Haemodynamic changes of the deep vein system of the leg after surgery of the incompetent great saphenous vein

Surgical treatment of chronic venous disease primarily aims to restore the normal haemodynamic conditions in the venous system. The objective of the study was an assessment of the influence of incompetent saphenous vein removal on the haemodynamical changes within the venous and arterial system of the operated extremity. Patients, materials, methods: The study utilised a group of 50 patients presenting with varicose veins (C2 according to CEAP classification) and great saphenous vein incompetence selected for saphenous vein stripping. In all patients, duplex Doppler examination of femoral and popliteal veins as well as femoral and popliteal arteries was performed before surgery, on the first postoperative day and 30 days after surgery. Results: After the removal of an incompetent great saphenous vein, a statistically significant increase in the minute volume flow in the femoral (p = 0.0004) and popliteal veins (p = 0.0011) was observed. Following saphenous vein stripping, a statistically significant reduction of the venous reflux time in the deep vein system was also observed in the common femoral, femoral and popliteal veins, as compared to a pre-operative examination. Postoperatively, normalisation of the venous reflux time was achieved in 36–40% of patients from the group with concomitant deep vein system incompetence. As far as the arterial system is concerned, an increase in the volume flow in the femoral (p = 0.0463) and popliteal arteries was observed, but statistical significance was not achieved in the latter (p = 0.2912). Conclusion: The flow in the deep vein system increases after the removal of the incompetent great saphenous vein. In some patients with an incompetent deep vein system, venous reflux time returns to normal after the incompetent saphenous vein has been removed.

The role of the tissue plasminogen activator as a prognostic and differentiation factor in patients with pancreatic cancer and chronic pancreatitis

Unsatisfactory pancreatic cancer treatment outcomes have prompted multiple avenues of research focused on identifying not only biomarkers of pancreatic adenocarcinoma progression but also potential prognostic survival factors in patients with pancreatic adenocarcinoma. Study consisted of 75 patients who underwent pancreatic resections between 2006 and 2011: 35 patients with pancreatic ductal adenocarcinoma (PC), 30 patients with chronic pancreatitis (CP), and a non-malignant control group (NMCG) of 10 patients who underwent surgery due to benign tumors. Tissue plasminogen activator (t-PA) concentrations in tissue homogenates and sera were evaluated. The mean t-PA concentration in PC tissue homogenates was 12.3 ± 2 (7.5, 15) ng/mg. Compared with the t-PA concentration in the PC group, lower concentrations of t-PA (3.3 ± 0.7 (2.2, 4.7) ng/mg and 5.9 ± 0.8 (4.6, 7.3) ng/mg (P < 0.01)) were observed in tissue homogenates of the CP and the NMCG patients, respectively. Although serum concentrations of t-PA did not differ between patient groups, in PC patients, the t-PA concentrations were higher in sera than in tissue homogenates. In contrast, the CP and NMCG patient groups had lower t-PA concentrations in sera compared with tissue homogenates. Increasing tissue homogenate t-PA concentrations were associated with blood vessels infiltration. Tissue homogenate and serum t-PA concentrations were not related to the survival rate of patients with PC. The t-PA concentration above 7.45 ng/ml in tissue homogenates was indicative of PC. We concluded that higher concentrations of t-PA were observed in pancreatic cancer tissue compared to chronic pancreatitis, suggesting its potential role in the development and progression of pancreatic cancer. In contrast, the lack of significant differences in the serum t-PA concentrations between treatment groups suggests that serum t-PA concentrations may not be suitable as a biomarker for the diagnosis of pancreatic cancer.

Sulodexide suppresses inflammation in patients with chronic venous insufficiency

AIM

According to previously performed studies, inflammation plays a crucial role in vein wall and leg tissue injury related to chronic venous insufficiency (CVI) development. Sulodexide (SUL) is a balanced mix of glycosaminoglycans with potential anticoagulant and profibrinolytic activity, also protecting endothelial cells and suppressing inflammatory reactions in various vascular disease-related conditions. The goal of the present study was to evaluate the anti-inflammatory action of SUL in patients with CVI.

