Ultrasound-guided foam sclerotherapy for the treatment of varicose veins.

BACKGROUND: The aim was to assess the early efficacy and complications of ultrasound-guided foam sclerotherapy (UGFS) in a cohort of patients with varicose veins. METHODS: Of 192 consecutive patients referred with varicose veins over 15 months, only 11 chose surgery; the rest underwent UGFS treatment. Polidocanol was foamed 1 : 3 with air. Under ultrasound control via butterfly or Seldinger cannulation, 1 per cent foam was injected into superficial veins and 3 per cent foam into saphenous trunks, up to a total volume of 14 ml. Outcome was defined as complete when occlusion of the saphenous trunk and/or over 85 per cent of the varicosities was achieved, and partial closure when less. RESULTS: In 163 legs, complete occlusion occurred after one intervention, a further 32 after a second, and one after a third (overall 91 per cent). Of the remainder, all other legs achieved partial occlusion after up to three interventions, apart from two legs with great saphenous vein (GSV) incompetence, which failed. All 23 legs with small saphenous veins had complete occlusion after one intervention compared with 64 of 97 legs with GSV incompetence (P < 0.010). Occlusion rates were also higher when the GSV was cannulated directly: 56 of 70 versus 8 of 27 (P < 0.001). CONCLUSIONS: UGFS achieved early complete occlusion safely in over 90 per cent of legs with varicose veins.

A comparison of physiology scores and morphology in a group of patients evaluated for endovascular repair of infrarenal aneurysms.

AIM: Endovascular repair (EVR) of abdominal aortic aneurysms (AAA) is an accepted alternative to open repair (OR). Anatomical suitability for EVR of 196 consecutive AAA referrals is analysed, according to aneurysm size and relative physiological fitness for OR. METHODS: Patients were evaluated for suitability according to 2 sets of arbitrary EVR anatomical criteria: flexible criteria (FC), and a subgroup, rigid criteria (RC) with few technical risks. Suitability was related to aneurysm size and operative risk (POSSUM). RESULTS: Eighty-eight patients (45%) were suitable by FC, 33 (17%) by RC, and 108 (55%) were unsuitable for EVR. Inadequate neck length (56%) and angulation (26%), were principle reasons for unsuitability. Mean AAA diameter was 60.5 mm for the whole group, 58.4 mm for those suitable by FC, 56.5 mm for those suitable by RC and 62.1 mm in those unsuitable (p<0.01). Median physiology scores (interquartile ranges) were 19 (17-21) overall, 18 (17-21) in those suitable FC, 18 (17-19) in those suitable by RC and 19 (18-21) for unsuitable patients (NS). High risk patients with large aneurysms. There were 133 larger aneurysms (=/>55 mm in diameter), of which there were 56 patients with physiology scores =/>20. Of these 16 (29%) and 4 (7%) were suitable by FC and RC, respectively. By comparison, of the remaining 77 with physiology scores of =/<19.35 (45%) were suitable for FC and 15 (19%) for RC (p<0.05). CONCLUSION: Unfit patients with significantly sized aneurysm; ironically those most likely to benefit, tend to be less suitable for EVR.

Role of subintimal angioplasty in the treatment of chronic lower limb ischaemia.

OBJECTIVES: To determine the clinical outcome of subintimal angioplasty (SA) and to assess impact on surgical workload. DESIGN: Retrospective review of a single radiologist's case series. MATERIALS: One hundred and twenty two patients with critical limb ischaemia and 26 with claudication. METHODS: One hundred and fifty eight limbs treated by SA. MAIN OUTCOME MEASURES: Technical success and complications; cumulative patency, limb salvage and survival; affect of SA on vascular workload. RESULTS: The technical success rate was 85%. There were 26 procedural complications (16%) but no patient required emergency surgery; 30-day mortality was 3%. Primary and secondary 12-month patency rates were 27 and 33%. Limb salvage rate was 88% at 12 months. SA initially reduced the number of patients needing arterial surgery, although this then increased due to late failure of SA and an increase in de novo bypass. CONCLUSIONS: SA carries a low risk of major complications and high immediate technical success. Poor long-term patency suggests that SA is not as durable as bypass surgery. However, failed SA did not compromise subsequent surgery, which only became necessary in a proportion of patients. Our data suggests that there is little to be lost by using SA as first-line treatment for patients with limb-threatening ischaemia who are poor operative risks or who have no autologous vein available.

Primary lower limb varicosities arising directly from normal deep venous systems: a series report.

