Duplex Ultrasound Assessment of Neovascularization after Saphenofemoral or Sapheno-Popliteal Junction Ligation

Objective:

Evaluation of neovascularization at the saphenous ligation site as a cause of recurrent varicose veins.

Design:

Prospective duplex study of a single patient group.

Setting:

Vascular clinic of a University Hospital.

Patients:

131 patients (177 limbs) were evaluated 2 and 12 months after varicose vein surgery.

Intervention:

Clinical assessment and colour duplex scanning of operated limbs.

Main outcome measures:

Limbs were classified according to the degree of neovascularization: grade 0 = no new communicating vein, grade 1 = new communicating vein with diameter <4 mm, and grade 2 = new communicating vein with diameter >4 mm and pathological reflux.

Results:

Two months postoperatively, grade 0 was observed in 173 limbs (98%) and grade 1 in four limbs (2%). Twelve months postoperatively, 152 limbs (86%) scored grade 0, 16 limbs (9%) grade 1 and nine limbs (5%) grade 2.

Conclusions:

After correctly performed previous surgery, neovascularization of varying degree may occur within 1 year, as can be demonstrated on postoperative duplex examination.

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.

Closure of the Cribriform Fascia: An Efficient Anatomical Barrier Against Postoperative Neovascularisation at the Saphenofemoral Junction? A Prospective Study

BACKGROUND

Neovascularisation at the sapheno-femoral junction (SFJ) ligation site in the groin may occur within one year after great saphenous vein (GSV) surgery. Several anatomical and prosthetic barrier techniques have been proposed to prevent this evolution.

OBJECTIVE

A prospective study examined whether closing the cribriform fascia could reduce the incidence of postoperative neovascularisation in the groin.

PATIENTS AND METHODS

Patients with primary varicose veins and incompetence at the level of the SFJ were included. After SFJ ligation in 235 limbs of 193 patients an anatomical barrier was constructed by closing the cribriform fascia. Postoperative duplex scanning was performed after 2 and 12 months. Results were compared with historical control groups in which either a silicone patch saphenoplasty or no barrier technique had been performed.

RESULTS

After one year, 10 limbs had developed recurrent thigh varicose veins and duplex scan showed neovascularisation at the SFJ ligation site in 15 of 223 re-examined limbs (6.7%). This was comparable to the group of 191 limbs with silicone patch saphenoplasty (5.2%) (P=0.526) and superior to the group of 189 limbs without barrier (14.8%) (P<0.01).

CONCLUSION

Interposition of an anatomical barrier by closing the cribriform fascia after SFJ ligation reduced ultrasound detected neovascularisation at the SFJ after one year. In primary varicose vein operations application of an anatomical barrier technique (without prosthetic patch) is an alternative option to prevent postoperative neovascularisation.

Current management of spontaneous pneumothorax

Spontaneous pneumothorax is divided into primary, when there is no underlying lung disease, and secondary, mainly caused by chronic obstructive pulmonary disease. A variety of different non-invasive and invasive treatment options exist. Due to the lack of large randomised controlled trials no level A evidence is present. A first episode of a primary spontaneous pneumothorax is treated by observation if it is < 20% or by simple aspiration if it is > 20%, but recurrences are frequent. For recurrent or persisting pneumothorax a more invasive approach is indicated whereby video-assisted thoracic surgery provides a treatment of lung (resection of blebs or bullae) and pleura (pleurectomy or abrasion). In patients with a secondary spontaneous pneumothorax related to chronic obstructive pulmonary disease, there is an associated increased mortality and a more aggressive approach is warranted consisting of initial thoracic drainage followed by recurrence prevention by thoracoscopy or thoracotomy in patients with a low or moderate operative risk. Talc instillation by the thoracic drain is preferred for patients with a high operative risk.

Accuracy of Duplex Evaluation One Year after Varicose Vein Surgery to Predict Recurrence at the Sapheno–Femoral Junction after Five Years

OBJECTIVE

To investigate whether the results of duplex examination 1 year after sapheno-femoral junction (SFJ) ligation might be helpful in predicting long-term results after 5 years.

PATIENTS AND METHODS

Follow-up data concerning patients operated on for primary or recurrent varicose veins of the great saphenous vein were studied 1 year and 5 years after surgery, focusing on the thigh and groin region. Clinical examination was undertaken to detect recurrent thigh varicose veins. The site of SFJ ligation was carefully screened for any signs of neovascularisation by duplex ultrasound. Sensitivity, specificity, positive and negative predictive value of the 1-year duplex scan were calculated, based upon the outcome of a further duplex scan 5 years following surgery.

