Valsalva maneuver in phlebologic practice.

Forced expiration against an airway obstruction was originally described as a method for inflating the Eustachian tubes and is accredited to Antonio Maria Valsalva (1666-1723). The Valsalva maneuver is commonly applied for different diagnostic purposes. Its use for phlebologic diagnosis is the object this review. Venous reflux is the most frequent pathophysiologic mechanism in chronic venous disease. Reflux is easily visualized by duplex ultrasound when properly elicited, in standing position. A simple way to elicit reflux is the so-called "compression-release maneuver": by emptying the muscle reservoir, it determines a centrifugal gradient, dependent on hydrostatic pressure, creating an aspiration system from the superficial to the deep system. The same results are obtained with dynamics tests activating calf muscles. The Valsalva maneuver elicits reflux by a different mechanism, increasing the downstream pressure and, thus, highlighting any connection between the source of reflux and the refluxing vessel. The Valsalva maneuver is typically used to investigate the saphenofemoral junction. When the maneuver is performed correctly, it is very useful to analyse several conditions and different hemodynamic behaviours of the valvular system at the saphenofemoral junction. Negative Valsalva maneuver always indicates valvular competence at the saphenofemoral junction. Reverse flow lasting during the whole strain (positive Valsalva maneuver) indicates incompetence or absence of proximal valves. Coupling Valsalva maneuver to compression-release maneuver, with the sample volume in different saphenofemoral junction sections, may reveal different hemodynamic situations at the saphenofemoral junction, which can be analysed in detail.

The E point: a new echographic great saphenous identification sign in specific anatomical variants and applications.

Objective To describe a new ultrasound marker of the Great Saphenous Vein at the groin. Method An ultrasound marker of the Great Saphenous Vein was identified as follows: the Great Saphenous Vein was tracked in cross-sectionally starting from the Sapheno Femoral Junction and optimally visualized where it crosses the Adductor Longus muscle, i.e., 3-5 cm below the junction. This marker, corresponding to a very superficial position of Great Saphenous Vein, was named "E Point," where E means easy to find. The search for the E point was performed on 230 limbs of 126 subjects with or without chronic venous insufficiency (training population) and the method was validated in 58 subjects (testing population). Results The E point was successfully recorded in 128/144 (89%) pathologic and in 85/86 (99%) healthy limbs. Being free from other structures, at the E point the Great Saphenous Vein was always easily calibrated. In 17 cases, the E point could not be identified due to an hypoplasic Great Saphenous Vein; in such instances, the Anterior Accessory Saphenous Vein was well evident and substituted for the Great Saphenous Vein as the main draining vein at the groin. Conclusion The E point identifies the Great Saphenous Vein in healthy and varicose patients. Failure to identify the E point indicates Anterior Accessory Saphenous Vein dominance over a hypoplasic Great Saphenous Vein.

Dilution of a mepivacaine-adrenaline solution in isotonic sodium bicarbonate for reducing subcutaneous infiltration pain in ambulatory phlebectomy procedures: a randomized, double-blind, controlled trial.

BACKGROUND: Varicose veins are treated under local infiltration anesthesia. Literature shows that adding sodium bicarbonate reduces the pain associated with local infiltration anesthesia. Nonetheless, sodium bicarbonate is underused. OBJECTIVE: We sought to assess if the use of a solution of mepivacaine 2% plus adrenaline with sodium bicarbonate 1.4% results in less pain associated with local infiltration anesthesia preceding ambulatory phlebectomies, compared with standard preparation diluted with normal saline. METHODS: In all, 100 adult patients undergoing scheduled ambulatory phlebectomy were randomized to receive either a solution of mepivacaine chlorhydrate 2% plus adrenaline in sodium bicarbonate 1.4% or a similar solution diluted in normal saline 0.9%. RESULTS: Median pain scores associated with local infiltration anesthesia reported in the intervention and control groups were 2 (SD=1.6) and 5 (SD=2.0) (P<.0001), respectively. A general linear model with bootstrapped confidence intervals showed that using the alkalinized solution would lead to a reduction in pain rating of about 3 points. LIMITATIONS: Patients were not asked to distinguish the pain of the needle stick from the pain of the infiltration. Moreover, a complete clinical study of sensitivity on the infiltrated area was not conducted. CONCLUSIONS: Data obtained from this study may contribute to improve local infiltration anesthesia in ambulatory phlebectomy and other phlebologic procedures.

The foot venous system: anatomy, physiology and relevance to clinical practice.

OBJECTIVE: This review aims to summarize present knowledge of foot venous return, with a special interest in clinical and research implications. METHODS: It is based on the latest available publications on foot anatomy and hemodynamics. MATERIALS ANATOMY: Five systems are described: the superficial veins of the sole, the deep veins of the sole (with particular attention to the lateral plantar vein), the superficial dorsal plexus, the marginal veins and the dorsal arch and the perforating system. The Foot Pump: The physiology of venous return is briefly described, with an emphasis on the differences between standing and walking and the interplay of the foot and calf venous systems. RESULTS: The hypothesis that the foot and calf venous systems may be in conflict in several clinical conditions (localization of leg ulcers, corona phlebectatica, foot vein dilatation, arteriovenous fistulas of the foot, foot-free bandaging) is presented, briefly discussed, and mechanistically interpreted. CONCLUSIONS: Foot venous return could be more important than is commonly thought. Certain clinical conditions could be explained by a conflict between the mechanisms of the foot pump and the leg pumps most proximal to the foot, rather than by generic pump insufficiency, with possible effects on treatment and compression strategies.

Patients with migraine with aura have increased flow mediated dilation.

