Paul R. Cordts

Pelvic congestion syndrome : early clinical results after transcatheter ovarian vein embolization

PURPOSE This case series describes the early radiographic and clinical results of attempted transcatheter ovarian vein (OV) embolization in 11 women with symptoms that were suggestive of the pelvic congestion syndrome (PCS). METHODS Eleven women (mean age, 33.1 years) who were multiparous were referred for lower extremity or vulvar varicosities (n = 8) or for tubo-ovarian varicosities (n = 3). After a clinical diagnosis of PCS was established, the women underwent ovarian (n = 5) or ovarian and iliac vein (n = 6) venography. Enlarged or incompetent OVs were embolized with 0.035-inch stainless steel coils or with 0.018-inch platinum microcoils and absorbable gelatin sponge. Incompetent tributaries to hypogastric veins were embolized as well (n = 1). Symptoms before embolization and after embolization were recorded with a standard questionnaire, and the post-embolization symptoms were expressed as individual and overall percent relief. RESULTS Nine of the 11 women underwent embolization. Embolization of both OVs (n = 4), of the left OV alone (n = 4), or of a left obturator vein that communicated with vulvar varices (n = 1) was performed. Eight of the 9 women (88.9%) had more than 80% immediate relief. Overall and individual symptom relief varied from 40% to 100% at the mean 13.4-month follow-up. One woman with variant anatomy and one woman with evidence of prior left OV thrombosis were not treated. There were no major complications. Two women had a mild to moderate return of the symptoms at 6 and 22 months. CONCLUSIONS Transcatheter embolization provides excellent initial and variable midterm relief in women with typical PCS symptoms and with OV or OV and internal iliac (hypogastric) tributary vein incompetence. This interventional technique may replace or complement the traditional surgical approaches to this rarely recognized and poorly understood disease.

Vascular applications of telepresence surgery: Initial feasibility studies in swine

PURPOSE Telepresence surgery is a novel technology that will allow procedures to be performed on a patient at locations that are physically remote from the operating surgeon. This new method provides the sensory illusion that the surgeons hands are in direct contact with the patient. We studied the feasibility of the use of telepresence surgery to perform basic operations in vascular surgery, including tissue dissection, vessel manipulation, and suturing. METHODS A prototype telepresence surgery system with bimanual force-reflective manipulators, interchangeable surgical instruments, and stereoscopic video input was used. Arteriotomies created ex vivo in segments of bovine aortae or in vivo in femoral arteries of anesthetized swine were closed with telepresence surgery or by conventional techniques. Time required, technical quality (patency, integrity of suture line), and subjective difficulty were compared for the two methods. RESULTS All attempted procedures were successfully completed with telepresence surgery. Arteriotomy closures were completed in 192+/-24 sec with conventional techniques and 483+/-118 sec with telepresence surgery, but the precision attained with telepresence surgery was equal to that of conventional techniques. Telepresence surgery was described as intuitive and natural by the surgeons who used the system. CONCLUSIONS Blood-vessel manipulation and suturing with telepresence surgery are feasible. Further instrument development (to increase degrees of freedom) is required to achieve operating times comparable to conventional open surgery, but the system has great potential to extend the expertise of vascular surgeons to locations where specialty care is currently unavailable.

A prospective, randomized trial of Unna's boot versus Duoderm CGF hydroactive dressing plus compression in the management of venous leg ulcers

Leg ulcers caused by chronic venous insufficiency plague an estimated 500,000 Americans, but there have been few improvements in conservative treatment in this century, and Unnas boot continues to be a mainstay of therapy. A recent report suggests that Duoderm CGF dressing provides greater patient comfort and enhanced compliance, but Duoderm alone (without compression) resulted in slower healing compared with Unnas boot. We enrolled 30 patients (30 ulcers) in a clinical trial to compare Duoderm CGF plus compression (Coban wrap) to Unnas boot. No significant difference was observed between the two groups with respect to age, sex, initial ulcer area, ulcer duration, or extent of venous insufficiency by duplex scan. Eight of 16 ulcers (50%) in the Duoderm group healed completely versus 6 of 14 ulcers (43%) in the Unnas boot group (p = 0.18). Healing rates (square centimeters per week) correlated significantly with initial ulcer area and initial ulcer perimeter for both groups but best correlated with initial ulcer perimeter (r = 0.88 with Duoderm, p less than 0.0001; r = 0.80 with Unnas boot, p less than 0.002). After adjusting for differences in initial ulcer perimeter, healing rates were significantly faster for patients on Duoderm than patients on Unnas boot during the first 4 weeks of therapy (0.384 +/- 0.059 cm2/wk/cm perimeter for Duoderm versus 0.135 +/- 0.043 cm2/wk/cm perimeter for Unnas boot; p = 0.002). At 12 weeks patients on Duoderm again appeared to heal faster than those on Unnas boot, although the result did not reach statistical significance (0.049 +/- 0.007 cm2/wk/cm perimeter for Duoderm versus 0.020 +/- 0.017 for Unnas boot, p = 0.11).(ABSTRACT TRUNCATED AT 250 WORDS)

