Thomas F. O'Donnell

Classification and Grading of Chronic Venous Disease in the Lower Limbs-A Consensus Statement-

Classification and grading of chronic venous disease in the lower limbs : A consensus statement

Estrogen inhibits the response-to-injury in a mouse carotid artery model.

The atheroprotective effects of estrogen are well documented, but the mechanisms responsible for these effects are not well understood. To study the role of physiologic (nanomolar) estrogen levels on the arterial response-to-injury, we applied a mouse carotid artery injury model to ovariectomized C57BL/6J mice. Mice were treated with vehicle (-E2, n = 10) or 17 beta-estradiol (+E2, n = 10) for 7 d, subjected to unilateral carotid injury, and 14 d later contralateral (normal = NL) and injured carotids from -E2 and +E2 animals were pressure fixed, harvested, and analyzed by quantitative morphometry. E2 levels in +E2 mice were consistently in the nanomolar range (2.1-2.5 nM) at days 0, 7, and 14. At 14 d, measures of both intimal and medial area were markedly increased in the -E2 group: (-E2 vs NL, P < 0.05 for both), but were unchanged from normal levels in the +E2 group (+E2 vs NL, P = NS and +E2 vs -E2, P < 0.05 for both). Cellular proliferation, as assessed by bromodeoxyuridine (BrdU) labeling, was significantly increased over NL in the -E2 mice, but this increase was markedly attenuated in the estrogen replacement group (total BrdU positive cells/section: NL = 6.4 +/- 4.5; -E2 = 113 +/- 26, +E2 = 40 +/- 3.7; -E2 vs NL, P < 0.05; +E2 vs NL, P = NS; -E2 vs +E2, P < 0.05). These data (a) demonstrate significant suppression of the mouse carotid response-to-injury by physiologic levels of estrogen replacement; (b) support the utility of this model in the study of the biologic effects of estrogen on the vascular-injury response; and (c) suggest a direct effect of estrogen on vascular smooth muscle cell proliferation in injured vessels.

Investigation of factors determining the optimal glucose infusion rate in total parenteral nutrition

We have used the primed constant infusion of U-13C-glucose to study glucose metabolism during conventional total parenteral nutrition (TPN) in five postoperative surgical patients. Glucose production from nonrecycled carbon sources was suppressed to 17% of the basal level at the lowest rate of glucose infusion tested (4 mg/kg x min). Subsequent increases in glucose infusion rate had minimal effect in further suppressing glucose production. Additional nitrogen-sparing effects of glucose when glucose is infused at rates in excess of 4 mg/kg x min must therefore be derived from oxidation of the infused glucose. An increase in the infusion rate from 4 mg/kg x min to 7 mg/kg x min was associated with an increased rate of glucose oxidation, but a further increase in glucose infusion rate (9 mg/kg x min) was without significant effect on glucose oxidation. As the rate of TPN administration (glucose and amino acids) increased, both metabolic rate and RQ rose significantly. Our calculations indicate that the high RQs observed during the highest glucose infusion rate (X = 1.13) could be attributed to the synthesis of fat from infused glucose, and that about 30% of the increase in VO2 above the basal level could also be attributed to fat synthesis. The progressive increase in the ability to clear glucose from the blood that occurred as TPN progressed was not due to an increase in the rate of oxidation of glucose; we found no correlation between glucose clearance and glucose oxidation.

Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery ® and the American Venous Forum.

Thomas F. O’Donnell Jr, MD, Marc A. Passman, MD, William A. Marston, MD, William J. Ennis, DO, Michael Dalsing, MD, Robert L. Kistner, MD, Fedor Lurie, MD, PhD, Peter K. Henke, MD, Monika L. Gloviczki, MD, PhD, Bo G. Eklof, MD, PhD, Julianne Stoughton, MD, Sesadri Raju, MD, Cynthia K. Shortell, MD, Joseph D. Raffetto, MD, Hugo Partsch, MD, Lori C. Pounds, MD, Mary E. Cummings, MD, David L. Gillespie, MD, Robert B. McLafferty, MD, Mohammad Hassan Murad, MD, Thomas W. Wakefield, MD, and Peter Gloviczki, MD

