Kazutaka Soejima

Prospective randomized efficacy of ultrasound-guided foam sclerotherapy compared with ultrasound-guided liquid sclerotherapy in the treatment of symptomatic venous malformations

OBJECTIVE To compare the clinical outcome between ultrasound-guided foam sclerotherapy (UGFS) and ultrasound-guided liquid form sclerotherapy (UGLS) in patients with venous malformations (VM). METHODS Eighty-nine patients with symptomatic VM were treated with ultrasound-guided sclerotherapy. There were 22 males and 67 females with mean age of 14.5 years. The sclerosing agents used were 1% polidocanol (POL) or 10% ethanolamine oleate (EO). POL was injected predominantly into smaller, superficial lesions, whereas EO was used for large, deeper lesions. Foam sclerosing solution was provided using Tessaris method. Patients were randomized to receive either UGFS or UGLS. Post-sclerotherapy surveillance was done at 6 months after last session using duplex ultrasound. Findings obtained by duplex scanning were divided into four groups: (1) disappeared group: the venous space was occluded and was totally shrunk; (2) partially recanalized group: the venous space was partially recanalized and was partially shrunk; (3) totally recanalized group: the venous space was totally recanalized and returned at the same size; and (4) worsened group: the venous space was totally recanalized and became worse. RESULTS Forty-nine patients were treated with UGFS and the remaining 40 were treated with UGLS. There were no significant differences in age and men:women ratio. There was no significant difference in the anatomic distribution of VMs between the two groups. The amount of POL was significantly smaller in patients who were treated with UGFS (P = .022). Similarly, there was a significant reduction in the use of EO in patients treated with UGFS (P = .005). The proportion of VM with total disappearance and partial recanalization was significantly higher in patients treated with UGFS (P = .002). No major complications related to sclerotherapy were encountered in both groups. CONCLUSIONS These findings suggest that UGFS could have greater promise compared with UGLS in the treatment of VMs.

Multiple Small-Dose Injections Can Reduce the Passage of Sclerosant Foam into Deep Veins During Foam Sclerotherapy for Varicose Veins

OBJECTIVE To compare the proportion of foam sclerosant that enters deep veins between multiple injections of <0.5 ml foam per injection and a few injections of >0.5 ml foam per injection. DESIGN & METHODS One hundred and seven patients with superficial venous incompetence were randomised to receive either multiple injections of <0.5 ml 1% polidocanol (POL) -foam (multiple injections) or a few injections of >0.5 ml 1% POL-foam per injection (few injections) for the treatment of varicose tributaries. All patients then received ultrasound-guided foam sclerotherapy for refluxing great saphenous vein (GSV) using 3% POL-foam. Only a single session was allowed per patient in order to standardise treatment. Qualitative ultrasonographic inspection of the foam was carried out during a 5-min period before compression was applied. Post-sclerotherapy surveillance was done at day 3, 2 weeks, 1 month, 3 months, and 6 months. RESULTS Fifty-six limbs in 53 patients were treated with multiple injections and the remaining 56 limbs in 54 patients were treated with a few injections. There were no significant differences in age or male:female ratio between the groups. The mean volume of 1% POL-foam was 2.2 S.D. 0.6 ml (range: 0.7-4.0 ml) in the multiple injections group and 2.5 S.D. 0.6 ml (range: 1.0-4.0 ml) in the few injections group (p=0.003). The mean volume of 3% POL was 1.5 ml (range: 0.7-3.0 ml) and 1.4 ml (range: 0.7-3.0 ml), respectively (p=0.137). Ultrasonographic inspection immediately after sclerotherapy demonstrated that foam was distributed significantly more commonly in the deep veins of patients treated with a few injections (p=0.0003). Two (4%) of the patients treated with a few injections developed migraine during the procedure, but recovered quickly with no further complications. There was no significant difference in the success rate between the groups at 6 months (p=0.257). CONCLUSIONS These findings suggest that multiple small-dose injections can reduce the amount of foam sclerosant and the risk of foam sclerosant entering the deep veins in patients with superficial venous insufficiency.