The role of air plethysmography in monitoring results of venous surgery

The development of an objective, noninvasive method to assess the hemodynamic effects of venous surgery has long been awaited. Previous methods used to evaluate the results of surgery for varicose veins and venous stasis ulceration have been limited in their quantitative assessment. Now, by use of air plethysmography (APG), we can accurately quantify the effectiveness of corrective venous surgery. Twenty-five extremities that had evidence of venous insufficiency were examined with use of APG before and after venous surgical procedures. Surgery was directed at specific sites of venous incompetence as defined by physical examination and high-resolution duplex imaging. Twenty-one extremities underwent ligation and stripping of the greater saphenous vein. In these patients, APG showed an improvement in venous reflux as demonstrated by a decrease in the venous filling index from 6.6 +/- 0.7 ml/sec to 1.8 +/- 0.3 ml/sec (p = 0.0001) and venous volume from 177.1 +/- 14.5 ml to 139.2 +/- 8.9 ml (p = 0.0008). In addition, these patients showed a mild improvement in calf muscle pump function as noted by an improvement in ejection fraction from 45.8 +/- 2.0% to 50.8% +/- 2.5% (p = 0.07). The residual volume fraction decreased from 45.0% +/- 3.4% to 42.0% +/- 3.7%, a difference that was not statistically significant (p = 0.4). Four extremities with grade III chronic venous insufficiency underwent popliteal vein valve transplantation with use of an autogenous axillary vein valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Anatomic and physiologic changes in lower extremity venous hemodynamics associated with pregnancy

PURPOSE The purpose of this study was to describe the physiologic effects of pregnancy on lower extremity venous hemodynamics. METHODS Eight pregnant women, six with no known venous disease (NVD) and two with documented deep venous obstruction (DVO), were identified in the first trimester (TM) and studied monthly until delivery and once postpartum (pp) by air plethysmography and duplex scan. RESULTS None of six women in the NVD group (12 extremities) had obstruction or elevated ambulatory venous pressures as estimated by air plethysmography. In addition, despite significant increases in common femoral vein and saphenofemoral junction diameters, no woman in the NVD group had reflux by either test. Venous filling index increased significantly during pregnancy and decreased significantly pp, but all values remained within the normal range (0.55 +/- 0.2 ml/sec first TM, 1.01 +/- 0.38 ml/sec late third TM, 0.58 +/- 0.08 ml/sec pp; p < 0.03 both comparisons). Common femoral vein diameters increased and decreased in similar fashion (0.99 +/- 0.25 cm first TM, 1.21 +/- 0.25 cm late third TM, 0.80 +/- 0.11 cm pp; p < 0.0005 first vs late third TM, p < 0.005 late third TM vs pp). Saphenofemoral junction vein diameters similarly increased and decreased in size (0.46 +/- 0.07 cm first TM, 0.68 +/- 0.19 cm late third TM, 0.50 +/- 0.10 cm pp; p < 0.01 first vs late third TM, p < 0.03 late third TM vs pp). Neither of the two women in the DVO group showed deterioration of outflow fraction or venous filling index as pregnancy progressed, and neither had thromboembolic complications despite moderate to severe preexisting obstruction. Both women in the DVO group delivered uneventfully. No woman in either group developed varicose veins. CONCLUSIONS Pregnancy-induced changes in lower extremity venous hemodynamics in the NVD and DVO groups were detected but were small. Hormonal or other systemic factors must play a significant role in the development of postpartum varicose veins.

Do infected inguinal lymph nodes increase the incidence of postoperative groin wound infection

PURPOSE Risk factors for postoperative wound infection in patients undergoing vascular surgery may include age, comorbid conditions, wound classification, use of prosthetic grafts, and repeat operations. Groin incisions, in particular, pose substantial risk during placement of prosthetic grafts. METHODS To investigate the role of infected inguinal lymph nodes (LN) in groin wound infection (GWI), we excised an inguinal LN from 69 consecutive patients (89 groins) undergoing 36 infrainguinal reconstructions, 24 aortobifemoral bypasses, 12 extra-anatomic femoral bypasses, 11 vein stripping, and 6 femoral pseudoaneurysm repairs. LN Gram staining was performed, and aerobic and anaerobic cultures were obtained. In addition cultures were taken from any ulcerated or gangrenous lesion on the ipsilateral open extremity lesion. RESULTS Bacteria were isolated from 10 of 89 LN (11.2%) and included Staphylococcus species, gram-negative rods, diphtheroids, and Peptostreptococcus. Three of the 10 LN were taken from extremities with open lesions; seven were not. In no case did organisms cultured from a groin LN correlate with its corresponding open extremity lesion. Four GWI developed after operation (4%). In each case results of the groin LN cultures were negative. Three of the GWI were associated with an ulcerated or gangrenous lesion on the ipsilateral extremity (p = 0.08, odds ratio = 7.6), but in only one case did the organisms from the GWI correspond to that in the open lesion. The development of a GWI was strongly associated with insulin-dependent diabetes mellitus (p = 0.009, odds ratio = 22.9). CONCLUSION In conclusion, 11% of groin LN harbored bacteria, but none of these were associated with subsequent development of a wound infection. Instead, insulin-dependent diabetes mellitus and the presence of an open skin lesion on the ipsilateral extremity seemed to be associated with an increased risk of wound infection.