Safety, feasibility, and early efficacy of subfascial endoscopic perforator surgery: A preliminary report from the North American registry

PURPOSE The North American Subfascial Endoscopic Perforator Surgery (NASEPS) Registry was established to evaluate the safety, feasibility, and efficacy of minimally invasive endoscopic Linton operations for treatment of chronic venous insufficiency. METHODS Retrospective analysis was performed on the clinical data of 151 patients who underwent attempt at 158 SEPS in 17 medical centers in the United States and Canada between June 1993 and February 1996. RESULTS SEPS was completed on 155 limbs of 148 patients, 81 male and 67 female (mean age, 56 years; range, 27 to 87 years). Three procedures were aborted. Seven patients had bilateral procedures (data from one limb were analyzed). One hundred four limbs (70%) had active ulcers, and 22 (15%) had healed ulcers. A single endoscopic port without insufflation was used in 66 procedures (45%) and laparoscopic instrumentation, with two or three ports, in 82 (55%), with CO2 insufflation in 78 (53%). A tourniquet was used on 112 patients (76%). Concomitant venous procedures were performed in 106 patients (72%; saphenous stripping in 71, high ligation in 17, varicosity avulsion in 85). No early deaths or thromboembolism occurred. Complications included wound infections (9), superficial thrombophlebitis (5), cellulitis (4), and saphenous neuralgia (10). Seven patients with wound infection had open ulcers; nine of 10 with neuralgia had concomitant procedures. A roll-on tourniquet caused skin necrosis in one patient. The clinical score improved from 9.4 to 2.9 after surgery (p < 0.0001). Mean follow-up was 5.4 months; 31 patients had > or = 6 months follow-up. Ulcers healed in 88% (75 of 85); recurrence or new ulcer was reported in 3% (4 of 120). CONCLUSIONS The SEPS modified Linton operation appears safe, with no postoperative deaths or early thromboembolism. Wound infection after SEPS remains important. Early results indicate rapid ulcer healing. Prospective evaluation of long-term results is warranted.

RELATION BETWEEN POSTPHLEBITIC CHANGES IN THE DEEP VEINS AND RESULTS OF SURGICAL TREATMENT OF VENOUS ULCERS

41 patients with venous ulceration, investigated by ascending phlebography, had operations to ligate incompetent calf perforating veins. Recurrent ulceration developed within five years of operation in all 23 patients with evidence of deep-vein damage on the initial phlebograms. Only 1 of the seventeen patients with normal deep veins had a recurrent ulcer during the same period of follow-up. Thus local surgery to the perforating veins in postphlebitic limbs was shown to be ineffective.

Carotid endarterectomy contralateral to an occluded carotid artery: Perioperative risk and late results

To define better the short-term risk and long-term benefit of carotid endarterectomy opposite an occluded carotid artery, we reviewed our experience since 1961. Angiographic data are available for 598 of 670 (89.3%) patients in our carotid registry. In 63 (10.5%) patients the internal or common carotid artery on the side opposite the endarterectomy was occluded. All operations were carried out under general anesthesia with selective shunting based on electroencephalographic criteria. Shunting was required in 29 of 63 (46.0%) patients with contralateral occlusion and 72 of 535 (13.5%) control subjects (p less than 0.0001). Perioperative strokes occurred in 3 of 63 (4.8%) patients with contralateral occlusion and 14 of 535 control subjects (2.6%) (p = 0.23). Perioperative death occurred in 0 of 63 patients with contralateral occlusion and 6 of 535 (1.1%) control subjects (p = 0.40). Life-table cumulative stroke-free rates at 1, 5, and 10 years were 95.2%, 91.0%, and 76.2% in the group with contralateral occlusion and 96.0%, 89.4%, and 84.1% in control subjects (p = 0.25). Life-table cumulative survival rates at 1, 5, and 10 years were 93.1%, 80.8%, and 75.4% in the group with contralateral occlusion and 94.8%, 77.0%, and 57.9% in control subjects (p = 0.58). Carotid endarterectomy contralateral to an occluded carotid artery may be carried out with acceptable risk and late stroke-free and survival rates comparable to those seen in other patients who have undergone carotid endarterectomy.

