Neovascularisation after surgery for recurrent saphenofemoral incompetence: does surgical dissection technique matter?

BACKGROUND: The effect of the type of surgery on neovascularisation in the groin is unknown. The aim of the present study was to compare three different surgical techniques used for recurrent saphenofemoral incompetence in view of their effect on neovascularisation in the groin at short- and long-term follow-up after surgery. PATIENTS AND METHODS: 36 consecutive patients undergoing surgery for recurrent saphenofemoral incompetence were randomised. 12 patients underwent sharp dissection with knife or scissors and excision and ligation of scar tissue using absorbable suture material; 12 had dissection with electrocoagulation and 12 dissection with ultrasound (Ultracision Harmonic Scalpel). Clinical outcome was assessed using the venous clinical severity score and venous disability score, and the saphenofemoral junction was evaluated by means of duplex sonography three months and seven years after the operation respectively. If neovascularisation was present, the maximal diameter of new refluxing veins in the groin was measured. RESULTS: There was no statistically significant difference between the three surgical techniques. Duplex ultrasound showed neovascularisation with an average maximal diameter (± standard error) of the newly formed refluxing vessel of respectively 2.00 (± 0.63) mm, 1.00 (± 0.45) mm and 0.50 (± 0.50) mm after three months and 4.29 (± 1.41) mm, 3.32 (± 0.90) mm and 3.00 (0.83) mm after seven years (no significant difference between groups). After seven years no reflux was detected in 8/36 patients, no varicose veins were found in 14/36 patients. The patients were less symptomatic than before our redo operation and no one needed reoperation within the seven years. CONCLUSIONS: Dissection techniques in the groin did not influence the clinical and sonographic result at 3 months and at 7 years after redo surgery for recurrent varicose veins.

Recurrence after surgery for varices in the groin is not dependent on body mass index.

OBJECTIVE: To investigate if the body mass index (BMI) differs between different groups of patients (incomplete ligation also defined as technical error, neo-revascularisation, uncertain and mixed) in recurrent same site inguinal varices after surgery (REVAS). METHODS: During a six and half year time span, we retrospectively analysed 203 consecutive procedures in 153 patients undergoing recurrent same site vein surgery in the groin. Individual BMI was calculated and compared within the different REVAS nature of the source groups. RESULTS: The median BMI was 28 for patients undergoing recurrent vein surgery in the groin with no relevant difference in BMI between the different source groups (confidence interval for the difference of adjusted group means equals [-1.5, 2.6]). CONCLUSIONS: There is no relevant difference in BMI between the two commonest REVAS groups. This may be due to small sample size, but confidence limits for difference of.

Follow-up after deep venous thrombosis in azygos continuation.

BACKGROUND: To determine the sequelae of patients after deep venous thrombosis inpatients with azygos continuation defined as agenesis of the inferior vena cava with collateral flow. PATIENTS AND METHODS: Five patients post deep venous thrombosis in the context of azygos continuation were followed up clinically and with colour duplex ultrasonography. RESULTS: All five patients had to our knowledge after the initial deep venous thrombosis no further thromboembolic events. Three patients after isolated iliac thromboses are symptom free or nearly symptom free, two after more extended thromboses still sufferfrom venous claudication. Four patients are without anticoagulation, one patient is permanently orally anticoagulated. CONCLUSIONS: Azygos continuation may not influence the risk of recurrent venous thrombo-embolism nor the outcome of a deep venous thrombosis. Careful deep venous thrombosis prophylaxis in patients with azygos continuation may be sufficient when a risk factor is present but conclusions lack due to the small numbers of patients of enough supportive data.

A randomised trial of ultrasonic dissection versus electrocoagulation to reduce lymphatic complications after surgery for recurrent sapheno-femoral incompetence.

