stripping was the only choice for patients with saphenous insufficiency, surgical interruption of perforating veins, either by subfascial endoscopic surgery (SEPS) or through small incisions, was considered minimally invasive. In a new clinical environment, invasiveness and wound complication risk of these surgical techniques exceeds that of the treatment of saphenous veins. Achieving this goal theoretically should convert the patient into being asymptomatic, eliminate or reverse existing signs, and prevent progression to more advanced stages of venous disease. Practical challenges that face the surgeon who will treat a patient with chronic venous disease include selection of which vein to treat and which technique to employ.