BACKGROUND: Endothelium-derived nitric oxide (NO) mediates the arterial dilation following a flow increase (i.e. flow-mediated dilation, FMD), easily assessed in the brachial artery. NO is also involved in cerebral hemodynamics and it is supposed to trigger vascular changes occurring during migraine. This study aimed at investigating whether migraine patients present an altered response to NO also in the peripheral artery system. METHODS: We enrolled 21 migraineurs (10 with aura [MwA], 11 without aura [MwoA]), and 13 controls. FMD was evaluated with ultrasound in all subjects by measuring the percentage increase of the brachial artery diameter induced by hyperaemia reactive to sustained cuff inflation around the arm above systolic pressure. FMD values were then normalized for shear stress. RESULTS: Normalized FMD values were higher in patients with MwA (28.5 10-2%.s) than in controls (9.0 10-2%.s) and patients with MwoA (13.7 10-2%.s) (p < 0.001). FMD was over the median value (19%) in 23.1% of controls, in 45.5% of the MwoA patients, and in 90% of the MwA patients. CONCLUSIONS: Migraineurs with aura present an excessive arterial response to hyperaemia, likely as an effect of an increased sensitivity to endothelium-derived nitric oxide. This phenomenon observed peripherally might reflect similar characteristics in the cerebral circulation.

Endothelial dysfunction in chronic obstructive pulmonary disease.

BACKGROUND: Cardiovascular diseases are prevalent in people with chronic obstructive pulmonary disease (COPD). We hypothesized that endothelial dysfunction could be a marker of the proatherogen status in COPD. METHODS AND RESULTS: We measured endothelial dysfunction by flow-mediated dilation (FMD) and after sublingual administration of nitroglycerin (nitrate-mediated dilation: NMD) in 44 COPD patients and 48 controls. Compared with controls COPD patients had worse mean FMD (5.4% vs 8.2%, P < .001) and NMD (12.0% vs 13.9%, P = .007). FMD was inversely related to FEV1/VC ratio (r = -0.327, P = .030). The negative association between COPD and FMD was confirmed after correction for potential confounders in a multiple linear regression model (beta = -0.019, P = .002). In the same model NMD (beta = 0.396, P < .001) was positively associated with FMD. CONCLUSIONS: Endothelial-dependent and, to a lesser extent, endothelial-independent dilations are significantly impaired in COPD, and the impairment is proportional to the severity of bronchial obstruction.

Catastrophic antiphospholipid syndrome presenting with multiorgan failure and gangrenous lesions of the skin.

A 38-year-old woman with a 20-year history of systemic lupus erythematosus and positive anticardiolipin antibodies developed anuria and hypotension. 20 days before, she had discontinued 25 mg prednisone, but not warfarin, on medical advice. 3 days before admission, she developed extensive necrosis and blisters involving both arms and legs and a multiorgan failure. She improved after immunosuppressive and antibiotic therapy, 3 sessions of dialysis and 5 sessions of plasmapheresis. It was decided that she could be discharged after 45 days. Her skin lesions were complicated by several abscesses requiring surgical drainage and finally healed almost completely within 9 months. Catastrophic antiphospholipid syndrome is a distinctly rare dramatic condition characterized by widespread thrombosis of small vessels, which in the present case was likely triggered by the abrupt withdrawal of steroid therapy. It should be borne in mind in cases of multiorgan failure, which does not recognize a well-defined etiology.

The association between metabolic syndrome and restrictive ventilatory dysfunction in older persons.

BACKGROUND: The restrictive, but not the obstructive respiratory dysfunction, is associated with an increased risk of developing type 2 diabetes mellitus. Our aim was to verify in an elderly nondiabetic population whether a restrictive respiratory pattern was associated with a higher prevalence of metabolic syndrome and increased insulin resistance than were obstructive and normal respiratory patterns. METHODS: We performed a cross-sectional study of 159 consecutive nondiabetic elderly persons attending two social centers. According to their spirometric pattern, volunteers were classified into the following categories: normal spirometry, obstructive (forced expiratory volume in 1 second/forced vital capacity<0.70), and restrictive pattern (forced vital capacity<80% predicted, forced expiratory volume in 1 second/forced vital capacity>or=0.70). Independent correlates of the metabolic syndrome were identified. RESULTS: The prevalence of metabolic syndrome was higher in restrictive (56%) than in both normal (21.4%, p=.001) and obstructive volunteers (12.9%, p=.001). Insulin resistance, as assessed by the log transformation of the HOmeostasis Model Assessment (HOMA), was higher in restrictive than in obstructive and normal volunteers (1+/-0.6 vs 0.3+/-0.6 and 0.5+/-0.5, p<.001). Restriction was an independent correlate of metabolic syndrome, also after adjustment for waist circumference and body mass index (odds ratio=3.23, 95% confidence interval, 1.23-8.48; p=.01). CONCLUSION: Restrictive, but not obstructive respiratory pattern, is associated with metabolic syndrome and insulin resistance, and does not only reflect a limitation of ventilation due to visceral obesity. Metabolic abnormalities likely mediate cardiovascular risk in patients with restrictive respiratory impairment.

Age, cancer and the risk of venous thromboembolism.

Cancer increases the risk for venous thromboembolism (VTE) and patients presenting with a seemingly idiopathic VTE often have an occult cancer. Aging also is a risk factor for VTE. Therefore, old patients with cancer are supposed to be at very high risk for VTE, but inherent data are sporadic and contrasting. We reviewed the literature about the relation between cancer and VTE, with particular attention to findings concerning elderly patients. While aging and postmenopausal status enhance the risk of chemotherapy-induced VTE in women with breast cancer, the rate of a cancer diagnosis in the first year after VTE seems to be even lower in elderly compared to young subjects. Thus, further studies are needed to understand whether or not aging and cancer have additive thrombogenic effects. Finally, we discuss prophylactic and therapeutic strategies.