OBJECTIVE: Prospectively to compare lymphatic drainage after ultrasonic dissection, an electrocoagulation technique and sharp dissection in the groin during surgery for recurrent sapheno-femoral incompetence. DESIGN: Prospective, randomised study comparing three surgical techniques. METHODS: Thirty-six consecutive patients undergoing surgery for recurrent sapheno-femoral incompetence were randomised. Twelve patients underwent dissection with ultrasound, 12 with electrocoagulation and 12 controls had sharp dissection with ligation of scar and lymphatic tissue using absorbable suture material. RESULTS: The mean drain output per patient was 13.5 ml in the ultrasonic group, 15.4 ml in the electrocoagulation group and 8.3 ml in the suture ligation group. Six minor cases of lymphatic leakage occurred in the ultrasonic group. This resulted in no clinical problem. There were no other significant differences between the three groups. CONCLUSIONS: There is no detectable advantage for the use of ultrasound or electrocoagulation in recurrent saphenous high ligation compared to sharp dissection.

Morbidity in superficial thrombophlebitis and its potential surgical prevention.

Thrombophlebitis is a common condition which can lead to deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE). Thrombophlebitis can reach the deep venous system via the long or short saphenous vein or via perforating veins. Between the 1st of January 1999 and the 31st of December 2000 a total of 17 cases of superficial (or ascending) thrombophlebitis closer than 5 cm to the deep venous system were surgically treated in our clinic. 14 times the long saphenous vein was affected and 3 times the short-saphenous vein. The age of the nine females and seven males ranged from 31 to 77 (mean of 54.6) years. Duplex ultrasound was performed in all patients. In the case of a deep venous thrombosis (four cases) a computer tomography scan (CT) of the pelvis and abdomen was performed to define the extension of DVT. In all 17 (100%) cases a high ligation (crossectomy) and in four (23.5%) cases a venous thrombectomy was performed. In all of these four cases the DVT was limited to the common femoral vein. In all seventeen procedures including venous thrombectomy there was no mortality and no relevant morbidity. Mean hospitalization time was 3.1 days for crossectomy with thrombectomy, and 1.8 days for crossectomy alone. Follow-up has been so far uneventful (mean follow-up time being 12 months in the case of a DVT). In the literature there is no clear concept of how to treat, conservatively or operatively, ascending thrombophlebitis. The surgical procedure can be performed under local anesthesia, and it is safe and efficient.

Percutaneous catheter thrombus aspiration for acute or subacute arterial occlusion of the legs: how much thrombolysis is needed?

OBJECTIVE: To evaluate the role of a combined percutaneous endovascular approach including thrombus aspiration, catheter thrombolysis, and percutaneous transluminal angioplasty (PTA) to treat acute and subacute occlusions of native leg arteries. MATERIALS AND METHODS: Retrospective evaluation of the effectiveness and safety of this catheter therapy in 89 consecutive patients (93 legs) in a single centre. RESULTS: Treatment was initially successful in 90% of legs. Mortality at 30 days was 8%, and at 12 months 19%. Amputation-free survival at 12 months was 78%. Aspiration alone was sufficient in 31% of cases, urokinase (mean dose 112 500+/-55 900 IU) was used in 22%, PTA was added in 69%. There was no major bleeding except for one false aneurysm treated by ultrasound-guided compression. Secondary interventions within 12 months were required in 30% of cases (14 endovascular, 16 open surgical procedures). CONCLUSIONS: Catheter thrombus aspiration in combination with thrombolysis and/or PTA is highly effective. Only in a minority of patients are thrombolytics in modest doses necessary, and serious bleeding complications are rare. We recommend this procedure as first-line treatment for acute or subacute infrainguinal arterial occlusions.

Active renin, prorenin, and renin gene expression after reduced renal perfusion pressure in term ovine fetuses.

We studied the pattern of plasma active renin concentration (ARC), prorenin concentration (PRC), renal renin concentration, and the renin mRNA levels in ovine fetuses subjected for 24 h to reduced renal perfusion pressure (RPP). The results obtained in five animals (133.8 +/- 1.4 days of gestation) in which RPP was reduced by 10 mmHg were compared with those in seven control fetuses (130.3 +/- 0. 8 days of gestation) without pressure reduction. Plasma samples were obtained before and at intervals of 24 h after initiating reduced RPP. The plasma ARC increased within 60 min of reduced RPP, reaching a maximum (13.0 +/- 4.7 vs. 115.7 +/- 23.8, P < 0.01) at 3 h. The ARC then declined toward control values. In contrast, plasma PRC did not increase consistently until 4 h into reduced RPP, with maximal levels at 24 h (8.2 +/- 2.4 vs. 87.7 +/- 21.9, P = 0.016). Within the kidney PRC, but not ARC, increased significantly, by 2.5-fold. Reduced RPP also increased renal renin mRNA levels (P = 0.004). We conclude that a chronic reduction in RPP in the near-term ovine fetus increases renal PRC and is associated with increased plasma prorenin levels. The data suggest that the conversion of prorenin to active renin is an important regulation point of the renin ANG system during development.