METHODS

The study was performed on a group of 11 patients with chronic venous disease (stage C5 according to CEAP classification). The mean age of the patients was 58.4±7.7 years, and none of them were diabetic. The patients were treated for 8 weeks with orally-administered SUL (2 x 500 LSU/day). Blood samples were collected at the start and at the end of the study for measurement of MMP-9, IL-6 and monocyte chemoattractant protein-1 (MCP-1). Additionally, the effect of the obtained serum samples on the function of human venous endothelial cells (HVEC) in in-vitro culture was evaluated.

RESULTS

After treatment with SUL, the serum concentration of MMP-9 (ng/mL) decreased from 6.50±3.48 to 5.41±1.36, P<0.05, and the concentration of IL-6 (pg/mL) decreased from 11.5±3.4 to 10.1±2.3, P<0.005. There was also a trend of decreased serum MCP-1 (pg/mL) from 31.3±23.0 before treatment to 27.1±10.7 at the end. Intracellular generation of oxygen-derived free radicals in HVEC maintained in in-vitro culture was lower in the serum samples collected after treatment with SUL: 3.09±0.35 abs/μg protein vs. 3.63±0.32 abs/μg protein, at the start, P<0.05. Synthesis of IL-6 was lower in HVEC exposed in vitro to serum collected at the end of SUL treatment: 1.02±0.31 ng/μg cell protein vs. 1.32±0.41 ng/μg cell protein before SUL treatment. The proliferation rate of HVEC was similar in serum collected at the beginning and at the end of SUL treatment.

CONCLUSION

We conclude that treatment with SUL in patients with CVI reduces intravascular inflammation and is protective for the endothelial cells and for the extracellular matrix changes related to metalloproteinase expression.

Analysis of the efficacy and safety of new oral anticoagulant drugs in the secondary stroke prevention in patients with AF: single center experience based on 311 patients

AIM

According to the performed trials, an introduction of the new oral anticoagulant drugs (NOAC) in the chronic anticoagulation in patients with non-valvular AF (NVAF) is an interesting treatment option. In addition to the encouraging results of the randomized controlled trials the efficacy of this treatment modality in the real-world clinical settings should also be confirmed. In the article, the two-year single center experience with NOACs in the secondary prevention of cerebral stroke in patients with NVAF and previous ischemic stroke was presented. The objective of the study was to evaluate the efficacy, safety and tolerability of the NOACs in the secondary stroke prevention in patients with NVAF.

METHODS

Three hundred eleven patients (M/F 98/213) with NVAF (mean age 62.22 years [41-85]) on NOAC in secondary prevention of cardiogenic stroke, were enrolled into a prospective study. All of them started the therapy during the acute period of cerebral ischemia from III to IX day after the stroke onset. The estimated risk of stroke was based on the CHA2DS2VASc and the risk of hemorrhage on the basis of HAS-BLED scale. Patients underwent a long-term follow-up within the period from 12 to 24 months after initiation of NOAC therapy (mean follow up 18.6 months). 230 patients were treated by the means of rivaroxaban, in 78 patients dabigatran was administered and 1 patient received apixaban. The rate of stroke recurrence, bleeding as well as the drug intolerance were evaluated.

RESULTS

Ischemic stroke during NOAC treatment was diagnosed in 6 patients (1.92%); TIA was observed in 3 cases (0.96%). Hemorrhagic complications during follow-up were recorded in 29 patients (9.32%), of which 3 patients had major bleedings (0,96%): intracranial bleeding (1), bleeding from the genital tract (1) and from the urinary tract (1). There were no deaths caused by bleeding associated with the use of medications, 1 patient died after ischemic stroke when taking NOACs. In 59 patients (18.97%) NOAC therapy was discontinued in the course of follow-up, mostly because of bleeding (29 patients) or renal function worsening (10 patients). There were no significant differences in the efficacy and safety between the groups on selective factor II inhibitor (dabigatran) or factor Xa inhibitor (rivaroxaban).

CONCLUSION

Clinical application of NOAC in a real-world clinical setting results in the treatment profile of high efficacy and acceptable safety for patients with non-valvular AF and stroke.

Post-operative Venous Thromboembolism in Patients Operated on for Aorto-iliac Obstruction and Abdominal Aortic Aneurysm, and the Application of Pharmacological Thromboprophylaxis

OBJECTIVE/BACKGROUND

In light of the methods generally used to assess the risk of venous thromboembolism (VTE), major vascular operations should be regarded as high risk procedures. Nevertheless, no principles for implementing and maintaining thromboprophylaxis have so far been developed. The aim of this study was to determine the frequency and nature of VTE occurrence in patients routinely applying pharmacological thromboprophylaxis following implantation of an aorto-bifemoral prosthesis.

