T. Hummel

Residual Stumps Associated with Inguinal Varicose Vein Recurrences: A Multicenter Study

PURPOSE It is unclear whether a residual sapheno-femoral stump left in place after stripping of the great saphenous vein can contribute to the formation of late inguinal varicose vein recurrence. In order to obtain information about the time course of recurrence development, patients with histologically proven residual stumps were recruited and asked about the interval between the initial operation and the first clinical signs of varicose vein recurrence. METHODS A multi-centre study involving 7 centres was conducted amongst patients undergoing redo-surgery for inguinal varicose vein recurrences. The sapheno-femoral stumps resected during the redo-surgery were classified histologically. Patients with a proven long residual sapheno-femoral stump were asked to describe the first signs of varicose vein recurrence with the help of a standardised questionnaire. From these data the symptom-free interval, consisting of the time frame between the initial operation and the first signs of recurrence, was determined. RESULTS In 279 legs of 251 patients a long residual sapheno-femoral stump was present. Most patients had experienced a symptom-free interval after the initial operation with a mean duration of 7.4 S.D. 5.5 years. Recurrent varicose veins became apparent after a mean time interval of 6.3 S.D. 5.3 years and congestion symptoms occurred after a mean interval of 8.5 S.D. 5.7 years. CONCLUSIONS In patients with symptomatic groin recurrences, a long residual sapheno-femoral stump was found in about two thirds of cases. The first clinical signs of varicose vein recurrence can be expected 7-8 years after the initial treatment at the earliest. Long term follow up is required reliably to asses the outcome of treatment for varicose veins.

Long-term results after transfemoral venous thrombectomy for iliofemoral deep venous thrombosis.

OBJECTIVE In patients presenting with extensive venous thrombosis affecting the pelvic veins, transfemoral venous thrombectomy has been suggested as an effective treatment in selected patients. We present our experience of this technique as well as its long-term results. PATIENTS AND METHODS Between January 1998 and January 2008, a total of 83 patients underwent transfemoral venous thrombectomy in our Department of Vascular Surgery. In 22 cases, this was combined with angioplasty and stenting of an iliac vein stenosis. Isolated intra-operative thrombolysis was performed in eight cases to treat deep venous thrombosis (DVT) affecting veins distal to the common femoral vein. All patients suffered from a DVT involving the pelvic veins. A DVT involving all venous segments from the pelvis to the calf was present in 63% of cases. Patients were followed up at 3 months, 6 months and yearly thereafter by clinical and duplex ultrasound examination. RESULTS In all patients, the procedure was successful in achieving re-canalisation of the pelvic veins at the end of the operation. Perioperatively, there was no mortality and there was no case of clinically detected pulmonary embolism. Life-table analysis showed that, after a mean duration of 60 months following treatment, approximately 75% of the treated venous segments remained patent. Moderate post-thrombotic syndrome (PTS; clinical severity, etiology, anatomy and pathophysiology (CEAP) C2-C4) was present in 20% of cases; severe PTS (CEAP C5 and C6) did not occur in any of the treated patients. CONCLUSIONS It is safe and effective to treat extensive iliofemoral DVT using transfemoral venous thrombectomy and this prevents the development of severe PTS in the long term. The procedure is only feasible in a subset of patients with DVT, depending on the extent and the age of the thrombosis.

Laparoscopic needle catheter jejunostomy: modification of the technique and outcome results

Background: We describe a modification of the technique for laparoscopic jejunostomy in patients with stenosis of the upper gastrointestinal tract and assess the patients outcomes with this enteral access. Methods: In a retrospective study of 80 patients, we evaluated the outcome of a modified technique for the laparoscopic placement of a jejunostomy catheter into the proximal jejunum. Standard laparoscopy equipment and ready-to-use jejunostomy catheters were used. After the creation of a pneumoperitoneum, the proximal jejunal loop was fixed to the parietal peritoneum. The jejunum was then punctured with a split needle, and the catheter (9F) was pushed into the jejunum. Finally, the catheter was secured with an additional purse-string suture. The external fixation was performed with nonabsorbable sutures. Enteral nutritional support with a polymeric enteral diet was initiated after fluoroscopic control on the first postoperative day at a rate of 20 ml/h. The flow rate was increased progressively until the nutritional goal of 60–80 ml/h was reached on the 3rd or 4th postoperative day. Results: In all patients (n = 80), the placement site of the catheter was correct, and all patients were able to receive enteral nutrition on the 1st postoperative day. There were no intraoperative complications. The mean operating time was 51 min. Two patients developed a localized infection at the catheter site; one patient developed an abscess; and three patients had catheter obstructions. Conclusions: Patients in need of intermediate or long-term enteral nutrition may benefit from laparoscopic catheter jejunostomy. The technique described is safe, effective, and less invasive than alternative techniques of laparoscopic jejunostomy.

