T. Igari

Angioscopic External Valvuloplasty in the Treatment of Varicose Veins

Objective: To report on the surgical treatment of varicose veins by angioscopic valvuloplasty to preserve the long saphenous vein (LSV) and the efficacy of this method compared with conventional stripping and high ligation. Methods: A total of 306 limbs in 187 patients with reflux at the sapheno-femoral junction to below knee level were operated on using intraoperative angioscopy to diagnose valve insufficiency. Angioscopic external valvuloplasty was attempted for the subterminal valves in the LSV by three techniques: total plication of the dilated annulus by running polypropylene sutures (technique 1), plication by autogenous femorofascial sleeve or Dacron-reinforced silicone (technique 2), and plication of the commissure with shortening of the cusps from outside the vein wall (technique 3). Partial stripping or segmental ligation was performed for varicose veins below knee level and the incompetent perforating veins were treated simultaneously by suprafascial ligation. Results: The subterminal valves were classified as follows: valves with elongated and atrophic cusps – type I, 136 (44%); valves with expanded and depressed commissures with cusp changes – type II, 108 (35%); valves that had cusps with other deformities – type III, 38 (13%); and absence of valves between the saphenofemoral junction and mid-thigh level, 24 limbs (8%). Valvuloplasty of the LSV was successfully performed in 62 limbs (20%). There were two cases with occlusion of the LSV (3%) and four with recurrence of varicose veins (6%) at 2–89 (mean 55, SD 21) months follow-up. Conclusions: Angioscopic external valvuloplasty is effective in the treatment of varicose veins to preserve the LSV. Further data are needed for complete evaluation of this procedure.

Prevention of paraplegia in transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms

OBJECTIVE To evaluate the efficacy of a temporary balloon occlusion test for the prevention of paraplegia following transluminally placed endoluminal prosthetic grafts for descending thoracic aortic aneurysms. SUBJECTS AND METHODS Two occlusion balloons were inserted via the brachial and femoral arteries and positioned in the proximal and distal neck of the descending thoracic aortic aneurysms using fluoroscopy. After temporary occlusion of the thoracic aorta by inflation of both the proximal and distal balloons, the evoked spinal potential was measured for 15 mins. A maximum amplitude during temporary balloon occlusion test decreasing by more than 20% of the pre-balloon occlusion level was considered to be significant, enough to not perform transluminally placed endoluminal prosthetic grafts, but instead an open repair. The test was applied in 12 cases (9 males and 3 females, 50-86 years old). All aneurysms were located between the Th6 and Th12 with a maximum diameter of 40-70 mm, and average of 56 mm. RESULTS The changes in maximum amplitude of evoked spinal potential remained within 20% of the value before balloon occlusion in 11 cases. Transluminally placed endoluminal prosthetic grafts were performed in these 11 cases and no instance of paraplegia or other complication relating to the test was observed. Deployment of stent-grafts was successful in 10 cases (91%). CONCLUSION It is suggested that the preoperative measurement of evoked spinal potential during temporary balloon occlusion is clinically useful for the assessment of the risk to paraplegia occurring in transluminally placed endoluminal prosthetic grafts.

External valvuloplasty for primary valvular incompetence of the lower limbs using angioscopy

The morphology of 145 vein valves of venous stasis syndrome was studied and classified into three types by means of angioscopy. External valvuloplasty for primary valvular incompetence (PVI) was performed in 21 highest valves of the superficial femoral vein and 46 subterminal valves of the long saphenous vein under direct vision using angioscopy. Within external valvuloplasty, Technique I is total plication of the dilated vein annulus by running a suture around the vein; Technique II is plication by placing an autogenous femorofascial band; and Technique III is direct suture of valve commissure including the leading edge of the cusp from the outside vein wall using horizontal mattress suture with pledgets. Venous regurgitation was reduced from grade III–IV to grade 0–1 in descending phlebography after external valvuloplasty. Ambulatory venous pressure improved from 42% to 54% postoperatively. Reflux volume by Duplex scanning was significantly decreased after external valvuloplasty and maintained a reduced level. Surgical results of external valvuloplasty using angioscopy are satisfactory in all cases of the superficial femoral vein and in 91% of the long saphenous vein in 2–4-year follow-up. External valvuloplasty using angioscopy is a simple and reliable surgical technique. It is necessary to have a longer follow-up in order to fully evaluate the value of these external valvuloplasty techniques.

The Appearance of Cytokines and Adhesion Molecules in Saphenous Vein Valves in Chronic Venous Insufficiency

Objective: To evaluate the difference between competent valves and incompetent valves with regards to the development of expression of cytokines and adhesion molecules in primary varicose veins. Methods: Specimens were obtained from 13 patients with primary varicose veins during surgery. Valves were classified according to the angioscopic findings: 8 competent and 17 incompetent valves; type I (7 valves with elongated cusps) and type II (10 valves with expansion of commissures). The mRNA levels of interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumour necrosis factor-α (TNF-α), transforming growth factor-β (TGF-β), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and endothelial leucocyte adhesion molecule-1 (ELAM-1) were measured by polymerase chain reaction (PCR) amplification of cDNA reverse-transcribed from RNAs. Results: In all cases there were few appearances of IL-6, IL-8 and TNF-α at the valve cusps. TGF-β and VCAM-1 levels were highly elevated in the cusps of incompetent valves compared with competent valves (p<0.05). At the venous wall IL-6 and IL-8 occurred more frequently in incompetent valves than in competent valves (p<0.05). Conclusion: This study suggests that inflammatory cytokines and adhesions molecules, especially TGF-β, IL-6, IL-8 and VCAM-1, may be related to the occurrence of valve insufficiency.

Clinical Studies of Anticoagulant Therapy by Monitoring of Heparin Concentration.

体外循環中の抗凝固療法の指標であるACTは血液希釈, 低体温により延長するため, ヘパリン投与不足や硫酸プロタミンの過剰投与による凝固線溶異常, 出血量増加を生じることがある. 著者は開心術症例68例 (成人32例, 小児36例) を対象に体外循環中のヘパリン濃度を一定に保つヘパリン投与法 (HC群) とACTを基準とするヘパリン投与法 (NC群) を比較し, 適正な抗凝固療法について検討した. ヘパリン総投与量はHC群で有意 (p<0.01) に増量され, 硫酸プロタミンはHC群で有意 (p<0.01) に減量された. 成人例では凝固線溶系因子に有意差を認めず, 小児例ではTAT, PIC, D-dimer が体外循環終了時にHC群で有意 (p<0.05) に低値を示した. 手術・止血時間, 術中・術後出血量, 輸血量に有意差を認めなかった. 小児例では従来法のヘパリン投与量では著明に不足となり, 凝固因子温存のためにはヘパリン濃度管理がとくに有用であると考えられた.