Reconstruction of burn deformity using artificial dermis combined with thin split-skin grafting

Twelve patients with post-burn contracture were treated using artificial dermis combined with thin split-skin grafting during the period January 1994 to April 1996. Bilayer artificial dermis was grafted onto full thickness open wounds of the skin, after excision of scar contracture tissue. About 3 weeks later, the silicone layer was removed and thin split-skin, 8/1000 in. thick, was grafted onto the newly synthesized dermis-like tissue in the wound bed. Scalp was chosen as the donor site in 11 of the 12 cases. Artificial dermis grafting was undertaken to ensure that morbidity at the donor site could be reduced as much as possible in the treatment of burn deformity. The skin grafts took completely in all cases. Postoperative management was performed in accordance with conventional skin grafting. Postoperative contraction or hypertrophic scar was observed in three cases, but a soft, favorable quality was obtained in the other nine cases. Treatment of burn deformity with artificial dermis may be beneficial in selected cases.

Presence of lower limb deep vein thrombosis and prognosis in patients with symptomatic pulmonary embolism: preliminary report.

OBJECTIVES To investigate the presence of lower limb deep vein thrombosis (DVT) and prognosis in patients with symptomatic pulmonary embolism (PE). MATERIALS AND METHODS A total of 203 consecutive referral patients with PE were included. The distribution of DVT was evaluated with compression ultrasound (CUS), and all patients were then followed for 12 months for investigation of recurrence of venous thromboembolism (VTE) and fatal events as adverse outcome. RESULTS The mean age of the patients was 62.8 years, and 78 (38.4%) were males. DVT was found in 118 (58.1%) patients. Of these patients, 61 (30.0%) had proximal DVT. Multivariate analysis demonstrated that active cancer, inadequate anticoagulation, leg symptoms, male gender, presence of DVT, presence of proximal DVT, and previous DVT were independent risk factors for adverse outcome. A clinical risk score ranging from 0 to 10 points was generated on the basis of multivariate regression coefficients. Receiver operating characteristic curve analysis showed that an appropriate cut-off point for discriminating between the presence and the absence of an adverse event was 4. Using this category, 166 (81.8%) patients were classified as low risk and 37 (18.2%) as high risk for adverse outcome. The adverse event rates were 6.0% for the low-risk group and 59.5% for the high-risk group. CONCLUSIONS This study has confirmed the clinical significance of surveillance CUS in patients with a first episode of PE. Furthermore, a simple risk score on the basis of available variables can identify patients at risk of an adverse outcome in patients with PE.

High peak reflux velocity in the proximal deep veins is a strong predictor of advanced post-thrombotic sequelae.

Summary.  Background: The presence of reflux in the femoral vein (FV) and popliteal vein (POPV) after acute deep vein thrombosis (DVT) is considered to contribute to the development of advanced post‐thrombotic syndrome (PTS). However, a quantification of reflux has yet to be determined. The purpose of study was to determine the indicative parameters reflecting the progression of PTS. Methods: Venous abnormalities were evaluated in 131 limbs out of 130 patients who completed a six‐year follow‐up after an acute DVT. Clinical manifestations were categorized according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification, and the patients were divided into two groups at a six‐year follow‐up point: group I, C0–3Es,As,d,p,Pr,o, early chronic venous insufficiency (CVI); group II, C4–6Es,As,d,p,Pr,o, advanced CVI. Venous segments were examined whether they were occluded or recanalized. The reflux parameters assessed were the diameter (cm), the reflux time (RT; s), the peak reflux velocity (PRV; cm s−1), and total refluxed volume, and these parameters were assessed especially in the FV and POPV at the two‐year (early phase) and subsequent six‐year (late phase) follow‐up points after DVT. Results: There were 98 limbs in group I and 33 in group II. The frequency of venous reflux was significantly higher in group II (<0.0001). In contrast, the proportion of occlusion did not differ between the groups (P = 0.138). The proportions of FV and POPV incompetence were significantly higher in group II (P < 0.0001 and P < 0.0001, respectively). In these veins, the RT did not improve the discrimination power between the two groups. In contrast, the PRV had significant discrimination power in these veins at both the two‐ and six‐year follow‐up points. In the superficial venous system, there were no significant differences in any of the determined parameters between the groups. In group II, 19 patients (58%), who had early symptoms of CVI at the two‐year follow‐up point, subsequently developed advanced symptoms of PTS. After calculating a suitable cutoff point using receiver operating characteristic curves analysis at the two‐year follow‐up point, multivariable analysis showed that a PRV of >25.4 cm s−1 in the POPV was the strongest independent predictor of advanced CVI [odds ratio (OR) 60.32; 95% confidence interval (95CI) 43.1–1238.97, P < 0.0001]. Similarly, in the FV, a PRV of >24.5 cm s−1 was found to be a strong predictor of advanced CVI (OR 25.77, 95CI 10.56–331.12, P < 0.0001). Conclusions: These findings suggest that the presence of a high PRV in the proximal deep veins is an independent predictor of advanced symptoms of PTS.