METHODS

The prospective non-randomized study included 105 patients with aortoiliac obstruction and 119 patients with abdominal aortic aneurysm (AAA) treated surgically. During hospitalization pharmacological thromboprophylactic procedures were observed. A duplex test was performed on the day before surgery, on the day of discharge, and 30 days after the patients had left the hospital.

RESULTS

VTE was detected in 18.1% of the patients with aortoiliac obstruction (9.5% of patients during hospitalization and 8.6% of patients after discharge). VTE was diagnosed in 21.0% of patients with AAA (15.1% of patients during hospitalization and 5.9% of patients after discharge). The incidence of VTE was comparable in both groups, both during hospitalization (p = .51) and in the 30 day period following the end of hospitalization (p = .48). It is advisable that before hospital discharge routine duplex ultrasonography tests should be conducted on the venous systems of all patients who have undergone major vascular operations.

CONCLUSIONS

It is likewise advisable to consider whether thromboprophylaxis for vascular patients should be extended beyond their discharge from hospital.

Endothelial dysfunction in patients with chronic venous disease: an evaluation based on the flow-mediated dilatation test

AIM

The vascular system constitutes a functional whole, and it has been assumed that the arterial endothelium and the venous endothelium are organs integral to internal secretion. Despite previous studies concerning the potential role of endothelial cells in the development of chronic venous disease (CVD), there is still no direct clinical confirmation of endothelial dysfunction in CVD patients. The aim of this study was to document the presence of endothelial cell dysfunction in a clinical setting in CVD patients.

METHODS

In this study, the flow-mediated dilatation (FMD) test was performed in 131 patients with CVD (at stages C0s-C3 according to the CEAP classification) and 84 healthy volunteers. With the help of a precise algorithm, all the patients with other confirmed factors that could potentially influence endothelial activity were excluded from the examination.

RESULTS

FMD test values were lower in the CVD group (median: 7.87 ± 3.31%) compared to the control group (median: 12.06 ± 3.94%) (p<0.05). With sex separation and partition into two age groups (20-40 and 41-60 yrs.), characteristic, significant FMD value differences were obtained. In the statistical analysis, the clinical severity of CVD negatively correlated with the FMD value.

CONCLUSION

According to the FMD test results, endothelial dysfunction was observed in patients with CVD. The change in the endothelial activity observed in this examination correlates with the clinical severity of chronic venous disease.

Altered elastase-alpha1-antitrypsin balance in the blood of patients with chronic venous disease

OBJECTIVES

Although leukocyte elastase is suspected to be involved in the damage of vein wall during chronic venous disease, the equilibrium between this protease and its inhibitor, alpha1-antitrypsin, has not yet been evaluated. The aim of the present study was to determine the relationship between leukocyte elastase and alpha1-antitrypsin, in the blood of patients with chronic venous disease.

PATIENTS AND METHODS

The concentration and the activity of leukocyte elastase along with the activity of alpha1-antitrypsin were evaluated in the blood of 55 chronic venous disease patients. The results were compared with those obtained in 33 healthy age and sex-matched volunteers.

RESULTS

A significant decrease in the leukocyte elastase activity that correlated with an increased alpha1-antitrypsin activity was observed in the serum of patients with mild clinical symptoms of chronic venous disease.

CONCLUSIONS

The results of the study did not confirm a hypothesis about an important role of proteolytic activity of leukocyte elastase in the vein wall injury mechanism. They show that the leukocyte elastase-alpha1-antitrypsin balance is rather shifted toward antiprotease activity, especially in an early stage of chronic venous disease.

The value of extended preoperative thromboprophylaxis with dalteparin in patients with ovarian cancer qualified to surgical treatment

AIM

Ovarian cancer (OC) is associated with a high risk of venous thromboembolism (VTE) in both, pre- and postoperative period. The aim of the study was to analyse the efficacy and the safety of an early prophylaxis with dalteparin in patients with OC qualified to surgery.