The Circulatory Abnormalities of Heat Stroke

Abstract Serial hemodynamic measurements in eight Marine recruits suffering from acute heat stroke (mean rectal temperature of 41.5°C) revealed a hyperdynamic circulation pattern in seven: mean car...

Duplex assessment of venous reflux and chronic venous insufficiency: The significance of deep venous reflux

PURPOSE This study was undertaken to examine the role of superficial and deep venous reflux, as defined by duplex-derived valve closure times (VCTs), in the pathogenesis of chronic venous insufficiency. METHODS Between January 1992 and November 1995, 320 patients and 500 legs were evaluated with clinical examinations and duplex scans for potential venous reflux. VCTs were obtained with the cuff deflation technique with the patient in the upright position. Imaging was performed at the saphenofemoral junction, the middle segment of the greater saphenous vein, the lesser saphenous vein, the superficial femoral vein, the profunda femoris vein, and the popliteal vein. Not all patients had all segments examined because tests early in the series did not examine the profunda femoris or lesser saphenous vein and because some patients had previous ligation and stripping or venous thrombosis. VCTs were examined for individual segment reflux, grouped into superficial and deep systems, and then correlated with the clinical stage as defined by the SVS/ISCVS original reporting standards in venous disease. Segment reflux was considered present if the VCT was greater than 0.5 seconds, and system reflux was considered present if the sum of the segments was greater than 1.5 seconds. Between-group differences were analyzed with analysis of variance and post hoc tests where appropriate. RESULTS Sixty-nine limbs studied were in class 0, 149 limbs were in class 1, 168 limbs were in class 2, and 114 limbs were in class 3. VCTs in the superficial veins were significantly lower in class 0 than in the other clinical classes. There was no difference in superficial reflux in the symptomatic limbs (classes 1 to 3). Reflux VCTs in the superficial femoral and popliteal veins increased as the clinical symptoms progressed, with a significant increase in class 3 ulcerated limbs when compared with nonuclerated limbs. The incidence of deep venous reflux was 60% in class 3 limbs, compared with 29% in class 2 limbs, whereas the incidence of superficial venous reflux did not differ among the symptomatic limbs. Isolated superficial femoral and popliteal vein reflux was uncommon, even in class 3 limbs, but combined superficial femoral and popliteal vein reflux was found in 53% of class 3 limbs, compared with 18.5% of class 2 limbs. CONCLUSIONS Reflux in the deep venous system plays a significant role in the progression of chronic venous insufficiency. Deep system reflux increases as clinical changes become more severe, with significant axial reflux contributing to ulcer formation.

Correlation of clinical findings with venous hemodynamics in 386 patients with chronic venous insufficiency

Deep venous insufficiency secondary to deep valvular incompetence predominated over superficial venous insufficiency in an unselected patient population with advanced chronic venous insufficiency. Venous obstruction was uncommon (5 percent), suggesting that venous bypass surgery may have limited applicability in the management of chronic venous insufficiency. Although the majority of patients (72 percent) with stage III venous disease (ulcer) had deep venous insufficiency alone and would be potential candidates for deep valvular reconstruction, 13 percent were found to have superficial venous insufficiency alone, and the remaining 15 percent, deep venous insufficiency with a hemodynamically significant component of superficial venous insufficiency. These findings suggest that not all patients with stage III disease have altered hemodynamics on the basis of deep venous valvular incompetency. Although most stage III chronic venous insufficiency is secondary to altered deep venous hemodynamics, as demonstrated by shortened venous refill time, there is a significant group of patients with severe chronic venous insufficiency having superficial venous insufficiency alone or in combination with deep venous insufficiency (28 percent). Thus, it is imperative that those patients with superficial venous insufficiency be identified by a widely available and reproducible method, such as light reflection rheography, since they may respond to surgery of the superficial venous system alone.