Perforator reflux and clinical presentation in primary superficial venous insufficiency.
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Age Factors↗
Biomedical subjects
A D Giannoukas
Publications and source records attributed to A D Giannoukas.
Patterns of venous reflux in limbs with venous ulcers. Implications for treatment.
AIM: To investigate the anatomic distribution of vein reflux in limbs with healed or active ulcers (CEAP V and VI). METHODS: Sixty limbs (58 patients) belonging to CEAP classes V and VI were identified from 798 limbs (519 patients) with ultrasonically proven chronic venous insufficiency (CVI). Age, gender, duration of the venous ulcer, and history of deep venous thrombosis were correlated to the anatomic distribution of the venous reflux. RESULTS: The prevalence of active or healed ulcers in limbs with CVI was 7.5%. Among 60 limbs with ulcers, primary CVI was present in 34 (56.7%) and post-thrombotic CVI in 26 limbs (43.3%). No difference in age and gender was found between the 2 groups (p=0.2 and p=0.8, respectively). However, the duration of the ulcer was longer in limbs with post-thrombotic CVI (p<0.05). The prevalence of perforator reflux was 41.2% (14/34) in limbs with primary CVI and 38.5% (10/26) in limbs with post-thrombotic CVI (p=0.8). Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI; it was rare in limbs with post-thrombotic CVI (22/34 or 64.7% vs 2/26 or 7.7%, p<0.01). Deep vein insufficiency was present in 35.3% (12/34) of the limbs with primary CVI and in 92.3% (24/26) of the limbs with post-thrombotic CVI (p<0.01). CONCLUSION: Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI, whereas, deep venous insufficiency was present in most of the limbs with post-thrombotic CVI. The prevalence of perforating vein reflux was comparable in both settings. Thus, elimination of superficial reflux is expected to result in ulcer healing of most limbs with primary CVI, whereas, the value of such treatment in post-thrombotic limbs is not clear.
Adult↗
Early thrombus remodelling of isolated calf deep vein thrombosis.
OBJECTIVE: this prospective study was designed to evaluate the evolution of thrombus propagation and lysis in relation to patterns and distribution of isolated calf DVT. METHODS: fifty-two limbs in 48 patients mean age 59+/-15, range 24-78 years, with isolated calf DVT that had at least one exam within 10 days of DVT detection were included in the study. Patients with a documented episode of prior DVT or evidence of post-thrombotic changes during the initial ultrasound exam were excluded. The initial thrombus length, patterns and location of the thrombi were recorded. On follow-up the propagation and lysis patterns of the clot were studied. RESULTS: remodelling of the thrombus, excluding echotexture and vein diameter changes on ultrasound, occurred in 23 limbs, (44%). Ascending propagation only was seen in seven limbs (13%) descending propagation only in two (4%) and in both directions in five (10%). Propagation at least to popliteal vein was detected in seven limbs (13%). Thrombus developed or extended to initially uninvolved veins in six limbs (12%). Pulmonary embolism developed only in one patient (2%; 95% CI: 0-11%). The site and the size of thrombus or the number of veins involved in the baseline exam did not correlate with the remodeling of thrombus. Soleal and gastrocnemial veins were comparable with the posterior tibial and peroneal veins in terms of thrombus propagation and lysis. CONCLUSIONS: early thrombus remodelling occurs in 44% of limbs with isolated calf DVT. This includes ascending and descending thrombus propagation and lysis. Thrombus development or propagation to initially uninvolved calf veins is found in 12%. Thrombus remodelling does not appear to be related to size, site and patterns of thrombosis.
Adult↗
The importance of communication between physicians and patients. Special considerations in the era of endovascular therapy.
Most of the lawsuits in medical practice are the result of inadequate communication between doctors and patients and litigation has very little to do with errors. In the era of the technological development and the implementation of new techniques such as endovascular therapy, good communication between physicians and patients is essential. The purpose of this review is to elicit important considerations on challenging issues relating to the art of communication between physicians and patients and to provide information on what the vascular surgeon or interventionalist should bear in mind in obtaining an adequate informed consent from the patients.