METHODS

The prospective, non-randomized study was performed in the group of OC patients qualified to surgical treatment. The study group (SG) consisted of 37 patients with OC in whom thromboprophylaxis was started at the moment of qualification to the surgery (mean 16,1 days ± 11,32 SD before procedure). The control group (CG) consisted of 61 patients with OC qualified to surgery in whom thromboprophylaxis was started 12 hour before surgical treatment. The duration of postoperative prophylaxis was 4 weeks in both groups. Dalteparin 5000 U/day was used in both groups. The primary end points were occurrence of VTE and major bleeding. The patients underwent color Doppler US and D-dimer (DD) assessment at the moment of qualification for surgery, 1 day before and 7, 14, 28 days and 3 months after procedure.

RESULTS

The total duration of thromboprophylaxis was 45.3 ± 10.7 days in SG and 27.9 ± 3.7 days in CG (P < 0.0001). The deep venous thrombosis rate was 2,7% in SG and 16.4% in CG (P = 0.042). Neither pulmonary embolism, nor major bleeding were observed. Median preoperative DD concentration in all patients was 1700 ng/ml and was significantly higher in patients who developed postoperative DVT when compared to those who did not, 2556.8 and 1691.0 ng/mL respectively (P = 0.0009).

CONCLUSION

Prolonged preoperative thromboprophylaxis with dalteparin in patients with ovarian cancer qualified to the surgical treatment is safe, decreases the risk of thromboembolic complications. To determine indication, dosage and timing of such thromboprophylaxis in this group of patients further studies are required.

Topical treatment of nonhealing venous leg ulcer with propolis ointment

An investigation of effectiveness of topical treatment of nonhealing chronic venous leg ulcers with propolis ointment was conducted. 56 patients were included in the study and randomized into two groups. In group 1, there were 28 patients (ulceration area: 6.9-9.78 cm(2)) treated by means of topical propolis ointment application and short stretch bandage compression. In group 2, there were 29 patients (ulceration area: 7.2-9.4 cm(2)) treated by means of Unna boot leg compression without topical propolis treatment. In the study, the efficacy of both treatment methods in patients with resistive venous leg ulcers was compared. The ulceration of patients from group 1 healed completely after 6 weeks of therapy in all cases. In all patients from group 2, the process of healing was longer but successfully completed after 16 weeks of the therapy. We found that an adjunctive propolis ointment treatment increases the efficacy of the short stretch bandage compression stocking, and this combined treatment is more effective than Unna's boot compression alone.

Neck duplex Doppler ultrasound evaluation for assessing chronic cerebrospinal venous insufficiency in multiple sclerosis patients

INTRODUCTION

Recent clinical studies have suggested a relationship between multiple sclerosis (MS) and the occurrence of pathological changes in the jugular, vertebral and azygous veins that result in abnormal blood outflow from the brain and the spinal cord. Together, these pathological changes have been designated chronic cerebrospinal venous insufficiency (CCSVI). The aim of the present study was to evaluate the usefulness of duplex Doppler ultrasound in the evaluation of central nervous system venous outflow disturbances in patients suffering from MS.

METHODS

We examined 181 patients with MS, diagnosed on the basis of the McDonald criteria, and 50 healthy volunteer controls. All patients underwent Doppler ultrasound examination of the internal jugular veins (IJV) and vertebral veins (VVs). The presence of outflow disturbances and morphological abnormalities were evaluated.

RESULTS

Pathological changes in the extracranial jugular veins were diagnosed in 148/181 MS patients (82%) and 7/50 control group volunteers (14%). The following abnormalities in the MS group were revealed: the presence of a reflux in the IJVs and/or VVs (54%), narrowing (54%), a complete block in the flow through the IJV (10%) and an abnormal postural control of the cerebral outflow route (25%). These particular pathologies were of statistical significance in the MS group compared with the control group. This study also revealed a correlation between the occurrence of inverted flow in patients in a sitting position and chronic progressive MS (P = 0.0033).

CONCLUSIONS

The examinations undertaken indicate a possible connection between MS and CCSVI. The widely accessible and highly sensitive and specific Doppler ultrasound test may be useful for revealing, and preliminary analysis of, CCSVI pathologies.

