Perspectives in Vascular Surgery and Endovascular Therapy current issue

Phlebolymphemeda: Usually Unrecognized, Often Poorly Treated

Bunke, N., Brown, K., Bergan, J. — Fri, 18 Sep 2009 04:22:51 PDT

Phlebolymphedema is a condition of mixed venous and lymphatic insufficiency. It is usually not recognized and it is usually not treated. The lymphatic and venous systems are intimately interrelated. In the presence of venous hypertension, which is characteristic of most venous disorders, the increase in lymphatic flow becomes much greater than the lymph transport capacity. The diagnosis of phlebolymphedema is based on a detailed history and physical examination. Patients with phlebolymphedema have skin changes of venous insufficiency, which are easy to recognize. Treatment for chronic phlebolymphedema consists of treating the venous abnormality and watching regression of the lymphatic problem.

The ESCHAR Trial: Should It Change Practice?

Wright, D. D. I. — Fri, 18 Sep 2009 04:22:51 PDT

Introduction: Most leg ulcers are caused by venous disease, the most common cause of venous hypertension being superficial vein incompetence. The ESCHAR trial tested the value of superficial vein surgery combined with compression in the healing and recurrence of venous leg ulcers compared with compression alone. Methods: A total of 500 patients with chronic venous leg ulcers, or recently healed ulcers, were randomized to superficial vein surgery and compression or compression alone. Vein surgery was saphenofemoral ligation and great saphenous stripping and phlebectomy or saphenopopliteal ligation and phlebectomy. Results: Ulcer healing was virtually identical between the 2 groups at 65% at 24 weeks; subgroup analysis failed to show a benefit for surgery to promote ulcer healing. Ulcer recurrence rate was halved in those that underwent surgery regardless of the presence of deep vein incompetence. Conclusion: Superficial vein surgery should be considered in all leg ulcer sufferers to reduce ulcer recurrence rather than accelerate ulcer healing.

Endovenous Laser Ablation: Strategies for Treating Multilevel Disease

Markovic, J. N., Shortell, C. K. — Fri, 18 Sep 2009 04:22:51 PDT

Since its introduction in 1999 and FDA approval in 2002, endovenous laser ablation has been widely accepted to effectively treat superficial venous reflux, with minimal side effects. Anatomically, any combination of superficial, perforator and deep venous disease can result in various stages of chronic venous insufficiency. In general, when multiple levels of venous disease are involved the manifestations of venous insufficiency increase in severity. Given that one patient with significant reflux in deep system will have no resultant symptoms, while another patient may progress to an active ulceration from a saphenous reflux alone, individual treatment strategies in the patient with multilevel reflux disease should be based on a thorough clinical and duplex evaluation to determine their specific anatomy and pathology. A basic understanding of mechanism of laser-tissue interaction, venous pathophysiology and the relationship of deep to superficial reflux disease assists in refining procedural techniques and strategies.

Update on Radiofrequency Ablation

Markovic, J. N., Shortell, C. K. — Fri, 18 Sep 2009 04:22:51 PDT

The two currently available methods to achieve ablation of incompetent veins using radiofrequency energy are radiofrequency ablation (VNUS Closure Plus^tm) and radiofrequency powered segmental ablation (VNUS Closure Fast^tm). Both treatment modalities expose vascular endothelium to high-frequency alternating current. This results in contraction of venous wall collagen with subsequent fibrotic endoluminal obliteration which eliminates hydrostatic and hydrodynamic pressures as the main hemodynamic mechanisms for varicosities. Radiofrequency segmental ablation has become available relatively recently, but increasing amount of clinical data and patient’s satisfaction support this technique as a reasonable therapy for superficial reflux disease. Although initial experience with Closure Fasttm catheter documented substantially decreased average procedural time, little postoperative discomfort and short-term occlusion rates that approximated 100%, larger clinical trials are needed before this modification of traditional radiofrequency ablation can be accurately evaluated in the treatment of superficial reflux disease.