Effect of cultured endothelial cells on angiogenesis in vivo.

&NA; The purpose of this study is to evaluate the effect of cultured endothelial cells on angiogenesis in vivo. Endothelial cells obtained from thoracic aorta of male Wistar rats were cultured in thermoresponsive dishes, which are tissue culture polystyrene dishes bound with thermoresponsive poly (N‐isopropylacrylamide). Using the thermoresponsive dishes, a confluent layer of endothelial cells can be detached as an intact sheet by low temperature treatment. The obtained sheets of cultured endothelial cells were grafted to 3 X 3 cm full‐thickness skin defects that had been made on the backs of rats in combination with either free skin grafts or artificial dermis grafts. Histologic examinations were performed. The findings showed that, with each of the grafting procedures, the number of vessels in a unit area (1.0 X 10‐4 mm2) was significantly larger in the group with transplantation of cultured endothelial cells. This result suggests that the cultured vascular endothelial cells exert an angiogenic effect at the graft site. (Plast. Reconstr. Surg. 101: 1552, 1998.)

Comparison study of intense pulsed light versus a long-pulse pulsed dye laser in the treatment of facial skin rejuvenation.

Currently, various nonablative skin resurfacing techniques are being used to rejuvenate facial skin, including lasers and intense pulsed light (IPL). There are few direct comparison studies between IPLs and lasers. The objective of our study is to compare the effectiveness of intense pulsed light versus a long-pulse pulsed dye laser (LPDL) in the treatment of facial skin rejuvenation. Ten Asian patients with Fitzpatrick skin types III–IV were enrolled in this study. One half of the face was treated with IPL (6 treatment sessions) and the other side was treated by LPDL (3 treatment sessions). An LPDL with a wavelength of 595 nm and spot size of 7 mm was used. Utilizing the compression method, lentigines were treated using a PDL with a fluence between 9–12 J/cm2 and a pulse duration of 1.5 ms. Wrinkles were treated with fluences between 10 to 12 J/cm2 and a pulse duration of 20 ms, using a pulse-stacking technique. An IPL with a type B handpiece was used. Lentigines and wrinkles were treated with fluences between 27 to 40 J/cm2 and a pulse duration of 20 ms. The improvement of lentigines was 62.3% and 81.1% for IPL and LPDL respectively. There was no significant difference between IPL and LPDL in wrinkle reduction. There was no scarring or pigmentary change seen with either device. Both IPL and LPDL are effective for facial skin rejuvenation in Asians, but LPDL treatment is significantly better than IPL treatment in the treatment of lentigines. The use of the compression technique may allow this LPDL to be used effectively for facial rejuvenation and with fewer treatment sessions, when compared with the IPL.

