Gunnar Plate

Venous function assessed during a 5 year period after acute ilio-femoral venous thrombosis treated with anticoagulation

To determine the chronological changes of venous physiology following major thromboses, 20 patients were repeatedly examined for over 5 years after an acute ilio-femoral thrombosis which was treated with conventional anticoagulation. Radionuclide angiography showed that 70% of the patients had obstructive lesions of the iliac vein with only minor changes occurring from 6 months to 5 years. In spite of this, the plethysmographic maximum venous outflow increased from 31 to 45 ml/min/100 ml (P less than 0.001). The foot volumetric reflux did not change with time and about half of the patients had abnormal values. Venous reflux assessed by the refill time of foot vein pressure, deteriorated with time (P less than 0.05), and at 5 years all but one patient had a refill time less than 20 s. The muscle pump function, examined by foot volumetry, was abnormally low in about half of the patients throughout the study. The ambulatory foot vein pressure was constantly pathological (greater than 60 mmHg) in half of the patients and only two of 18 patients had normal values (less than 45 mmHg) at 5 years. Five patients with thromboses involving only the proximal veins had better physiological results than 15 patients with thromboses that extended to the peripheral veins. Three patients who developed venous claudication had iliac vein obstruction and an impaired venous outflow and three patients who developed venous ulcers had venous reflux and severe venous hypertension. Although venous outflow continuously improves following ilio-femoral thromboses, valvular competence and muscle pump function are constantly pathological, creating severe venous hypertension with a risk of post-thrombotic sequelae.

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.

Abdominal aortic aneurysm with perianeurysmal fibrosis: Experience from 11 Swedish vascular centers ☆ ☆☆

Case records of 2026 patients operated on because of abdominal aortic aneurysms from 11 Swedish Vascular Centers were reviewed and revealed 98 cases (4.8%) of inflammatory abdominal aortic aneurysm. Also included in this case-control study was an analysis of a randomized group of 82 patients from the same centers who had noninflammatory abdominal aortic aneurysms. Four inflammatory aneurysms were ruptured, compared with 16 in the noninflammatory group (p less than 0.01). A higher proportion of patients with inflammatory abdominal aortic aneurysms had symptoms that led to radiographic investigations. The median erythrocyte sedimentation rate was 39 mm versus 19 mm (26% of patients with inflammatory abdominal aortic aneurysms had erythrocyte sedimentation rates greater than 50 mm; p less than 0.001), and the serum creatinine level was increased in 27 and 8 patients (p less than 0.01) in the inflammatory and noninflammatory groups, respectively. Preoperative investigations revealed ureteral obstruction in 19 patients with inflammatory abdominal aortic aneurysms, of whom 12 had preoperative nephrostomy or ureteral catheter placement. At operation, 20 additional patients exhibited fibrosis around one or both ureters. Although ureterolysis was performed in 19 patients, preoperative and postoperative creatinine levels did not differ between these patients and the conservatively treated ones. Duration of surgery (215 vs 218 minutes), intraoperative blood loss (2085 vs 2400 ml) and complications did not differ significantly between the groups. Overall operative (30-day) mortality was equal (11% vs 12%) but was increased for patients undergoing elective surgery for inflammatory abdominal aortic aneurysms (9% vs 0%; p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Does the Correction of Insufficient Superficial and Perforating Veins Improve Venous Function in Patients with Deep Venous Insufficiency

Thirty limbs in 25 patients with chronic deep venous insufficiency and recurrent ulceration were examined by ascending and descending contrast phlebography, occlusion plethysmography, foot volumetry and ambulatory venous pressure. Superficial venous insufficiency was surgically corrected by stripping of the saphenous vein and local excision of the varicosities (op1) in 12 limbs. Perforating venous insufficiency was then corrected by extensive subfascial ligation of perforating veins (op2) in all limbs. Venous outflow capacity, measured by occlusion plethysmography, and muscle pump function, measured by foot volumetry, were not affected by either procedure. Venous reflux, measured by foot volumetry, (Q/EVrel) and by venous pressure return time (RT90) improved significantly with op1 but no change was seen after op2. Venous hypertension decreased significantly with op1 but did not change after op2, and 59% of the limbs still had severe venous hypertension (> 60 mmHg) after both procedures. Initial clinical results were good, ulcers persisting in only three limbs, but recurrences occurred in an additional six limbs within 27 months. The limbs with persistent or recurrent ulcers had severe phlebographic reflux and severe venous hypertension. These results demonstrate that improvement in venous reflux and hypertension may be achieved by correction of superficial venous insufficiency, but the addition of ligation of perforating veins seems to be of less benefit to the venous circulation.

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.

Physiologic and therapeutic aspects in congenital vein valve aplasia of the lower limb.

Ten patients with congenital vein valve aplasia verified at contrast phlebography were evaluated clinically and by physiologic examinations. All had orthostatic edema and varicose veins, but leg ulcers and other “postphlebitic” sequelae were infrequent. Foot volumetry and measurement of ambulatory foot vein pressures revealed a severe deep venous incompetence with a defective muscle pump function and considerable reflux. Eight limbs were operated on with conventional varicose vein surgery and physiologically re-examined six to 26 weeks after the operation. All had an improved ambulatory pressure reduction (p > 0.001). Foot volumetry revealed better muscle pump function (p > 0.01), while the reflux flow was unchanged. Surgery of the incompetent superficial venous system is therefore recommended in cases with deep venous insufficiency due to congenital vein valve aplasia.

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.

Is Abnormal Coagulation or Defective Fibrinolysis of Aetiological Importance in the Development of Deep Venous Thrombosis

The present investigation was performed to study the aetiological importance of abnormal coagulation or defective fibrinolysis in the development of deep venous thrombosis (DVT). Sixty-nine patients with acute iliofemoral venous thrombosis were subjected to evaluation of coagulation and fibrinolytic parameters. Defective fibrinolysis, usually with an increased activity of the rapid tissue plasminogen inhibitor, was detected in 31 patients (45%), and increased factor VIII with normal fibrinogen was recorded in 10 patients (14%). Two patients had a hereditary deficiency of plasminogen and protein C, respectively, and a lupus anticoagulant was demonstrated in another patient. Antithrombin III deficiency was not detected in any patient. Abnormal findings were most frequently recorded in patients with ‘idiopathic’ DVT. Although the exact relationship between the development of DVT and the recorded abnormalities could not be determined in all instances, it is obvious that defective vessel wall fibrinolysis and increased factor VIII are frequently recorded in patients with extensive DVT of the lower limb. Pathological alternations of antithrombin III, plasminogen and protein C seem to be less common.