Validity of duplex-ultrasound in identifying the cause of groin recurrence after varicose vein surgery

INTRODUCTION Often groin recurrences after varicose vein surgery are diagnosed and classified with the help of a duplex ultrasound scan. There are, however, no studies indicating if duplex ultrasound scans can reliably distinguish between the different forms of recurrent vessels, ie, neovascularization or a residual stump. To address this issue, we have conducted a prospective study in which ultrasound scan assessment of groin recurrences was compared to the histological classification of the recurrent groin veins. MATERIALS AND METHODS All patients undergoing redo-surgery for symptomatic groin recurrences after previous stripping of the greater saphenous vein (GSV) during a 1-year period (May 2006-May 2007) were included in the study. Preoperatively, all patients had a duplex-ultrasound scan examination of the groin vessels. Based on the duplex scan findings, the recurrent veins in the groin were classified as either a residual stump or neovascularization. During the redo-surgery, a specimen of the recurrent groin veins was obtained and underwent histologic evaluation. Based on histologic criteria, the recurrence was also classified as a residual stump or neovascularization. RESULTS During the 1-year study period, 125 groin recurrences in 95 consecutive patients (74 female, 21 male, mean age 58.7 years, standard deviation [SD] 10.3 years) were included. In the 119 cases where both duplex-ultrasound scan and histological evaluation were available, a residual stump was seen at the histological examination in 80.7% of cases, a neovascularization in 10.9% of cases, and a combination of both entities in 8.4% of cases. Duplex-ultrasound scan classified the recurrent groin veins as a residual stump in 68.1% of cases, as neovascularization in 26.1%, and as a combination of both in 5.8% of cases. With histological classification as the gold-standard, duplex ultrasound scans reached a sensitivity of 77.1% and a positive predictive value of 91.4% in correctly identifying a residual stump as the cause of recurrence. For the correct classification of neovascularization, sensitivity was 61.5% and the positive predictive value 25.8%, while a combination of both was recognized with a sensitivity of 10% and a positive predictive value of 14.3%. CONCLUSION While duplex-ultrasound scan is a reliable tool to diagnose groin recurrences after varicose vein surgery, its validity in classifying the different types of recurrent groin vessels is limited. Especially the correct identification of neovascularization which is poor with a sensitivity of 62% and a positive predictive value of 26%. Histological examination should still be regarded as the gold-standard when trying to differentiate between different types of groin recurrences.

Transcranial Ultrasound Perfusion Imaging and Perfusion-MRI—A Pilot Study on the Evaluation of Cerebral Perfusion in Severe Carotid Artery Stenosis

Severe internal carotid artery stenosis can cause constriction of cerebral perfusion. Different techniques of measuring brain perfusion are currently available. Ultrasound perfusion imaging (UPI) can differentiate hypoperfused and nonperfused cerebral tissue. Aim of this study was to compare the value of UPI and perfusion-weighted magnetic resonance imaging (pw-MRI) in the evaluation of cerebral perfusion in patients with severe internal carotid artery stenosis. Ten patients with severe internal carotid artery stenosis were included. UPI was performed with phase-inversion-harmonic-imaging and bolus application of contrast media for semiquantitative analysis of time-intensity curves. Time-to-peak intensity (TPI) values were compared with time-to-peak maps of pw-MRI examinations in predefined regions-of-interest (ROI). Further, a comparison of pre- and postoperative UPI data was performed in selected cases. Seven of 10 patients could be evaluated. Eighty ROIs were used for the comparison of UPI and pw-MRI, 37 ROIs were used for pre- and 36 ROIs for postoperative comparison of UPI data. There was no delay in any MRI ROI. In UPI, there were relevant delays in seven of 37 ROIs (18.9%) before and in nine of 36 ROIs (25.0%) after surgery. Eleven of these 16 ROIs (68.8%) were in the inner border zone. Compared with the established pw-MRI technique, UPI described possible subtle perfusion delays mainly of the inner border zone. These preliminary results suggest a possible diagnostic power of UPI as a noninvasive tool for the detection of hemodynamic relevance in severe internal carotid artery disease.