Communication↗
Clinical presentation and anatomic distribution of chronic venous insufficiency of the lower limb in a typical Mediterranean population.
BACKGROUND: The aim of this study was to demonstrate the characteristics of lower limb chronic venous insufficiency (CVI) in a homogeneous Mediterranean population. METHODS: Investigation of 694 patients with uni- or bilateral symptoms and signs of lower limb CVI using colour duplex scanning. Limbs with previous venous surgery were excluded. The limbs were classified according to history and ultrasonic findings into those with post-thrombotic and those with primary CVI. The clinical presentation according to the CEAP classification was correlated to the anatomic distribution of venous reflux. RESULTS: Most of the symptomatic limbs (537/656, 81.5%) with primary CVI belonged to classes 1 to 3. In these limbs reflux confined to superficial veins was very common (64.5%, 424/656) whereas the prevalence of deep and perforator vein reflux was 18.5 and 25.5%, respectively. In contrast most of the limbs (69.5%) with post-thrombotic CVI belonged to classes 4 to 6, had a complex pattern of reflux, and involvement of deep and perforator veins was common (86.5 and 48%, respectively). In about a quarter (24%) of patients with suspected primary CVI no reflux was found in either limb on duplex scanning. Most of them (48%) had telangiectasis. Bilateral reflux was found in 71% of the patients with primary CVI. CONCLUSIONS: The clinical presentation was worse in limbs with post-thrombotic CVI than in those with a primary disease. Post-thrombotic CVI was associated with a complex pattern of reflux, affecting mostly the deep and perforator veins, whereas superficial reflux was the most common pattern in limbs with primary CVI. Therefore, surgery aiming to eliminate superficial reflux would confer only a minimal benefit in limbs with post-thrombotic CVI but would treat the majority of the limbs with the primary CVI. The high prevalence of bilateral reflux found in patients with primary CVI suggests a bilateral predisposition, which supports the hypothesis of the existence of a generalised venous disease.
Female↗
Can ultrasound replace arteriography in the management of chronic arterial occlusive disease of the lower limb?
OBJECTIVES: to investigate whether colour duplex scanning can be used as the sole diagnostic investigation prior to lower limb revascularisation. PATIENTS AND METHODS: the results of angiography and duplex were compared in 80 limbs (69 claudication, 11 critical limb ischaemia [CLI]) from 68 patients. RESULTS: excellent diagnostic agreement (kappa value 0.89, 95% CI 0.85-0.93) was achieved at the femoropopliteal segment. Agreement was good for the aorto-iliac segment (kappa value 0.69, 95% CI 0.61-0.77) and moderate for the infrapopliteal segment (kappa value 0.59, 95% CI 0.55-0.63). Similarly, in the decision-making process excellent agreement was achieved for the femoropopliteal segment (kappa value 0.91, 95% CI 0.88-0.94), good for the aortoiliac segment (kappa value 0.62, 95% CI 0.56-0.68), and moderate for the infrapopliteal segment (kappa value 0.46, 95% CI 0.42-0.50). Duplex detected patent 12 tibial arteries in 10 limbs that were not opacified on arteriography. In four limbs duplex revealed significant disease in the above knee popliteal artery that was missed on arteriography. CONCLUSIONS: treatment of femoropopliteal disease can be based upon duplex alone in the great majority of cases. However, where there is disease in the aortoiliac segment, or where infrapopliteal revascularisation is long considered both duplex and angiography should be performed to maximise pre-operative information.
Aged↗
Occult aorto-iliac disease in patients with symptomatic coronary artery disease.
