Robert R. Mendes

Treatment of superficial and perforator venous incompetence without deep venous insufficiency: is routine perforator ligation necessary?

PURPOSE We investigated whether routine ligation of incompetent perforator veins is necessary in treatment of symptomatic chronic venous insufficiency (CVI) due to combined superficial and perforator vein incompetence, without deep venous insufficiency. METHODS This was a retrospective review of prospectively collected data. Twenty-four limbs with both superficial and perforator venous incompetence but no deep venous insufficiency were identified at venous duplex scanning. Air plethysmography (APG) was performed preoperatively, to obtain venous volume (VV), venous filling index (VFI), ejection fraction (EF), and residual volume fraction (RVF) of the affected limb. Saphenous vein stripping from the groin to knee and powered transilluminated phlebectomy for varicosity ablation were performed in all patients. Postoperatively, all patients underwent duplex scanning and APG to determine the status of the perforator veins and hemodynamic improvement from surgery. RESULTS Average patient age was 55.8 years; 62% of patients were women. CVI was class 3 in 4 limbs, class 4 in 12 limbs, and class 5 and class 6 in 4 limbs each. Postoperative duplex scans demonstrated that 71% of previously incompetent perforator vessels were now competent or absent. Significant improvement in all APG values was documented after superficial surgery. VFI improved from 6.0 +/- 2.9 preoperatively to 2.2 +/- 1.3 after surgery (P <.001); EF improved from 56.3 +/- 18 to 62 +/- 21 (P =.02); and RVF improved from 40.1 +/- 19 to 28.3 +/- 18 (P =.009). Mean preoperative symptom score (5.3 +/- 1.9) was significantly improved at mean follow-up of 18.3 months (1.4 +/- 1.2; P <.001). CONCLUSION Patients with superficial and perforator vein incompetence and a normal deep venous system experienced significant improvement in APG-measured hemodynamic parameters and clinical symptom score after superficial ablative surgery alone. This suggests that ligation of the perforator veins can be reserved for patients with persistent incompetent perforator vessels, with abnormal hemodynamic parameters or continued symptoms after superficial ablative surgery.

Endovenous Saphenous Ablation Corrects the Hemodynamic Abnormality in Patients with CEAP Clinical Class 3–6 CVI Due to Superficial Reflux

This investigation was designed to determine whether minimally invasive radiofrequency or laser ablation of the saphenous vein corrects the hemodynamic impact and clinical symptoms of chronic venous insufficiency (CVI) in CEAP clinical class 3–6 patients with superficial venous reflux. Patients with CEAP clinical class 3–6 CVI were evaluated with duplex ultrasound and air plethysmography (APG) to determine anatomic and hemodynamic venous abnormalities. Patients with an abnormal (>2 mL/second) venous filling index (VFI) and superficial venous reflux were included in this study. Saphenous ablation was performed utilizing radiofrequency (RF) or endovenous laser treatment (EVLT). Patients were reexamined within 3 months of ablation with duplex to determine anatomic success of the procedure, and with repeat APG to determine the degree of hemodynamic improvement. Venous clinical severity scores (VCSS) were determined before and after saphenous ablation. Eighty-nine limbs in 80 patients were treated with radiofrequency ablation (RFA) (n=58), or EVLT (n=31). The average age of patients was 55 years and 66% were women. There were no significant differences in preoperative characteristics between the groups treated with RFA or EVLT. Postoperatively, 86% of limbs demonstrated near total closure of the saphenous vein to within 5 cm of the saphenofemoral junction. Eight percent remained open for 5–10 cm from the junction, and 6% demonstrated minimal or no saphenous ablation. The VFI improved significantly after ablation in both the RF and EVLT groups. Postablation, 78% of the 89 limbs were normal, with a VFI <2 mL/second, and 17% were moderately abnormal, between 2 and 4 mL/second. VCSS scores (11.5 ±4.5 preablation) decreased significantly after ablation to 4.4 ±2.3. Minimally invasive saphenous ablation, using either RFA or EVLT, corrects or significantly improved the hemodynamic abnormality and clinical symptoms associated with superficial venous reflux in more than 90% of cases. These techniques are useful for treatment of patients with more severe clinical classes of superficial CVI.