Smooth Muscle Cell Apoptosis in Primary Varicose Veins

OBJECTIVES

One of the important factors responsible for vessel wall remodelling is programmed cell death. In the paper the role of smooth muscle cell (SMC) apoptosis in primary varicose veins (PVV) is investigated.

MATERIAL AND METHODS

Vein specimens were obtained from 40 patients with PVV. In each case proximal and distal (upper crural) great saphenous veins (GSV) were harvested. Morphometric computer assessed quantitative evaluation of SMCs, collagen and elastin content was carried out. Apoptotic cells were detected by TUNEL assay. The levels of p53, BAX, BCLl-2 and p21 mRNA expression were assessed by real time RT-QPCR and the presence of respective proteins in the vessel wall was confirmed by immunohistochemistry.

RESULTS

In the proximal GSV segments a significant increase of p53, p21 and BCL-2 mRNA levels was found in PVV patients. In the distal segments BAX and BCL-2 expression levels were higher. Taking into account the patient age, elevated p53 mRNA expression level was noticed in the distal incompetent GSVs of young PVV patients. In this group a statistically significant increase in the apoptotic index (APIx) within the vein media was found which correlated positively with p53 mRNA expression level. There was no increase of the apoptotic activity in elderly patients that led to the structural changes increase. In proximal GSV segments, despite SMC amount reduction or presence of structural changes in perivalvular wall region, no increase of the APIx with was noticed.

CONCLUSIONS

P53-related apoptosis is one of the regulatory mechanisms of vein wall homeostasis maintenance. During varicose vein development its activation is related to the early stages of the disease. In the further course, the down-regulation of the SMC apoptosis within the vein media leads to the structural changes increase. The reduction of the SMC population corresponding to an increase of p21 expression in proximal saphenous vein segments suggests that the cell cycle disturbances may lead to the 'weakness' of the proximal GSV wall. Valve injury is not the only factor leading to the varicose veins occurrence.

Congenital vena cava inferior agenesis

A patient aged 25 years with lower extremity deep vein thrombosis in the course of vena cava inferior agenesis is described. This very rare malformation can be connected with chronic venous insufficiency or thrombotic complications. In such cases other congenital abnormalities should be excluded and suspicion of vena cava inferior agenesis should always be taken into consideration in young patients with idiopathic deep vein thrombosis.

The effect of prolonged ischaemia and cryopreservation on the cell viability of human aortic and femoral artery allografts

The viability of the human arterial allograft cells depends on the time and method of vessel procurement and storage. In this study, an evaluation of the effect of the duration of 4 degrees C ischaemia and cryopreservation on human aortic and femoral artery allograft viability was performed. After the isolation of arterial wall cells, the identification of cultured cells was performed using mRNA analysis for estimation of smooth-muscle markers of differentiation: desmin and heavy-caldesmon. The viability of cells from the medial layer of the aortic wall ranged from 74 to 90% (61-79% for femoral arteries). Cold ischaemia time (from harvesting until the beginning of the preparation) is a statistically significant factor influencing smooth muscle cell viability. Smooth muscle cells represented the majority of live cell population.

[Eventration as a complication in general and vascular surgery]

Eventration is a serious complication in the abdominal surgery. Despite the surgical suture technique improvement the frequency of this complication is still increasing. In the paper the cases of the patients operated for the diseases requiring laparotomy from November 1991 to December 1997 were retrospectively analysed. There were 4030 laparotomies done because of vascular or other surgical diseases. In 23 cases eventrations were postoperatively observed (0.57%). Mean age was 58.7 years. 11 patients were qualified for the emergency surgery (6 patients with acute abdominal diseases and 5 with vascular diseases). 12 patients were operated electively (6 patients--general surgery, 5--vascular reasons). Among 23 patients with eventrations--16 patients were qualified for the relaparotomy with abdominal cavity suture. In 7 cases because of bad general condition of the patient only the skin suture above the eventration in the intensive care station was performed and abdomen was wrapped with the bandage. There were 8 deaths: 2 patients (8.7%) after skin suture and 6 patients (26.1%) after reoperation. Respiratory or respiratory and circulatory insufficiency was observed in 13 patients (56.5%). In 60.8% of cases (14 patients) wound infection was recognized and in 3 cases sepsis occurred in the postoperative period. The disease that was the reason for the surgery did not play a significant part in the eventration occurrence frequency. The condition of the patient before the surgery was the most important prognostic factor of the eventration. In patients with bad condition it is more convenient to perform the suture of the skin above the abdominal viscera first and later the reoperation.