RESULTS

A total of 100 limbs were studied: 50 limbs operated on for primary varicose veins and 50 limbs for recurrent varicose veins. The 1-year duplex ultrasound of the SFJ ligation site had a sensitivity of 80%, a specificity of 91%, a positive predictive value of 70% and a negative predictive value of 95% in assessing the 5 year recurrence rate.

CONCLUSION

A postoperative duplex scan of the SFJ 1 year after varicose vein surgery to the great saphenous vein predicts which patients are most likely to have a good outcome 5 years after surgery. The 1-year duplex scan is a reliable diagnostic tool for future studies evaluating the effect of new methods of treating sapheno-femoral incompetence.

Can interposition of a silicone implant after sapheno-femoral ligation prevent recurrent varicose veins?

OBJECTIVES

To investigate whether a silicone implant at the sapheno-femoral ligation site could prevent recurrent varicosities.

MATERIALS AND METHODS

Two non-randomised groups of patients were studied prospectively. In group A 173 patients and 212 limbs had sapheno-femoral ligation, while 172 patients and 210 limbs additionally had a piece (2x3cm) of silicone sheet sutured to the saphenous stump to cover the anterior half of the common femoral vein. The implant was fixed in apposition to the deep vein by carefully closing the cribriform fascia. Colour duplex scanning was performed after 2 and 12 months.

RESULTS

In the no implant group neovascularisation was observed in 35 (17%) after 12 months, but only in 13 (6%) limbs treated with a silicone implant (p<0.05).

CONCLUSIONS

Interposition of a partition of silicone implant seems to lower the incidence of neovascularisation one year after saphenofemoral ligation. This technique may constitute an efficient method to prevent recurrence at the correctly ligated saphenous stump.

Operative staging of lung cancer

For earlier stage non-small cell lung cancer, surgical resection remains the most effective therapy. Complete resection of the primary tumour and lymph nodes should be the final aim in order to obtain the best long-term prognosis. Resectability depends on the tumour stage, and precise pre- and peroperative staging are of the utmost importance. In some cases, lung-sparing or extended operations are indicated. Despite modern scanning techniques, invasive staging by mediastinoscopy or thoracoscopy often remains necessary for determining resectability or deciding on a specific treatment. During thoracotomy, precise evaluation of the tumour and node factor is imperative for determining the extent of resection and achieving a complete tumour clearance. A systematic nodal dissection during thoracotomy is advised. Lung resection after induction therapy remains a technical challenge, especially after combined chemoradiotherapy. Peroperative staging is often difficult as distinction between viable tumour and fibrotic reaction is not easily made. Although combined modality treatment has an overall increased morbidity and mortality rate, it improves survival in selected cases of locally advanced non-small cell lung cancer.

Lack of compressibility of the common femoral vein: an unequivocal sign of proximal deep venous thrombosis on duplex ultrasound?

The authors report a case of false positive diagnosis of iliac vein thrombosis on duplex ultrasound. The misreading of the duplex scan was based on the presence of an incompressible common femoral vein. External compression on the iliac veins, caused by enormous postoperative lymphoceles, was responsible for the false positive diagnosis.

Superficial thrombophlebitis of pubic collateral veins after gynecological surgery: a case report

Superficial pubic collateral veins are the result of iliac vein occlusion due to previous thrombosis. They can be accompanied by deep crossover veins. We present a patient with thrombophlebitis of superficial pubic collateral veins after a hysteroscopic procedure.

Spontaneous rupture of the uterine artery in pregnancy

A case of spontaneous rupture of the uterine artery in the third trimester of pregnancy is described. Review of the literature reveals only three similar cases. Clinical signs are sudden abdominal pain with hemodynamic collapse and a decrease in the level of hemoglobin. Treatment consists in performing a laparotomy with suturing of the ruptured artery.

Colour duplex scanning versus angiography: a retrospective assessment of carotid stenosis

A retrospective study was performed to investigate the reliability of colour duplex scanning as a screening method in detecting carotid artery disease. The results of this technique and digital subtraction arteriography of 100 carotid bifurcations in 50 patients undergoing carotid endarterectomy were compared. In accordance with suggested standard reports dealing with cerebrovascular disease, the diameter reduction was classified in one of five categories: < 20%, 20-59%, 60-79%, 80-99% and total occlusion. In 78% the gradings determined using digital subtraction arteriography and duplex scanning correlated perfectly, and in 99% of the studied bifurcations the difference was not more than one grade. The sensitivity and specificity of colour duplex scanning in detecting a stenosis with a diameter reduction of more than 60% was 98% and 87.7%, respectively. The best non-invasive method to identify carotid bifurcation disease is duplex scanning. Although the role of duplex scanning as an alternative to angiography is currently evolving, the authors still advocate carotid angiography when surgery is considered.

Is recurrence of varicose veins after surgery unavoidable?