Cortisol infusion depresses the ratio of bioactive to immunoreactive ACTH in adrenalectomized sheep fetuses.

We examined the effects of exogenous cortisol on plasma immunoreactive adrenocorticotropic hormone (iACTH), bioactive ACTH (bACTH), and ACTH-(1-39) in nine adrenalectomized fetuses at 126-130 and 136-140 days of gestation. Fetuses received 4 h of cortisol (2 micrograms.kg-1.min-1) or saline infusions on consecutive days. Blood was obtained before and at intervals during infusions. Arterial blood gases and hematocrits were normal and did not change with age. Plasma cortisol did not change during saline infusions but increased significantly (range 30-70 ng/ml) during cortisol infusions. Basal plasma iACTH, bACTH, ACTH-(1-39), and bACTH-to-iACTH and ACTH-(1-39)-to-iACTH ratios were significantly higher in the older fetuses. Cortisol infusions decreased plasma iACTH, bACTH, and ACTH-(1-39) in both groups, and the suppression as a percent of the baseline was similar. The bACTH-to-iACTH ratio declined to the same level at 126-130 (0.201 +/- 0.040 to 0.051 +/- 0.002) and 136-140 (0.389 +/- 0.088 to 0.046 +/- 0.002) days of gestation. These data suggest that physiological concentrations of cortisol selectively inhibit bACTH secretion, and the ACTH response to cortisol inhibition is not different between 126 and 140 days of gestation in adrenalectomized sheep fetuses.

Effects of chronic infusion of angiotensin II on renin and blood pressure in the late-gestation fetal sheep.

OBJECTIVES: Our purpose was to determine whether chronic physiologic elevations in plasma angiotensin II levels decrease plasma renin concentration, alter the relationship between active renin and prorenin in fetal plasma and kidney, and depress the expression of renal renin messenger ribonucleic acid in the fetus. STUDY DESIGN: Seventeen chronically catheterized ovine fetuses at approximately 130 days' gestation were infused with either angiotensin II (48.9 +/- 3.5 ng/kg x min) or vehicle (5% glucose in water) for 72 hours. RESULTS: Mean arterial pressure increased significantly by 1 hour of infusion and continued to increase throughout the infusion. The plasma active renin concentration was significantly decreased by 1 hour of the infusion, whereas the prorenin concentration was not decreased until 24 hours of the infusion. After 72 hours of angiotensin II infusion the renal tissue prorenin content decreased (21.5 +/- 5.1 ng/mg x hr angiotensin I vs 46.4 +/- 6.6 ng/mg - hr angiotensin I in the control animals, p = 0.01), whereas the active renin concentration did not change (26.6 +/- 5.1 ng/mg x hr angiotensin I vs 35.1 +/- 5.4 ng/mg x hr angiotensin I in the control animals, p = 0.28). The renal renin messenger ribonucleic acid expression tended to be lower in the angiotensin II-treated fetuses (p = 0.10). CONCLUSION: Chronic physiologic increases in fetal plasma angiotensin II suppress the secretion of active and prorenin and alter the relationship between processing and secretion of renin in the fetal kidney.

Regulation of bioactive and immunoreactive ACTH secretion by CRF and AVP in sheep fetuses.

