[Sclerotherapy with ultrasonography in various risk zones (summary of a video film)]. / Sclérose sous échographie dans certaines zones a risques (résumé d'un film vidéo).

The sclerosing injection of varicose veins remains a technique which is often essential in the management of a patient with superficial venous insufficiency. The sclerosing injection of high reflux sites, in particular the junctions of the great and small saphenous veins with the deep venous system, is technically difficult. Even great skill and long experience cannot necessarily protect the most hardened phlebologist from a complication which may often be catastrophic. An alternative is therefore suggested: the sclerosing injection of junction sites under ultrasonographic control. This method enables endovenous injection under visual control. It would nonetheless be wrong to think that this method finally eliminates all possible risk: clinical, phlebological and ultrasonographic training are the sole guarantees of optimum and constant results from the technique. More than 2,500 injections have be performed in this way since 1987, without any complications. Although the follow-up remains short, results suggest that the use of the method will become more widespread. It is an extremely valuable aid in the training of future phlebologists, but under no circumstances should be used by untrained practitioners.

[Effect of noise on circulatory disorders]. / Incidence du bruit sur les troubles circulatoires.

The author reports a dramatic case of severe functional and trophic disorders of the lower limbs which proved to be entirely caused by noise. This case led him to study noise and its repercussions on the vascular system: physical characteristics, methods of measurement, epidemiology of this environmental nuisance, general and vascular diseases produced by the traumatic-vibration syndrome, and study of its mechanism of action. He concludes by calling for interdisciplinary action to combine fundamental research, screening and prevention of the disorders caused by noise.

[Advice of the phlebologist concerning care of the foot, walking and the selection of shoes]. / Conseils du phlébologue concernant l'hygiène du pied, la marche et le choix des chaussures.

The symbolic potential of the foot explains excessive psychological crystallizations and major patients' resistances to the phlebologist's advices. The author reviews hygiene advices concerning the feet (washing, pedicure, prevention of dermatoses and locking of joints), the three phases of physiological gait (heel gait, plantar and digital gait) and after a historical review of the shoes, exposes the damages caused by heels which are too high and describes the qualities of a physiological shoe.

[2 cases of recurrent deep venous thrombosis with protein C deficiency]. / A propos de deux cas de thromboses veineuses profondes à répétition avec déficit en protéine C.

Because of their gravity and the complications involved, repeated deep venous thromboses require everything to be done to produce an aetiological diagnosis, for only this will make a preventive treatment possible. Amongst causes of phlebitis, haemostatic disorders and coagulation factor anomaly should be systematically looked for, as these can sometimes be corrected. Following the discovery of the Antithrombin III deficiency, the protein C deficiency shows clear progress along these lines. The author here describes two cases of the protein C deficiency in patients who have suffered repeated deep and superficial venous thrombosis, with thromboembolic family antecedents.

[Veins and contraception]. / Veines et contraception.

PIP: Oral contraceptive (OC) use entails certain modifications in the venous anatomy and metabolism: hyperviscosity of the blood which slows microcirculation; with blood cells particularly affected and estrogens and possibly progestins playing a role, 2) modifications in coagulation factors caused by synthetic estrogens, 3) augmentation in very low density lipoprotein (VLDL) triglycerides and high density lipoprotein (HDL) cholesterol by norsteroid progestins, and 4) proliferation of the venous epithelium and intimal thickening associated with duration of use and of unproven reversibility on termination of OC use. Venous thromboembolism risk appears to be correlated with high doses of ethinyl estradiol (50 mcg or higher); the androgenic progestins with which they are usually combined appear to have more influence on arterial risk. Varicosities induced by exogenous or endogenous hormonal modification is a clinical entity distinct from other varicosities. Estrogens appear to have indirect effects, while progestins have a direct effect acting as myorelaxants on the venous wall. Some women genetically predisposed to venous problems are particularly sensitive to OCs, but in general venous problems are becoming much more rare with the advent of low-dose OCs. Functional venous problems including cramps, feelings of heaviness in the legs, morning edema and others which may appear before the formation of varices should be distinguished from other conditions that could cause the same symptoms. If measures such as elevating the legs, avoiding tight clothing, and appropriate exercise along with use of a phlebotonic do not relieve the symptoms, the OC can be discontinued to see if symptoms disappear. If they disappear and reappear on resumed OC use, a low-dose pill can be substituted. If the problems persist, a different method of contraception should be used. Varicosities occur relatively frequently in OC users and do not contraindicate OC use. They are not pathogenic but may have an undesirable effect on the body image of the OC user. Diffuse varices do not contraindicate OC use under certain conditions. A minipill or a low-dose progestin is always preferable in such cases. If there is a family history of venous disease, some other contraceptive method should be used. A history of venous thrombosis is the only true contraindication to OC use at present. Some phlebologists are less absolute, regarding previous venous thrombosis as a risk factor to be followed carefully rather than as an absolute contraindication, but it appears prudent to avoid OC use in such patients.^ieng

[Pigmentation following sclerosis]. / Les pigmentations après sclérose.