The importance of deep venous reflux velocity as a determinant of outcome in patients with combined superficial and deep venous reflux treated with endovenous saphenous ablation

INTRODUCTION Twenty to thirty percent of patients with symptomatic chronic venous insufficiency (CVI) are found to have combined superficial and deep venous reflux on duplex testing. It is currently unclear whether endovenous ablation (EVA) of the saphenous vein will result in correction of CVI without addressing the deep venous reflux. In this study, we examined deep venous reflux velocities to determine whether these would predict outcome after endovenous ablation. METHODS Patients with symptomatic CVI and both saphenous and deep venous reflux were identified using duplex ultrasonography. Reflux times and maximal reflux velocity (MRV) in each examined vein segment were determined. In each limb, the venous filling index (VFI) and the venous clinical severity score (VCSS) were obtained both before and after laser ablation of the great and/or small saphenous veins. Preoperative venous reflux velocities were correlated with improvement in VFI and VCSS after ablation. RESULTS 75 limbs with both deep and superficial venous reflux were identified. Seventy-five percent of limbs were CEAP clinical class 3 or 4 and the other 25% were class 5 or 6. Forty limbs demonstrated deep venous reflux in the femoral and/or popliteal vein. After EVA, significant improvements in VFI and VCSS were seen, but this depended on MRV in the deep vein. When MRV in the popliteal or femoral vein was <10 cm/sec, limbs had significantly better outcomes than limbs with MRV >10 cm/sec as measured by both VFI (P = .01) and VCSS (P = .03). In 35 limbs, deep venous reflux was identified only in the CFV. In this group, the average pre-procedure VFI (6.54 +/- 3.9 cc/sec) decreased significantly to 2.2 +/- 1.9 cc/sec (P < .001) and the VCSS improved markedly from 7.0 +/- 2.8 to 1.3 +/- 1.4 (P < .001). CONCLUSIONS EVA of the saphenous veins can be performed in patients with concomitant deep venous insufficiency with hemodynamic and clinical improvement in most cases. Patients with popliteal or femoral reflux velocities lower than 10 cm/sec usually experience marked improvement in both the VFI and the VCSS. Patients with femoral or popliteal reflux velocities greater than 10 cm/sec have a high incidence of persistent symptoms after EVA.

Initial report of the use of an injectable porcine collagen‐derived matrix to stimulate healing of diabetic foot wounds in humans

A novel injectable scaffolding matrix (E‐Matrix™) has been developed to accelerate wound healing in diabetic foot ulcers. This porcine collagen‐derived matrix is designed to mimic tertiary embryonic connective tissue and to stimulate fetal wound repair mechanisms including angiogenesis. In vitro and animal studies have indicated a beneficial effect on tissue growth and an acceptable safety profile. In this report, we describe the initial use of this product in a pilot study of six humans with chronic nonhealing diabetic foot ulcers. A dramatic initial response to injection was seen, with an average wound size reduction of 72% 2 weeks after injection. Randomized trials are underway to define the potential benefit of this new treatment modality for diabetic foot ulcers.

Endovascular repair of blunt thoracic aortic injury: Techniques and tips

Since the initial report 1 of treating blunt aortic injuries (BAI) with endovascular methods, its application in the traumatically injured patient has continued to gain acceptance and use. This may be attributed to an increase in the number of available thoracic stent grafts as well as the accumulation of experience by endovascular specialists. Additionally, experience has revealed several important procedural details that help ensure a successful result. This article describes the techniques and tips that may be useful to optimize outcomes for this high-risk group of patients. EVALUATION

Endovascular Exclusion of an External Carotid Artery Pseudoaneurysm Using a Covered Stent

Aneurysmal lesions of the external carotid artery are extremely rare. A case is presented of a 3.8 cm right external carotid artery pseudoaneurysm treated by transluminal exclusion using an endovascular stent-graft. Following stent-graft placement, complete occlusion of the aneurysmal sac and main vessel lumen patency was successfully demonstrated. This report demonstrates the technical feasibility of utilizing stent-grafts to treat aneurysmal lesions involving the external carotid artery.

Management of Abdominal Aortic Aneurysm in the Setting of Coexistent Renal and Splanchnic Disease

By definition, an infrarenal abdominal aortic aneurysm (AAA) is located in the distal portion of the abdominal aorta, inferior to the renal arteries. The segment of aorta between the renal arteries and an infrarenal aneurysm is commonly referred to as the “neck” of the aneurysm. The anatomic character istics of this area are of critical importance when considering therapeutic strat egies for both open and endoluminal interventions. Prior to the endovascular era, optimal management of coexistent aortic aneurysmal disease and visceral pathology was somewhat controversial. While some centers advocated open endarterectomy for stenotic ostial lesions of the renal and visceral vessels at time of aneurysm repair, others preferred reimplantation or bypass for similar lesions. The choice of intervention was often individualized and based some what upon surgeon preference.