The purpose of this study was to determine the effects of corticotropin-releasing factor (CRF) or arginine vasopressin (AVP) on the secretion of bioactive adrenocorticotropic hormone (bACTH) and immunoreactive ACTH (iACTH), the latter being measured by radioimmunoassay and separate two-site immunoradiometric assays for ACTH-(1-39) and ACTH precursors. Experiments were performed on chronically catheterized fetal sheep at 0.70 (n = 9) and 0.90 (n = 8) gestation. Each fetus received a 15-min infusion of CRF, AVP, or saline on 3 consecutive days. Blood was obtained before and 15 and 60 min after the infusion began. CRF significantly increased iACTH at 15 (younger group) and 60 min (both groups). CRF significantly increased bACTH and the bACTH-to-iACTH ratio (bACTH/iACTH) in both groups at 15 and 60 min. AVP significantly increased iACTH, bACTH, and bACTH/iACTH in both groups at 15 min. In two subgroups (n = 4/subgroup), CRF significantly increased ACTH-(1-39) and ACTH precursors at 15 and 60 min. CRF increased the ratio of ACTH-(1-39) to ACTH precursors [ACTH-(1-39)/ACTH precursors] at 15 (younger group) and 60 min (both groups). AVP increased ACTH-(1-39), ACTH precursors, and ACTH-(1-39)/ACTH precursors in both groups at 15 min. These findings show that both CRF and AVP can stimulate the secretion of bACTH, ACTH-(1-39), and ACTH precursors at 0.70 and 0.90 gestation. The proportional increments in bACTH/iACTH and ACTH-(1-39)/ACTH precursors suggest that CRF and AVP evoke selective increases in bACTH and ACTH-(1-39).

Cortisol up-regulates corticotropin releasing factor gene expression in the fetal ovine brainstem at 0.70 gestation.

Glucocorticoids are important for the development of the central nervous system. In the ovine fetus, increased levels of plasma cortisol at term provide a stimulus to initiate parturition. CRF is central to this event in that it is one of the main modulators of the hypothalamic-pituitary-adrenal (HPA) axis. The purpose of the present study was to determine the effect of physiological increases in fetal plasma cortisol levels on corticotropin-releasing factor (CRF) gene expression in the developing ovine brain. Fetal plasma cortisol levels were chronically elevated at 0.70 gestation (100 days) to physiological levels found at 0.90 gestation (130 days; term 145 +/- 2 days) when glucocorticoid-induced maturational changes are known to occur in the HPA axis. The 3' end of the ovine CRF gene encodes 4 putative polyadenylation (poly(A)) signals that may post-transcriptionally regulate gene expression through stability, translation and localization of the mRNA in a temporal and spatial manner. To determine whether CRF mRNA levels or poly(A) site usage are differentially regulated by cortisol in a region-specific manner, we used an RNase protection assay with an antisense CRF RNA probe from the 3' coding and untranslated regions of the gene to quantify changes in mRNA levels in the hypothalamus (Hypo), hippocampal-amygdala complex (H and A), frontal cerebral cortex (FCC) and brainstem. Our novel finding was a 3.5-fold increase in CRF mRNA levels in the medulla oblongata of fetuses from the cortisol group compared to those from the saline group (P = 0.001). CRF mRNA levels in the Hypo, H and A and FCC did not change significantly in fetuses from the cortisol group.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of chronic infusion of cortisol on renin gene expression and renin response to hemorrhage in fetal lambs.

In the ovine fetus, plasma renin levels increase close to term, and renin responses to various stimuli are enhanced when compared with responses earlier in gestation. These changes are accompanied by increases in renal renin gene expression and renin content, and they occur in conjunction with elevations in fetal plasma cortisol. Thus, the purpose of this study was to test the hypothesis that a chronic, physiologic elevation in fetal plasma cortisol in early gestation would increase activity in the renin-angiotensin system prematurely. We studied fetuses (control, n = 8; cortisol infused, n = 11) at 94 +/- 2 d of gestation. Fetal vessels were catheterized, and cortisol or saline solution was infused for 6 d. At the end of infusion, fetuses were hemorrhaged approximately 30% of estimated blood volume. Blood samples were collected to measure plasma renin concentration. Then the animals were killed, and kidneys were removed to measure renin mRNA and renin content. Plasma cortisol concentrations in the control and cortisol-treated animals were 7.2 +/- 0.8 and 57.7 +/- 8.6 nmol/L (p < 0.01), respectively. Basal plasma renin concentrations were similar in the two groups 3.2 +/- 0.4 versus 4.4 +/- 1.8 ng of angiotensin I/mL/h, and there was a significant increase after hemorrhage in the cortisol-treated group only. Renal renin content and mRNA levels were similar in the two groups. These data indicate that chronic increases in cortisol in fetal lambs at 0.65 gestation significantly enhance the renin response to hemorrhage but do not alter renal renin gene expression.