Physiologic similarities between extremities withvaricose veins and with chronic venous insufficiency utilizing air plethysmography

Air plethysmography (APG) was used to measure maximal venous outflow rate (MVO), a test for proximal venous obstruction; venous volume; venous filling index, an estimate of valvular incompetence; ejection fraction (EF), a test of calf-muscle pump efficiency; and residual volume fraction (RVF), an estimate of ambulatory venous pressure. MVO was lower in patients with chronic venous insufficiency (CVI) than in those with varicose veins (VV), but the difference was small (p = 0.06). RVF was significantly greater in extremities with CVI when compared with those with VV (p less than 0.01). However, the degree of abnormality in venous volume, venous filling index, and EF was similar in CVI and VV extremities. In summary, although RVF tends to be higher in extremities with CVI when compared with those with VV, there is tremendous overlap between VV and CVI for each of the hemodynamic variables measured by APG. Therefore, the pathophysiology of CVI is likely to involve not only hemodynamic abnormalities but also other factors that have not yet been clearly identified.

Mycotic renal artery degeneration and systemic sepsis caused by infected renal artery stent

Abstract A case of Staphylococcus aureus renal artery stent infection was studied. Fourteen days after the procedure, the patient had a fever, hypotension, and an elevated white blood cell (WBC) count. Blood cultures were positive for S aureus on admission and during the patients hospitalization, despite intravenous vancomycin therapy. Evaluation included serial CT scans, revealing increasing persistent inflammation with development of multiple renal intraparenchymal abscesses, and arteriography, showing marked degeneration of the renal artery. Therapy required resection of the renal artery/stent and nephrectomy. This case confirms the severe nature of S aureus stent infection; we recommend prophylactic antibiotics before these procedures, as well as expeditious evaluation and consideration for aggressive surgical therapy if this complication is suspected. (J Vasc Surg 1998;28:547-50.)

Can air plethysmography accurately identify upper extremity deep venous thrombosis

PURPOSE Air plethysmography (APG) is an established, noninvasive means of evaluating lower extremity venous outflow. METHODS To determine whether APG could identify deep venous thrombosis (DVT) of the upper extremity, we measured the percentage of venous outflow in the first second (maximum venous outflow [MVO]) of four groups of arms: (1) normal volunteers (no previous central vein catheters), (2) the affected, (3) the unaffected arms of the patients with DVT (proven by venography or duplex scanning), and (4) hospital patients (no previous central vein catheters). RESULTS The results of an analysis of variance were as follows: the mean MVO (%) of the affected arms of patients with DVT, 29.4 +/- 2.6, was significantly less than their unaffected arms, 55.3 +/- 3.9, hospital controls, 64.3 +/- 2.2, and normal volunteers, 64.2 +/- 0.9 (p < 0.05). In addition, the unaffected arms differed significantly from all groups (p < 0.05). An MVO of 45% was 2 SD below the mean MVO of the normal volunteer group. Two unaffected arms of the patients with DVT were below 45%, whereas only one affected arm of the patients with DVT was above 45% (45.6%). Therefore a comparison of the distribution of the MVO values revealed virtually no overlap of the affected arms of the patients with DVT with the other three groups. CONCLUSIONS We conclude that APG clearly discriminated arms with documented DVT from controls and is a highly accurate means of identifying upper extremity DVT.

Questionnaire for Trial Submission

Please return the completed questionnaire as soon as possible to the Section Editor: Susan Galandiuk, MD Department of Surgery School of Medicine University of Louisville Louisville, KY 40292, USA Tel.: +1 502 852 5442 Fax: +1 502 852 8915 or contact: S. Karger AG Attn.: Ms. Yvonne Rebmann Allschwilerstrasse 10 PO Box CH–4009 Basel Tel.: +41 61 306 13 51 Fax: +41 61 306 12 34 E-Mail: y.rebmann@karger.ch ABC K I 99 69 3