Recurrence of varicose veins is a common problem. Four main reasons for recurrence are discussed: insufficient understanding of venous anatomy and haemodynamics, inadequate preoperative assessment, incorrect or insufficient surgery and development of new locations of superficial-to-deep insufficiency. Better insight in the variable anatomy of the venous system and better training of junior surgeons in this matter may improve the results of venous operations. Accurate preoperative assessment using (colour) duplex sonography should permit the surgeon to give the patient a differentiated, individualized treatment. Careful dissection of the saphenofemoral junction combined with additional stripping of the long saphenous trunk to just below the knee appears to be the best way to prevent recurrence from the long saphenous vein in the thigh. Concerning the short saphenous vein preoperative location of the exact level of the saphenopopliteal junction is of major importance in the prevention of recurrence. In this way, all diagnostic and surgical efforts should aim to minimize recurrence to about only 5% of patients.

Preoperative colour-coded duplex examination of the saphenopopliteal junction in recurrent varicosity of the short saphenous vein

Undetected anatomical variations of the short saphenous vein (SSV) are a major contributing factor to recurrent varicose veins in the SSV area. Preoperative venography and varicography of the SSV have been proposed as a means of exact localization of its termination. The present study evaluated whether colour-coded duplex (CCD) examination constituted a reliable alternative for localization of the saphenopopliteal (SP) junction. Between 1989 and 1990, 12 patients were reoperated on after previous classical ligation of the SSV. Preoperative CCD examination revealed an abnormally high SP junction with persistent reflux in 11 patients and a Giacomini vein in one patient. When comparing these results with venographic and operative findings an accuracy of 100% was reached in these specific cases. It is concluded that for patients with recurrent varicosis of the SSV preoperative CCD examination provides a reliable non-invasive alternative for venography in the exact localization of the SP junction.

Preoperative colour-coded duplex examination of the saphenopopliteal junction in recurrent varicosis of the short saphenous vein

Undetected anatomical variations of the short saphenous vein are a major contributing factor to recurrent varicose veins in the saphenous vein area. Perioperative venography and varicography of the short saphenous vein have been proposed as a means of exact localization of its termination. The present study evaluated whether colour-coded duplex examination constituted a reliable alternative for localization of the saphenopopliteal junction. Between 1989 and 1990, 12 patients were reoperated on after previous classical ligation of the short saphenous vein. Preoperative colour-coded duplex examination revealed an abnormally high saphenopopliteal junction with persistent reflux in 11 patients and a Giacomini vein in one. When comparing these results with venographic and operative findings an accuracy of 100% was reached in these specific cases. It is concluded that for patients with recurrent varicosis of the short saphenous vein, preoperative colour-coded duplex examination provides a reliable non-invasive alternative to venography in the exact localization of the saphenopopliteal junction.

Hypoxic ventilatory response and carotid endarterectomy

Carotid endarterectomy is reported to abolish hypoxic ventilatory responsiveness. This effect is thought to be due to denervation or destruction of the carotid bodies by surgical exposure. The technique of carotid endarterectomy, however, does not require the sacrifice of these structures. Six patients who had bilateral carotid endarterectomy with careful preservation of the carotid bodies and their innervation were studied pre- and postoperatively with respect to hypoxic ventilatory responsiveness and the latter was taken as a measure of chemoreceptor activity. Five patients showed a weak or absent response to hypoxia before surgery. In four of these there was a significant increase in reactivity after the procedure (p less than 0.01 in one case, p less than 0.05 in three others). The fifth patient had a non-significant increase and the sixth had a normal response before and after surgery. Thus, loss of chemoreceptor function after bilateral carotid endarterectomy was not observed in this group of patients with preserved carotid bodies. The low ventilatory hypoxic sensitivity before surgery and its occasional increase after removal of the plaque suggests that atherosclerosis might well impair the microscopic blood supply to the carotid bodies, inducing sensor dysfunction but this hypothesis requires further investigation.

Division and reanastomosis of the internal carotid artery for endarterectomy

In an attempt to meet superior hemodynamic criteria without patch angioplasty and to prevent recurrent stenosis, Division-Endarterectomy-Reanastomosis (D.E.R.) was used as a routine technique in a prospective study on 26 consecutive interventions in 25 patients. One patient had a residual technical stenosis of less than 30%. Eight patients died during the one and a half year follow-up from nonstroke-related causes. After on an average 14 months flow parameters were evaluated with Color Duplex Sonography to detect recurrent stenosis. One (5.5%) mild asymptomatic recurrent stenosis of less than 50% was diagnosed. The residual stenosis remained unchanged and all other sites showed normal flow patterns. Division-Endarterectomy-Reanastomosis of the internal carotid artery, as described, meets all requirements for safe carotid restoration.