The effects of chronically elevated plasma cortisol on the bioactive and immunoreactive corticotropin secretory responses to hemorrhage in the fetal sheep at 0.70 gestation.

OBJECTIVE: Our purpose was to test the hypothesis that a long-term physiologic elevation of plasma cortisol would not alter the basal plasma concentrations of immunoreactive and bioactive corticotropin, yet it would evoke an increase in the ratio of bioactive to immunoreactive corticotropin secreted during stress. We define immunoreactive corticotropin (i.e., immunoreactive corticotropin-like activity) as that material obtained from plasma that displaces the binding of tracer quantities of iodine 125-labeled corticotropin from antisera directed toward the 6-24 portion of the corticotropin (1-39) molecule, whereas bioactive corticotropin (i.e., bioactive corticotropin-like activity) is defined as that material obtained from plasma that stimulates the secretion of corticosterone from dispersed rat adrenal cells in comparison to known concentrations of synthetic corticotropin (1-39). STUDY DESIGN: We studied the plasma immunoreactive and bioactive corticotropin response to hemorrhage in eight vehicle- and 10 cortisol-treated fetal sheep at 101 +/- 1 days of gestation. At 94 +/- 1 days of gestation each fetus began receiving a 6-day continuous infusion of either vehicle or cortisol. During the last 10 minutes of the infusion about 30% of the estimated blood volume was withdrawn from the fetuses. RESULTS: Basal plasma cortisol was significantly higher in the cortisol group (20.6 +/- 2.3 ng/ml vs 2.7 +/- 0.3 ng/ml). Basal plasma immunoreactive ACTH and bioactive corticotropin were not significantly different between groups. In both groups the plasma immunoreactive corticotropin significantly increased during hemorrhage, although the increase in the cortisol group (32 +/- 8 to 40 +/- 8 pg/ml) was significantly less than that in the vehicle group (45 +/- 14 to 86 +/- 28 pg/ml). In contrast, plasma bioactive corticotropin increased significantly during hemorrhage in the vehicle group (10 +/- 1 to 16 +/- 3 pg/ml) alone. CONCLUSIONS: In the early-gestation fetal sheep a chronic elevation of plasma cortisol does not significantly lower basal plasma immunoreactive and bioactive corticotropin. Nevertheless, it (1) attenuates the immunoreactive corticotropin response and (2) abolishes the bioactive corticotropin response to hemorrhage. It is possible that some of the negative feedback effects of plasma cortisol on corticotropin release occur at the posttranslational level.

Corticotropin releasing factor mRNA and peptide levels are differentially regulated in the developing ovine brain.

The regulation of CRF mRNA and protein in the developing ovine brain has been studied to assess the hypothesis that CRF is differentially regulated in the hypothalamus (Hypo), hippocampal-amygdala complex (H & A), frontal cerebral cortex (FCC) and brainstem (BS). We used a quantitative RNase protection assay and radioimmunoassay to determine mRNA and peptide concentrations, respectively, from the last third of gestation until term (i.e., from 95 to 142 days gestation (dg); term approximately 145 days). The major findings from this study are: (1) Hypothalamic CRF mRNA was increased by 2-fold in 140-142 dg fetuses compared to 128-138 and 95-123 dg fetuses; P = 0.016. (2) In the hypothalamus of 140-142 dg fetuses, there was a 2.5-fold increase in CRF mRNA derived from polyadenylation at poly(A) sites 2, 3 or 4; P = 0.005. (3) In 128-138 dg fetuses, CRF mRNA in the frontal cortex was 2-fold higher than in the other brain regions during this time period; P = 0.008. (4) CRF peptide concentrations in the Hypo were 2.5-fold higher in 140-142 dg fetuses compared to 95-106 and 128-138 dg fetuses; P = 0.007. (5) CRF peptide concentrations in the frontal cortex were 5.5-fold higher in 140-142 dg fetuses compared to fetuses at 95-106 dg; P = 0.004. (6) CRF peptide concentrations in the H & A were 5-fold higher in 140-142 dg fetuses compared to 95-106 dg fetuses; P = 0.029. The results from the present study demonstrate for the first time that CRF mRNA and peptide are differentially regulated in a region-specific manner during development.