BACKGROUND: Atherosclerosis may affect the entire cardiovascular system despite absence of symptoms. Early changes in the wall of the carotid artery have been related to a higher morbidity and mortality from coronary artery disease (CAD). This study was conducted to investigate the relationship between the presence of occult aorto-iliac disease (OAID) and certain risk factors with the severity of CAD. METHODS: Two hundred and eighty-four consecutive patients subjected to coronary angiography (CA) were studied. Additional images of the aorto-iliac arterial segment were taken. Patients with negative CA or symptomatic lower limb arterial disease (LLAD) were excluded from further analysis. In the remaining patients, the risk factors (age, smoking, diabetes mellitus, hypertension, hyperlipidemia and positive family history for atherosclerosis) and the severity of coronary artery disease (CAD) were analyzed in relation to the presence or absence of OAID. RESULTS: Twelve patients with impaired renal function were excluded from the study. Negative CA was found in 12% (32/272) and symptomatic LLAD was present in 14% (37/272). Eligible for further analysis were 203 patients with positive CA and no LLAD. A hundred and ten of them had a positive CA and the presence of OAID whereas the remaining 93 patients had only a positive CA. The patients with OAID had more severe CAD on CA (p=0.003). There was no difference between the two groups concerning age and gender. The most common risk factors in both groups were hypercholesterolemia and a positive family history but with a significantly higher prevalence in the patients with OAID (p=0.008 and p<0.001, respectively). CONCLUSIONS: The presence of OAID in coronary patients was associated with more severe CAD and with a significantly higher prevalence of hypercholesterolemia and positive family history for atherosclerosis. This subset of patients may represent those with more aggressive atherosclerosis.
Adult↗
Recurrent varicose veins of both lower limbs due to bilateral ovarian vein incompetence.
A case of a 43-year-old female patient with mild pelvic pain and bilateral recurrent varicose veins due to incompetence of both ovarian veins is presented here. Ovarian vein incompetence was suspected from the presence of vulva varicosities and was confirmed by transvaginal ultrasound and descending ovarian venography. Treatment with transcatheter embolization of the ovarian veins was followed by local excision of the leg varices. Four years later, the patient remains asymptomatic and without any recurrence of varicose veins in both lower limbs.
Adult↗
Experience with new techniques for extraanatomic arterial reconstruction of the lower limb.
The aim of this report is to present our experience with new techniques for extraanatomic lower limb arterial reconstruction. Two techniques are described here of construction of an extraanatomical bypass for lower limb revascularization either through the wing of the iliac bone or underneath the iliopsoas fascia through the muscular lacuna close to the anterior superior spine of the iliac crest. Both techniques are recommended for the treatment of a severely injured groin, such as in patients with pelvic malignancy and/or an acute groin bleeding due to postirradiation femoral artery erosion or an infected femoropopliteal bypass graft with severe upper medial thigh sepsis. These techniques were used in nine patients (five with malignancy and four with an infected femoropopliteal bypass graft). Our results showed that the transosseous route through the wing of the iliac bone or underneath the iliopsoas fascia through the muscular lacuna may be considered effective alternate routes for lower limb arterial extraanatomic reconstruction when the common femoral cannot be used for arterial inflow.
Aged↗
Misdiagnosed post-traumatic occlusion of the internal carotid artery in a young woman.
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Accidents, Traffic↗
The impact of isolated lesser saphenous vein system incompetence on clinical signs and symptoms of chronic venous disease.