[Inflammatory abdominal aortic aneurysm]

The reported incidence of inflammatory abdominal aortic aneurysm (IAAA) is from 2% to 14% of patients with abdominal aortic aneurysm and the etiology of this disease is still discussed--according to the literature several pathogenic theories have been proposed. From 1992 to 1997 32 patients with IAAA were operated on. The patients were mostly symptomatic--abdominal pain was present in 68.75% cases, back pain in 31.25%, fever in 12.5% and weight loss in 6.25% of the operated patients. In all the patients ultrasound examination was performed, in 4 patients CT and in 3 cases urography. All the patients were operated on and characteristic signs of inflammatory abdominal aortic aneurysm like: thickened aortic wall, perianeurysmal infiltration or retroperitoneal fibrosis with involvement of retroperitoneal structures were found. In all cases surgery was performed using transperitoneal approach; in three cases intraoperatively contiguous abdominal organs were injured, which was connected with their involvement into periaortic inflammation. In 4 cases clamping of the aorta was done at the level of the diaphragmatic hiatus. 3 patients (9.37%) died (one patient with ruptured abdominal aortic aneurysm). Authors present diagnostic procedures and the differences in the surgical tactic, emphasizing the necessity of the surgical therapy in patients with inflammatory abdominal aortic aneurysm.

[The infection of the vascular prosthesis treated by the human cryopreserved allograft implantation: a case report]

75 years old patient was admitted to the Department with infection of the previously implanted bifurcated aorto-bifemoral by-pass. Periprosthetic retroperitoneal abdominal abscess in the US--colour doppler examination was recognized. Unilateral femoral pulse was present--the patient after femoral amputation of the right leg. In the first step of the treatment, the drainage of the periprosthetic abscess was performed. Because of poor results of the local and pharmacological treatment and bleeding from the prosthesis, in the next step, human cryopreserved aorto--femoral allograft was implanted "in situ". Simultaneously, bifurcated prosthesis was evacuated. In the postoperative period, healing of the inquinal wounds was excellent. There were no problems connected with peripheral circulation. The patient was discharged from the hospital on the 24th post-operative day in the good local and general condition. Homograft is an efficient and promising alternative for the treatment of severe vascular prosthesis infections.

[Analysis of mortality risk factors in patients with ruptured abdominal aortic aneurysm]

The purpose of the study was to estimate which factors could have effect on successful outcome of surgery in patients operated on for ruptured abdominal aortic aneurysm (RAAA). The analysis referred to 66 patients operated upon from 1992 to 1995. The specification of all factors which could bring the influence on the successful result of the surgical treatment, was done. The statistical analysis was taken using the Yule-Kendall test and according to it for each factor the risk coefficient Q (from 0.8 to 1.0) was suggested. The group of factors conditioning in each case the failure of surgical procedure was noticed. There were differences in mortality after surgical treatment of RAAA -from 41.2% to 83.3%, mean 63.6%. The mortality of 100% was ascertained in patients with Q above 3.5. The correlation between number of patients with expected risk factors and increasing mortality rate was done. This method is useful for explaining divergences in results of surgical treatment in patients with RAAA and may be helpful for qualification of patients for surgical procedure.

[Second look in abdominal surgery]

The paper presents authors experience and indications for an elective relaparotomy performed as the second-look laparotomy after primary operation. 12 patients with vascular or surgical diseases were operated on for: abdominal neoplastic tumors (2 patients), elective abdominal aneurysm (2 patients), ruptured abdominal aneurysm (2), abdominal aneurysm ruptured into the inferior caval vein (1), ruptured aneurysm of the iliac artery (1), abdominal aortic coarctation with visceral arteries abnormality (1), thrombosis of the superior mesenteric artery (1) and peritonitis because of intestinal ischaemia and necrosis (2 patients). In all cases an elective relaparotomy was done on the 1st or 2nd postoperative day. 5 patients died, in 4 cases complications found during second look relaparotomy required surgical treatment (2 of this patients died, two other were successfully treated). The authors discuss indications and advantages of elective second-look laparotomy in abdominal surgery according to the anticipated risk factors and patients condition.