Primary lower limb varicosities classically arise from incompetence of the junction of the superficial and the deep venous systems with retrograde flow into the saphenous veins. However, some patients with superficial varicosities have no demonstrable incompetence of the saphenofemoral or saphenopopliteal junctions. In this study, we examined 52 limbs with primary varicose disease in whom saphenofemoral and saphenopopliteal incompetence had been excluded (clinically and with the hand-held Doppler) using a duplex ultrasound scan. Seventeen (33%) of the limbs had superficial varicosities despite normal long and short saphenous veins. The varicosities in 12 of these legs originated from groin veins, while those in the remaining 5 limbs communicated directly with normal deep veins. In this latter group of limbs, the superficial varicosities were found on the lateral aspect of the thighs only. Primary varicosities arising from normal deep venous systems have not been previously described, and are relatively rare (1.0% of patients referred to our clinic). As this complex venular anatomy was only detected on duplex scanning, we conclude that this study provides further evidence of the need for this imaging modality in patients with varicose disease of uncertain origin and/or those with an unusual distribution of superficial varicosities.

The selective use of duplex scanning in the pre-operative assessment of primary and uncomplicated varicose veins identifies patients with 'early' morphological disease.

The standard management of primary lower limb varicosities (stripping of the long saphenous vein (LSV) with avulsion of the varicosities) is based on the assumption that the disease originates from primary valvular insufficiency and incompetent perforating veins. It has recently been suggested that the LSV may be spared in patients with superficial varicosities without incompetence of this vein, i.e., early disease. However, pre-operative identification of suitable patients for conservative surgery has proved difficult. In this study, we employed selective duplex scanning in cases with primary varicosity in whom sapheno-femoral and sapheno-popliteal incompetence had been excluded both clinically and with the hand-held Doppler (52 limbs [10% of new referrals]). We found that the varicosities in these limbs were of 3 types: (a) those arising independent of superficial vein incompetence (Type 1); (b) those associated with segmental LSV incompetence (Type 2); (c) those in whom incompetence of the sapheno-femoral junction and LSV was missed (Type 3). We therefore suggest that long saphenous varicosity may progress from Type 1 through to Type 3 with each type representing an increase in severity of the disease. We suggest that selective use of duplex scanning will assist in identifying those patients with early stages of the disease who can then be treated effectively with LSV-sparing surgery.

Reoperation for recurrent saphenofemoral incompetence: a prospective randomised trial using a reflected flap of pectineus fascia.

OBJECTIVE AND DESIGN: in 1978 Sheppard described using a flap of pectineus fascia in an attempt to reduce the further development of neovascularised veins at the saphenofemoral junction. The perceived benefits of this manoeuvre have not been tested by a prospective randomised trial. MATERIALS AND METHODS: consecutive patients with symptomatic recurrent varicose veins referred to a single consultant were examined for evidence of further reflux from the saphenofemoral junction. This was subsequently confirmed in forty limbs (thirty-seven patients) by descending venography. All had features of a neovascularised segment. These patients were treated by complete exposure and ligation of the recurrences arising from the common femoral vein, with or without the placement of a flap of pectineus fascia (prospectively randomised). The patients were assessed a minimum of eighteen months later by both clinical examination and duplex ultrasound scanning. RESULTS: six patients were lost to follow-up. This left seventeen limbs remaining in each half of the study. The characteristics in each group were broadly matched. CONCLUSIONS: this study failed to demonstrate any apparent benefit from the application of a flap of pectineus fascia. Most patients showed evidence of re-recurrence arising from the common femoral vein.

A comparison of duplex scanning and continuous wave Doppler in the assessment of primary and uncomplicated varicose veins.

OBJECTIVES: To compare the findings of continuous wave Doppler (CWD) with duplex ultrasound in the assessment of primary and uncomplicated varicose veins, and to determine how their relative roles might be best applied. MATERIALS AND METHODS: One hundred consecutive limbs were studied in 73 patients with primary (no previous surgery) and uncomplicated (no significant skin change) varicose veins. CWD was employed by a single observer; followed by duplex scanning performed "blind" and independently. RESULTS: There were 87 limbs with long saphenous incompetence on duplex; all but four of which were correctly identified by CWD, by which technique there were no false positives. (Sensitivity 95%, specificity 100%.) There were 21 limbs with short saphenous incompetence on duplex, all but two of which were recognised on CWD. However, CWD incorrectly diagnosed reflux at the saphenopopliteal junction in five limbs (false positives) with what was, in fact, segmental reflux in the long saphenous trunk on duplex (sensitivity 90%, specificity 93%.) This would have led to inappropriate exploration of the saphenopopliteal junction had surgery proceeded without checking with duplex. CONCLUSIONS: CWD is adequate for long saphenous incompetence. All "reflux" demonstrated on CWD in the popliteal fossa (about 25% of cases) should be checked by duplex. If this policy had been followed, all the patients in this study would have undergone the correct procedure. The only "errors" would have been missing coexistent short saphenous incompetence in two limbs undergoing appropriate long saphenous exploration.

Intraoperative heparinisation, blood loss and myocardial infarction during aortic aneurysm surgery: a Joint Vascular Research Group study.

