The management of venous aneurysms of the lower extremities.

Vein aneurysms have been reported in both the deep and superficial vein system of the lower extremities. In the iliofemoral area of the deep system the most common presentation is of an abdominal or iliac fossa mass while thromboembolism is not uncommon. The aneurysms are thought to result mainly from a congenital weakness of the vein wall, with an AV fistula present in over 50% of cases. Existing AV fistulae must be ligated; however, as the results of simple AV fistula or vein ligation are poor, reconstruction should always be attempted. Aneurysm excision with an end-to-end anastomosis might be feasible in the proximal iliac segment while the use of PTFE grafts or the LSV seems appropriate in cases of attempted reconstruction. In the popliteal area there is agreement on the aetiology (congenital, traumatic, post operative and after an AV fistula formation), the symptomatology (mainly thromboembolism) and the diagnosis (duplex scanning). Symptomatic cases should be treated surgically since the reported surgical results are excellent while the incidence of recurrent pulmonary embolism in patients treated conservatively exceeds 80%. Asymptomatic popliteal vein aneurysms could remain under close observation only but, if complicated with thromboembolism during the follow-up period, surgery should be performed immediately. The crural and superficial veins represent a minor danger and can be easily treated with ligation and/or excision with excellent results.

Low molecular weight heparins in the initial treatment of deep vein thrombosis.

All major trials to-date provide strong evidence that, for the initial treatment of DVT, adjusted-dose LMWHs are at least as effective and safe as unfractionated heparin (UFH). When compared with UFH, LMWHs achieved better thrombus lysis and had less bleeding complications (21-91% risk reduction) and mortality (51% reduction). They also reduced the incidence of recurrent DVT and PE at 90 days follow-up while there was no need for monitoring. Despite these exciting findings however, long-term evaluation of mortality rate, recurrent venous thromboembolism, blood monitoring tests efficacy and thrombus propagation/reduction are open issues. Furthermore, venous haemodynamics have never been tested. There is an ongoing Canadian study today, aiming to determine LMWHs effectiveness in reducing death, recurrent venous thromboembolism and haemorrhagic complications; it is obvious however that further studies are needed. We must determine if a prolonged use of LMWHs (i.e. 90 days) is more effective in preventing the post-thrombotic sequelae, reducing also the incidence of haemorrhagic complications; we also need to know the nature of the haematological changes that develop and the relationship between these changes and the recurrence rate; and finally, we must identify effective blood tests to monitor this treatment.

Complications of the balloon assisted percutaneous transluminal angioplasty. Review article.

Percutaneous Transluminal Angioplasty (PTA), has become a widely used technique in the management of atherosclerotic and nonatherosclerotic stenoses or occlusions in almost all arterial segments. The long term success rate and the complication rate of the PTA have been reported to be equal to surgical intervention in selected indications. Despite the enormous literature on PTA, little attention has been given to the detailed identification of the etiology, the risk factors and the accepted range of the complications. The aims of this literature study are (a) to evaluate the safety of the balloon assisted PTA in the treatment of stenosed and occluded arterial lesions, (b) to provide detailed information on the etiology of complications, (c) to discuss the indications for the appropriate use of this procedure and (d) to identify the accepted complication rate.