Influence of local finger cooling on laser Doppler flux and nailfold capillary blood flow velocity in normal subjects and in patients with Raynaud's phenomenon.

We examined the influence of local cooling (-15 degrees C, 60 sec) on blood flow velocity in nailfold capillaries and on laser Doppler flux (LDF) at the fingertip in 12 patients with primary Raynaud's phenomenon (PRP) and 13 patients with secondary Raynaud's (SRP) in comparison with 10 health controls. Skin temperature at the pulp of the finger decreased significantly during local cooling in RP but not in controls. LDF before cooling was comparable between patients and controls and dropped significantly under cooling. Flux motions at the fingertip were present in all individuals with 7.9-9.1 cycles/min. Flux motions persisted throughout the cooling test and faded away in 5 patients (1 PRP, 4 SRP) with cooling. Frequency of LDF motions was little influenced by a change in skin temperature. The amplitudes were dampened in relation to the drop in LDF level during local cooling in patients with RP. We conclude that LDF does respond to local cooling of the fingertip by significant decrease of perfusion but not with regard to flux motions. The wide overlap of the single values does not allow as good a separation of patients with RP from controls as capillary microscopy.

Bioactive-to-immunoreactive ACTH activity changes with severity of stress in late-gestation ovine fetus.

The late-gestation ovine fetus (> 130 days, 0.90 gestation, full term 145 days) is capable of increased pituitary-adrenal activity following a variety of stressors. To examine the relationship between plasma immunoreactive adrenocorticotropic hormone (iACTH) and bioactive ACTH-like activity (bACTH), late-gestation fetuses were studied under nonstress (group I, chronically catheterized), "mild" stress (group II, acutely exteriorized), or marked stress (group III, acutely exteriorized and hemorrhaged 30% of blood volume). Plasma iACTH was determined by standard radioimmunoassay. Plasma bACTH was determined by a bioassay that utilized dispersed rat adrenal cells. Plasma iACTH was lower in group I than in groups II or III (78.4 +/- 16.3 vs. 320 +/- 116 and 622 +/- 144 pg/ml, respectively, mean +/- SE, P < 0.05 group I vs. III). Plasma bACTH was significantly lower in groups I and II than in group III (13.8 +/- 2.7 and 52 +/- 22 vs. 601 +/- 106 pg/ml, respectively, P < 0.05). The ratio of bACTH to iACTH was low in groups I and II but elevated in group III (0.188 +/- 0.028 and 0.091 +/- 0.07 vs. 0.996 +/- 0.122, P < 0.05). We conclude that the amount of bACTH compared with iACTH in the late-gestation fetus is low under nonstress states or mild stress and that bACTH increases disproportionately compared with iACTH after marked stress. This suggests that a change in ACTH processing and/or secretion is associated with stimulus intensity in the late-gestation ovine fetus.

[Color-coded Doppler sonography in iatrogenic spurious aneurysms in the groin]. / Farbkodierte Duplexsonographie bei iatrogenen Aneurysmata spuria in der Leiste.

Pseudoaneurysm of the femoral artery occurred in five patients (aged between 61 and 82 years) after catheterization of the artery, four times after percutaneous transluminal angioplasty of the leg arteries and once after left-heart catheterization. The pseudoaneurysms were correctly diagnosed by colour-coded duplex Doppler sonography by demonstrating turbulence within the aneurysm and a connection to the femoral artery with bidirectional shunting. Enough pressure was exerted with the instrument head to stop flow in the aneurysm and its connection to the artery without, however, significantly reducing arterial flow. After 30-35 min flow into the aneurysm had ceased even when the compression was released. Re-examination up to 11 months later (mean of 7.6 months) indicated that the treatment had been successful in all.