After discussing the psychological importance of the problem, the author stresses that the best treatment of pigmentations after sclerosis is prevention, based on experience and faultless technique (careful choice of sclerosants, local compression, evacuation of thrombi). The author then briefly reviews the pathophysiology of melanin dyschromias and their causes and presents the histological finding of a mixed origin for post-sclerosis pigmentations (melanin and iron). Various attempts at treatment are presented. The most effective form of treatment seems to be the percutaneous application of a mixture consisting of : -an iron chelator (desferoxamine), -an anti-inflammatory (alpha-chymotrypsin), -an anti-melanin agent (mequinol).

Varicose eczema.

The term "varicose eczema", although made acceptable by its use, is ambiguous and misleading. It would prompt us to believe that varicose eczema is different from common dermatological eczema. There is no such difference, and it would be more correct to speak of eczema of the varicose patient. The development of eczema in the case of a varicose patient may: --either develop in the case of a varicose patient who does not normally suffer from eczematous dermatosis; in this case static dermatitis represents a point of local reference for an eczematous crisis triggered off by a general factor and finding there a zone of reduced resistance; --or develop in the case of a known habitual eczematic. In this case, venous stasis increases and maintains the eczema. In both cases no local dermatological treatment will be able to cure the eczema, which will develop into a critical condition often provoking the development of a leg ulcer, and will necessitate the suppression of the venous counter-current. To try and understand the pathological mechanism of "varicose eczema", we have to remember the rudiments of the physiology of the cutaneous barrier, familiar to dermatologists but less so to phlebologists, and also some elements of the physiopathology of venous insufficiency, and in particular the tissular elements following the pattern explained by Comel's Italian school, by the term "histo-angiological decompensation". The circulatory unit "arteries-capillaries-veins-lymphatic-vessels-tissues" form an ensemble which has to be taken into account, as any disorders in any one of these elements reacts on all the others. These elementary rudiments lead us to understand the importance of an integral aetiopathogenic picture of varicose eczema, and the importance of the multidisciplinary collaboration between phlebologists and dermatologists in order to treat this affection, the border-line of our two specialties.

[Veins and contraception (author's transl)]. / Veines et contraception.

PIP: Vascular side effects of any type are certainly the most serious complications caused by OCs (oral contraceptives). Thromboembolic accidents are caused by 3 main factors: 1) coagulation problems, to be often found in a predisposed woman; 2) parietal alterations, also often hereditary; and, 3) hemodynamic problems responsible for stasis, leading to varicose veins. Varicose veins are definitely a less serious problem that thrombotic accidents, but much more frequent. The etiology of varicose veins is, according to the latest studies, to be found in the opening of arterial and venous shunts, which usually happens in consequence of hormonal inbalance, which explains varices during pregnancy and during OC use. A patient affected by varicose veins should use the mini pill only, and not regularly dosed pills, should never expose herself to vasidilator heat (sauna, hot baths), exercise regularly and fight excessive weight; regular checks by a phlebologist are also necessary, and the only contraindication to OC would be an antecedent of deep thrombosis.^ieng

[Effect of chronic venous insufficiency in gonarthrosis]. / Influence de l'insuffisance veineuse chronique dans la gonarthrose.

The author has been struck by the unexpected improvement of the gonarthrocace in several patients treated for varicose disorders by sclerotherapy. He puts forward the theory that stasis in varicose patients and inverse venous current provoke tissular anoxaemia and histo-angeial decompensation affecting not only the teguments but the bones and cartilage as well. The author first mentions vascularisation, with complications, of the knee, and various experiments carried out on animals, and then he gives the results of twenty years' work, which prove his theory. Out of several hundred patients with associated gonarthrocace and varices, 60% were improved by the treatment of their varices, a figure far above that of the percentage of cases improved by rheumatological treatment on its own. This seems to prove the importance of the venous factor in gonarthrocace.

[Impotence following stripping]. / Réflexions au sujet d'une impuissance apres stripping.