PURPOSE: The purpose of this study was to determine the patterns of isolated lesser saphenous vein (LSV) system incompetence and correlate the distribution and extent of such reflux with symptoms and signs of chronic venous disease (CVD). METHODS: During a 3-year period, 2254 limbs in 1682 patients with signs and symptoms of CVD were evaluated with color flow duplex scanning. Extremities with isolated reflux in the LSV system were selected for this study. Limbs with perforating venous reflux connected to this system only were also included. Limbs that had marked reflux in the greater saphenous or deep vein, that had a documented history of deep venous thrombosis, and that previously underwent surgery or sclerotherapy were excluded. The clinical severity of the limbs was graded with the CEAP classification system. RESULTS: There were 226 limbs in 200 patients with reflux in the LSV system; 61% were female patients with a mean age of 49 years (range, 18-82 years). There were 174 patients (87%) with unilateral and 26 with bilateral disease, and 41% of the limbs belonged in CVD class 2, 26% in class 3, 12% in class 4, 3.5% in class 5, and 3% in class 6. Classes 0 and 1 were present in 14.5% of the limbs. Symptoms were present in 139 limbs (61.5%). Some degree of ache or burning sensation was the most frequent symptom (41%), followed by itching (32%), heaviness (29%), cramps (24%), and restless limbs (18%). Reflux in the main trunk of the LSV was the most prevalent (177 limbs [78%]), followed by the saphenopopliteal junction (146 limbs [64.6%]), the vein of Giacomini (39 limbs [17%]) and the gastrocnemial vein (23 limbs [10%]). Reflux involving both the saphenopopliteal junction and the LSV was seen in 50% of limbs, but almost any other combination of reflux was present, which indicated the complexity of this system. Perforator vein incompetence was detected in 56 limbs (25%). We found 83 perforator veins, resulting in a mean of 1.5 veins per limb. Both the number of incompetent perforator veins and the extent of superficial reflux correlated with clinical severity. Four main types of termination of the LSV were identified with at least nine variations. The LSV was duplicated for at least half of its length in five limbs (2.2%). Nonsaphenous reflux was detected in seven limbs (3.1%). Superficial vein thrombosis in the LSV system was found in eight limbs (3.5%), and in the gastrocnemial vein it was found in four (1.8%). CONCLUSIONS: Isolated LSV system incompetence can cause the entire range of signs and symptoms of CVD. Clinical deterioration is associated with a longer extent of reflux and perforator incompetence. Classes 2 to 4 are the most frequent clinical presentations, whereas classes 5 and 6 are uncommon. The complex anatomy of this system and the great variation in the patterns of reflux warrant the use of color flow duplex scanning before planning treatment.
Adolescent↗
Primary superficial vein reflux with competent saphenous trunk.
OBJECTIVES: because reflux in superficial vein tributaries is most often collectively reported with the main saphenous veins, its importance remains largely unrecognised. This study was designed to identify the distribution and extent of non-truncal superficial venous reflux and its association with the signs and symptoms of chronic venous disease (CVD). PATIENTS AND METHODS: eighty-four limbs in 62 patients with signs and symptoms of CVD and evidence of reflux on continuous-wave Doppler were subsequently examined with colour-flow duplex imaging. Incompetent superficial vein tributaries were imaged throughout their extent and both ends were identified. Limbs with reflux in the main trunk of the saphenous veins or the deep, perforator or muscular veins, superficial or deep vein thrombosis, injection sclerotherapy, varicose-vein surgery, arterial disease and inflammation of non-venous origin were excluded from the study. The CEAP classification system was used for staging clinical severity of CVD. RESULTS: the prevalence of tributary reflux alone was 9.7% (84/860). Reflux was detected in 171 tributaries. The number of incompetent tributaries ranged from 1 to 5 per limb. Most prevalent were the tributaries to the greater saphenous (111, 65%<0. 0001), followed by those of lesser saphenous (33, 19%) or a combination of both (12, 7%). Incompetent non-saphenous tributaries were uncommon (15, 9%). Among the named tributaries in the lower limb the posterior arch vein was most often incompetent (46, 27%) followed by the anterolateral vein of the thigh (30, 18%), the medial accessory vein (16, 9%) and the anterior arch vein (14, 8%). Reflux in above-the-knee tributaries alone was found in 18 limbs (21%), in below the knee in 23 (28%) and in both sites in 43 (51%). The vast majority of the limbs (71%,p <0.0001) belonged to CVD class 2, 14% in class 3, 9% in class 1 and only 6% in class 4. Class 3 and 4 patients tended to have a longer duration of signs and symptoms, higher number of incompetent tributaries per limb and also a higher prevalence of combined above- and below-knee reflux. CONCLUSIONS: these data indicate that reflux confined to superficial tributaries is found throughout the lower limb. Because this reflux is present without greater and lesser saphenous trunk, perforator and deep-vein incompetence or proximal obstruction, it shows that reflux can develop in any vein without an apparent feeding source. Greater saphenous tributaries are affected significantly more often than those of lesser saphenous, while non-saphenous reflux is uncommon. Most limbs have signs and symptoms of CVD class 2 and 15% belong in classes 3 and 4.