OBJECTIVES: The primary aim of this prospective multi-centre study involving patients undergoing elective abdominal aortic aneurysm (AAA) surgery was to investigate the relationship between intraoperative intravenous heparinisation, blood loss during surgery and thrombotic complications. METHODS: Two hundred and eighty-four patients were randomised to receive intravenous heparin (n = 145) or no heparin (n = 139). Groups were evenly matched for age, sex, weight, aneurysm size, haemoglobin concentration, platelet counts and distal occlusive disease measured by ankle/brachial systolic pressure. RESULTS: There were no statistically significant differences in blood loss (median 1400 ml vs. 1500 ml; z = 0.02, p = 0.98, 95% C.I. = -200 to 200), blood transfused (4.0 units vs. 4.0 units; z = 1.09, p = 0.28, 95% C.I. = -1 to 0) or distal thrombosis between the two groups. However, analysis of the clinical outcome revealed that 5.7% of the non-heparin group but only 1.4% of the heparinised patients suffered a fatal perioperative myocardial infarction (MI); p < 0.05. All MI, including non fatal events, affected 8.5% and 2% respectively (p = 0.02). CONCLUSIONS: Heparin does not increase blood loss or the need for blood transfusion during surgery. Heparin is not necessary to prevent distal thrombosis when the aorta is cross clamped. The results of the study are consistent with the known mechanisms leading to intraoperative MI and strategies for its prevention. Intravenous heparin, given before aortic cross clamping, is an important prophylaxic against perioperative MI in relation to AAA surgery.

Benzodiazepine use among injecting heroin users.

OBJECTIVES: To determine the extent and patterns of benzodiazepine use among heroin users, and whether preferences for different benzodiazepines exist among this group. SUBJECTS AND METHODS: 210 heroin users who were current users of benzodiazepines volunteered for the study and completed a structured questionnaire. RESULTS: Heroin users had used a median of five different benzodiazepines, most commonly diazepam. Almost half the subjects (48%; 95% CI, 41-55) had injected benzodiazepines, 17% (95% CI, 12-22) within the preceding six months. Diazepam and temazepam were the most widely injected benzodiazepines. CONCLUSIONS: Flunitrazepam, diazepam and temazepam should be prescribed to heroin users with caution. A less popular and rarely injected benzodiazepine, nitrazepam, may be a better option for this group.

Diagnostic features and management of bacterial arteritis with false aneurysm formation.

Primary bacterial arteritis with false aneurysm formation is an uncommon condition. This report presents seven patients admitted to one unit over a 5-year period. Interesting aspects of the clinical presentation are discussed. The importance of surgical debridement, extra-anatomic bypass, antibiotic therapy and antibiotic irrigation of the infected aneurysm cavity is stressed. The relative merits of extra-anatomic bypass and in situ grafting for aortic infection are discussed. By following these principles, this series of patients have had a successful surgical outcome and all the signs of infection have been eradicated.

The morphology of recurrent varicose veins.

Over an 18-month period, of 444 patients referred for treatment for varicose veins, 95 (21%) had had previous surgery. By means of clinical hand-held Doppler and in selected venographic evaluation these were subdivided into three groups as follows. Type 1:29 of the 95 patients had recurrence through thigh perforators. Type 2:10 patients had developed incompetence through a second saphenous system, in nine of the 10 in the short saphenous having had previous long saphenous surgery. Type 3:46 patients had recurrent sapheno-femoral incompetence and 10 sapheno-popliteal incompetence. A persistent long saphenous trunk in the thigh was present in approximately two-thirds of cases of types 1 and 3. In over half of the type 3 patients saphenofemoral recurrence was by reconstitution of the junction by neovascularisation. These morphological studies demonstrate why there may be an increased risk of recurrence if the long saphenous trunk is not excised at the time of primary surgery.

Femoral pulse palpation before and after exercise: a guide to occult iliac stenosis?

Iliac artery stenosis may produce significant haemodynamic impairment in the absence of any visible iliac narrowing on uniplanar arteriography. Such stenoses may be unmasked by the use of biplanar angiography or by direct femoral pressure measurements before and after papaverine. The aim of this study is to determine whether simple femoral pulse palpation is a reliable guide to haemodynamic impairment in the radiologically normal aorto-iliac segment, and in particular whether occult iliac stenosis can be unmasked by noting a reduction in the palpable pulse after exercise. Twenty-nine limbs with normal aorto-iliac segments on uniplanar angiography were examined at rest and after exercise and the femoral pulses were graded clinically. Haemodynamic assessment was performed by direct femoral pressure measurements before and after intra-arterial papaverine injection. Significant haemodynamic impairment was noted in 8 out of 29 limbs. Six of these 8 limbs had normal resting femoral pulses and 4 of the 8 limbs had a diminished pulse after exercise. Four out of the 21 limbs with normal haemodynamic studies had diminished pulses after exercise. Resting femoral pulse palpation is a poor guide to radiologically occult but haemodynamically significant iliac stenosis although pulse palpation after exercise may help to unmask a proportion of such stenoses.