Foam Sclerotherapy: Techniques and Uses

Bunke, N., Brown, K., Bergan, J. — Fri, 18 Sep 2009 04:22:51 PDT

Sclerosant foam has been increasing in use in recent times. It has certain advantages over liquid sclerosants and is quite safe to use, despite the fact that there are adverse events that have been reported. The history of sclerosant foam goes back in time many years. Tessari developed the current method of creating sclerosant foam in 2001, and his technique has been modified. In our experience, the sclerosant foam has totally replaced other methods of treating venous insufficiency, and the results of treatment are superior to other methods. It is apparent that treatment of a variety of venous disorders can be accomplished using foam sclerotherapy. Our experience and that of others has shown that there are early advantages in the use of foam in the management of varicose veins compared with surgery and other methods.

What Is New in Duplex Scanning of the Venous System?

Zygmunt, J. — Sat, 01 Jun 2002 00:00:00 PDT

The diagnosis and treatment of chronic venous disease has undergone a quantum leap forward in recent decades. In many ways, the venous system is now considered more complex than the arterial system. This is a result of the advances in understanding due to improvements in duplex ultrasound equipment, diagnostic techniques, and communication standards as they relate to findings in anatomy, pathology, and hemodynamics. Currently, it is self-evident that duplex ultrasound has become the gold standard for diagnosis of the venous system providing anatomic and functional information. Mapping techniques, understanding of superficial reflux, and other factors that affect duplex ultrasound findings are presented. These factors and techniques can affect diagnostic results and therefore have significant impact on the planning and approach to treatment of primary and recurrent venous insufficiency.

Progress in MR Imaging of the Venous System

Spritzer, C. E. — Sat, 01 Jun 2002 00:00:00 PDT

This article reviews the utility of magnetic resonance imaging (MRI)/magnetic resonance venography (MRV) in the assessment of common venous problems. There is a brief synopsis of current MRI/MRV techniques used for such purposes. This is followed by a review of application of these techniques to specific diagnoses. In short, MRV is quite useful for assessing venous pathology.

Nutcracker Syndrome: When Should It Be Treated and How?

Menard, M. T. — Sat, 01 Jun 2002 00:00:00 PDT

Nutcracker syndrome refers to compression of the left renal vein by the superior mesenteric artery and aorta. Patients typically present with left flank pain and associated symptoms of pelvic congestion. Hematuria is frequently present, and vulvar or lower extremity varices are seen in a subset of patients. Clinical suspicion of the syndrome is confirmed by duplex scanning, computerized tomography, or magnetic resonance imaging. Documentation of a hemodynamically significant pressure gradient across the point of compression during venographic assessment in patients with appropriate symptom severity is important prior to undertaking treatment. A variety of surgical procedures have been described to achieve venous decompression, the most popular being that of transposition of the left renal vein to the more distal inferior vena cava. Long-term data on the success of surgical treatment is scarce. More recently, endovascular stenting of the left renal vein has been used.

Anticoagulation Strategies for Venous Thromboembolism

Peterson, D., Harward, S., Lawson, J. H. — Sat, 01 Jun 2002 00:00:00 PDT

Venous thromboembolism (VTE) continues to be a major source of morbidity and mortality in the United States with an estimated incidence of greater than 600 000 clinically evident cases each year. It results in more than 200 000 deaths per year and is thought to be the number one cause of preventable in-hospital deaths. This review presents the history, pathophysiology, diagnostic considerations, and treatment options for VTE.

Vascular Malformations: An Update

Fri, 18 Sep 2009 04:22:51 PDT

Vascular malformations occur as a result of an arrest in the development of the vascular system. The modified Hamburg classification distinguishes arterial, venous, arteriovenous, capillary, lymphatic, and mixed vascular malformations. Each malformation is further subdivided based on anatomy and on the time when arrest in development of the embryogenesis occurred; malformations can be truncular or extratruncular. Progress in the last decade in management has been significant because of improvements in open surgical procedures and perfection of percutaneous and hybrid endovascular interventions and devices, such as balloons, stents, and stent-grafts. There has been increasing use of embolization for the treatment of malformations with coils, other particles, glue, or with endovascular placement of occlusive plugs. Absolute alcohol, detergent liquids, or foam have been used for sclerotherapy with improved efficacy. The agents are delivered percutaneously or through a catheter placed either into the feeding arteries or the draining veins. This review aims to aid vascular and endovascular specialists in staying familiar with vascular malformations. These specialists need to be able to evaluate the patients, perform treatment if appropriate, or refer complex cases to multidisciplinary vascular malformation clinics and vascular centers.