Rekanalisierende Therapie der tiefen Bein-/Beckenvenenthrombose

ZusammenfassungDie konservative Therapie der tiefen Bein-/Beckenvenenthrombose (TVT) führt zu einer Defektheilung, die bei langstreckigem Verschluss und Beteiligung der Beckenetage mit einem hohen Risiko für die Entwicklung eines postthrombotischen Syndroms behaftet ist. Solche Folgeschäden an den tiefen Venen können nur dann vermieden werden, wenn es gelingt, die verschlossenen Venen frühzeitig zu rekanalisieren und die Funktion des Klappenapparates wieder herzustellen. Diese Zielsetzung verfolgt die rekanalisierende Therapie der TVT mit chirurgischen, fibrinolytischen und interventionellen Methoden. Allerdings ist der potenzielle Vorteil rekanalisierender Verfahren gegenüber der Standardbehandlung mit Antikoagulation bislang nicht innerhalb methodisch überzeugender Vergleichsstudien abgesichert worden. Daher muss die Indikation zur rekanalisierenden Therapie streng und nach einer sorgfältigen Risiko-Nutzen-Analyse gestellt werden.AbstractThe conservative treatment of deep leg and pelvic vein thrombosis leads to permanent damage of recanalised veins, which in cases of long distance clots as well as involvement of the pelvic level, increase the risk of developing a postthrombotic syndrome. Such subsequent damage of the deep veins can only be avoided if occluded veins are rapidly recanalised and the function of the valves is successfully reestablished. Recanalisation may consist of surgical, fibrolytic and interventional methods and aims to minimize any subsequent damage; however no potential benefit of recanalisation versus standard treatment has yet been proven by means of methodologically adequate comparative studies. Thus, the indications for recanalisation must remain strict and be founded on a thorough risk-benefit assessment.

A rare case of septic deep vein thrombosis in the inferior vena cava with pulmonary embolism

This paper presents the case of a 61-year-old female patient who complained about exhaustion and fever during curative therapy, a few weeks after hysterectomie and adnexectomy. Antibiotic therapy could only improve these symptoms though only in the short term. Additionally, a venous port, which had been implanted for the purpose of cytoreduction chemotherapy, was suspected of a catheter infection and was removed. However, this did not lead to a substantial improvement of the patient’s general state of health, but ultimately triggered a sepsis, making necessary treatment in intensive care unit. At this stage, the detailed search for the focus of the infection led to the discovery of an infected thrombosis of the inferior vena cava with bilateral septic pulmonal embolisms and with an abscess. Thus, the source of sepsis had to be removed by surgery, a transfemoral thrombectomy was performed and an inguinal arteriovenous fistula was created. The further course of the disease was without complications; the patient could be released into ambulant treatment 24 days after the surgery. The elective sealing of the arteriovenous fistula was carried out 11 months later. In the follow-up, there were no hints for infection; the deep venous system in particular did not indicate any new thrombosis or of residual thrombi, with the tumor follow-up-care showing a complete remission.This paper presents the case of a 61-year-old female patient who complained about exhaustion and fever during curative therapy, a few weeks after hysterectomie and adnexectomy. Antibiotic therapy could only improve these symptoms though only in the short term. Additionally, a venous port, which had been implanted for the purpose of cytoreduction chemotherapy, was suspected of a catheter infection and was removed. However, this did not lead to a substantial improvement of the patient’s general state of health, but ultimately triggered a sepsis, making necessary treatment in intensive care unit. At this stage, the detailed search for the focus of the infection led to the discovery of an infected thrombosis of the inferior vena cava with bilateral septic pulmonal embolisms and with an abscess. Thus, the source of sepsis had to be removed by surgery, a transfemoral thrombectomy was performed and an inguinal arteriovenous fistula was created. The further course of the disease was without complications; the patient could be released into ambulant treatment 24 days after the surgery. The elective sealing of the arteriovenous fistula was carried out 11 months later. In the follow-up, there were no hints for infection; the deep venous system in particular did not indicate any new thrombosis or of residual thrombi, with the tumor follow-up-care showing a complete remission.