Among the iatrogenic complications of the surgery of varicose veins, the author has encountered several cases of impotence following stripping of the internal saphenous. Without rejecting the possibility of a psychogenic impotence due to the operation itself, he raises the question of the possible mechanism of this complication. Alter considering the vascularization of the erectile body and the haemodynamic process of erection, he reviews the arterial and venous causes of impotence and sets out the hypothesis which he feels to be the most plausible. Under the arch of the internal saphenous passes the external pudendal artery; injury to this does not usually produce any significant damage, since the erectile body of the penis is vascularized by the internal pudendal artery. But if as a result of a congenital anomaly of the internal pudendal, the supply derives from the external pudendal, ablation of the latter, sometimes carried out by surgeons in the course of ligature of the arch of the internal saphenous vein, could explain this complication. If this hypothesis proves correct, it would be necessary to require surgeons to touch the external pudendal artery in order to avoid this complication, which though exceedingly rare, is psychologically traumatic.

[Fitness and competitive sports in venous pathology]. / Sports d'entretien et de compétition en pathologie veineuse.

Since chronic venous insufficiency is a constitutional disorder, the principles of healthy living can be of major importance in its prevention and treatment. Among these, the influence of physical activities has attracted the attention of the author, who has attempted to analyze the mechanisms of each sport in order to study its effects on the peripheral vessels. As a result of long terme comparative studies, he has been able to classify the various sports into two categories, the sports which are beneficial and those which are harmful in subjects with vulnerable veins. Into the first category come those activities which assist the physiological mechanisms assuring the return of venous blood, in particular walking, swimming, cycling and gymnastics. Into the second category come sports which involve risks of constriction, trauma, and jolting of the vertebral column (skating, rugby, tennis, etc.), as well as all competitive sports because of the risks of thromboses, often unrecognized, and of excessive efforts which strain the valvular mechanism.

[Errors of the placebo test]. / Les mensonges du placebo.

The difficulties inherent in clinical experimentation in phlebology, stem from the fact that they concern highly subjective functional problems, and are thus difficult to measure. The answer to these difficulties seems to be found in the use of the double blind method. This method, however, contains numerous causes of errors in phlebology, since in order to be mathematically applied to computer use, it is too sketchy and does not take into account many additional factors, incidental parameters and unfavorable coincidences related either to chronobiology (weather, seasonal changes), to hormonal problems (periods of the cycle, pregnancies, contraception, menopause), to the environment (professional posture, ground heat, periods of vacation or work), or associated diseases (neuro-vegetative and rheumatic disorders, excessive weight, metabolic disorders), etc. It seems that in such cases, wide experimentation, with a very critical clinician, who attributes the improvement obtained to the drugs prescribed only when left with no other possibility and after having eliminated all the coincidental factors, gives results closer to reality than double blind experiments, behind whose pseudo-scientific appearance lies a sketchiness that is the cause of numerous errors.

[Experience with sclerosis of the perforating veins]. / Pratique de la sclêrose des perforantes.

The problem of sclerosis of the perforating veins, a subject of heated debate, seems now unanimously accepted. Indeed, their suppression is considered as important as sclerosis of the arches in preventing early and complete relapses. Their investigation can be clinical (examination of staged tourniquet), phlebographic or instrumental (thermography or Doppler). Their treatment can be either surgical (excellent in long reflux, perforating veins that are large in size and few in number) or medical (sclerotherapy). The latter present many variations with either direct injections in the perforating veins, telesclerosis above or below the perforating veins, telesclerosis on open veins after thrombectomy or extirpation with a Bassi hook. But whatever the technique used we cannot neglect the suppresion of short reflux which is a condition of the quality and duration of the results obtained.

[Venous ecology]. / Ecologie veineuse.

The purpose of venous ecology is to study the effect of the environment on the peripheral vessels. It is very extensive but still little explored subject in need of multidisciplinary study. The author reviews some of the major problems of ecophlebology: --pollution and harmful effects of urban life (atmospheric pollution, stress and influence of noise on the vessels); --the influence of habitat (furniture, ergonomics, urbanism, sociological studies and under-floor heating); --the cites new research on terrestrial electro-magnettism, meteoropathology, biological clocks and the influence of the mass media. In conclusion he hopes that ecophlebology will be the object of research which will permit a better understanding, and hence better control, of the pathological mechanisms resulting from the environment.

[Effects of various sport activities on peripheral venous diseases]. / Influence des diverses activités sportives sur la pathologie veineuse périphérique.

The study of the influence of different sporting activities on peripheral venous pathology should be based on venous physiology and precise understanding of the technology of each sport (study of the movements, positions, and muscles brought into play, the rhythm, the material employed, the risks run). At the conclusion of a long study on sportsmen of both average and highly competitive ability, and on yogis, the author was able, by means of a simple methodology applicable to all physical activity, to classify the principal sports into two categories: those which improve and those which work against the peripheral venous circulation. However he does not recommend a complete ban on the harmful sports in highly motivated patients, but rather that they should counter the disadvantages by performing antagonistic movements.