Adolescent↗
Symptomatic deep venous thrombosis of the lower limb.
BACKGROUND: Deep vein thrombosis (DVT) is a common problem in clinical practice causing severe complications. In this retrospective study, the distribution and extent of DVT in the lower limb in symptomatic patients were evaluated. Certain risk factors were also investigated. METHODS: The venograms of 187 symptomatic individuals (postoperative, medical, and out-patient) with suspected DVT and symptoms having been present for less than 6 days, were reviewed. Seventy-seven limbs of 76 patients had DVT. Twenty-seven were male (age range 14-82 years, mean 57) and 49 female (age range 12-82, mean 56). RESULTS: Age over 40 years and gender (female) were significant predisposing factors, (Z = 4.23, p < 0.001 and Z = 2.19, p < 0.05 respectively). Isolated calf DVT alone was the most common pattern (46%, 36 of 77 limbs), and no difference was seen between postoperative and medical patients (chi 2-test, p = 0.7). Postoperative DVT was found in 29 (38%) limbs. Prophylaxis with LMWH had been given in only 15 of them (52%). No difference was seen in the distribution and extent of thrombosis in relation to the prophylaxis with LMWH (chi 2-test, p = 0.34). CONCLUSIONS: Identification of the predisposing factors may enable us to distinguish patients at high risk of developing DVT. The majority of the thrombi commenced in the calf veins and thus meticulous investigation of these veins in symptomatic patients with suspected DVT is necessary.
Adolescent↗
The role of venous outflow obstruction in patients with chronic venous dysfunction.
OBJECTIVE: To quantify the functional venous outflow obstruction with different location and extent of obstruction attributed to previous deep vein thrombosis. DESIGN: Case-control study. SETTING: Vascular Laboratory, St Mary's Hospital Medical School, London, England. PATIENTS: Two groups: group 1, 25 case patients and 9 control subjects, and group 2, 45 case patients and 30 control subjects. INTERVENTIONS: Ascending venography, duplex scanning, air plethysmography, and venous pressure measurements in the foot and the arm via a 21-gauge butterfly needle. MAIN OUTCOME MEASURES: Venous outflow fraction (VOF), venous outflow resistance (VOR), and arm-foot pressure differential (A-F PD) at rest and after reactive hyperemia. RESULTS: Venous outflow resistance was evaluated in group 1. Twenty-two case patients underwent VOF testing, and 16 had A-F PD measurement performed. Case patients in group 2 underwent VOF testing. Signs and symptoms of chronic venous dysfunction were associated with the anatomical extent of obstruction. Limb swelling and ache were present in most of the patients; skin changes were noted in about 30% and ulceration in 10% of patients. The results of all tests showed no evidence of obstruction in control subjects. In most case patients with popliteal vein obstruction, test results were similar to those in control subjects: the more proximal the veins involved, the more severe the obstruction. In 16 case patients, all 3 tests were performed and agreement between A-F PD and VOR test results was found in 14 of them. The VOF test results agreed with the results of A-F PD and VOR tests in 9 case patients. In group 2, 50% of the limbs with obstruction proximal to the popliteal vein had a reduced VOF, which became worst in the limbs with extensive obstruction, particularly when the iliac veins were involved. Of the 73 limbs tested for VOF in both groups, only 7 limbs (9.6%) had their venous outflow markedly reduced by occlusion of the superficial veins. CONCLUSIONS: The anatomical extent of venous obstruction and the development of collateral circulation determine the hemodynamic severity of the chronic venous obstruction. The deep collaterals seem to be more important than the superficial venous system in bypassing the obstruction. The VOR and the A-F PD tests can be used to identify those patients who have venous obstruction, whereas the use of the VOF test may reduce the need for performing the above tests in 50% of the patients.