Treatment of giant pigmented nevus using artificial dermis and a secondary skin graft from the scalp

From January 1994 to October 1995, 5 patients with congenital giant pigmented nevi were treated using artificial dermis with a secondary skin graft from the scalp. The nevus was excised in full thickness and the open wound was grafted with artificial dermis. About 3 weeks later, thin split-thickness skin grafting on the newly synthesized, dermislike tissue was required. We chose the scalp as the donor of the secondary skin graft. Epithelialization of each donor site was completed within 1 week. In addition, the donor site was not complicated with alopecia or hypertrophic scars. Morbidity at the donor site was minimized and favorable tissue quality of the grafted skin was obtained. The clinical results revealed that the scalp was a favorable donor of a secondary skin graft for the treatment of giant pigmented nevus with artificial dermis.

Combined use of pretest clinical probability score and latex agglutination D-dimer testing for excluding acute deep vein thrombosis.

OBJECTIVE Currently, the latex agglutination D-dimer assay is widely used for excluding deep vein thrombosis (DVT) but is considered less sensitive than the enzyme-linked immunosorbent assay-based D-dimer test. The purpose of the present study was to determine if a combination of different cutoff points, rather than a single cutoff point of 1.0 microg/mL, on the latex agglutination D-dimer assay and the pretest clinical probability (PTP) score would be able to reduce the use of venous duplex ultrasound (DU) scanning in patients with suspected DVT. METHODS The PTP score and D-dimer testing were used to evaluate 989 consecutive patients with suspected DVT before venous DU scanning. After calculating the clinical probability scores, patients were divided into low-risk (< or =0 points), moderate-risk (1-2 points), and high-risk (> or =3 points) pretest clinical probability groups. Receiver operating characteristic (ROC) curve analysis was used to determine the appropriate D-dimer cutoff point for each PTP with a negative predictive value of >98% for a positive DU scan. RESULTS There were 886 patients enrolled. The study group included 609 inpatients (68.7%) and 277 outpatients (31.3%). The prevalence of DVT in this series was 28.9%. There were 508 patients (57.3%) classified as low-risk, 237 (26.8%) as moderate-risk, and 141 (14.9%) as high-risk PTP. DVT was identified in 29 patients (5.7%) with low-risk, 118 (49.8%) with moderate-risk, and 109 (77.3%) with high-risk PTP scores. ROC curve analysis was used to select D-dimer cutoff points of 2.6, 1.1, and 1.1 microg/mL for the low-, moderate- and high-risk PTP groups, respectively. In the low-risk PTP group, specificity increased from 48.9% to 78.2% (P < .0001) with use of the different D-dimer cutoff value. In the moderate- and high-risk PTP groups, however, the different D-dimer levels did not achieve substantial improvement. Despite this, the overall use of venous DU scanning could have been reduced by 43.0% (381 of 886) if the different D-dimer cutoff points had been used. CONCLUSIONS Combination of a specific D-dimer level with the clinical probability score is most effective in low-risk PTP patients for excluding DVT. In moderate- and high-risk PTP patients, however, the recommended cutoff points of 1.0 microg/mL may be preferable. These results show that different D-dimer levels for patients differing in risk is feasible for excluding DVT using the latex agglutination D-dimer assay.

Monitoring the changes in intraparenchymatous venous pressure to ascertain flap viability.

Background: Disruption of venous outflow can lead to tissue necrosis. Thrombosis of a venous channel at the coaptation site in instances of free tissue transfer could cause death of the transplanted tissues. Although various techniques have been used to monitor the viability of transferred tissues, there has been no technique designed specifically to check the flow within and the patency of the venous channel. The authors have devised an approach with which to monitor the changes in venous pressure in a composite tissue transferred by means of microsurgical technique for bodily reconstruction. Methods: The status of the venous system in various composite tissue grafts was monitored at the time of surgery or for 3 days after the completion of surgery by placing a small-caliber catheter in the vein within the transferred tissue. A total of 52 patients participated in the study. Results: The venous pressure noted in grafts with a patent venous channel remained constant within a range between 0 and 35 mmHg. Venous insufficiency was detected in three of the 52 cases, with unmistakable findings of an elevated venous pressure of over 50 mmHg. Conclusions: The technique of measuring the venous pressure by means of an indwelling venous catheter to monitor changes was found to accurately assess the patency of the venous channel and, by inference, the viability of the transferred tissue. No morbidity was associated with the technique.