Combined endovenous laser therapy and pinhole high ligation in the treatment of symptomatic great saphenous varicose veins.

BACKGROUND: The aim of this study was to determine the effectiveness and short-term outcomes of endovenous laser therapy (EVLT) combined with pinhole high ligation (PHL) in the treatment of great saphenous varicose veins. METHODS: From February 2011 to May 2012, 200 patients with great saphenous varicose veins were treated using combined EVLT and PHL. Sixty-eight of them had concurrent TriVex suction. There were 118 men and 82 women with a median age of 61 (range 28-82) years. All patients had more than one of the following presentations, including lower extremity heaviness, pain, edema, varicose vein, skin changes, or ulceration. Based on the CEAP clinical classification, 20 patients had C2, 85 had C3, 48 had C4, 23 had C5, and 24 had C6 chronic venous disease. Ninety patients had VV involving the left lower extremity, 56 involving the right lower extremity, and 54 involving the bilateral lower extremities. Duplex ultrasound (US) was performed for all the 200 patients, and showed great saphenous valve dysfunction and reflux in 148 patients. Fifty-two of the 200 patients had concurrent mild femoral vein reflux. Deep venous thrombosis (DVT) was ruled out in all the patients. RESULTS: Technical success rate of PHL and laser ablation was 100%. Median follow-up was 9 months, ranging from 3 to 20 months. Symptoms were resolved or significantly improved in all patients after surgery. The ulcers healed in 23 of the 24 patients (96%) within 3 months. Ten patients developed subcutaneous hematoma, and 8 had slightly worsening edema. Ten patients with complications of numbness due to saphenous nerve burning injury were treated with mecobalamin, and the numbness sensation improved within 1 month and disappeared within 3 months. Nine patients sustained saphenous vein thrombophlebitis postoperatively and were treated with ibuprofen and a heating pad. There was no recanalization of the great saphenous vein, deep venous thrombosis (DVT), or deaths in this group of patients. CONCLUSIONS: Combined EVLT and PHL are less invasive and are effective in the treatment of symptomatic great saphenous varicose veins. PHL prevents DVT, and significantly decreases recanalization of the great saphenous vein after endovenous laser ablation. Short-term outcomes have been satisfactory, but long-term follow-up is needed.

Predicting final infarct size using acute and subacute multiparametric MRI measurements in patients with ischemic stroke.

PURPOSE: To identify early MRI characteristics of ischemic stroke that predict final infarct size three months poststroke. MATERIALS AND METHODS: Multiparametric MRI (multispin echo T2-weighted [T2W] imaging, T1-weighted [T1W] imaging, and diffusion-weighted imaging [DWI]) was performed acutely (<24 hours), subacutely (three to five days), and at three months. MRI was processed using maps of apparent diffusion coefficient (ADC), T2, and a self-organizing data analysis (ISODATA) technique. Analyses began with testing for individual MRI parameter effects, followed by multivariable modeling with assessment of predictive ability (R(2)) on final infarct size. RESULTS: A total of 45 patients were studied, 15 of whom were treated with tissue plasminogen activator (tPA) before acute MRI. The acute DWI and DWI-ISODATA mismatch lesion size, and the interactions of ADC, T2, and T2W imaging lesion with tPA remained in the final multivariable model (R(2) = 70%). A large acute DWI lesion or DWI < ISODATA lesion independently predicted increase in the final infract size, with predictive ability 68%. Predictive ability increased (R(2) = 83%) when subacute MRI parameters were included along with acute DWI, DWI-ISODATA mismatch, and acute T2W image lesion size by tPA treatment interaction. Subacute DWI > acute DWI lesion size predicted an increased final infarct size (P < 0.01). CONCLUSION: Acute-phase DWI and DWI-ISODATA mismatch strongly predict the final infarct size. An acute-to-subacute DWI lesion size change further increases the predictive ability of the model.

Multiparametric iterative self-organizing MR imaging data analysis technique for assessment of tissue viability in acute cerebral ischemia.

BACKGROUND AND PURPOSE: Defining viability and the potential for recovery of ischemic brain tissue can be very valuable for patient selection for acute stroke therapies. Multiparametric MR imaging analysis of ischemic lesions indicates that the ischemic lesion is inhomogeneous in degree of ischemic injury and recovery potential. We sought to define MR imaging characteristics of ischemic lesions that are compatible with viable tissue. METHODS: We included patients with supratentorial ischemic stroke who underwent multiparametric MR imaging studies (axial multi-spin-echo T2-weighted imaging, T1-weighted imaging, and diffusion-weighted imaging) at the acute (< 24 hours) and outcome (3 months) phases of stroke. Using the algorithm Iterative Self-Organizing Data Analysis Technique (ISODATA), the lesion was segmented into clusters and each was assigned a number, called the tissue signature (white matter = 1, CSF = 12, all others between these two). Recovery was defined as at least a 20% size reduction from the acute phase ISODATA lesion volume to the outcome phase T2-weighted imaging lesion volume. The tissue signature data were collapsed into the following categories: < or = 3, 4, 5, and > or = 6. Logistic regression analysis included the following parameters: lesion volume, tissue signature value, apparent diffusion coefficient (ADC) value, relative ADC (rADC) expressed as a ratio, T2 value, and T2 ratio. The model with the largest goodness of fit value was selected. RESULTS: We included 48 patients (female-male ratio, 26:22; age, 64 [+/-14] years; 15 treated with recombinant tissue plasminogen activator [rt-PA] within 3 hours of onset; median National Institutes of Health Stroke Scale score, 7 [range, 2-26]). Median symptom onset-to-MR imaging time interval was 9.5 hours. With ISODATA processing, we generated 200 region-of-interest tissue records (one to nine tissue records per patient). Regarding tissue recovery, we detected a three-way interaction among ADC, ISODATA tissue signature, and previous treatment with rt-PA (P = .003). In the group not treated with rt-PA, ischemic tissues with acute rADC greater than the median (0.79) and tissue signature < or = 4 were more likely to recover (80% vs. 31% and 13%, odds ratio [95% CI]: 0.12 [0.05, 0.30] and 0.04 [0.01, 0.18] for tissue signatures 5 and 6, respectively). CONCLUSION: ISODATA multiparametric MR imaging of acute stroke clearly shows inhomogeneity and different viability of the ischemic lesion. Ischemic tissues with lower acute phase ISODATA tissue signature values (< or = 4) and higher rADC values (> or = 0.79) are much more likely to recover than those with higher signature values or lower rADC values. The effect of these factors on tissue recovery, however, is dependent on whether preceding treatment with rt-PA had been performed. Our approach can be a valuable tool in the design of therapeutic stroke trials with an extended time window.