Adult↗
Where does venous reflux start?
PURPOSE: This study was designed to identify the origin of lower limb primary venous reflux in asymptomatic young individuals and to compare patterns of reflux with age-matched subjects with prominent or clinically apparent varicose veins. METHODS: Forty age- and sex-matched subjects with no symptoms (age, 15 to 35 years; 80 limbs; group A), 20 subjects (age, 19 to 32 years; 40 limbs) with prominent but nonvaricose veins (n = 26 limbs; group B), and 50 patients (age, 17 to 34 years; 100 limbs) with varicose veins (n = 64; group C) were examined with color flow duplex imaging. All proximal veins (above popliteal skin crease), superficial, perforator, and deep, in the lower limb were examined in the standing position, and all the distal veins in the sitting position. Patients who had a documented episode of superficial or deep vein thrombosis, previous venous surgery, or injection sclerotherapy were excluded from the study. RESULTS: The prevalence of reflux in group A was 14% (11 of 80), in group B 77% (31 of 40), and in group C 87% (87 of 100). In more than 80% of limbs in the three groups, reflux was confined to the superficial veins alone. Deep venous reflux or combined patterns of reflux were uncommon even in group C. Reflux was detected in all segments of the saphenous veins and their tributaries. In the 125 limbs that had superficial venous incompetence, the below-knee segment of the greater saphenous vein was the most common site of reflux (85, 68%), followed by the above-knee segment of greater saphenous vein (69, 55%) and the saphenofemoral junction (41, 32%). Nonsaphenous reflux was rare (3, 2.4%). Reflux in the lesser saphenous vein (21, 17%) was seen in all groups, whereas involvement of both greater and lesser saphenous veins (8, 6.4%) was seen in group C alone. The incidence of multisegmental reflux was significantly higher in group C (61 of 64, 95%) than in group A (two of 11, 18%) or group B (14 of 26, 54%). The prevalence of distal reflux was comparable in all groups. CONCLUSIONS: Primary venous reflux can occur in any superficial or deep vein of the lower limbs. The below-knee veins are often involved in asymptomatic individuals and in those who have prominent or varicose veins. These data suggest that reflux appears to be a local or multifocal process in addition to or separate from a retrograde process.
Adolescent↗
Pre-bypass quality assessment of the long saphenous vein wall with ultrasound and histology.
OBJECTIVES: Pre-existing unsuspected wall changes in saphenous vein grafts have been implicated in the graft outcome. Pre-bypass assessment of the vein may identify grafts at high risk for failure. This study was conducted to evaluate preoperatively the quality of the long saphenous vein (LSV) wall with ultrasound and histology. DESIGN: Prospective clinical study. MATERIAL AND METHODS: Three particular LSV segments, ankle, knee and mid-thigh, were evaluated preoperatively by ultrasound in 40 limbs of 38 patients, candidates for coronary artery bypass grafting. The venous wall was characterised based on its thickness and echogenicity in three categories: normal, moderately and severely fibrotic. LSV specimens taken from the above sites were also grouped into the same three categories based on their fibrotic content found on histology. RESULTS: In total, 89 vein specimens were evaluated. On ultrasound, 81 specimens were detected as normal (91%), seven as moderately (8%) and one as severely fibrotic (1%). On histology, only eight specimens were found normal (9%), 75 with moderate (84%) and six with severe fibrosis (7%). Similar wall characterisation with both examinations was found in only 19% (17/89) of the specimens. Eighty-one specimens (91%) had some degree of fibrosis on histology. Different grades of fibrosis were found on histology in different sites of the same vein. CONCLUSIONS: Pre-existing wall changes are very common in vein grafts used for bypass surgery. However, the ultrasonic characterisation of the venous wall preoperatively cannot reliably identify these changes.
Aged↗
The role of venous reflux and calf muscle pump function in nonthrombotic chronic venous insufficiency. Correlation with severity of signs and symptoms.
OBJECTIVE: To determine the lower-limb venous hemodynamics in patients with varying grades of chronic venous insufficiency (CVI), not due to deep vein thrombosis, when matched for age and duration of disease. DESIGN: Case-control study. SETTING: Normal volunteers and patients with different grades of CVI referred to the vascular unit of a university hospital. MATERIALS: Fifty-one legs (40 patients) with CVI, but without a history of deep vein thrombosis, and 24 normal legs (20 volunteer subjects). These selected legs were grouped according to the severity of CVI (classes 0 - through 3) so that each class was matched for age (all study participants <60 years) and duration of signs and symptoms (<10 years). INVESTIGATIONS: Air plethysmography and color flow duplex imaging. MAIN OUTCOME MEASURES: Venous volume, venous filling index, and outflow, ejection, and residual volume fractions were assessed in all limbs with air plethysmography. The presence of reflux was confirmed by the results of color flow duplex imaging. RESULTS: Ten (42%) of 24 limbs in class 0 had no reflux. Twenty-five (57%) of the 44 limbs in classes 0 and 1 had superficial reflux alone, while all the limbs in class 1 had some degree of reflux in the superficial veins. The sites of reflux in these limbs were similar. The patterns of reflux in classes 2 and 3 were more complex. Eight (26%) of the 31 limbs had superficial reflux alone, whereas 10 (32%) had all three systems involved (superficial, deep, and perforating). The venous volume, venous filling index, and residual volume fraction worsened with progression of CVI. Significant statistical differences could, however, only be demonstrated between classes 0 and 1 vs classes 2 and 3. No changes could be found in the ejection and outflow fractions. CONCLUSIONS: Patients (age <60 years) with CVI of less than 10 years' duration and with no history of deep vein thrombosis had venous hemodynamic changes that correlated well with the clinical severity of the disease. This was owing to the increased reflux, as the ejecting ability of the calf muscle pump remained intact, and the venous outflow was normal.
Adult↗
Protection of the gastroduodenal mucosa from the effects of diclofenac sodium: role of highly selective vagotomy and misoprostol.
The aim of this study was to determine the effectiveness of highly selective vagotomy (HSV) or misoprostol, a prostaglandin E1 (PGE1) analog, for protecting the gastroduodenal mucosa (GDM) from the effects of diclofenac sodium (DS). Fifty mongrel dogs were randomly allocated to five groups. HSV alone was performed in group I dogs (controls) to standardize the operation. DS was given intramuscularly for 12 consecutive days to the group II dogs, whereas in the group III dogs HSV was performed, followed a month later by DS administration, as in group II. DS was given in combination with misoprostol for 12 days to the group IV dogs. HSV was performed on the group V dogs, and a month later DS and misoprostol were given, as in group IV. After sacrificing the animals the GDM was examined for macroscopic and histologic lesions. Statistical analysis was made by Fisher's exact test. HSV alone did not protect the gastric or duodenal mucosa from the effects of DS (p = 0.474 and p = 0.62, respectively). Misoprostol alone also did not offer significant protection to the gastric or the duodenal mucosa (p = 0.08 and p = 0.65, respectively). The combination of HSV plus misoprostol protected the gastric mucosa (group V, p = 0.007) but not the duodenal mucosa (group V, p = 0.08). Hence HSV or misoprostol alone offers no protection to the GDM from the effects of DS. The combination of HSV and misoprostol offers significant protection only to gastric mucosa. Enhancement of the mucosal defense mechanisms combined with strong reduction of gastric acidity may offer adequate protection to gastric mucosa from the effects of nonsteroidal antiinflammatory drugs.
Animals↗